for nurse practitioners and physician assistants, also referred to as advanced practice providers

為執業護士和醫生助理，也被稱為高級執業醫師。

or mid-levels.

或中層。

Debates regarding this issue often become echo chambers with both sides repeating what

關於這個問題的辯論往往成為回聲室，雙方都在重複著什麼

others have said before them.

其他人在他們之前已經說過。

But what does the body of scientific evidence actually say about mid-level encroachment?

但是，關於中層侵佔的科學證據體系實際上是怎麼說的？

Let’s find out.

讓我們拭目以待。

Dr. Jubbal, MedSchoolInsiders.com

Jubbal醫生，MedSchoolInsiders.com

Welcome to another episode of Research Explained, where we deep dive into a topic, spend countless

歡迎收聽《研究解釋》的另一集，在這一集裡，我們深入研究一個主題，花了無數的時間和精力。

hours scouring the scientific literature, and summarize it so that you don’t have

仔細研究科學文獻的時間，並對其進行總結，這樣你就不會有

to.

到。

We’ve covered several other topics on our Research Explained playlist - link in the

我們已經在我們的 "研究解釋 "播放列表中涵蓋了其他幾個主題--鏈接在

description.

描述。

Here’s what the scientific literature has to say about independent practice for nurse

以下是科學文獻對護士獨立執業的評價

practitioners and physician assistants, and how their care compares to that of physicians.

執業醫師和醫生助理，以及他們的護理與醫生的護理相比如何。

There are several arguments in support of independent practice for midlevel providers.

有幾個論點支持中級醫療機構的獨立執業。

The first is that PAs and NPs have sufficient training to treat patients independently and

首先是PA和NP有足夠的培訓來獨立治療病人和

without the need for a supervising physician.

而不需要指導醫生的幫助。

To become an NP, one must hold a bachelor’s degree in nursing, be licensed as a registered

要成為一名國家護士，必須持有護理學學士學位，獲得註冊護士執照。

nurse, graduate from a nationally accredited graduate NP program and pass a national NP

護士，畢業於國家認可的研究所學生NP課程，並通過國家NP考試。

board certification exam.

董事會認證考試。

Similarly, physician assistants must complete a bachelor’s degree, complete a nationally

同樣地，醫生助理必須完成學士學位，完成全國性的 "醫生助理 "考試。

accredited physician assistant program, meet national standards, and pass a board certification

認可的醫生助理課程，符合國家標準，並通過委員會認證。

exam.

考試。

In addition, many states that currently allow for independent practice require a certain

此外，目前許多允許獨立執業的州要求有一定的

number of hours or number of years working underneath a supervising physician before

在上級醫生手下工作的小時數或年數，然後才是

APPs can practice independently.

APPs可以獨立練習。

The American Association of Nurse Practitioners argues that “a head-to-head comparison of

美國執業護士協會認為，"正面比較一下

educational models is not the appropriate measure of clinical success or patient safety.”

教育模式不是衡量臨床成功或病人安全的適當標準"。

Nurse Practitioner education is competency-based, not time-based, meaning that NP students don’t

執業護士的教育是以能力為基礎的，而不是以時間為基礎的，也就是說，執業護士的學生不需要

progress or graduate based on number of hours spent in a rotation or by the number of times

根據輪換的小時數或輪換的次數來決定進步或畢業。

they’ve seen a particular ailment, rather they do so when knowledge and skill competency

他們已經看到了一個特定的疾病，而是在知識和技能能力的情況下這樣做的

are achieved.

實現了。

Some argue that mid-levels also have experience before graduate level training as a PA or

有些人認為，中級職稱的人在接受研究所學生水準的培訓之前也有經驗，成為一名PA或

NP which often includes physical assessment skills, interpreting diagnostic test results,

NP，通常包括身體評估技能，解釋診斷性測試結果。

evaluating the appropriateness of medications, and evaluating patients’ response to treatments.

