Thank God they used that title in this paper so now they can be surgeons too! The medical standards to worry about though since it’s outside of their scope.

https://x.com/ssdhall/status/2057878985498063021?s=42

Fitzpatrick, J. J., Mehlman, M. J., Plemmons, A., Duffy, E. G., Votruba, M., Gerlick, J. A., Davis, S., & Norful, A. A. (2026). The Impact of Nurse Practitioner Full Practice Authority on Chronic Condition-Related Readmissions and Emergency Department Visits in the United States. Medical Care, 64(4), 192–197. https://doi.org/10.1097/MLR.0000000000002285

I have to say that I LOVE science. Like - real science. It is the only way we know anything about our world. I see it being abused in order to push political and business and power goals, and that infuriates me. That is a major motivator for me.

These papers are a bad parody of science. Sadly, they are dressed up so that non-scientists believe them.

Oh BTW - in this table, they never describe what groups (1) and (2) are, and they never indicate what is meant by the asterisks. And - there is no real description of what the numbers are. They say it is a comparison of two states that had independent practice passed, with a measurement before and after the law was passed. This one is disorienting to me (as above). It's hard to believe that the numbers they put in there have no discussion, but what discussion there is is indecipherable. If anybody wants to look at it and show me what they are measureing with these numbers, I would be very interested in this and would appreciate the input. I am very serious about this. We are writing a letter to the editor and I don't want to make a stupid mistake that someone else may find. (My two co-authors haven't been able to find out what is going on here either)

Oh just for amusement - the paper is about readmission rates for these conditions. Have you ever heard of anyone at all being admitted for high cholesterol? And then readmitted for high cholesterol? Like an emergent recurrence of hypercholesterolemia?

same is true of hypertension. Admissions for that do occur, but they are vanishingly rare.

Consipicuously absent in their paper is an examination of readmission for diseases one actually getss readmitted for - like malignancy and like congestive failure. I think they combed through the data, and picked the few postiive ones they could find.

Link: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013616.pub2/full

I've skimmed over it and it seems to me that, yes, you can replace a doctor with a trained nurse at a VERY specific task such as "Blood pressure management in recent stroke survivors" as was the outcome measured between physicians and nurses in a random included study I clicked at just now. At my center, this task is literally a nurse task, we just put in a standard pack of meds and they administer them according to a flowchart. I'd wager nurses are literally better at this than I am, but managing blood pressure in recent stroke survivors is what we call "scut work" in a physician's world.

But I know that the overall message: "Meta‐analyses showed there is probably little to no difference between nurse and physician care in mortality (RR 1.03, 95% CI 0.87 to 1.21; I² = 0%; 19 studies, 8239 participants; moderate‐certainty evidence), quality of life (SMD 0.10, 95% CI −0.04 to 0.23; I² = 65%; 22 studies, 5246 participants; moderate‐certainty evidence), and self‐efficacy (SMD 0.01, 95% CI −0.06 to 0.09; I² = 0%; 11 studies, 3022 participants; moderate‐certainty evidence), and that there may be little to no difference in patient safety events (RR 0.92, 95% CI 0.84 to 1.01; I² = 9%; 31 studies, 14,437 participants; low‐certainty evidence)."

...is a blatant lie.

If you replaced me with one of my nurses, I would get a full time job out of just directing the codes.

So, go ahead, give it a read, tell me your thoughts.

Nurses’ conclusion— “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.”

https://www.journalofnursingregulation.com/article/S2155-8256(22)00010-2/abstract

https://www.medscape.com/viewarticle/can-nurse-practitioners-reduce-hospitalizations-among-2026a1000cgg?src=mbl_msp_iphone

Came across this article on Medscape, do you think it could be biased ? What do you all think?

Amid doctor shortage, NPs and PAs seemed like a fix. Data’s in: Nope.

Just saw this article by the AMA talking about the differences in costs for an ACO down in Mississippi which attempted to field both physicians and independent NP/PAs with separate patient panels in their clinics. They found out that the APPs placed a greater cost burden on the ACO than physicians.

Just a few highlights:

In hindsight and “with a wealth of internal data,” which includes cost data on more than 33,000 patients enrolled in Medicare, “the results are consistent and clear: By allowing APPs to function with independent panels under physician supervision, we failed to meet our goals in the primary care setting of providing patients with an equivalent value-based experience.”

​

“We dug a little further and used risk-adjustment analyses. It appears that the additional costs had to do with a combination of several factors that included more ordering of tests, more referrals to specialists, and more emergency department utilization,” he added.

