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This is an area of ongoing research, for a long time there was a bunch of non-inferiority type studies published by the nursing lobby which were apples to oranges comparison. Ex: NPs with simple cases and MDs with hard cases had similar outcomes.
Now that the NPs have made such a mess of things you have more research such as this: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs#:~:text=The%20study%20found%20the%20physician,complexity%20of%20the%20patient's%20condition.
It's important to keep in mind that NPs get effectively no training. Even if you think medicine is grossly simple (which....sigh), you should have some training.
I think people really struggle to understand how big the gap is no matter how often it's pointed out. You wouldn't trust Juan the day laborer working construction with designing a skyscraper, but that's a reasonably apt comparison in training differences and amounts.
NPs don't save the healthcare economy because while they do get paid less they do more unnecessary testing, it's just a wealth transfer from MDs to hospitals. They also stress the system more with unnecessary consults and admissions which only makes the doctor shortage issues worse.
Thanks for sharing the study, it is really very good! Reading it was a Sunday well-spent.
The conclusions that the authors reach have a lot of nuance, and help explain both why so many people have negative impressions of NPs while others have positive impressions: the variability of the productivity[1] within each profession dwarfs the difference between the average NP and the average doctor.
The other useful estimate from the study: randomly pick an NP and a Doctor working for VA emergency department; 6 out of 10 times, the Doctor is more productive, 4 out of 10 times, the NP is.
I understand that VA hospitals have trouble attracting talented doctors, though I assume that they have similar problems attracting talent in other professions, NPs in particular.
If I were in charge of VA, I would make a rule that any doctor who got their license in any OECD country can work unsupervised (provisional on training on HIPPA or whatever other US-specific medical laws). Then get a whole bunch of H1 Visas for any doctor who wants to come work for VA for five years.
[1] "productivity" was operationalized as the total cost of care (negatively coded), including the cost for any avoidable hospitalization due to screwing up, which makes sense in the VA emergency department.
What do you gain from this? If the goal to decrease healthcare costs this doesn't do much. If it's to solve the shortage it also doesn't help that much.
I would love to know why you don't think it wouldn't help with the shortage. I figure that, having a shortage of doctors willing to work in VA, combined with doctors from other countries who are willing to work at VA because it will gain them the higher US pay + a path to US citizenship, would indeed alleviate shortage of doctors at VA. However, I am not a medical doctor, so what am I missing?
Coming in way too hot.
The VA has had hiring freezes for the last two years, to my understanding. So no traditional shortage there.
Hiring extra VA physicians does nothing for the general problems we have in any case (which isn't a traditional shortage).
VA had a hiring spree last year, in large part because of the expanding benefits from the PACT Act.
Your impression of a hiring freeze remains partly correct, because VA has budget shortfalls and plans to lay off staff:
I suspect that VA tends to paint a bleak picture to Congress as a standard operating procedure, in hopes of getting more funding. Though my nephew assures me from his VA experience that more funding would not go amiss.
So back to my off-the-cuff idea of importing doctors: my point is that any VA hospital that finds it challenging to attract a decent US doctor ought to be able to do what the private sector does. Right now, the VA follows AMA's standards, which require any non-US-trained doctor to do 3+ years of residency (plus other things) before they can practice medicine in US. Residency slots are, apparently, the bottleneck for US doctor supply in the first place.
My question is: just how crucial is it for someone already practicing as a doctor in a French or German hospital to do 3+ years of residency in US?
I've never met a foreign trained doctor who came to the U.S. with Medical School and Residency training in Western Europe. We might actually have reciprocity agreements for those countries, I don't know, I've never encountered one. Scott did his Medical School in Ireland IIRC, which is note quite the same. The vast majority of foreign doctors I've met are from Asia (mostly India) and do absolutely need retraining and will generally admit as such, however frustrating it is.
Every time this comes up I have to drag out a few facts.
-There is actually a surplus of residency spots. Yes you heard me.
-We do have something of a shortage of some specialties, but this can't adequately be solved by increasing spots without decreasing training quality.
-Nobody wants to go into primary care because it pays significantly less, is one of the harder jobs, and has been made less attractive by regulatory burden and other factors.
-Most jobs are in primary care anyway, aka most doctors work in primary care.
-Even within primary care we have more of an allocation problem than a shortage. Doctors train very hard and start their adult life late. They want to be in desirable locations so Iowa has a shortage but NYC does not.
-NPs and PAs were meant to fix this but make it worse - they still want to go into specialties (and can since they have no specialty training, they can just do what they want) and they still hang around the same urban areas.
-You could hypothetically fix this by importing a ton of foreign doctors but you'd have to enslave them and force them to work in the undesirable locations long term or they would just leave immediately when given the option.
-You can fix this using the resources we have by raising salaries to what incentivizes the behavior you want. Nobody wants to do this, they just want to continue giving doctors the pay cuts they've been getting for the last 20-30 years, even though doctors are not a high percentage of healthcare costs.