評估藥物的適當性，以及評估病人對治療的反應。

There are also a number of studies comparing outcomes between physicians and midlevel providers

也有一些研究比較了醫生和中級醫療人員之間的結果

in support of independent practice.

以支持獨立實踐。

A 2018 study examined the relationship between primary care provider type and diabetes outcomes

2018年的一項研究考察了初級保健提供者類型和糖尿病結果之間的關係

among patients and found no clinically significant differences between the three provider types

在病人中，發現三種類型的提供者之間沒有臨床上的顯著差異。

in terms of diabetes outcomes.

在糖尿病的結果方面。

The authors suggest that similar chronic illness outcomes may be achieved by physicians, NPs

作者認為，醫生、非執業醫師可能會取得類似的慢性病結果。

and PAs.

和PAs。

In addition, a 2021 meta-analysis of 39 different studies found that the quality of care delivered

此外，2021年對39項不同研究的薈萃分析發現，提供的護理品質

by the PA was comparable to a physician’s in 15 studies and exceeded that of a physician

在15項研究中，助理醫師的治療效果與醫生相當，並超過了醫生的治療效果。

in 18 studies.

在18項研究中。

Another argument in favor of independent practice is that it improves access to care.

支持獨立執業的另一個論點是，它可以改善獲得醫療服務的機會。

As it stands in the United States, we have a shortage of physicians - specifically in

目前在美國，我們有一個醫生短缺的問題--特別是在

primary care specialties.

初級護理專業。

According to the AAMC, we can expect shortages of between approximately 38,000 and 124,000

根據AAMC的數據，我們可以預計大約有38,000到124,000人的短缺。

physicians by the year 2034.

到2034年，醫生的數量將增加。

By granting independent practice to PAs and NPs, some argue that we can help offset the

一些人認為，通過授予PA和NP獨立執業，我們可以幫助抵消

growing demand for physicians, especially in underserved areas.

對醫生的需求不斷增加，特別是在服務不足的地區。

A 2016 study compared geographic accessibility of primary care clinicians between states

2016年的一項研究比較了各州之間初級保健臨床醫生的地理可及性

with more restrictive and less restrictive scope-of-practice laws.

有更多限制性和較少限制性的執業範圍法。

They found that access to primary care nurse practitioners was highest in rural areas and

他們發現，農村地區獲得初級保健護士的機會最高，而

that less-restrictive scope-of-practice states had as much as 40% more primary care nurse

執業範圍限制較少的州的初級保健護士人數多達40%。

practitioners compared to more restrictive states.

與限制性更強的國家相比，從業者。

They concluded that removing restrictive scope-of-practice laws may help to expand the overall capacity

他們的結論是，取消限制性執業範圍的法律可能有助於擴大整體能力。

of the primary care workforce.

的初級保健勞動力。

Lastly, proponents of independent practice argue that PAs and NPs can help decrease healthcare

最後，獨立執業的支持者們認為，PA和NP可以幫助減少醫療服務的費用。

costs.

費用。

In the same 2021 meta-analysis, the authors found that in 29 out of 39 studies, the labor

在2021年的同一項薈萃分析中，作者發現在39項研究中的29項中，勞動

and resource costs were lower when the PA delivered care compared to when the physician

與醫生相比，由助理醫師提供護理時，資源成本較低。

delivered care.

提供護理。

This makes sense as PAs and NPs make substantially less than physicians.

這是有道理的，因為PA和NP的收入大大低於醫生。

According to the Bureau of Labor Statistics, the average PA makes approximately $122,000

根據勞工統計局的數據，PA的平均收入約為122,000美元。

per year and the average NP makes approximately $118,000 per year.

年，而國家護士的平均年薪約為118,000美元。

The average physician, by comparison, makes around $208,000 per year according to the

相比之下，醫生的平均年薪約為208,000美元。

BLS.