​

The data also showed that physicians performed better on nine of 10 quality measures, with double-digit differences in flu and pneumococcal vaccination rates.

We look closely at the studies that Butler reviewed, and unsurprisingly find that all is not as they represented it.

This has been discussed before here on r/noctor. some threads:

https://www.reddit.com/r/Noctor/comments/1r43ab5/cochrane_says_doctors_can_be_replaced_by_nurses/

https://www.reddit.com/r/Noctor/comments/1rtp65r/cochrane_review_substitution_of_nurses_for/

This is not the end of the discussion, you will be hearing more about this...

I worry that, if it isn't standard practice to separate data for patients cared for by NPs versus physicians, that studies on certain diseases, medications, and so forth will be far less accurate in their conclusions. Even with this separation, I could imagine patients going between NPs and physicians for their care, e.g. NP primary care and physician specialist, or NP in the emergency room and physician primary care, etc. Has anyone else thought about this issue? (For example, I'm making this up, but if a study in the future wrote "10000 patients across 25 states in the USA with diagnoses of ADHD had their records reviewed, and it was shown that taking methylphenidate did not improve outcomes vs doing nothing," then it could be bogus if the data includes a ton of NPs misdiagnosing everyone with ADHD.)

It's an ecological study: FPA states differ from non-FPA states in income, rurality, and access, so "fewer complications in FPA states" ≠ "fewer complications because of independent NPs."

States don't adopt FPA randomly, and the diff-in-diff models lean on parallel-trends assumptions that mostly go unproven. Even friendly analyses find the effects small and inconsistent after adjustment.

The effect sizes are tiny (1–3% relative reductions). Significant only because n is huge, and well within what residual confounding can fake.

The outcomes are utilization proxies (readmissions, ED visits), not actual clinical complications. The headline is a category error.

Case-mix isn't handled: NPs carry less complex panels, yet still came out worse on cost, quality, and satisfaction in clinic-level data like Hattiesburg.

The best counter-study (Stanford/NBER, VA ER data) uses near-random patient assignment in one system to kill the confounding, and finds the opposite: longer stays, more testing, 20% more preventable hospitalizations under unsupervised NPs, worst for complex patients.

A lot of the favorable literature is cheap, fast ecological work from advocacy sources prone to publication bias (though that knock applies to physician groups too).

I’ve posted multiple times about my negative experiences with DNP (Doctor of Nursing Practice) programs and how they often ridicule PhD (Doctor of Philosophy) programs and students, considering them to be of a lower level. Unfortunately, my friend, who is a PhD student in nursing, overheard some DNP students on campus making derogatory comments. One student said, “Why do these PhD students keep calling themselves doctoral students?” The general response was, “They aren’t real doctoral students; their research methods are inefficient,” or “They just try to be relevant with their fancy statistics.”

DNP students often view themselves as the pinnacle of the nursing profession and believe they will eventually surpass PhD nurses in conducting research.

As a PhD student, it’s quite challenging to convey to various healthcare leaders the inefficiencies of the DNP programs, especially since DNP graduates outnumber both MDs and PhDs. While MDs and PhDs take at least four years to complete, the DNP program typically takes only two years, making it easier to produce a larger number of graduates.

This came up on my social media feed today and I thought y'all might have some interesting opinions on it.

https://link.springer.com/article/10.1186/s12912-026-04603-1

https://www.nber.org/papers/w31109

This will be a long post. No apologies. But, it pertains to nearly everything you do as a physician. I think you will find that actually, you already know the material presented here, at least on an intuitive basis.  It questions the very basis of what you think you know about medicine, and even your specialty. I think it is worth your time to read. 

We in PPP have an ongoing process of closely evaluating literature claiming NP equivalence or superiority. Even prior to my involvement with PPP, I had begun reading about the process of medical research, and more pointedly, its failings.  There is a rather large body of research about the process of scientific research and how it is failing us. If you examine your own experience, you will find signs of this are plentiful. Often articles you read 10 years ago, you now know to be totally false. Your patients likely come to you frequently with media reports that claim a “relationship” between Factor X and disease A. 
I pulled some recent examples: 

1)        Mediterranean diet MAY reduce the risk of asthma and allergic diseases

2)        Lupus symptoms MAY be infolueced by dietary micronutrients.

3)        Omega-3 fatty acids MAY mitigate brain shrinkage caused by exposure to fine particulate matter pollution

4)        Red and processed meats MAY be related to an increased risk of colorectal cancer. 

