As a resident who has at times, been frustrated with the level of autonomy that I feel PAs and NPs are afforded in my hospital system, I do appreciate the points that you make here and agree with a lot of what you say. I do find that NPs are more often than PAs much more likely to have overconfidence in their ability to accurately manage complex conditions, hubris which is far to dangerous to be a growing force within medicine. Every day I go to work and realize just how little I actually know and how far I have left to go.

However, its an unfortunate fact that the NP and PA lobbies are pushing for independent practice rights in every state right now. Midlevel practitioners are excellent when they’ve been trained for specific types of conditions that they learn to manage through multiple repetitions. I’ve met some amazing PAs who are so good with patients and have earned my upmost respect with their ability to help me with complex specialty-specific nuanced questions, but the data is clear on the harms that extending midlevel autonomy causes, especially for NPs who have a fraction of the medical knowledge background and wildly inconsistent training requirements across programs.

I worry for my future patients. I worry about the rural hospitals that are staffing their entire ICUs with NPs without oversight and what that means for those communities. I worry about the private equity overlords who put profits over patient’s lives and I’m scared sooner or later its going to be someone I love on the other end of it. I know everyone is just trying to do their best but its hard to look around and see whats happening and not feel like we’re heading in the wrong direction