BLS。

As a result, it costs hospitals far less to employ APPs than it does to employ physicians.

是以，醫院僱傭APP的成本遠遠低於僱傭醫生的成本。

In addition, a 2021 study found that the average primary care physician’s cost of care is

此外，2021年的一項研究發現，初級保健醫生的平均護理成本是

34% higher than primary care nurse practitioners in low-risk patients, 28% higher in medium-risk

在低風險患者中，比初級保健護士高34%，在中等風險中，比初級保健護士高28%。

patients, and 21% higher in high-risk patients.

患兒，而高危患者則高出21%。

They conclude that these differences mostly reflect the lower quantity of services provided

他們的結論是，這些差異主要反映了所提供服務的數量較少。

by primary care NPs relative to primary care MDs which is reflected most in low-risk populations.

相對於初級保健醫生而言，初級保健護士的工作量更大，這在低風險人群中體現得最為明顯。

Now let’s talk about the arguments against independent practice.

現在我們來談談反對獨立實踐的論點。

The primary argument against independent practice is that mid-level providers do not have sufficient

反對獨立執業的主要論點是，中層提供者沒有足夠的

training to see patients without a supervising physician.

在沒有指導醫生的情況下，接受培訓為病人看病。

The average family medicine physician fresh out of residency will have over 20,000 hours

剛從實習期出來的家庭醫生平均會有超過20,000小時的工作。

of graduate-level training including over 15,000 hours of clinical experience.

的研究所學生水準的培訓，包括超過15,000小時的臨床經驗。

If we compare this to the average nurse practitioner at the point of certification, they will have

如果我們將其與獲得證書時的普通護士相比，他們將有

received anywhere from 3,000 to 5,500 hours of graduate-level training and only 500 to

接受了3,000至5,500小時的研究所學生水準的培訓，但只有500至500小時的培訓。

1,500 hours of clinical experience.

1,500小時的臨床經驗。

If we factor in the 2,000-4,000 hours of practice underneath a supervising physician that many

如果我們把許多人在上級醫生上司下的2000-4000小時的練習時間考慮進去

states require for independent practice, NPs still have less than half of the clinical

在各州要求獨立執業的情況下，非執業醫師仍然只有不到一半的臨床經驗。

hours of a newly-licensed physician.

新持證醫生的工作時間。

This is also assuming that clinical practice as an NP under the supervision of a physician

這也是假設在醫生的監督下，作為一名非執業醫師進行臨床實踐

is equal to that of a resident physician being trained to practice independently - which

與正在接受獨立執業培訓的住院醫生的情況相同--這

I would argue it is not.

我認為它不是。

Physicians are trained with the goal of independent practice from day one.

醫師從第一天開始就以獨立執業為目標進行培訓。

They go into their training knowing that they’ll be on their own one day and won’t be able

他們在接受培訓時，知道有一天他們會自力更生，無法

to rely on anyone else for guidance.

依靠其他任何人的指導。

They need to be confident in their knowledge and skills in order to make the right decision

他們需要對自己的知識和技能有信心，以便做出正確的決定。

as they’ll ultimately have to live with the consequences of those decisions.

因為他們最終將不得不承受這些決定的後果。

In contrast, PAs and NPs are not typically trained to practice independently.

相比之下，PA和NP通常不接受獨立執業的培訓。

Although they still treat patients and make decisions on a daily basis, they are doing

雖然他們仍在治療病人，並在日常工作中做出決定，但他們正在做的是

so with the knowledge that they have a supervising physician to fall back on for guidance.

是以，他們知道他們有一個指導醫生可以依靠，以獲得指導。

As such, there’s a different level of responsibility and accountability that is put on doctors

是以，醫生要承擔不同程度的責任和義務。

during their training that you don’t get with PAs or NPs who are trained to work in

在他們的培訓過程中，你無法從接受過培訓的PAs或NPs那裡得到這些資訊。

a more collaborative manner.

