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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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