Welcome to 'patients at risk,' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host and the co author of the book 'patients at risk the rise of the nurse practitioner and physician assistant in health care,' Dr. Rebekah Bernard, and thanks for joining us again for part two of my discussion with Dr. Alyson Maloy and Dr. Phil
Shaffer. And in this segment of our discussion, we're going to be talking about the rebuttal that was written by April Kapu. She is a nurse practitioner and the current president of the American Association of nurse practitioners, who wrote a rebuttal to an article that Dr.
Maloy wrote. It was published in Medical Economics, and it was called 'full practice authority for nurse practitioners needed to address physician shortage.' I'm being joined now by Dr. Maloy and by Dr. Phil Shaffer to talk about point by point the- we'll call it misstatements. I think we could use other stronger words here. But there were a lot of flaws in the arguments that April Kapu wrote
here. So let's start out with the just the beginning here, which was that they talk about that we're facing a primary care crisis, and that COVID-19 has exacerbated it. Basically, they're saying that if they have NPs that are unsupervised, or now have full practice authority, somehow that is going to increase health care to all Americans and especially underserved Americans. Phil, what was your thought when you read that part of this article?
You know, it's divided into two pieces, one that's about primary care and one about rural. And the presumption is that if you give unsupervised care to nurse practitioners, they will one go into primary care and to go rural, and none of those are true. They state this and they never prove any of it, they leave it out there as just a statement and try to make it somehow intuitive. We can start first with the primary care
part. there was there's been an experiment that was done by the federal government as part of the ACA legislation is called the graduate nurse education project. And the federal government starting in 2012, I believe, gave money to five schools to produce more NPs. And the stated goal was to encourage them to go into underserved and rural areas. And that was in the origination document for the
project. So they, they ran this project for five years, and doing things like having their clinical hours be done in rural clinics and that sort of thing. And at the end of the time, what happened was they found that, first of all, they spent $180 million doing this, and they found that only 9% of nurse practitioners went to rural areas, and 75% went to areas that were well stocked with physicians and nurse practitioners. So that part of the experiment was an utter
failure. They couldn't encourage these people to go rural. And then the final report to Congress, it's interesting that they that original goal that they had stated five years earlier, was not even referred to.
That's interesting.
And other thing is they did exit interviews that were designed to find out why nurse practitioners wouldn't go to rural areas. And they found two things that when you hear them, you'll find them utterly unsurprising. The nurse practitioners decided to go to places where they could get the schedule they wanted, and the money they wanted. And, you know, that absolutely makes
sense. But saying that simply by giving nurse practitioners unsupervised care, they will suddenly flock to rural area and primary care to rural areas. It's not true. There are two other experiments of sort that have been running in that two states, Arizona and Oregon has had unsupervised care for nurse practitioners for 20 years. Now, we can look at those states and try to see what has happened as - Have they gone primary care and have they gone to rural
areas? And in those two states in particular, there have been studies to determine this. And in both cases, they did not go rural, and they did not flock to primary care. One is was mentioned by April Kapu and her article, and that was that she said that in Arizona after full practice authority was given the next five years, there were 73% More NPs in rural practice after full practice authority. She didn't cite the reference to that, but I happen to have it. And I read where she got that.
To the listeners here. Sorry for this, but we got to get down into the weeds sometime. Okay. Her statement came from one table, and the authors had the data analyzed in two different ways. One was by a geographic determination of whether an area was rural or urban, based upon political divisions, like counties and that sort of thing. The other was done on a zip code Classification developed by University of Washington called
rural urban community areas. And this the authors said gave a better view of what was actually going on. So if you look at the county data, in fact, it does say that there are 73% More NPs after five years. But if you look at the preferred way, it said that there were 52% more. And in fact, that is essentially equal to the increase in the urban areas, which was 53%. So no change. What's worse, is that this same organization, published another article in another five years looking at
the subsequent five years. And in that period of time, the number of NPs in urban areas had gone up another 31% I believe, and the number of NPs in rural areas, the what they call isolated rural areas had gone down by 11%. So the other point is that these two reports exist side by side on the website. If you clicked on one, you could click on the other, and you could see what has happened. She cherry picked the data showing only what she wanted, which is dishonest.