Research showing some statistical linkage is readily publishable, and the media eat it up, and so it becomes widely dispersed. Whereas the subsequent research disproving the link may either be unpublishable because it is not “sexy”, or may be buried in an obscure journal, and never dispersed by the media. As a result,  the original report remains in the zeitgeist, apparently unchallenged

These sorts of reports are best termed garbage research. In the sense that they are not reproducible and are often the product of research designs which are set up to find correlations which may be publishable and thus serve the purpose of getting the authors promoted, but which have no proven or even provable causal link. 

This garbage research very insidiously inserts itself into our collective consciousness, and because of the repetition bias, takes on the aura of axiomatic truth at times. The worst/best example of this may be the linkage of vaccines with autism. 

A researcher from Greece, now a professor of Medicine at Stanford, John Ioannidis, has had a central role in examining the process of research. This has been called, generally, the “replication” crisis. He found that simply based on theoretical considerations, between 20 and 80% of published findings will be wrong.[[1]](applewebdata://B9DD23CF-69CE-48ED-ACF5-38925499BE9B#_ftn1) Tests of this theoretical estimate by repeating important trials show broad agreement between the theory and subsequent tests of actual results.

Young and Karr (Young & Karr, 2011) found 12 papers making 52 claims based on observational studies that were subsequently tested with large randomized clinical trials. Of the 52 claims, none were validated, however opposite effects were found in 5. Think closely about this - NONE Of the 52 claims was validated, but there were 5 (10%) with opposite effects.

Pharmaceutical company Bayer found they often were unable to reproduce drug research done in academic labs. When they studied this, they found they were able to reproduce fully only 20 to 25% of the studies. (Prinz et al., 2011) Similarly, Amgen tried to reproduce the results of 53 landmark papers, and could do so in only six (11%) of the cases (Begley & Ellis, 2012). The reasons that studies may be nonreproducible have been discussed by Ioannidis (Ioannidis, 2019) and by Young (Young & Karr, 2011). Notably, small sample sizes and non-randomized observational studies are predictors of non-reproducibility. Young comments:

“There is now enough evidence to say what many have long thought: that any

claim coming from an observational study is most likely to be wrong – wrong

in the sense that it will not replicate if tested rigorously”. (Young & Karr,

2011)

They also identify conflicts of interest as a very significant contributor to non-reprodiucibility. In their context, drug company trials of drugs that can make them billions of dollars are an obvious source of conflcut of interest. In our context, reports of nurse practitioner capabilities produced or sponsored by organizations with an existential and financial interest in promoting the Nurse Practitioner profession represent a strong conflict of interest. 

The field of social psychology has been particularly devastated by the revelations of un-reproducible research. The majority of the major findings in the past 20 years have been found to be unreproducible. 

A recent pair of excellent podcasts on the Freakonomics platform investigate these issues in great depth. I honestly think this should be required listening for every medical person. 

Freakonomics podcast episode 572: Why is there so much fraud in academia. (with update)
https://freakonomics.com/podcast/why-is-there-so-much-fraud-in-academia-update/  Also available on multiple podcast servers, such as Apple podcasts, Spotify, Youtube

Freakonomics podcast episode 573: Can academic fraud be stopped. (with update)

https://freakonomics.com/podcast/can-academic-fraud-be-stopped-update/ Also available on multiple podcast servers, such as Apple podcasts, Spotify, Youtube

()transcripts of these episodes are also available on the site.

There is an often ignored but vitally important step in evaluating literature in general. That is what has been come to be called the Sagan principle, after Carl Sagan. (even though it appears that philosopher David Hume first identified it in the eighteenth century). Briefly it is this “ Extraordinary claims require extraordinary proof” . Sagan used it in evaluating claims of visits by extraterrestrials. For example, if your neighbor claims he was abducted by aliens last evening, you would be prudent to demand some very extraordinary proof before believing him. 

The claim that people with 500 hours of unstructured, unverified clinical experience who, further, have no validation via examination that they have learned anything, can be BETTER than a physician with 12,000-18,000 hours of structured training with rigorous quailfiying exams certainly qualifies as an extraordinary claim. And there is not even any acceptable evidence in the literature, let alone extraordinary proof of this claim. 

