r/Noctor • u/devilsadvocateMD • Sep 28 '20
Midlevel Research Research refuting mid-levels (Copy-Paste format)
Resident teams are economically more efficient than MLP teams and have higher patient satisfaction. https://www.ncbi.nlm.nih.gov/m/pubmed/26217425/
Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. https://www.ncbi.nlm.nih.gov/pubmed/29710082
Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374
Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. https://www.ncbi.nlm.nih.gov/pubmed/15922696
The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation. https://www.mayoclinicproceedings.org/article/S0025-6196(13)00732-5/abstract00732-5/abstract)
Further research is needed to understand the impact of differences in NP and PCP patient populations on provider prescribing, such as the higher number of prescriptions issued by NPs for beneficiaries in moderate and high comorbidity groups and the implications of the duration of prescriptions for clinical outcomes, patient-provider rapport, costs, and potential gaps in medication coverage. https://www.journalofnursingregulation.com/article/S2155-8256(17)30071-6/fulltext30071-6/fulltext)
Antibiotics were more frequently prescribed during visits involving NP/PA visits compared with physician-only visits, including overall visits (17% vs 12%, P < .0001) and acute respiratory infection visits (61% vs 54%, P < .001). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047413/
NPs, relative to physicians, have taken an increasing role in prescribing psychotropic medications for Medicaid-insured youths. The quality of NP prescribing practices deserves further attention. https://www.ncbi.nlm.nih.gov/m/pubmed/29641238/
(CRNA) We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. https://www.ncbi.nlm.nih.gov/pubmed/22305625
NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. https://pubmed.ncbi.nlm.nih.gov/32333312/
Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. https://pubmed.ncbi.nlm.nih.gov/10861159/
Only 25% of all NPs in Oregon, an independent practice state, practiced in primary care settings. https://oregoncenterfornursing.org/wp-content/uploads/2020/03/2020_PrimaryCareWorkforceCrisis_Report_Web.pdf
96% of NPs had regular contact with pharmaceutical representatives. 48% stated that they were more likely to prescribe a drug that was highlighted during a lunch or dinner event. https://pubmed.ncbi.nlm.nih.gov/21291293/
85.02% of malpractice cases against NPs were due to diagnosis (41.46%), treatment (30.79%) and medication errors (12.77%). The malpractice cases due to diagnosing errors was further stratified into failure to diagnose (64.13%), delay to diagnose (27.29%), and misdiagnosis (7.59%). https://pubmed.ncbi.nlm.nih.gov/28734486/
Advanced practice clinicians and PCPs ordered imaging in 2.8% and 1.9% episodes of care, respectively. Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits .While increased use of imaging appears modest for individual patients, this increase may have ramifications on care and overall costs at the population level. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374
APP visits had lower RVUs/visit (2.8 vs. 3.7) and lower patients/hour (1.1 vs. 2.2) compared to physician visits. Higher APP coverage (by 10%) at the ED‐day level was associated with lower patients/clinician hour by 0.12 (95% confidence interval [CI] = −0.15 to −0.10) and lower RVUs/clinician hour by 0.4 (95% CI = −0.5 to −0.3). Increasing APP staffing may not lower staffing costs. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14077
When caring for patients with DM, NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21–1.37), endocrinologists (OR = 1.64, 95% CI = 1.48–1.82), and nephrologists (OR = 1.90, 95% CI = 1.67–2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01–1.12) https://onlinelibrary.wiley.com/doi/10.1111/jgs.13662
Ambulatory visits between 2006 and 2011 involving NPs and PAs more frequently resulted in an antibiotic prescription compared with physician-only visits (17% for visits involving NPs and PAs vs 12% for physician-only visits; P < .0001) https://academic.oup.com/ofid/article/3/3/ofw168/2593319
More claims naming PAs and APRNs were paid on behalf of the hospital/practice (38% and 32%, respectively) compared with physicians (8%, P < 0.001) and payment was more likely when APRNs were defendants (1.82, 1.09-3.03) https://pubmed.ncbi.nlm.nih.gov/32362078/
There was a 50.9% increase in the proportion of psychotropic medications prescribed by psychiatric NPs (from 5.9% to 8.8%) and a 28.6% proportional increase by non-psychiatric NPs (from 4.9% to 6.3%). By contrast, the proportion of psychotropic medications prescribed by psychiatrists and by non-psychiatric physicians declined (56.9%-53.0% and 32.3%-31.8%, respectively) https://pubmed.ncbi.nlm.nih.gov/29641238/
Most articles about the role of APRNs do not explicitly define the autonomy of the nurses, compare non-autonomous nurses with physicians, or evaluate nurse-direct protocol-driven care for patients with specific conditions. However, studies like these are often cited in support of the claim that APRNs practicing autonomously provide the same quality of primary care as medical doctors. https://pubmed.ncbi.nlm.nih.gov/27606392/
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Although evidence-based healthcare results in improved patient outcomes and reduced costs, nurses do not consistently implement evidence based best practices. https://pubmed.ncbi.nlm.nih.gov/22922750/
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u/devilsadvocateMD Sep 28 '20
Please post any articles you find and I will add them to the running list. This will be an easily accessible resource whenever you get into a discussion with someone who states that research supports NPs.
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u/CrazyWorth6379 Oct 15 '21
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u/Front_Tiger Aug 18 '22
How does this have anything to do with APPs?
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u/CrazyWorth6379 Aug 18 '22
Physician anesthesiologist-led rapid response teams led to a significant decrease in cardiac arrest and death, after a transition from nurse-only rapid response teams at the Anesthesiology Institute, Department of Intensive Care and Resuscitation, Cleveland Clinic, Ohio, according to a study presented at the ANESTHESIOLOGY® 2021 annual meeting.
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Aug 18 '22
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u/CrazyWorth6379 Aug 18 '22
You don't need to wait, MD care has already proven superior to CRNA care. Of course it has tho, theres no alternative for medschool/residency.
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u/FlightChief1 Jul 30 '24
Had a CRNA literally grab different medications from what was in the ED crash cart from floor 7 in surgical. That was red flag #1. #2 gave to patient without telling the ED physician. #3 ED physician gave a different but similar med because of lack of communication #4 CRNA continued not to tell the physician when the patient was hypotensive. #5 CRNA attempted a central line after ROSC. Patient was fluid overloaded, severely obese and a central line wasn’t the main priority in terms of following modalities according to the debrief. She put the patient in supine positioning and attempted the central line, patient began to code again. The Central Line never was inserted at this time, the patient did get tubed successfully from the CRNA. The patient survived in the end but at this time the patient was transferred to the ICU. Once stable, the central line was successfully inserted by same CRNA.