Yeah. And that's the same thing that happens when she gives the numbers of primary care. So she says 90% of nurse practitioners are quote, 'prepared' in primary care. And the reason of course, is that the number one the most common type of nurse practitioner is a family nurse practitioner, which means someone that supposedly is going
to work in family medicine. But government data actually shows even though maybe 90% are trained in primary care, only 52% of nurse practitioners actually practiced primary care in 2010. And the number of nurse practitioners choosing Primary Care has declined 40% Since
2004. And there was another study from Oregon, Oregon center for nursing workforce that said, 'careful analysis of multiple factors suggests that only 25% of Oregon's nurse practitioner workforce are practicing primary care.' So Alyson, what what does this mean, we have all these family nurse practitioners, why aren't they practicing primary care? What are they doing?
I don't know if I'm qualified to even answer that question on our you know, epidemiologic standpoint. But what I will say is, I know what they're not doing, and they're not practicing medicine. And no matter what they're doing, whether they're working in family practice, whether they're working in, let's say, cardiology, and in the last segment, we went over how an NP can just work in a clinic and call themselves a cardiology NP, whereas a physician has to train for more than a decade to call
themselves a cardiologist. I just want to mention here because anyone who's a listener who is not in the medical field who's not a physician, some of this might be confusing, because it sounds like what's the problem with a non physician practitioner going rural? And even if there's just one or two
added, what's the problem? And I think the three of us would agree that to work in rural areas, you have to be, you have to be the best of the best, the best and the most, you cannot be unsupervised to think about an NP with 3% of the training of a physician working alone. You know, when I moved to Maine, I was had just finished a six year residency and a one year fellowship. And when I was a new attending, I still didn't feel
prepared to work alone. I ran things by my physician colleagues, I worked in that job for two years. I've worked for three years and another inpatient job before I went out on my own in private practice right now. I'm 47 years old You know, to go out on your own is such a dangerous thing. And you studies show that putting these poor nurse practitioners in these positions, which again, is being forced by leadership, most don't want that is driving them
out of primary care. Because it's so stressful and scary.
you know, you're making such a good point because my first job was at a federally qualified health center in a very, very rural part of South Florida. And honestly, it was like doing another residency program that first year, the pathology that I saw the amount of, you know, patients that hadn't had access in a long time, the socio economic challenges that I pulled every little bit of my
training out. And then some I looked up, I was on up to date constantly, I was talking with my physician colleagues, there was so much that I needed to know and learn. And I needed every every bit of my training to do it, because these patients are very complicated. Then, of course, the other argument I always say is, you know, why shouldn't rural patients deserve to get care from the top quality as well? Why are they relegated to see someone with less training? That's doesn't seem fair to me.
And the painful piece about this is that it's almost like the average person doesn't know that. It doesn't need to be this way, that the only reason is this way is that the government didn't fund enough residency positions. It's almost like people assume, well, we don't have enough doctors, it's just the way it is, we have to get by with these, you know, complicated, bizarre solutions when we're here, the United
States of America. We're like one of the richest countries in the world, like if we need to produce more doctors is not a problem.
Right? There's a pathway for that, as you said, and what you're saying is so true. But what legislators and the public is hearing is exactly like what April Kapu, put in this rebuttal, where she put full practice authority strengthens patients access to high quality care. So the idea is if they keep saying that they provide high quality care, then it must be true. Phil, talk
about is this true? Is there sufficient evidence that nurse practitioners can provide care without physician supervision at a high level?