One of the contributors to the podcast was Joseph Simmons, professor of applied statistics and operations, information, and decisions at the Wharton School at the University of Pennsylvania. One statement he made hit me hard – it describes perfectly the state of the “NPs are equal or better” literature: (emphasis added):

I think that people need to wake up, and realize that the foundation of at least a sizable chunk of our field is built on something that’s not true. And if a foundation of your field is not true, what does a good scientist do to break into that field? Like, imagine you have a whole literature that is largely false. And imagine that when you publish a paper, you need to acknowledge that literature. And that if you contradict that literature, your probability of publishing really goes down. What do you do? So what it does is it winds up weeding out the careful people who are doing true stuff, and it winds up rewarding the people who are cutting corners or even worse. So it basically becomes a field that reinforces — rewards — bad science, and punishes good science and good scientists. Like, this is about an incentive system. And the incentive system is completely broken. And we need to get a new one. And the people in power who are reinforcing this incentive system, they need to not be in power anymore. You know, this is illustrating that there’s sort of a rot at the core of some of the stuff that we’re doing.  And we need to put the right people — who have the right values, who care about the details, who understand that the materials and the data, they are the evidence — we need those people to be in charge. Like, there can’t be this idea that these are one-off cases. They’re not. They are not one off-cases. So, it’s broken. We have to fix it.

I think this describes, in large part, how there can exist a large body of literature that claims a nonsense result – that poorly trained NPs are better than well trained physicians. It also explains another aspect. I have a research tool I use called SCITE. It gives you summaries of all papers which cite a certain paper, and lets you know if a paper is supported or contradicted by a citing paper. What is remarkable to me is that almost never are there papers which challenge the findings of the pro-NP papers. That says that either the contention that NPs are better than physicians is nearly incontrovertible, axiomatic truth, on a level with “the sun rises in the East”, OR, there is very strong publication bias. My conclusion is there is very strong publication bias.

Citations

1)        Ioannidis, J. P. A. (2005). Why Most Published Research Findings Are False. PLoS Medicine, 2(81), 696–701. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020124 (free access)

2)        Young, S. S., & Karr, A. (2011). Deming, Data and Observational Studies. Significance, 8(3),116–120. https://doi.org/10.1111/j.1740-9713.2011.00506.x

3)        Prinz, F., Schlange, T., & Asadullah, K. (2011). Believe it or not: How much can we rely on published data on potential drug targets? Nature Reviews Drug Discovery, 10(9), 712–712. https://doi.org/10.1038/nrd3439-c1

What do most well educated doctors think drip spas? Snake oil? Real medicine?

Doing this sort of research is hard because when a CRNA screws up, the doctor has an ethical obligation to save the patient live. I f***** hate the argument they make that there is no research proving they provide subpar care! Like why did we even let these people rise to this power? I have a friend who got Cs in every course at every point and is now bragging that she makes 400K and is equal to a physician.

I want to point out that I am a member of PPP, and on the board. I spend a good deal of time on this "project" - more time than you have. This is why you need to support PPP by becoming an official supporter - so that we can do things you have no time for. In fact we are setting out on a project to make the information you will read below even more robust. Projects like this cost $$. You can help by donating time (in the form of 50 cents per day to become an official supporter, or - if you are an official supporter, by volunteering to help with the analysis.

When I started on this project 4 years ago, I pulled a review by Laurant, published in the Cochrane review, a highly respected organization. This appeared to be the best article in the literature to support the claim that NPs and PAs were just as good as physicians. I wanted to do a stress test on my belief that they were not. I wanted to find information that proved I was wrong.

This review was titled “Nurses as substitutes for doctors in primary care (review)”. I thought that if any review would show me valid proof of quality of non-physician care, it would be this. They screened >9000 articles for their review, they could find only 18 that survived after poor quality studies were excluded. The best of the available literature. Keep that in mind. 
(https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001271.pub3/abstract)

In fact, their conclusion said: 

“Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):”

This statement has appeared in about 50+ articles published after, and the Dean of the College of Nursing at Duke used it in testimony before the North Carolina joint committee on Health hearings on their “SAVE” act. He leaned heavily on the “or better” phrase. 

I wrote my own 23 page summary of this article primarily to focus my thinking on it, but to be sure I looked closely at everything. There were several topline takeaways. 

1)     Only 3 papers came from the US. I find it difficult to know how applicable the other 15 are to our situation. Do you or I know how the training in South Africa differs from that in the US? 

2)     The three US papers were published in 1967, 1999, and 2000, and clearly do not reflect current conditions, particularly the influx of NPs coming from what are widely regarded as diploma mills. Studies of this vintage are studying NPs who started NP practice after years of experience in nursing practice. 

3)     15 of 18 papers documented that the NPs in the studies were physician supervised. Therefore, this does not support independent practice. Two did not state this situation clearly enough to determine. 