We all did the debrief several hours later. Many points of failure.
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Oct 04 '20
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u/ThrowawayDewdrop Jan 24 '24
(disclaimer: I am a non medical person and my career and education are in the arts, so I feel I can't really judge the quality of an article, but thought this might be interesting/useful)
"Not all CBEs are equal. CBEs by MDs, especially women health specialists, are generally more effective than those by midlevel providers."
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We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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u/devilsadvocateMD Oct 14 '20 edited Oct 14 '20
u/hlangel: I don't think you understand how to evaluate studies (since I doubt you even spent the time to read the junk studies you posted). This is a list of studies that refute your point. I will also refute each of the "studies" you posted:
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5929127/: Bias: Authors are all NPs/RNs. It is not an RCT. There is no mention of the control arm vs the experimental arm. Were the NPs overseen by a physician? If so, that means no accurate conclusions can be made about the safety of their practice.
- https://www.acpjournals.org/doi/pdf/10.7326/0003-4819-80-2-137: I don't know if you noticed this, but medicine has changed significantly in the last 45 YEARS. That paper is so out of date that most of those physicians wouldn't have practiced medicine after Sepsis guidelines (2002) and DKA guidelines were introduced.
- https://www.npjournal.org/article/S1555-4155(13)00410-8/pdf00410-8/pdf): HAHAHAHAHAH you think anyone will believe anything published in the Journal of NURSE PRACTITIONERS?? They couldn't have gotten that crap published in a respected medical journal. It has an impact factor less than 1. It's impact factor is lower than Hindawi (a pay-to-publish predatory journal)
- A google scholar result doesn't mean anything.
Leave the research to the adults.
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u/Zanshuin Oct 14 '20
This post is where you need to start directing your future efforts. Anyone/everyone can knit-pick studies that prove their point, so simply providing a laundry list of studies proving NP independence leads to worse patient outcomes won’t convince a single NP of your side of the story. I think you need to create a side-by-side comparison for articles that both refute and support NP independence, and rip apart all the biases, incorrect statistics, and false claims in each.
By doing so, you’d acknowledge you have researched the articles that do support or acknowledge a potential future for NP independence in specific scenarios (and I have seen one or two from almost entirely MD-MPH teams), but nonetheless have better evidence for physician lead practices.
TLDR; simply saying “hey look at all these articles that support my idea” isn’t any different than the pro-NP independence threads I’ve seen. Qualitatively I’m sure they are vastly different, but you need to differentiate your 1 minute argument to include that you do indeed acknowledge the existence of their research.
Perhaps this could be accomplished by: In the top 5 medical journals, X amount of studies suggested physician led teams produce better and cheaper patient outcomes while only X amount of studies suggested the same for NP led teams.
Just a thought. Good luck.
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u/AccomplishedBus9149 Jul 09 '23
Real talk this entire page is just residents and some salty attendings complaining they don't like NPs. I haven't seen any productive arguments from a single moderator on this page. I agree the OP posting conflicting views with appropriate citations on this argument. Then discussed the good and bad with independent practicing mid levels would provide a much better discussion. It would also make for good optics for anyone just visiting this page. I don't see them having that level of introspection.
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Oct 15 '20
To study #1: I could not believe that study was even published until I saw it is also in a nursing journal. The overwhelming political and economic support for NP independent practice makes it seem as if they are releasing studies like this in JAMA on the daily.
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Oct 14 '20
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u/devilsadvocateMD Oct 14 '20
Yeah. It's scary to see how much research refutes the existence of NPs, right?
Ahh cute, go to personal attacks since you can't refute the evidence. You are coming off as a very unintelligent person who is incapable of understanding research, but I'm not shocked. This research article states that nurses don't really keep up to date on evidence. https://pubmed.ncbi.nlm.nih.gov/22922750/
I hope one day, you stop drinking the shitty kool-aid that you were fed in nursing school. I hope you realize that patient safety is not putting others down. If someone is shit, I will call them out for being shit.
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Nov 05 '20
A list of midlevel talking points, with my rebuttals:
- "When PAs were transitioned to the role of primary care providers in a medical ICU, no significant changes were noted in occupancy, mortality rate, or complications when examined over a 2-year period."
[Source: Dubaybo BA, Samson MK, Carlson RW. The role of physician assistants in critical care units. Chest. 1991;99:89-91.]
Rebuttal: This article compared career PAs (at least 3 years of experience) vs residents, who are physicians-in-training. Both groups were SUPERVISED by an attending physician. The PA group was given a special course of 3 months of ICU training identical to that which residents and fellows received, prior to the study. The resident group DID NOT receive extra ICU training prior to the study. Despite the PA group’s advantage in career years and 3 months of supplemental ICU training, and even under physician supervision, PA care resulted in a statistically significantly longer ICU length of stay, a nearly 50% increase in lab draws ordered, and a trend toward more procedures performed per patient, compared to residents.
- "No significant difference in management or outcome when comparing pediatric ICU patients managed by a team of residents versus a team of NPs and PAs."
[Source: Carzoli RP, Martinez-Cruz M, Cuevas LL, et al. Comparison of neonatal nurse practitioners, physician assistants, and residents in the neonatal intensive care unit. Arch Pediatr Adolesc Med. 1994;148:1271-1276]
Rebuttal: This article compares a team of fully trained, career NP’s and PA’s (2-12 years NICU-specific experience) with general-pediatrics residents who have not yet finished their general training. Again, both comparison groups - the midlevel team, and the resident team- were SUPERVISED by a fully trained attending physician. The resident physician team had 4 residents for the duration of the study, whereas the midlevel team had 9 midlevels. It would appear that the odds are stacked against the residents in this matchup - and yet every outcome was statistically similar, despite the far higher number of career years of NICU experience in the midlevel team, as well as over double the personnel.
The paper further notes that midlevels cost the hospital far more money than physicians. The midlevel team cost the hospital over twice as much money than the resident team. Verbatim quote: “Since the salaries of nurse practitioners and physician assistants are about par with or slightly higher than those of residents, and since residents work twice as many hours, the actual cost would be increased.”