Thanks for taking the time to share your experience with me.
Here's a citation re: open residency spots
https://www.nrmp.org/match-data/2024/06/results-and-data-2024-main-residency-match/
Table 1A - pretty normal for about 5-10% of offered spots to be unfilled.
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That AMA link gives such a laughably biased summary of the actual study, though. The paper itself suggests a far more nuanced picture than your metaphor about Juan the day laborer-- and that's a study led by an MD who presumably has his own professional axe to grind. (I'd be much more interested in seeing some adversarial MD-DNP research collaborations in this area.)
Notably,
- The study focused almost entirely on costs in an ED setting; on a skim, I can't find that it examined detailed health outcomes at all beyond 30-day mortality and "preventable hospitalization," the latter of which seems difficult to define in terms of patient welfare. They say NPs and MDs had no significant differences in 30-day patient mortality.
- The study did find that treatment by NPs cost the system more than treatment by MDs, owing to NPs calling for longer hospital stays and more tests. But the difference in costs diminished with more experienced NPs.
- The cost difference also diminished to a relatively trivial level for less complex cases, and the authors themselves suggest that this means NPs could be valuable substitutes for physicians in primary care.
- They found almost as much variability in productivity from clinician to clinician *within* professions as there was *across* professions. Money sentence from the abstract: "Importantly, even larger productivity variation
exists within each profession, leading to substantial overlap between the productivity distributions of the two professions; NPs perform better than physicians in 38 percent of random pairs."
I agree with you that NPs receive a disturbingly small amount of training before they're turned loose on patients. But I think the question we should be asking is what it suggests about doctors' care if MDs still realize such minor gains over DNPs.I mean you are always going to run into study design limitations. In this case most of the money in medicine wants NPs to look good so there isn't good funding for this. The VA (generally) has pretty much the worst healthcare in the country and the quality of care in the ED is also pretty much the worst in the hospital (because of how it gets misused). This is likely to flatten the curve a little bit - good doctors almost never work at the VA.
Psychiatry is a better example - psychiatric interviews and pharmacology are the most complicated in medicine. Mental health care NPs are terrible at both of these things, give people unnecessary medications and incorrect diagnoses and are legible experienced as lower quality by patients and staff with some regularity. In general hospital medicine nurses line up each other and that includes NPs but in most mental health care settings nurses will say they think the NPs are shit.
However the bad outcomes are mostly increased lifetime mortality and risk of side effects 20 years down the line when the patient is seeing someone else. This becomes effectively impossible to study so we don't.
Now you could argue that you don't really care about those problems and if its not obvious their is a skill difference in outcomes lets save money, who cares if people have the wrong medication or diagnosis. But that goes back to the ED stuff - you have a difference in mortality and morbidity, it may be small but most Americans value "the best possible" not "good enough."
Also, since this is why people normally bring it up - if you magically paid all doctors NPs salaries and didn't really change anything else......healthcare costs wouldn't go down at all in any substantive way.
I should emphasize that I have a lot of respect for psychiatrists, who seem to hurl themselves into the breach of various social ills in a way I certainly wouldn't want to do. But if we're searching for a test field where rigorous evidence makes it very legible which are the "necessary medications" and "correct diagnoses," so that MDs' highly effective healing practice contrasts clearly with NPs' useless flailing, then I'm not sure psychiatry is the obvious pick. We're talking about the same psychiatry that regularly diagnoses from subjective surveys and patient self-reports, correct? Where almost none of the biological mechanisms are thoroughly understood, either for the ailments being treated or the medications that treat them? Where exercise, healthy diet and getting plenty of sun/fresh air seem to work as well as the best drugs a lot of the time? Where official medical conditions pop in and out of the DSM with every passing political wind?
Would you say that psychiatry does a good job of monitoring its physicians' contribution to patients' lifetime mortality and/or risk of third-order side effects 20 years out, either across different levels of physician talent/conscientiousness, or versus not receiving psychiatric care at all?
I don't quite get the reasoning here. Is the idea that receiving NP salaries would cause physicians to practice as badly as you believe NPs practice, because all the competent MDs would decamp for higher-paid professions (notwithstanding the additional benefits of prestige, flexibility, autonomy and meaning in medicine)? Doctors in Canada, the UK and Germany earn about 1/3 to 1/2 what they earn in the US; is the contention that they must practice incompetently and waste a ton of money doing so?
It's called the art and science of medicine for a reason, in psych it can be pretty evident to the lay man, in other specialties it's less but still present. This means experience, heuristics, gestalts, they lead doctors astray yes, but for a lot of things we don't have good guidelines or understanding.
Importantly, doctors can be sued - this causes all kinds of problems but it does serve as a feedback mechanism that assess for problems and gives patients recourse.
Let me give a specific example of how this happens, sticking with psych because it's more interesting than me mumbling about open vs lap vs conservative appendix management.