以更加合作的方式。

There is also a great deal of variability in the training of midlevel providers, especially

中級醫療機構的培訓也有很大的差異，特別是

among nurse practitioners.

執業護士中。

There have been dramatic increases in the number of nurse practitioner programs over

執業護士項目的數量在過去幾年裡有了顯著的增長。

the last decade with many programs promising quick certification and high acceptance rates.

在過去的十年裡，許多項目承諾快速認證和高接受率。

The average acceptance rate for NP programs is estimated to be around 66%.

國家護士項目的平均錄取率估計為66%左右。

However, there are multiple NP programs in the US with 100% acceptance rates.

然而，在美國有多個非執業醫師項目具有100%的錄取率。

By comparison, the acceptance rate for the average medical school is only around 6.5%.

相比之下，一般醫學院的錄取率只有6.5%左右。

These high acceptance rates have brought into question whether the goal of these NP programs

這些高的錄取率使人質疑這些非營利組織項目的目標是否是

is to produce high-quality providers or to make money.

是為了生產高質量的供應商，還是為了賺錢。

There is also a great deal of variability in the clinical experience between different

在不同的臨床經驗中也有很大的差異性。

NP schools.

NP學校。

Many schools are 100% online and do not organize the clinical hours required as a part of their

許多學校都是100%在線，沒有組織所需的臨床時間作為他們的一部分。

curriculum.

課程。

Instead, it is up to the student to arrange for their own clinical experiences.

相反，要由學生來安排自己的臨床經驗。

As a result, it is difficult to ensure consistent, high-quality training among NPs in these programs.

是以，很難確保這些項目中的非執業醫師接受一致、高質量的培訓。

Those that oppose independent practice argue that his disparity in training leads to issues

反對獨立執業的人認為，他在培訓方面的差異導致了問題的出現

of patient safety, especially in primary care – the field with the biggest push for independent

在病人安全方面，特別是在初級保健領域--這個領域對獨立的推動最大。

practice for mid-level providers.

中級醫療機構的實踐。

Contrary to popular belief, primary care is one of the medical specialties that requires

與流行的看法相反，初級保健是需要的醫療專業之一

the broadest knowledge.

最廣泛的知識。

Whereas in other specialties, your knowledge becomes increasingly specialized as you progress

而在其他專業，隨著你的進步，你的知識變得越來越專業

through training, primary care physicians continue to use and develop the vast information

通過培訓，初級保健醫生繼續使用和發展大量的資訊。

they learned during medical school.

他們在醫學院期間學到的知識。

There are a number of research papers supporting this difference in quality of care between

有許多研究論文支持這種在護理品質上的差異。

physicians and midlevel providers as well.

醫生和中級醫療人員也是如此。

A 2018 study found that “compared to dermatologists, PAs performed more skin biopsies per case

2018年的一項研究發現，"與皮膚科醫生相比，PA在每個病例中進行更多的皮膚活檢

of skin cancer and they diagnosed fewer melanomas in situ, suggesting the diagnostic accuracy

他們診斷出的皮膚癌原位黑色素瘤較少，這表明診斷的準確性。

of PAs may be lower than that of dermatologists.”

執業醫師的工資可能比皮膚科醫生的工資低"。

Studies from 2005 and 2016 also demonstrated that NPs and PAs were more likely to inappropriately

2005年和2016年的研究也表明，非執業醫師和執業助理醫師更有可能不適當地

prescribe antibiotics than residents and attending physicians, which can contribute to population

比起住院醫生和主治醫生來，他們開的抗生素更多，這可能會導致人口老化。

level issues such as antibiotic resistance and the creation of superbugs.

層面的問題，如抗生素耐藥性和超級細菌的產生。

In addition, many of the studies that show that NPs and PAs deliver similar quality of

此外，許多研究表明，非執業醫師和執業助理醫師提供的服務質量相似。

care as physicians, including the studies from earlier in the video, do not assess PAs

作為醫生的護理，包括視頻中早先的研究，並沒有評估PAs

and NPs working independently, but rather those working as part of a healthcare team.