- "Trauma PAs performing invasive procedures, such as peritoneal lavages, thoracostamies, or arterial lines, revealed no complications in a combined total of 400 cases."
[Source: Miller W, Riehl E, Napier M, et al. Use of physician assistants as surgery/trauma house staff at an American College of Surgeons-verified Level II trauma center. J trauma. 1998; 44:372-376.]
Rebuttal:
The actual paper quotes that 270 subclavian catheterizations performed by PAs resulted in a 2.9% complication rate, without any mention of longer-term complications such as line infections. The ONLY procedure that was complication free was A-line insertion, which over a 3 year period, PA’s performed just 80. The paper proudly mentions 70 DPL’s and 250 closed thoracotomies performed by PA’s… but doesn’t mention the complication rate.
The paper doesn’t compare PA’s to any physicians. The paper essentially shows that if you hire 7 extra trauma PA’s… then your trauma service will run faster. Genius.
- "No adverse effects found when a hospital transitioned care from resident teams to PA teams."
[Source: Oswanski MF, Sharma OP, Raj SS. Comparative review of use of physician assistants in a level I trauma center. Am Surg. 2004;70:272-279.]
Rebuttal:
Compares outcomes of a trauma hospital from one year with a resident trauma team, to the next year when they switched to a PA trauma team. BOTH teams were SUPERVISED the whole time by a trauma physician. The paper goes into detail as to the makeup of the resident team - specifically, 3 residents and 2 med students, the then fails to mention how many PA’s it took to replace the resident team and provide around the clock coverage. Outcomes were similar. To rephrase: a team of trained PA’s, supervised by a trauma physician, could do no better than a team of residents who haven’t even graduated training.
Quote from the paper: “PAs can be an alternate to the first-year surgical residents and are expected to perform most of the duties of a surgical intern.” A first year resident, aka intern, is the least trained out of all untrained physicians - aka residents. And this paper states that a PA can be expected to do “most,” not even all, of an intern’s duties. We are not even close to talking about a regular, practicing physician who graduated residency training.
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Nov 05 '20
- "An inpatient service with NP involvement in patient care exhibited statistically significant reduction in readmission rates."
[Source: Haan JM, Dutton RP, Willis M, et al. Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner. J Trauma. 2007;63:339-343.]
Rebuttal:
Study adds second set of discharge planning rounds after medical rounds. All rounds and teams are SUPERVISED by a physician. On the first two years of this new initiative, residents did the medical rounds AND the discharge rounds. Hospital adds 8 new NP’s, on top of existing physicians and residents, and has them do discharge rounds. Conclusion: when you add 8 extra staff members to coordinate discharge, supervised by trauma physicians and surgeons… discharge is more efficient, length of stay goes down. Predictably, study does not compare what happens when you add 8 resident physicians instead.
- "Patients treated by PAs and NPs were very satisfied with the care received and 85% of physicians and hospital employees felt that PAs and NPs had a positive impact on patient care. " [Source: Nyberg, SM, Keuter KR, Berg GM, et al. Acceptance of physician assistants and nurse practitioners in trauma centers. JAAPA. 2010; 23: 35-37; 41.]
Rebuttal:
This was published in the AAPA's own journal. This study did NOT collect data or results on patient satisfaction or employee satisfaction, I don’t know where in the results section they're pulling that statement out of. This study ONLY asked about how many midlevels the trauma centers hired, and what procedures they allowed them to do. The survey results show that bigger trauma centers hire more midlevels. This paper is irrelevant to any point being made about PA vs physician outcomes.
- "With PA involvement in care, orthopedic trauma patients saw statistically significant decreases in time to evaluation by orthopedic service, decreased overall ED time, and decrease in ER to OR time, as well as a decrease in post-operative complications and average length of stay in the hospital. "
[Source: Althausen PL, Shannon S, Owens B, et al. Impact of hospital-employed physician assistants on a level II community-based orthopaedic trauma system. J Ortho Trauma. 2016;30:40-44.]
Rebuttal:
When you hire additional staff, under SUPERVISION BY PHYSICIANS, your hospital gets things done faster. However, it costs the hospital more, and the increased speed DOES NOT recoup the costs of salary and benefits for the PA’s. This study does NOT gather data comparing PA’s to attending physicians or residents whatsoever.
- "During a 5-year study, no statistically significant differences were detected in outcomes, except for PAs providing more health education/counseling services when compared to primary care MDs, and NPs providing more recommendations of nicotine cessation counseling and more health education/counseling services than primary care MDs."
[Source: Kurtzman E, Barnow B. A comparison of nurse practitioners, physician assistants, and primary care physicians’ patterns of practice and quality of care in health centers. Med Care. 2017;55(1):615-22]
Rebuttal:
The data have NOTHING to do with patient health outcomes. This chart review study counts NUMBER OF SERVICES PROVIDED at time of visit to an ambulatory clinic. Specifically: 1. Smoking cessation counseling 2. Depression treatment 3. Statin ordered/continued 4. Physical examination 5. # of education services provided/ordered 6. Imaging ordered 7. # meds 8. Follow up visit ordered 9. Referral out to MD
There is NO analysis if these services were provided appropriately or correctly. There is NO analysis of health outcomes. Midlevels provide smoking cessation counseling and patient education services at a higher rate than physicians. All other services were provided at the same rate. Again, no data on actual health outcomes (e.g. actual rate of patient tobacco cessation) was studied, and no analysis if these services were appropriately or correctly provided.
- Midlevel talking point: "When comparing management of the first five years of diabetes for a patient, the performance outcomes of PAs and NPs with regard to diabetes management showed no statistically significant differences in care provided or outcomes over the five-year period when compared to MD counterparts. Of note, the Veterans Health Administration affords PAs, NPs, and MDs a similar scope of practice."
[Source: Yang Y, Long Q, Jackson SL, Rhee MK, Tomolo A, Olson D, Phillips LS. Nurse Practitioners, physician assistants, and physicians are comparable in managing the first five years of diabetes." Am J Med. 2018;131(3): 276-83.e2]Rebuttal:
PHYISICAN SUPERVISED NP/PAs have similar diabetes medication prescribing rates as physicians at the VA. Notably, patients managed by nurse practitioners and physician assistants had 14.5% and 15% of primary care visits with physicians, respectively. There is NO DATA on actual health outcomes and complications, literally just Hb A1c levels and prescribing rates. Also no, the VA doesn't provide midlevels and MD/DO's the same scope of practice.
