I'm in an independent state and constantly seeing the mistakes NPs make with patients. Even as an M4 these mistakes are quite often obvious. In the past year: 85 yo with known orthostasis prescribed anticholinergic for back pain -> falls the first day taking it and gets a subdural, 67 yo with CLL has a blast crisis and gets sent home with tamiflu, 47 yo obese woman with CHF and a potassium of 2.8 gets sent home on doubled up Lasix and no potassium repletion. The only reason patients aren't suffering en masse is that at some point an adult, usually an ED physician, steers the car back on the road. The physician also does this without being able to bill more than a standard visit.
I still don't understand why we don't have something between NP/PA and MD. It is impractical to have physicians with 7 years of intense postgraduate training handling a rinky-dink urgent care (vs. being on-call as backup for someone with enough experience to actually effectively triage). However, we have no one with adequate training to actually triage patients effectively, which is actually a highly complex task. There is such a massive gap between "top 5% of their college class, > 90th percentile on an already highly self-selected entrance exam, 4 years of life-engulfing school, and 3 years of training so intense congress had to step in to cool things down," vs. most NPs, who are, frankly, entirely average people doing a 2 year, possibly online, possibly part-time, program that's so minimally intensive in comparison. It's hard to say out loud without being pretentious and insulting, but it's entirely true, and patient's don't deserve to be pawned off to subpar providers to save the CEO a buck. MDs and NPs are cut from a different cloth entirely. Their baseline ability level is miles apart to start, and their dedication is on different planets. I haven't met a single NP who cares about more than salary, quality of life, and location. There's no appreciation for pathophysiology and absolutely zero desire to learn above and beyond what's required to scrape through a day in the clinic or wards.
NPs and PAs should work only under close supervision. For experienced midlevels at the top of their class, there should be something in-between (e.g., additional 1.5-2 years of residency-level training) that's regulated by physician organizations to ensure high quality/sufficient intensity and standards. Graduates of these programs could then take on a more independent role which always includes, at least, a physician on-call. NPs/PAs in their current state of ability and training practicing independently is, quite frankly, pure insanity.
Also, a great way to express this to laypeople is, "Midlevels practicing independently is the shrinkflation of medicine. You get a lesser product for the same price, and the corporation keeps the difference." I think a lot of people believe that midlevels will make medicine cheaper, and they can relate more to a midlevel, so they root against physicians. Once they understand there's really nothing in it for them except care from someone undertrained so that some CEO can get a bigger bonus, it starts to come into focus.
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