和NP獨立工作，而是作為醫療團隊的一部分工作的人。

As such, it’s a big stretch to draw conclusions about independent practice when you’re looking

是以，當你在尋找獨立實踐的時候，要得出關於獨立實踐的結論是一個很大的延伸。

at studies with non-independently practicing mid-levels.

在與非獨立執業的中層人士的研究中。

Another argument is that independent practice increases healthcare costs despite APPs lower

另一種說法是，儘管APPs的成本較低，但獨立執業會增加醫療成本。

cost for services.

服務的費用。

Many physicians argue that mid-level providers order more unnecessary tests and have to refer

許多醫生認為，中級醫務人員會開出更多不必要的檢查單，而且必須轉診。

patients out to other physicians more frequently.

病人更頻繁地出去找其他醫生。

An issue that may have been handled by a primary care physician may now have to be referred

原本由主治醫生處理的問題，現在可能要轉介給其他醫生。

out leading to two separate visits instead of just one.

導致兩次單獨訪問，而不是隻有一次。

A 2013 article found that the “quality of referrals to an academic medical center were

2013年的一篇文章發現，"轉診到一個學術醫療中心的品質是

higher for physicians than for mid-level providers regarding the clarity of the referral question,

在轉診問題的清晰度方面，醫生比中級醫療人員高。

understanding of the pathophysiology, and adequate pre-referral evaluation and documentation.”

對病理生理學的理解，以及充分的轉診前評估和記錄。"

Referrals from physicians were also less likely to be evaluated as “unnecessary.”

來自醫生的轉診也不太可能被評價為 "不必要"。

In terms of cost, a 2015 study also showed that mid-levels are associated with ordering

在成本方面，2015年的一項研究也顯示，中層人士與訂購

more imaging services than PCPs for similar patients.

對於類似的病人，比初級保健醫生提供更多的成像服務。

While these increases were modest for individual patients, the authors conclude that these

雖然這些增長對個別病人來說是溫和的，但作者得出結論，這些

increases may be problematic for patient care and overall costs at the population level.

增長可能對病人護理和人口層面的整體成本造成問題。

A recent study published in 2022 in the Journal of the Mississippi State Medical Association

2022年發表在《密西西比州醫學會雜誌》上的一項最新研究表明

summarizes all of these points nicely.

對所有這些觀點進行了很好的總結。

The study compared physicians and independently practicing midlevels in terms of healthcare

該研究比較了醫生和獨立執業的中層人員在醫療保健方面的情況。

costs, patient outcomes, and patient satisfaction.

成本、病人結果和病人滿意度。

They collected data over 10 years from over 300 physicians, 150 APPs, 200,000 patient

他們在10年內收集了來自300多名醫生、150個APP、20萬名患者的數據。

surveys, and 33,000 unique Medicare beneficiaries.

調查，以及33,000名獨特的醫療保障受益人。

Here’s what they found.

以下是他們的發現。

To start, healthcare costs for Medicare patients were $43 higher per month for patients whose

首先，聯邦醫療保險患者的醫療費用每月高出43美元，而其

primary care provider was a mid-level instead of a doctor.

初級保健提供者是中級人員而不是醫生。

They estimated that this would equate to roughly 10.3 million dollars per year in increased

他們估計，這將相當於每年增加約1030萬美元的收入。

spending if all patients in their clinic were seen by APPs instead of physicians.

如果他們診所裡的所有病人都由APP而不是醫生來看病，那麼支出就會很大。

When they adjusted these findings for patient complexity, the difference was $119 per patient

當他們根據病人的複雜性調整這些結果時，每個病人的差異為119美元。

or 28.5 million dollars annually.