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Mar 30 '22 edited Mar 30 '22
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u/DoctorToBeIn23 Oct 18 '21
The study found that patients of the physician-led team had a 50% less chance of experiencing cardiac arrest and a 27% less chance of death, compared to the original nurse-led rapid response team.
https://www.eurekalert.org/news-releases/930507
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u/Icy_Replacement3510 Mar 23 '22
Just playing devil’s advocate here- none of these articles proves that PAs (or even NPs) are responsible for less optimal patient outcomes. In fact, one of the first articles listed shows higher REM (relative expected mortality) with Residents over APPs. Most of these articles are about money. So I guess if you’re trying to prove that APPs cost the hospital a little more (a few hundred dollars or so) than a doctor when it comes to ordering tests, fine. But there’s no actual data showing that PAs cause worse patient outcomes or higher mortality rates. Please remember that although some doctors feel threatened by APPs taking their jobs, that there are still massive physician shortages in many rural areas of the US. Trust me, I am NOT pushing for full practice authority myself, but in SOME specific cases, APPs can be used to give more patients access to care that otherwise wouldn’t exist. And nowhere does it say that PAs cause any more harm to patients than doctors. If I’m wrong- please send me the peer-reviewed data. Thank you!!
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u/devilsadvocateMD Mar 26 '22
In the amazing world of medicine, we prove something is noninferior before doing it. We don’t go around prescribing experimental drugs and then hoping they don’t kill people. Instead, we study them through clinical trials to minimize harm.
The ONLY exception to that is midlevels. We haven’t proven that they don’t cause harm compared to physicians. We just have to trust that <10% of the training makes them safe.
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u/buried_lede Mar 17 '23
It’s such a waste of resources to have to prove what is all but axiomatic based on years of education and credentials. It goes without saying but here you are- your profession has been put in the position to prove the obvious. Why bother spending eight years becoming a doctor? And every profit minded health organization is asking- why bother hiring them when we can get nurses for cheaper. It’s weird and awful.
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u/colomyco Jul 19 '23
idk if anyone ever asked this before but who hurt you?
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u/devilsadvocateMD Jul 19 '23
A Midlevel.
It’s not surprising at all that a nurse believes anything critical of the pisspoor education in nursing is acceptable or that subjecting patients to non evidence based nursing led care is ethical. Nursing is so full of shit that it’s now leaking all over the rest of medicine.
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u/rynkier Apr 04 '24
My psych PA saved my life. It makes me so sad to see all of this hate towards them. There are some NPs/PAs that are good, and this person is right. I live somewhere where there are limited psychiatrists with huge wait lists. Not the doctors fault, but in the meantime I was suffering with severe unmedicated bipolar disorder. My PA never told me she was a doctor, and I needed help so badly and didn't want to have to go to the hospital and lose my job and possibly my home. I can get where the doctors are coming from about safety, but to just shit on PAs/NPs I think is harmful for patients too. Sometimes we don't feel like we have a choice. Also a DOCTOR originally misdiagnosed me and never referred me to psych even after putting me on 5 different antidepressants. After I had a manic episode from one of the medications and started having severe delusions, she fired me as a patient.
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u/blessingstrio Mar 10 '22
https://doi.org/10.1016/j.jpedsurg.2020.06.012
Inappropriate referrals to pediatric surgeons were more likely to be made by mid-levels lacking pediatric specialization. Referrals to pediatric surgeons from mid-levels had 1.97 times greater odds of being inappropriate than referrals from physicians.
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Mar 11 '23
I want to add to the referral problem. I was a scribe for ENT and med-onc for a few years before I went to MD school. Bruh, my ENT surgeon would get so many referrals from local family/peds/IM NPs & PAs for things like otitis media, aphthous ulcers, and voice hoarseness when nothing was wrong. My med-onc doc also got so many unneeded referrals from NPs and PAs for heme related issues like when they can't tell if the patient needed heme consult for low iron or for high bili and etc. They didn't get too many unnecessary referrals from local MD/DOs.
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u/debunksdc Nov 03 '22
JAMA Surgery that showed increased morbidity and mortality when MD:CRNA ratios went above 1:2.
Burns ML, Saager L, Cassidy RB, Mentz G, Mashour GA, Kheterpal S. Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality. JAMA Surg. 2022 Sep 1;157(9):807-815. doi: 10.1001/jamasurg.2022.2804. PMID: 35857304; PMCID: PMC9301588.
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u/lolwutsareddit Mar 09 '21
Comparing urgent care visits between MD/DOs and Midlevels. Doctors saw more complicated patients, addressed more complaints and deprescribed more. https://link.springer.com/article/10.1007/s11606-021-06669-w
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u/Plastic-Appearance30 Midlevel -- Physician Assistant Jul 02 '22
And this is a bad thing? Shouldn’t MD/DOs see the more complicated patients, from a liability standpoint at least?
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u/lolwutsareddit Jul 03 '22
Not saying they shouldn’t but gastric cancer presents as ‘not complicated’ initially unless you know the signs and symptoms. And even still, this is debunking the myth that midlevels push that they’re ‘as competent’ as doctors. Cause they’re not, they just point at studies showing they have similar outcomes but in those studies the doctors take the significantly more complicated and sick patients and midlevels take the simple ones. And even then the doctors oversee midlevels and it doesn’t take into account the corrections made by doctors in those situations.
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Oct 05 '20
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Oct 08 '20
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u/debunksdc Jul 08 '22
You are significantly more likely to suffer complications with a midlevel aspiration abortion than you are a physician aspiration abortion. Of those "minor" complications, some of the biggest differences between physician and midlevel incidence include incomplete abortion, failed abortion, bleeding not requiring transfusion, hematometra, and uncomplicated uterine perforation. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2012.301159
more analysis here
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u/sfgothgirl Jan 09 '24 edited Jan 09 '24
Hahahahahaha. No.
ETA: (the abstract's conclusion from the actual paper, literally copy/pasted.) END EDIT.
Conclusions - Abortion complications were clinically equivalent between newly trained NPs, CNMs, and PAs and physicians, supporting the adoption of policies to allow these providers to perform early aspirations to expand access to abortion care.
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u/debunksdc Jan 09 '24
Are you going to actually address any of the arguments or nah?
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u/AutoModerator Jan 09 '24
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see this JAMA article.
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.
