Comment by mindslight
6 days ago
How are NPs not just the trend of enshittification? Most doctors already aren't very engaged in the tiny 15 minute slices of appointments, and now we're supposed to be happy that they'll be even less educated? The most straightforward way to address the doctor shortage is to make it so doctors are spending most of their time on healthcare, rather than appeasing "insurance" company bureaucrats with onerous paperwork.
Nurse-Practitioners work harder to get their certification than almost anybody who comments on HN and it is not OK to talk about them this way.
What an oddly personal reaction. Did you get bored of infosec or something?
Being HN, we're talking about systems and cohorts, not individuals. I've had some great individual NPs that were more actively engaged than most doctors. PAs as well. And I've had plenty of crappy MDs just phoning it in. But none of that is really relevant to the system meeting higher demand by simply lowering its standards rather than actually being reformed.
Finding good (and available) primary care providers has always felt like going to the casino in my experience. Currently seeing an older NP who has been great. I could see a future with many more NPs. Obviously, if you know a guy or need a specialist, then do what makes sense.
What a weird comment. What do you think you need an MD for, in your primary care visit, that an NP can’t do? What do you actually know about their education? What do you actually know about licensing? How much time, in a day, do you think doctors are spending on “insurance”, and what specific experience leads you to believe that?
(Because the actual answer is “near zero for literally any provider who isn’t completely independent, and almost none of them are, anymore”.)
Or was this just a way to memetically add “enshittification” to a conversation it doesn’t even slightly apply to, but you think that’s currently trendy?
You can be an NP in as few as 4-5 years out of high school with some courses. That’s to me the definition of not knowing what you don’t know. I’m a critical care paramedic who has corrected many NPs on fairly fundamental learning.
I’ve found that nurses with significant field experience do very well, but there are plenty of courses who will “zero to hero” you fresh out of high school.
Meanwhile, PAs go through a program near as rigorous as medical school and have to have physician supervision while NPs are not subject to oversight.
Doctors begin delivering clinical care in year 3 of med school. You're doing a sleight of hand with this "out of high school" thing; doctors are also educated "out of high school", the difference between the two roles is 1-2 years before clinical practice, and NPs tend to practice supervised for longer periods of time than doctors.
And, obviously, NPs cover a smaller range of conditions than doctors.
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> NPs are not subject to oversight.
Sorry, this is fundamentally incorrect. To the point I can only assume you’ve made up every other thing you’ve said. Though I’m fascinated by a paramedic having opinions on someone else’s medical training.
The world would be better if we had less strident opinions on things we know we don’t know anything about.
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Okay but what does that have to do with enshittification, as defined by Cory Doctorow, which refers to the decline in quality of online platforms and services over time, often driven by the pursuit of increased profits. This degradation is characterized by a shift in focus from user experience to maximizing revenue, typically through tactics like increased advertising, higher costs, or changes that favor business customers at the expense of users.
Or do you just like how the word has shit in the middle of it and are using it incorrectly?
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> What do you think you need an MD for, in your primary care visit, that an NP can’t do?
I guess not much at this point where PCPs don't seem to do much beyond use rubrics, prescribe, and refer. Which is why I used the word enshittification - it's part of a continual gradual march down in quality/services to a captive customer base. Basically the opposite environment of innovation aiming to serve customers.
> How much time, in a day, do you think doctors are spending on “insurance”,
I'd say at least half their time, if not much more. They certainly aren't scheduling these 10-15 minute appointments back to back all day. By "insurance" I am of course including all of the extra documentation and runaround they have to do simply to satisfy the third party beancounters' demands. I'd say this even includes a good number of patient visits themselves.
https://www.astralcodexten.com/p/what-your-doctor-spends-80-...
https://siderea.dreamwidth.org/1182366.html
Observations in my personal experience line up with this:
- Number of signs at my primary care office about their procedures for providing/processing referrals, like this is the majority of their work
- The numerous questionnaires every office makes you fill out ahead of every appointment, that they themselves never actually read
- Experience with a not-terribly-large specialist office who employed an entire full time "nurse navigator" whose job it was to help doctors prepare documentation for "prior approvals"
- The multiple times I've seen a doctor personally step in to grease the system for something way way below their pay grade, because it was the only way to provide appropriate health care
I'm sure I'm forgetting plenty too. Frankly I don't know how one could step into any moderately sized medical provider and not perceive the entrenched corporate government tentacles in every facet.
There are NP mills that will take you from high school, put you through an accelerated RN and prereqs and basically have you as an independent provider in just a few years out of high school (well, 4-5), that’s ridiculous.
Is there any evidence that _8_ years of post-secondary education (plus 3-7 years of residency at poverty wages) actually improves medical outcomes?
5 years could be plenty?
NPs are supervised, as are doctors on rotation, so it's 7 years before clinical practice for a doctor.
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