或每年2850萬美元。

They found that these additional costs had to do with several factors, including increased

他們發現，這些額外的費用與幾個因素有關，包括增加了

ordering of tests and images, more referrals to specialists, and higher emergency department

檢驗和影像的訂購，更多的專家轉診，以及更多的急診部門。

utilization compared to patients under the care of a physician.

與接受醫生護理的病人相比，利用率更高。

In terms of patient outcomes, physicians outperformed midlevels on nine out of ten quality metrics

在病人的結果方面，醫生在10個質量指標中的9個指標上優於中級醫生。

including cancer screenings and management of chronic diseases such as high blood pressure

包括癌症篩查和慢性病的管理，如高血壓。

and diabetes.

和糖尿病。

Physicians were also found to have higher patient satisfaction scores compared to midlevels.

還發現，與中層人員相比，醫生的病人滿意度得分更高。

The authors also tracked outcomes and cost data from patients who were co-managed by

作者還追蹤了那些被共同管理的病人的結果和費用數據。

a physician and an APP and found that patients who alternated visits with the physician and

一個醫生和一個APP，發現輪流看醫生和看APP的病人，都有一個共同點。

the APP had the best quality and cost outcomes of all.

在所有項目中，APP的品質和成本是最好的。

They concluded that, although APPs are an invaluable part of the healthcare team, they

他們的結論是，儘管APP是醫療團隊的一個寶貴部分，但他們

are best utilized when they are co-managing patients alongside physicians as opposed to

當他們與醫生一起共同管理病人時，就能得到最好的利用，而不是像現在這樣。

practicing independently.

獨立執業。

The Hattiesburg Clinic has since redesigned its care model so that a doctor is the primary

此後，哈蒂斯堡診所重新設計了其護理模式，使醫生成為主要的護理人員。

care physician for all patients and no one sees a nonphysician exclusively.

所有病人都有護理醫生，沒有人專門看非醫生。

Although this is just one clinic, in one state, this is one of the first studies that has

雖然這只是一個州的一家診所，但這是最早的研究之一。

collected robust data comparing healthcare costs, patient outcomes, and other metrics

收集了比較醫療成本、病人結果和其他指標的有力數據

between physicians and independently practicing mid-level providers.

在醫生和獨立執業的中級提供者之間。

Many previous studies, including those mentioned in support of independent practice at the

以前的許多研究，包括那些在支持獨立實踐時提到的研究

beginning of the video, have only compared outcomes between physicians and APPs when

在視頻的開頭，只比較了醫生和APP之間的結果，當

functioning in a collaborative role with physicians.

在與醫生的合作中發揮作用。

Although NPs and PAs are important members of the healthcare team, the solution to the

雖然非執業醫師和執業助理醫師是醫療團隊的重要成員，但解決的方法是

physician shortage is not to expand their scope and grant them independent practice.

要解決醫生短缺的問題，並不是要擴大他們的範圍，讓他們獨立執業。

The bigger issues that need to be addressed are the limitations preventing us from training

需要解決的更大問題是阻礙我們培訓的限制因素

more doctors.

更多的醫生。

There is no shortage of people interested in becoming physicians.

並不缺乏對成為醫生感興趣的人。

We can see this in the record number of applicants applying to medical schools this past cycle.

我們可以從過去這個週期申請醫學院的創紀錄人數中看到這一點。

The issue is that there is a bottleneck in the number of residency spots due to the lack

問題是，由於缺乏居住點的數量，出現了瓶頸。

of Medicare funding for new residency programs.

對新的住院醫師項目的醫療保險資金。

According to the NBME, in 2022 there were approximately 43,000 medical students that

根據NBME的數據，在2022年，大約有43,000名醫學生

applied for first-year resident positions, out of which only 34,000 matched.

申請第一年住院醫師職位，其中只有34,000人符合要求。

That means that approximately 9,000 medical students will either have to apply for the

這意味著大約9000名醫科學生將不得不申請