Comment by jmye
7 days ago
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.
No, I’m really not. You can do an accelerated RN program in 12 months - though 18 months is more common.
Many colleges offer RN to BSN courses. Some of them can be 12 months (and some less reputable places offer nine months).
Add in a one year graduate nursing degree with some electives and in some states you are now eligible to practice as an ARNP or CRNP.
I’ve personally met several NPs who are 24 years old and are practicing.
The issue is that at that point you are ignorant or often cocky about your knowledge.
Versus premed 4 year degree, med student practice in years 2 and 3 and continued hand holding through residency…? There’s just a little difference.
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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.
If you want to be pedantic, then everyone has oversight through medical licensing boards, including physicians.
But if you mean "supervising physician"? Then let's see:
* Alaska - Full Practice Authority (NPs can perform the full scope of practice without a supervising or collaborating physician.
* Arizona - Full Practice Authority (NPs can perform the full scope of practice without a supervising or collaborating physician.
* Colorado - Full Practice Authority (NPs can perform the full scope of practice without a supervising or collaborating physician.
We're six states in, and half have no requirement for an NP to have any supervision from a physician.
Let's keep going though:
Connecticut, Delaware, DC, Florida, Guam, Hawaii, Idaho... zero supervision required. At this point I couldn't be bothered going through the list. This list, from the AAFP telling physicians about their responsibilities in supervising NPs state by state: https://www.aafp.org/family-physician/practice-and-career/ma...
So to put that back on you, explain my fundamental incorrectness.
And again, if you're talking about DOH oversight, then that seems a little disingenuous, as even the Chief of Medicine at a Level 1 Trauma Center practices under that insight.
I'm very well aware of the limitations of my scope of practice. That's why I operate under online and offline protocols. But hey, maybe I should have done another year or two of school so I could have a "full scope of practice without any need for a supervising physician". Not sure the ad hominem has any relevance.
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?
It's not incorrect to use this word colloquially. See this post:
https://pluralistic.net/2024/10/14/pearl-clutching/#this-toi...
Specifically:
> The fact that a neologism is sometimes decoupled from its theoretical underpinnings and is used colloquially is a feature, not a bug. Many people apply the term "enshittification" very loosely indeed, to mean "something that is bad," without bothering to learn – or apply – the theoretical framework. This is good. This is what it means for a term to enter the lexicon: it takes on a life of its own. If 10,000,000 people use "enshittification" loosely and inspire 10% of their number to look up the longer, more theoretical work I've done on it, that is one million normies who have been sucked into a discourse that used to live exclusively in the world of the most wonkish and obscure practitioners. The only way to maintain a precise, theoretically grounded use of a term is to confine its usage to a small group of largely irrelevant insiders. Policing the use of "enshittification" is worse than a self-limiting move – it would be a self-inflicted wound.
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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.