Well, that gets to the statements she made in her article, which was, let me read it '50 years of research confirms high quality NP delivered care.' That is, you know, there's another propaganda tactic that you just say something often enough, and people will start to believe it. That's what's going on here. No, it's, there's there's not good evidence for that we've gone through a lot of the data. And the research is just poor. We've gone through there's, they have a list of 31 articles on their
website. And one of the ones that was the most important was a review by the Cochrane collaborative that went through. They they surveyed 1885 papers in the literature over two reviews they did, and they found only 18 that were at an equality, let me say this were of good enough quality to actually analyze. And the question was, can nurses or nurse practitioners replace physicians in primary care? Okay, so is that very specific question. There are only 18
papers. And when you read through each of these papers, categorize them look at the methods and that sort of thing. They were full of errors. And what none of them did was look at the functions of a physician to see if a nurse in their study
could do those. And that is, can you take an undifferentiated patient who walks in with a problem, interview the patient properly, examine them properly, form a differential diagnosis, understand what tests or other activities are going to be necessary to narrow the differential diagnosis, make a final diagnosis, determine the treatment, etc. No, none of them did that. They all were pieces of some of this, but none did
the whole thing. And we found things that were and these are included in the best papers. There was one paper that was in Britain, and it compared family or GPs in their in their system versus nurses in doing phone triage and why the endpoints illustrated the the shortcomings of the literature in general and that they choose weird endpoints. The endpoint was whether or not in a week, there are more deaths in the patient's triage by a nurse as opposed to a physician There were no deaths
on either side. So they say, Okay, it's their equal. That's nuts. Just crazy.
Exactly. The studies were so flawed and and I think one of the important things to point out in these studies was that there was almost always and I would say always, physician involvement in these studies, nurse practitioners had physicians to go to or that were following physician created protocols. Of course, they always excluded high risk patients. And they were always looking at just solitary, simple diagnoses, not
complex patients. So I think there's evidence that nurse practitioners can provide good quality care when they're following protocols with low risk patients, when they're working in close supervision with a physician, but their truth is, with this five decades of research, there's no evidence that that nurse practitioners or physician assistants can provide high quality care of complex, undifferentiated patients, especially without physician involvement.
When you start out looking at a an experiment or researching, you perform a hypothesis, and there is something the hypothesis has to be reasonable in some respect. And this is something that has kind of been hiding in plain sight. For example, let me see if I can bring one up just out of random is if I walk across the street today, will, you know, the streetlights light downtown. Okay. And does that
make any sense? No. And if I walk across the street in the street lights like you get, that's not proof that I caused it, okay, is maybe proof that I chose the right time. But their premise that they never say is that their hypothesis is that someone with 500 hours of training is just as good at all those tasks. This makes no sense whatsoever.
15,000 hours
Correct. And that makes no sense. So the Carl Sagan said, 'Extraordinary claims require extraordinary proof.' And it was in the arena of UFOs. And this hypothesis is kind of on the level of UFOs. So if you're going to prove that you need to have extraordinary proof, and the proof they have is is just non existent. So you know it just on the face of it, this hypothesis is almost certainly untrue. And they have done nothing to give us extraordinary proof.
And the 500 hours is unstandardized shadowing at any site, you can get someone to allow you to shadow them, and it's nursing. And one thing that was very troublesome about Kapu's response to my interview was saying how that physicians basically are trying to keep nurses down. 'Fulfilling the Promise of nursing means speaking truth to the medical establishment and making it acknowledge an ethical obligation to reform
professional hierarchies. The laws and norms that constrain nurses ability to practice to the full extent of their skills and training were were put in place by physicians to protect their privileges, independence and income. As the COVID 19 pandemic recedes, retrogressive lobbying campaigns by organized medicine have already
resurfaced. And that rolling back improvements in nursing practice authority, there were long overdue.' And this was a quote by William sage MD JD, that Phil can tell us about later was a paid propaganda quote, getting back to my point. Some people may argue, maybe a nurse only needs 500 hours to do easy things like high blood pressure, or something simple.
But the problem is that in order to know that something simple, you need to be so broadly trained to be an expert so that you can spot the zebra when it comes, you know that one person who has the zebra illness doesn't care that it occurs in one in 100,000 people they have it is a 100% likelihood this patient has it. And if it's not in the top two common diagnoses,
it's going to be missed. So, all these charts, all these comparisons, all the NPPs who want to say they have so many hours, the question is ours in what and it is not practicing medicine.