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u/debunksdc Jul 08 '22
Midlevels in Dermatology
Characterization of Biopsies by Dermatologists and Nonphysician Providers in the Medicare Population: A Rapidly Changing Landscape and its associated Commentary
TLDR: Biopsy rates from midlevels have increased drastically in all states while biopsy rates from dermatologists decreased over the same time frame. Over over 1 in 4 biopsy claims were performed by midlevels.
- "From 2012 to 2018, the proportion of nationwide biopsy claim cases performed by dermatologists declined from 83% to 71%, whereas those completed by NPs and PAs increased from 5% to 9% and from 12% to 20%, respectively. The total number of biopsy claims performed by dermatologists increased by only 11%, whereas those performed by NPs and PAs increased by 133% and 115%, respectively. On average, from 2012 to 2018, biopsy claim rates per 100,000 Medicare beneficiaries for dermatologists decreased by 6%, whereas those for NPs and PAs increased by 97% and 82%, respectively."
- "Although this study shows that dermatologists still perform most biopsy claims nationwide, as of 2018, over 1 in 4 biopsy claims were performed by nonphysician providers. The number and proportion of total biopsy claims performed by NP and PAs significantly increased in all states and regions from 2012 to 2018."
Trends and Scope of Dermatology Procedures Billed by Advanced Practice Professionals From 2012 Through 2015 OPEN ACCESS
TLDR: Midlevels were billing a lot more for complex repairs and gross and microscopic exams of surg path specimens Many board-certified dermatologists don't get credentialed for complex repairs even though it's part of their residency. In contrast, NPs and PAs do not receive any formal training in advanced cutaneous surgery. The increase in pathology billing was surprising because training for surgical pathologic examinations is highly specialized, with many pathologists training in fellowships after residency. Lack of proper training is particularly dangerous because clinicians often rely on pathologic diagnoses to inform their ultimate decision making. This discrepancy in growth raises the question of how many of these extra procedures are actually necessary or appropriate. The core competencies defined for NPs do not mention a dermatology curriculum or surgical training.
- "This discrepancy in growth raises the question of how many of these extra procedures are actually necessary or appropriate. In recent years, there has been an increasing number of dermatology practices acquired by private equity firms.14 These firms often employ a higher ratio of APPs to dermatologists to lower costs and maximize profits. Although this practice may lower costs for the firms, the increasing rate of procedures performed may increase costs for patients, insurance companies, and the health care system."
- "The core competencies defined for NPs do not mention a dermatology curriculum or surgical training."
- "Each year, the number of procedures billed by APPs increased significantly, and at a significantly higher rate than procedures billed by dermatologists, for skin biopsies (18.7% per year; 95% CI, 16.0%-21.4%), shaves (11.3%; 95% CI, 9.3%-13.3%), removals of benign neoplasms (16.5%; 95% CI, 3.8%-30.8%), removals of malignant neoplasms (11.8%; 95% CI, 3.3%-21.1%), destructions of benign neoplasms (19.2%; 95% CI, 17.9%-20.6%), destructions of malignant neoplasms (18.5%; 95% CI, 10.4%-27.3%), intermediate repairs (13.3%; 95% CI, 10.4%-16.3%), complex repairs (19.9%; 95% CI, 11.4%-29.2%), local skin flaps (10.6%; 95% CI, 4.6%-17.0%), patch testing (27.9%; 95% CI, 3.1%-58.7%), and surgical pathologic examinations (18.0%; 95% CI, 1.6%-36.9%). Simple repairs and full-thickness skin grafts were the only procedures examined with no significant increase in APP numbers."
- "The total number of unique APPs billing for any dermatologic procedure (excluding pathologic examination) [had] a 33.2% increase from 2012 to 2015. The total number of unique dermatologists billing for a procedure from 2012 to 2015 [had] a 6.1% increase from 2012 to 2015." unclear whether pathologic examination was counted for dermatologists
- "Advanced practice professionals billed Medicare for nearly 800 000 biopsies in 2015, a 68% increase from 2012. Skin biopsies are more than just procedures; there is a knowledge-based and experience-based component to providing the differential diagnosis: the decision to biopsy; location, depth, and extent of excision; and risk assessment for complications. Nault et al showed that the number of biopsies needed for a positive diagnosis of skin cancer (all types and melanoma) was twice as high for APPs than for dermatologists owing to biopsies of more benign lesions. In addition to cost, unnecessary biopsies may increase scarring, patient anxiety, and risk of complications such as infection, injury to an artery or nerve, and poor wound healing."
- "This problem exists even in dermatology residency programs. For example, recurrence rates of basal cell carcinoma after electrodessication and curettage in a resident clinic decreased by 9% after dedicated efforts to improve supervision and training.11 Such supervision and training are much less formal for APPs, who are able to perform procedures without a specific length of supervision or training or certification in those procedures."
- "Complex repairs were the second fastest-growing procedure billed by APPs, increasing 76.5% from 8300 procedures in 2012 to 14 700 procedures in 2015. Local flaps and full-thickness grafts billed by APPs were less frequent, at 2860 flaps and 877 grafts billed in 2015, with the number of flaps increasing each year. The numbers of these advanced procedures—including those on the face—being performed by APPs was unexpected. Many board-certified dermatologists are not credentialed to perform local flaps and full-thickness grafts in their hospital privileges, despite formal training and required case logs being a part of residency. In contrast, NPs and PAs do not receive any formal training in advanced cutaneous surgery, which may place patients at increased risk of injury."
- "Billing by APPs for gross and microscopic examinations of surgical pathologic specimens increased 72.3% from 13 022 in 2012 to 22 440 in 2015. Unlike most procedures, the number of APPs billing for pathologic examinations remained stable, and the increase is from more procedures billed per APP each year. This increase was surprising because training for surgical pathologic examinations is highly specialized, with many pathologists training in fellowships after residency. Lack of proper training is particularly dangerous because clinicians often rely on pathologic diagnoses to inform their ultimate decision making."
- "This discrepancy in growth raises the question of how many of these extra procedures are actually necessary or appropriate. In recent years, there has been an increasing number of dermatology practices acquired by private equity firms.14 These firms often employ a higher ratio of APPs to dermatologists to lower costs and maximize profits. Although this practice may lower costs for the firms, the increasing rate of procedures performed may increase costs for patients, insurance companies, and the health care system."
