NPs vs MDs: Diagnostic Reasoning in Complex Cases

Tom G. Bartol, NP


August 04, 2015


I recently read testimony from the Maine legislature about a bill to allow for independent licensure of NPs, without physician oversight or supervision. It was a contentious bill and those opposing the legislation repeatedly expressed fear that NPs, with so much less education than physicians, would not be able to give appropriate care to patients with complex problems. Over and over, opponents to the legislation expressed concern about patient care and patient safety with the fear that, if cared for independently by NPs, the NPs would miss diagnoses and cause patient harm.

This testimony was more than 20 years old, as the law granting independent licensure and autonomous practice to NPs in Maine was passed in 1995. The fears about patients having poor outcomes at the hands of the "lesser trained" NPs have been unfounded. There is no doubt that NP training and physician training are different. The total number of hours or years of training for physicians is longer than education for NPs. This does not mean that NPs give inferior or less optimal care or have poorer outcomes. Multiple studies have shown that patient outcomes are at least equal to those of physician care.[1,2] More years of training, rather than the specific type of training, does not inherently result in better patient care.[3]

What I find interesting about this study is that about 40% of the clinicians in both groups, NPs and physicians, did not come up with the correct diagnosis and about two thirds in both groups did not come up with the correct actions. This is consistent with other studies of complex diagnostic reasoning, in which only about half of the clinicians succeeded in making correct diagnoses.[4] It is not so much who was better, because in this case there was no difference, but what about the 40% of people who missed the diagnoses entirely?

I have seen clinicians make diagnoses and treatment decisions that are different from what I might have decided, or who go about the diagnostic process in a different way. What we do is still an art, not just a science. No matter how much we think we provide evidence-based care, much of what we do does not have evidence behind it, and in some cases, the evidence has been changing and evolving. We use the best data that we can come up with, along with our knowledge, to identify the problem and the treatment.

The type and duration of education are important, but so are our skills in developing a relationship with and eliciting information from patients. If we do not listen well or cannot develop a relationship such that the patient is comfortable sharing vital information, all of the knowledge and years of training in the world may not lead to the correct diagnosis.

The legislation in Maine has often been referred to as "independent practice legislation," which allows NPs to be licensed independently. As pointed out on the final day of testimony, the words "independent practice" did not even appear in the legislation. The legislation permits independent licensure for NPs, without physician supervision.

The reality is that none of us practices independently—and we should not. We work collaboratively, with our colleagues in the healthcare system, be they physicians, nurses, or other health professionals. The key question as I see it is not who has better diagnostic reasoning skills, but how can we strive to work together, in the interest of the patient, talking with our colleagues, interacting and sharing, so as to try to improve our diagnostic accuracy and treatment choices?

We all have something to offer the patient, and our title or level of education does not inherently make us better or worse. When we quit trying to prove who is better or who is worse, and instead work together to do our jobs better, the patient comes out ahead.



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