And physicians are not restraining this because of our desire to protect our quote, 'privileges, independence and income.' I'll point out here that Phil here is a retired physician. He has no privilege or income to protect. I have a full practice. I'm a lowly family physician, I don't employ or profit off of non physician practitioners, although Niran and I have been accused of that by the AANP in writing. And Alyson also has a full practice, we have many
retired physician members. So I think it's just a straw man argument, isn't it? Phil, when you try this, instead of making it about patient safety, you say, 'oh, physicians are just trying to keep nurses down, and it's a turf war.'
Yeah, that really lights me up. Every time I read it, the income thing is, is saying because the AANP has is one of their goals to increase the amount that we spend on nurse practitioners by making their pay equal to physicians, even though they're not trained as physicians.
And their training is a small percentage. I did four years undergrad at an Ivy League school, I did four years of medical school and graduate for graduate school, I did a six year double residency getting paid $30,000 a year for six years, did a one year fellowship. And to say that someone who got a master's degree in nursing should be paid the same as me. Forget about what the dollar number is, it's just asinine.
I'm sure after all, that education, you spent an awful lot of money getting that as well as deferring your income while you are completing your training.
This has been studied over and over again. And doctors, when you average out the $300,000 of debt we go into for education, the 10 to 15 years of lost earning potential, you know, the interest rates on the loans, and the fact that we
don't get overtime. And we all routinely work 60, 70, 80, 90, 100 hour weeks, I mean, I worked 120 hours a week in residency before, the laws were in place in the laws, by the way, restrict residents to working 80 hour weeks, which is still double a full time week, we make less than a high school teacher per hour. So you know, people who argue about protecting our income, I mean, just literally don't know anything about the practice of medicine and what we go through.
Right, there's a real misconception about, you know, the, quote, 'rich' doctor, and I mean, not to say that we're not privileged, and probably in the top percent of earners of Americans. But it's not, you don't go into medicine to make money because there are a lot of easier ways and easier paths to that. And medicine is probably not that path.
Well, and, you know, I'll just talk about my friends who graduated with me at Columbia. I mean, they were earning money in 1990, you know, seven, I started earning a salary above the poverty line in 2012 -2012.
I read a study that said that you would be better off becoming a UPS driver right out of high school. And then after you look at, you know, the amount of money that's invested properly, by the time you get to retirement, they would actually have more money than the average physician. I
thought that was interesting. I wanted to talk about one other thing that Kapu wrote here, which was that 'nurse practitioners couldn't agree more with Dr. Sage's assessment, it's time to break the healthcare glass ceiling.' And one of the things that I love that you guys wrote in your rebuttal, is that, what glass ceiling? Are they talking about? Because anyone that wants to be a physician, there is a way to do that. It's going to medical school and residency
that sort of invokes images of social injustice, in medicine, and medicine of all the professions. It's been open to anyone, particularly in the last 20 years. I mean, just look at PPP. I mean, sometimes I feel a little embarrassed there aren't more males in there.
It's a very female- dominated group. It's, and I've questioned that a lot like, Gosh, why are so many women - and there are plenty of men too. But women are seem to be disproportionately passionate about this issue. And I suspect it has something to do with the challenges that it takes to become a woman in medicine. And then, you know, to be accused, they say, Well, you know, it's sexist that nurses can't have these, you know, full practice providers. And it's like, there's no sexism in this at
all. If you want to be the leader in health care. You can go to medical school women are doing it all the time. Here's me and Alyson, and it's not an easy path. I'm not saying it is, but there is a path for that. And what I really find interesting is all the PPP members that we have, who were once nurse practitioners or physician assistants, and they decided to go on to become physicians, and there's a path for that. So the whole glass ceiling idea is ridiculous.
And it shows the Dunning Kruger effect because all of them say, Holy bejesus, I had no idea what medical school and residency were like, when I was a medic, when I was a PA, when I was an NP, I really had no idea.