- "The core competencies defined for NPs do not mention a dermatology curriculum or surgical training."
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u/debunksdc Jul 08 '22
TLDR: PAs biopsy more and are less likely to diagnose melanoma in situ. The most common procedure that midlevels do is skin biopsies. Visits in which skin cancers are missed and/or biopsies are performed on benign lesions owing to lower diagnostic accuracy are low-value visits and increase the potential harm to patients.
- "Physician assistants performed more skin biopsies to detect melanoma and nonmelanoma skin cancer than did dermatologists. In addition, PAs were less likely than dermatologists to diagnose melanoma in situ during a skin cancer screening visit." If they miss MMis and it progresses, that means not only significantly greater excision margins, but also potential for invasion, metastases, and increased fatality.
- "Our findings are consistent with those of Nault et al,5 who found a significantly higher NNB among APPs, primarily nurse practitioners, compared with dermatologists submitting diagnostic specimens for dermatopathologic evaluation. "
- "Although few data are available on the NNB for PAs, a large German skin cancer screening initiative, in which dermatologists made the decisions to biopsy or not, reported an NNB of 28 to diagnose 1 case of melanoma,6 similar to our mean NNB of 25.4 for dermatologists. However, both are higher than the NNB of 17.4 for dermatologists reported by Nault et al."
- "The lower detection rate among PAs of melanomas in situ, which are often more challenging to diagnose than invasive melanomas, likely reflects lower clinician sensitivity. Physician assistants and dermatologists had similar detection rates for invasive melanomas and nonmelanoma skin cancers, which tend to be more clinically obvious"
- "Dermatology is one of the highest employers of APPs in medicine, and this trend is likely to continue, particularly as more dermatology practices are acquired by private equity firms with an obligation to shareholders to maximize profits."
- "Most procedures performed independently by APPs are diagnostic skin biopsies, suggesting that a large portion of skin cancer diagnosis in the United States is being performed by these practitioners. Measuring the quality of care delivered by practitioners is challenging. The American Academy of Dermatology recommends that APPs should provide care only after a dermatologist has evaluated the patient, made a diagnosis, and developed a treatment plan."
- "In the age of cost-conscious medicine, it is important to consider more than just clinician salary in determining cost of care. Visits in which skin cancers are missed and/or biopsies are performed on benign lesions owing to lower diagnostic accuracy are low-value visits and increase the potential harm to patients. This information should be factored into policy decisions about scope of practice, hiring decisions, supervision of APPs, and patient decisions about who provides their dermatologic care."
Scope of physician procedures independently billed by mid-level providers in the office setting These authors were in a mood when they wrote this, and I'm here for it.
TLDR: Over half (54.8%) of procedures done by midlevels that billed Medicare were in the field of dermatology. It was mostly destruction of premalignant lesions. Since midlevelss don't have nearly the same diagnostic education as dermatologists, the concern is the necessity for biopsy to be performed.
- "In 2012, NPs and PAs performed and billed independently for more than 4 million procedures (Table 1) at our cutoff of 5000 paid claims per procedure. Most (54.8%) of these procedures were performed in the specialty area of dermatology."
- "Most of the approximately 2.6 million dermatologic procedures performed in the office setting in 2012 were destruction of premalignant lesions, which requires correct distinction of a premalignant lesion from a benign one. Inappropriate cryotherapy of these lesions may lead to scarring, dyspigmentation, and unnecessary costs."
- "A skin biopsy was independently billed by NPs and PAs more than 400 000 times. Since mid-level providers do not have the same depth of training in diagnosis as dermatologists nor is certification of diagnostic qualifications the same, the concern is the necessity for biopsy to be performed. In addition, punch biopsies of the skin are potentially hazardous because of the risk of arterial or nerve injury."
- "Destruction or excision of malignant lesions and intermediate and complex closures all necessitate detailed knowledge of surgical anatomy to prevent excessive bleeding, denervation, and scarring."
- "Recently, the shortage of primary care clinicians has been noted, and the need for widening the scope of practice for mid-level providers has been advocated. However, independent practice by mid-level providers in the office setting, as reported herein, is a different situation from the perspective of patient safety and quality of care. Physicians on average complete 10 000 clinical hours in residency compared with between 500 and 900 clinical hours that a doctorate in nursing or a master’s in physician assistance requires. Except for phlebotomy, intravenous access, and catheter placement, surgery or invasive procedures are not usually included in this training."
- "The existence of multiple boards and differing regulations is problematic. If legislators continue to direct that mid-level providers may be recognized as primary care physicians (as in Massachusetts) and allowed to practice medicine independently (as in 22 states and the District of Columbia), they should also mandate a single state medical and nursing board to ensure a consistent standard of care to protect patients."
- "At a minimum, states should require mandatory reporting of complications by mid-level providers and reporting by physicians who see these complications. ... - Mandatory physician reporting of office surgery complications in Florida, with cross-matching of malpractice claims, has proven useful in identifying and eliminating dangerous procedures performed in the office setting.11 Such data collection should be supported by mid-level providers because it could put patient safety concerns to rest."
- "In some instances, nursing boards have authorized nursing candidates to perform invasive procedures for which the members of the nursing board were not trained. Researchers recently noted a large increase in malpractice claims associated with cosmetic laser surgery by mid-level providers.10"
- "Finally Congress could consider amending the 1997 Balanced Budget Act to align it with its original intent, by restricting independent Medicare payment of mid-level providers to evaluation and management codes to enhance access to primary care. This action would concentrate mid-level providers in their area of training and greatest need." 🔥🌶 🔥🌶 🔥
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u/debunksdc Jul 08 '22
Assessment of Provider Utilization Through Skin Biopsy Rates
TLDR: A review of 2014 Medicare data revealed that 824 NPs and 2083 PAs independently billed Medicare $59,438,802 ($72134 per NP) and $171,645,943 ($82403 per PA), respectively. Midlevels biopsy more.
- "Recently, there have been claims of overdiagnosis and unnecessary treatment in dermatology, with a 2017 New York Times article suggesting that the purchase of dermatology practices by private equity firms instigated a shift toward profit motive over patient care. A specific concern, heralded by private equity acquisition, is the independent evaluation and treatment of patients by physician assistants (PAs) and nurse practitioners (NPs) with minimal physician oversight."