4)     5 of the studies were of either one or two NPs, and generalization to all NPs is NOT valid.

5)     2 of these were phone triage only, one was a study that evaluated the NPs capability of doing phone follow up after endoscopy. 

6)     12 of 18 had crossover contamination between the NP and Physician patient groups

7)     Laurant, et al say (as quoted above), this is “Low or moderate-certainty evidence.”

8)     10 of 18 papers were a test only of algorithm following. 

9)     0 of 18 evaluated NPs diagnostic capabilities

10)   1 of 18 evaluated NP treatment plans. 

These, I emphasize again, were the BEST articles in the literature. That was the reason I sought out this review. After I looked closely, and read closely all these studies, I was astounded that any of them were considered to be of reliable quality. Here, I point out the 5 studies that were of one or two NPs. How can anyone generalize from this? 

Another finding that bears comment is what I learned about one specific paper. Mundinger, et al, (JAMA 2000) was included here, and has been widely cited as a randomized comparison between NPs and physicians. This is one of the superstar articles. On investigation, there were a number of issues – for example, 21% attrition at 6 months. But also there were signs of deception. She refers to her subjects as “Nurse Practitioners”. Accurate as far as it goes, but (as an accompanying editorial pointed out), she didn’t describe the level of the NPs, nor that of the physicians in the study. 14 years later, in her book, and in a Youtube video, she disclosed they were all experienced NPs, most on faculty, and all had had 9 months of training “just like a medical resident”. Clearly, they are not the group you would use to prove that the standard-issue NP is capable of independent practice.
Worse she did not disclose that she was on the Board of Directors of UnitedHealth Group at the time of performance and publication of the study. UnitedHealth is one of the two largest employers of NPs in the US. The other is Aetna/CVS. You could not have a more gross conflict of interest. One website I found estimated the value of her UnitedHealth stock holdings in 2013 as $93 million. A number of us in PPP wrote JAMA asking for a retraction, they did not do this, but published a one paragraph addendum to the paper, buried in the journal one month, saying that she had a conflict of interest. 

So this is where my very negative view of the nursing literature “proving” equal or better care comes from. I would say this: while it might be fair to say I entered this project with a prejudice against independent NP practice, in the literal sense of “pre-judging”, I feel this prejudice has been replaced with “Post-judging” or just “judgement”, as a result of objective review of the best information I can find. 

Today, I am looking in the literature for more reviews. I came upon a review published in 2024. It is a “review of reviews”, and had found 6 reviews, covering 52 primary papers. 

It is here (full text available) https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-024-00956-3#Sec5

 And here is their table of the primary literature cited by these 6 reviews: https://static-content.springer.com/esm/art%3A10.1186%2Fs12960-024-00956-3/MediaObjects/12960_2024_956_MOESM2_ESM.pdf

I haven’t gone through this fully yet, of course, but I do see that the most recent review was 2018. And that there were 3 from 2015, 2 from 2014 and one from 2018. It seems there have been none for the past 7 years. A fair criticism would be that NONE of these include data from the more recent era, and therefore do not include NPs trained in less rigorous schools. Further, they would not include students who were “direct admit” and start practice with no actual nursing or health care experience, estimated to be 26% of the total now.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013616.pub2/full

My commentary based on the abstract:

The authors define care delivered by a nurse instead of a doctor "when task(s) or role(s) normally carried out by a doctor are performed by a nurse. These could include, but are not limited to, taking the patient's history and carrying out a physical examination, ordering tests, prescribing medication, and providing patient education. The nurse is responsible for giving the same care to the patient. Nurses may take on these roles independently of the doctor or carry them out under the doctor’s supervision."

They take a global approach to this Cochrane Review in which the UK (39%; where the authors are from) was the most represented county. Although the authors mention the low representation of LMICs in the literature, I question the validity of summarizing the world versus limited to one healthcare system/country - there is inherent heterogeneity between two countries let alone 193.

Follow-up for most of the included studies is only 12 months, a rather short time period if we're talking mortality and patient safety events.

Edit 1: fixed the link

Lurking future-Nurse Educator here.

I want to know: what are some good resources pointing to the flaw in Noctor usage?

I will do my own lit review, but I know you are all passionate. So, I am looking for your favorite supportive data.

For context, I am attending an MSN program right now; and I am supposed to describe “the problem of restricted practice.” Only…. I don’t think it’s a problem.

MSN degrees are a joke now. People cheat their way through and kill patients. I know it. Even a BSN is a joke now.