Yeah, we hear that over and over again. And then in just the very last couple of words of your rebuttal to April Kapu, you basically closed by saying, it's not the a AANP that can solve the physician shortage, they need to work on solving the bedside nursing shortage and improving their own training. The people that can really fix this is Congress. And it looks like from what I understand from the new infrastructure bill that's being
passed in Congress. Now, there should be at least some funding to increase residency spot spots, which sounds like a step in the right direction.
I have never seen such heroic, creative, you know, gymnastics to solve a simple problem. I mean, when I read Kapu's response to my interview, she made the whole interview as a springboard for her propaganda message of non physician practitioners in her case, and NPs filling the physician shortage. The Flexner Report in 1910, established what it takes to practice medicine. None of us here are reinventing the wheel of what it takes to
practice medicine. And there seems to be this bizarre movement in this country right now that anybody can practice medicine and call it whatever they want, call it Advanced Nursing, call it physician assistant and call it health care. No, we are talking about a physician shortage, people who have a license to practice medicine because I have a medical degree, who are taking care of patients. And I'm extremely frightened. As I know you both are about ourselves, when we find ourselves in an
ICU, or our children. losing access to doctors is really on the table here in the United States. And I really don't believe that the average American sees it happening. Maybe they do when they go to see their doctor, and they see, you know, a non physician practitioner, but they don't think much of it, because they don't really know what it takes to practice medicine.
Phil, any other last comments, before we wrap up?
Well, I'd like to cycle back a bit about the Flexner Report, because some of the listeners don't know what that is, in 1910, there was recognized that there was a serious problem with medical education, because there are a lot of private universities, quote, unquote, that we're putting out medical students, there is no standardization of the curriculum there. Atrocities occurring such as medical students being forced to steal bodies out of the ground to do
their anatomy work. And there is no standardization of the testing. And Flexner was tasked with going around and surveying these and he wrote the report, the result of that was 90% of the medical schools in the country at that time were closed. And the other result was there were committees formed to put medicine on a truly scientific basis, to make requirements as to what you had
to do to become a physician. And that is, you know, obviously since 1910, that's grown and become more and more complex. But that is the basis for medical education, just so the listeners understand what that was about. There are nurses who say, this is the same situation we had in 1900. And we need a Flexner Report for nursing. And it Truer words were never spoken. The same things happening. You get private schools who are making a lot of
money off this. They put as many students as they want through without any standardization, and then they're released into the population to do their work. And the legislators, I have to say, are asleep at the wheel here. They're not properly legislating the regulations for these people.
Well, I think your point is well made and the AANP really would be wise to focus on that rather than promoting full practice authority, especially considering that in 2017, a survey of nurse practitioners found that they overwhelmingly expressed concerns about feeling that they had adequate competency in evidence based
practice. So that's coming directly from nurse practitioners from a published study So rather than spending time rebutting our articles about physician shortage, it seems like they need to get their own house in order. And I would tell you that a lot of nurse practitioners I've talked to really feel strongly that that's the case
Just one quick last thing, I don't believe that they really care about the dangers that are happening on the front line. And this has become a huge political issue. And this article, when I read her response, like Phil, I was like, it's filled with lies, no data, blatant lies, and this is why legislators believe it. Because I have been in testifying, as I'm sure Phil has. And you have Rebekah, where the nurses stand up and restate
these things. And the legislators don't have the background to look at the original data. And to rebut it.
And that's why I'm so proud of both of you for writing this fantastic expose pointing out all the flaws to everything that was said the same regurgitation of the same mantra over and over again, it's like you said, Phil, if you keep saying something long enough, maybe people will think it's true, even if there's no data to support it. So thank you both so much for joining me
for this discussion. If you'd like to learn more about this topic, I encourage you to get the book 'patients at risk the rise of the nurse practitioner and physician assistant in healthcare.' It's available at Amazon and at Barnes and Noble. Please like and subscribe to our podcast and our YouTube channel. It's called patients at risk. And if you're a physician, please join us physicians for
patient protection. Our website is physiciansforpatientprotection.org Thanks so much, and we'll see you on the next podcast.