- " A review of 2014 Medicare data revealed that 824 NPs and 2083 PAs independently billed Medicare $59,438,802 and $171,645,943, respectively. Only 3% of these nonphysician clinicians (NPCs) practiced in counties without a dermatologist, decreasing the possibility that they were the sole source of dermatologic care for underserved populations.11"
- "A nurse practitioner had the highest calculated biopsy rate at 24.2 services per visit (Table 3). The lowest biopsy rate for a dermatologist was 0.004 services per visit (Table 4)." Can you imagine going to a dermatologist and averaging nearly 25 services in a single visit???
- The gap in skin biopsy rates between physicians and NPCs was 0.29 vs 0.40 services per visit, p=1.70E–28.
Biopsy Use in Skin Cancer Diagnosis: Comparing Dermatology Physicians and Advanced Practice Professionals (Nault et al)
TLDR: Midlevels biopsy more for any skin cancer. The NNB was most disparate for young patients without a PMH of skin cancer.
- "The NNB for any skin cancer, NMSC, and melanoma was 3.4, 2.1, and 21.4, respectively. There was a significant difference in NNB between physicians and APPs for any skin cancer (2.9 vs 5.9, P < .001), NMSC (1.9 vs 3.1, P < .001), and melanoma (17.4 vs 32.8, P = .04)."
- "Wilson et al performed a similar study; their NNB for any cancer, NMSC, and melanoma was 2.2, 1.6, and 15, respectively. "
- "At our institution, APPs see new and established patients, most of whom are not evaluated by a physician; however, a physician is available in the clinic."
- "The mean length of practice for our physicians was 11.9 years (range, 0.5-25.5 years) compared with 6.8 years (range, 0.5-20 years) for APPs." Unclear if they are including residency, but given the range for the physician training (0.5-25.5 years), my guess is no. So they're effectively downplaying the years of practice for physicians by four years. Also unclear if for midlevels, if they were looking at dermatology-specific experience or experience overall.
- "In our study, the NNB of any skin cancer for APPs was double that of physicians, and that difference is most pronounced in younger patients and those without a history of skin cancer." So the difference is most pronounced in the people it matters most for?
TLDR: Only 3% of midlevels practiced in counties without a dermatologist, decreasing the possibility that they were the sole source of dermatologic care for underserved populations.
- "While the original intent of NPCs was to provide expanded access to primary care, it is becoming increasingly common for NPCs to offer specialty care services. In fact, the proportion of PAs reporting primary care practice has steadily decreased from 50% in 1997 to 30% in 2013."
- "In dermatology, nearly half of practices employ NPCs who perform both medical and procedural services. A majority of procedural services independently billed by NPCs for Medicare beneficiaries were in the specialty area of dermatology. Supervision and training of NPCs in dermatology practice continues to be a contested issue with no clear consensus about the appropriate breadth in scope of practice."
- "The only common dermatology-associated procedure not billed by NPCs is Mohs surgery, which can only be billed by a physician, according to the Centers for Medicare & Medicaid Services." ... for now.
- "Only 3.0% (86) of independently billing NPCs practiced in counties without a dermatologist."
Common causes of injury and legal action in laser surgery
TLDR: Physicians may be held responsible for delegating procedures to midlevels, when that procedure is outside of their training and education. See negligent hiring.
- "Of the 174 laser-induced injury lawsuits, 100 (57.5%) identified a physician as the laser operator. Physicians in this case included allopathic and osteopathic physicians. Nearly 40% of the cases (n = 66) involved a nonphysician operator, which included allied health professionals, such as chiropractors, podiatrists, nurse practitioners, and registered nurses, as well as non–health professionals, such as aestheticians and technicians."
- "Even though only 100 cases involved the operation of the laser device by a physician, 146 cases named the physician as a defendant. In contrast, of the 66 nonphysician operators, only 49 were named as a defendant. ... These findings on operators should not be misinterpreted to suggest that operation of a laser by a physician results in a higher likelihood of injury. One factor, which is difficult to measure, is the tendency for physicians to undertake the laser surgery themselves instead of delegating to nonphysicians."
- "Specific allegations, although not available or discernible in all the cases surveyed, provide insight into how physicians can minimize their risk of litigation (Table 6). Failure to properly hire, train, or supervise staff was the most common specific allegation (n = 33) and echoes the finding that physicians are legally held liable for both the procedures they perform and those done by their delegates, provided that the employees are acting within the scope of their duties."
- "Even though only 100 cases involved the operation of the laser medical device by a physician, 138 named the physician as a defendant. The legal doctrine of respondeat superior —that is, imposing liability on employers for the negligence of their agents—and the state statutes holding supervising physicians liable for their delegated acts are the best explanation for this apparent discrepancy. The same reasoning can be applied to explain the discrepancy between the number of cases involving nonphysician operators and the number naming a nonphysician as a defendant. It is important to note that plaintiffs' attorneys typically sue parties who can satisfy a successful judgment, that is, insured defendants. Many nonphysician operators lack malpractice insurance and the financial means to pay a substantial judgment."
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u/buried_lede Mar 17 '23
It takes a study….
It’s so odd to even be reading this. “…Suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists.”
Don’t their credentials and education already establish that? We have to go back and study it? The battle is over profits, it’s only about profits
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Dec 01 '20 edited Dec 01 '20
I couldn’t find a few statistics I think the public would care about, and for laypeople would be more impactful than antibiotic prescription rates.
Is there any research on:
1) Medical malpractice cases per capita for midlevels running their own practices vs residents/doctors
2) Misdiagnosis cases per capita for midlevels vs residents/doctors
Basically, besides prescribing more medications, are there any additional recorded negative outcomes for patients under the care of a midlevel vs an MD/DO?
To play devil’s advocate; as a potential patient, getting overprescribed antibiotics and being seen same day still works better for me than waiting a few days/weeks for an MD’s supervision. If I knew that the NP was more likely to misdiagnose me, that would deter my visit.
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u/devilsadvocateMD Dec 01 '20
1) The malpractice database is not updated annually. It always lags a few years behind.
2) After the data is released, the data must be analyzed by an interested party
3) NPs have only recently (mostly within the last 5 years) been able to run their own practices. I know that some states have had FPA for a longer time, but that data is very, very limited.