Most people are aware of Bipolar disorder, at least superficially. Lots of people say "I have mood swings" and tell that to healthcare workers with less training, these people dutifully write down Bipolar in the chart. Or they say "you ever like have mood swings and be unable to sleep?" Gets the diagnosis. Someone who actually has Bipolar 1 with a manic episode barely sleeps for a week of more, does illegal things, or spends ALL of their money in the bank account and all kinds of other stuff. The diagnosis is serious and life limiting without treatment. The medications are also serious - most patients get antipsychotics these days which increase all cause mortality. They are worth it if you actually have the disease. Put undertrained staff give the dx to people who don't have it and then suddenly...
NPs also do things like mix benzos and stimulants, put people with depression or anxiety on antipsychotics which will result in an early death....just all kinds of ridiculous stuff.
The skill ceiling in psych (and medicine) is very high, but if you don't work in healthcare you'll (hopefully) never see it come into play. Most medical work isn't your quick annual physical with your doctor but for many patients (especially young ones) that's all you see.
As for the second point, no the issue is that physician salaries are less than 10 percent of healthcare spending, and it's been decreasing every year. Cutting doctor salaries does not solve the problem and introduces all kinds of new problems.
Likewise NPs don't save money because they do more unnecessary testing and over consult, which drains the specialists and slows down care.
OK, this is a good example for illustrating the difficulty I'm having with the binary MD-competent/ NP-incompetent model. So here we have a fairly clear, potentially dangerous error in practice. Insofar as it is fairly clear, you were able to explain it to me in a paragraph or so: now I, a random Mottizen, understand that it's bad to diagnose and medicate bipolar just on the basis of "mood swings" or "poor sleep," and that patients should instead be experiencing very florid manic episodes with clear life consequences. That's facile, but for someone going on to psych practice, I'd imagine a few additional hours of video case studies would eliminate the lowest-hanging 80-90% of obvious mistakes of the form "don't diagnose bipolar in this clearly not-bipolar patient, dummy." So presumably that same advice and video training could be administered to a DNP before they begin psych practice, problem solved.
Fine, says the MD, but what about the top-10% "art of medicine" situations where the line is far more nuanced? There aren't empirical tests to verify a diagnosis; what if the situation sounds right on the border? The precise mechanisms of bipolar are poorly understood; what if there are a lot of other things going on and it's not clear how they interact? Or it's not clear how medication will impact any particular patient, so what if the risk-benefit math around prescription is very challenging?
I can easily see how what you call the "skill ceiling" could come into play there, leading an NP to get those questions wrong. What I don't see is the training value-add that makes you confident a random board-certified psychiatrist would clear the skill ceiling and get them right. There's not good basic science around these issues, so the organic chemistry and anatomy from med school certainly won't help. Residency? Presumably this means that the MD encountered some difficult cases under supervision and was admonished to approach each case the way their attending would do it. However, (a) that could have been an indefinite amount of time ago, and there's nothing beyond some trivial online quizzes to ensure the MD has kept up with new data since their training; and (b) even back in training, nobody was checking to make sure the supervisor was themselves particularly judging the situation "correctly". Indeed, how could anyone even define "correctly," if the case was by definition so difficult and subtle, the kind of situation where the wrong call would just make a patient sadder and less functional 20 years hence, not cause them to keel over and die on the spot? Doubtless the attending felt confident that their approach was making a real difference; but we all know the various cognitive biases that would lead doctors to overestimate the correctness of their judgment and the effectiveness of their treatment under those circumstances.
I guess it boils down to the broader question "when psychiatry works clearly, it should work for DNPs too; but when it doesn't work clearly, how can you be sure it works at all?" One established answer is to turn to empirical investigation to discipline our judgment; but as you point out, psychiatry isn't a field with a lot of options for carefully blinded RCTs and massive long-term studies.
I think people in other fields fail to understand how egregiously poor a lot of NPs are. Most settings they are still supervised or deliberately have low complexity cases sent their way or have some other aspect of the environment that protects them (for instance inpatient NPs just consult specialists for everything and those specialists manage the patient even though the NP is on charge on paper).
Surely they must have some training, and they can't be that bad, right? Like who would let them practice if they are that bad?
They are that bad.
It's been hard to extract the data about this because of financial interests in NPs, and the general difficulty of doing medical research.
So much of medicine is opaque to those outside the field and even inside of it (I know nurses who have been working for 40 years and go "huh" when you tell them the resident has been working 24 hours in a row).
Fundamentally I see midlevels every week who make decisions that would make me go "holy shit you are the worst doctor in your specialty I've ever met," it's near constant.
It sounds histrionic and unbelievable but that's how so much nonsense in healthcare is.
Amazon, google, apple, tons of finances firms have all come into medicine and gone "damn that shit is run so poorly surely we can do better" and then run away screaming.
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