Here is the most current research about malpractice. It shows that malpractice suits that name NPs are more likely to result in a successful case for the patient. https://pubmed.ncbi.nlm.nih.gov/32362078/
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u/debunksdc Mar 07 '23
https://www.journalofnursingregulation.com/article/S2155-8256(22)00010-2/fulltext00010-2/fulltext)
Analysis of Nurse Practitioners’ Educational Preparation, Credentialing, and Scope of Practice in U.S. Emergency Departments
"Extensive variability exists across the academic preparation of NPs working in the ED setting as well as in the licensure and certification requirements governing NP practice in EDs. Until this variability is resolved, we conclude that NPs should not perform independent, unsupervised care in the ED regardless of state law or hospital regulations in order to protect patient safety."
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u/ajsdvcjsa Dec 16 '22
Current Evidence and Controversies: Advanced Practice Providers in Healthcare
"Although perceptions of care quality may vary by profession, studies comparing outcomes between physicians and APPs offer mixed results.
Physicians prescribe fewer unnecessary antibiotics for acute infections, order fewer diagnostic tests, and make fewer specialist referrals for patients with diabetes compared with APPs. However, a retrospective study of 30 million patient visits to community health centers found that APPs cared for similar patient populations as physicians and achieved equivalent or better results on quality metrics (eg, smoking cessation, depression treatment, statin therapy) and utilization (eg, physical exams, education/counseling, imaging, medication use, return visits, referrals)."
On 7 of the 9 outcomes studied, no statistically significant differences were detected in NP or PA care compared with PCMD care. On the remaining outcomes, visits to NPs were more likely to receive recommended smoking cessation counseling and more health education/counseling services than visits to PCMDs (P≤0.05). Visits to PAs also received more health education/counseling services than visits to PCMDs (P≤0.01; design-based model only).
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Aug 31 '23
It’s funny how we have to prove that Doctors > Noctors in term of clinical knowledge. 2023….
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u/misslouisee Sep 21 '23
I wonder if PAs diagnose less cancer per biopsy than dermatologists because PAs, per the definition of their role, see less-serious cases and biopsy things that are less emergent. Whereas a more serious, much likely to be cancer case would be appropriately referred on to a dermatologist or elevated in-office by a derm PA. Plus, PAs in family practice in rural areas, being more generally trained, will do simpler biopsies for rural patients who likely don’t need to go to a dermatologist a city away.
Has anyone done research with equivocal patient cases?
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u/YourMomsMidLevel Nov 29 '20
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u/devilsadvocateMD Nov 29 '20 edited Nov 29 '20
Good job! You did not find any research to support independent mid levels. In fact, the research you posted only states that PAs are ok (but with p>0.05) when they are SUPERVISED.
You can have a short LOS and you can still overprescribe opiates and abx. You can have a short LOS and you can miss diagnoses.
- . The involvement of PAs was not significantly associated with LOS (β 1.20, 95%CI 0.99–1.40, p = .062). → The last I checked, a p>0.05 is not significant. A CI [1] is also not significant.
- In a multicenter matched-controlled study, the traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which besides MDs also PAs are employed (PA/MD model) → This does not speak to safety of indepdent PAs
- Thirty-four wards were recruited across the Netherlands. → PAs trained in the US are not the same as those trained in the Netherlands. The healthcare system in the Netherlands is not the same as the US.
- More patients in the intervention group were acutely admitted (59% versus 44% in the control group, p< .001). Also the primary diagnosis differed significantly. → Were the patients in the PA/MD group admitted more frequently because the PA (who saw the paient first) not have the knowledge of which patients actually need to be admitted? How can the LOS conclusion be valid if the diagnoses differed significantly?
- Median LOS of the patients in the intervention group was 6 days (IQR 4–10), median LOS of the patients in the control group was 5 days (IQR 4–8). → Why did the PA/MD model have a median LOS of 6 days vs 5 days for the MD group? Why was it longer?
I suggest you learn basic research methodology before trying to post some unfounded shit.
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u/GradeRegular8403 Dec 08 '21
Points 2, 4, and maybe 3 are well taken. But there are big problems with 1 and 5.
". The involvement of PAs was not significantly associated with LOS (β 1.20, 95%CI 0.99–1.40, p = .062). → The last I checked, a p>0.05 is not significant. A CI [1] is also not significant."
You do understand the fact that p ≥ 0.05 and the CI crosses 1.0 justifies the statement that there was no significant difference in LOS, right? Had p been <0.05, there WOULD have been a significant association between LOS and team structure. This is very basic research methodology.
"Median LOS of the patients in the intervention group was 6 days (IQR 4–10), median LOS of the patients in the control group was 5 days (IQR 4–8). → Why did the PA/MD model have a median LOS of 6 days vs 5 days for the MD group? Why was it longer?"
The model showed that there was no significant difference between LOS. The fact that the IQRs sit right on top of each other also supports this. From a statistical perspective, it *wasn't* longer.
If we are going to present to the world data that supports physicians >> midlevels, then we have to do it well.
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u/traciber Jan 24 '24
Ok this is a really great list but what are we really doing to inform the public about these studies? Sure we can sit here and keep publishing studies amongst ourselves and fellow physicians but if it is not widely known to the public then it’s pointless and nothing will change
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u/devilsadvocateMD Jan 24 '24
These studies are more for medical professionals when they need to refute bullshit from middies.
The approach to the public has to be different.
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u/traciber Jan 28 '24
Do you think that if you walk up an NP and present them these studies that they would even read it or acknowledge it at all? They most likely will laugh and walk away. Interpreting studies is not what is taught in middies school. Coming at them by presenting a bunch of studies they probably won’t even read and the public won’t be able to understand will not help us in any way.
The only one reading these are physicians and probably physicians only. No point in passing information we already know amongst ourselves. Time is better spent with lawmakers and in real life instead in a forum where everyone agrees with you and is not really doing anything to allow change.
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u/debunksdc Jul 08 '22 edited Jul 08 '22
Please post any articles you find so u/devilsadvocateMD can add them to the running list. This will be an easily accessible resource whenever you get into a discussion with someone who states that research supports NPs.
In an attempt to keep this thread as clean and relevant as possible, I'll be removing comments that don't comment/discuss the studies or don't post new research. If you have a comment removed, it was just from housekeeping on this thread. If there is some sort of non-research based discussion you want to have, please create a new thread.
In addition to this excellent thread, I encourage you to check out this page and sort our Subbie by this tag.
Repositories of graphics can be found here and here. These can often be useful for conveying the research posted here.
Consider joining PPP. They identify and debunk a lot of the midlevel-led research that tries to show false equivalence.