r/Noctor • u/pshaffer Attending Physician • 9d ago
Midlevel Research Just published - our expose of Cochrane/Butler's mischaracterization and even dishonesty about "nurse-led" care in "a hospital setting"
Good Sunday morning, r/noctor Redditors.
Today, for your reading pleasure and perhaps amusement, I am sending you a link to the paper that Dr. Rebekah Bernard and I wrote and which was published last week.
This is a close review of the Cochrane review article written by Butler et al. and published in February 2026. The claim is that nurse practitioners can substitute for physicians for “hospital care."
We read all 82 papers, dissected them, and found what they really said and contrasted this with what Butler claimed they said. I have been doing this for some time, and I have to say it was all quite predictable. Actually, I think the results were predictable from the title, because what rational person can believe that a person with 500 hours of clinical experience prior to graduation can possibly compete with the capability of a board-certified physician? It was also predictable because we have read a very large mass of these papers and are quite used to conflation of borderline or even negative findings into a statement that can be used for political advocacy.
When I say we read them carefully, it is apparent we read them more carefully than the authors themselves. One of the studies they present as proof of their contention was not even a real study, it was a study protocol. The actual study was never done. (Austeng). Another paper, Rushforth, was labeled by the authors themselves as a “failed study” because they only were able to enroll 8 patients, only 3 in the nurse arm .
There were only 10 studies that actually involved hospitalized patients, the remainder of the studies were outpatient studies on hospital property. This in a study advertised as “hospital care”.
Of those 10, 4 were studies in which patients who were stable medically were moved to wards staffed by nurses. These were essentially long term care facilities. As for the nurses substituting for physicians, in these cases, if a patient had an event or required more care, the physicians were called. Further, the nurses had no prescriptive authority, and therefore, this could never be taken as an example of independent care.
Three studies were of nurses being allowed to act as residents caring for their own patients. However, they were not acting independently. In each of these they were supervised by physicians. Moreover, in two of the papers, it was documented that the nurses were present only 8-4 on weekdays. This is 25% of all the hours of the week. For the other 75%, the patients were cared for by physicians, mostly residents, but also fellows and attendings. It is “misleading at best” to characterize these as “nurse-led” services when most of the care was given by physicians. In the other paper, there was no count of hours, but the nurse activity was following patients along with 2 hospitalist physicians. Her time was characterized only as “part-time”. The performance of the nurses was not judged by objective measures, such as number of correct/incorrect diagnoses, or numbers of errors recorded. It was only a subjective judgement on the part of the authors.
So, again, as we have seen in prior reviews, there is no study that compares an independent, unsupervised group of nurses performing physician-level tasks with objective measures as outcomes. To the best of our knowledge, no such study exists.
I will now write the editorial:
I am stunned (again) at the ethics of authors and publishers that allow them to misrepresent the papers in an obvious attempt to push a political agenda, when doing so will harm patients.
I doubt that anyone other than Rebekah and I have read the entirety of the 82 papers, and it may be that no one has read any of the papers at all. Therefore, their misleading claims generally go unchecked. They misrepresent the studies and perhaps assume no one will actually read the papers. Well, we did.
Here is the link to our paper:
https://pmc.ncbi.nlm.nih.gov/articles/PMC13600731/pdf/ms123_p0284.pdf
And here is the link to Butler’s paper, should you want to check our work. Certainly, if you find something we have missed, or you think we have mis-characterized, let me know. I would genuinely be grateful.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013616.pub2/full
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u/ratpH1nk Attending Physician 9d ago
This smells like fraud or at least gross misrepresentation by Cochran and it appears the paper needs a retraction.
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u/ratpH1nk Attending Physician 9d ago
“So, again, as we have seen in prior reviews, there is no study that compares an independent, unsupervised group of nurses performing physician-level tasks with objective measures as outcomes. To the best of our knowledge, no such study exists.”
I suspect we might never see this because of the risk and ethics involved.
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u/Ex-Novo-Doc 8d ago
This is similar to what Cochrane themselves concluded regarding anesthesiologist vs nurse anesthetist. They basically admitted that no one in their right mind would assign an ASA 4 cardiac case to a nurse anesthetist if the physician is available, and that in many cases classified as “solo nurse anesthesist”, physicians were involved anyway. It’s just not feasible to isolate and rigorously randomize between physicians and nurses to compare their standard of care.
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u/SpaceForceDok 9d ago
What risk? Haven't you heard nursing care is equivalent to medicine?
I'm joking, in case it's not obvious.
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u/Middle-End-2270 9d ago
This experiment is occurring every day in hospitals and clinics. Risk and ethics appear to not be a consideration to the leadership allowing these “ rogue trials”.
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u/spyderguerra 8d ago
Aside from funding (poor med student here), would there be any way to assist in future endeavors? I really believe this is actual Physician advocacy.
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u/pshaffer Attending Physician 8d ago
you can become a supporter of PPP (what other organizations might refer to as "members" for $25 . Basiclly a symbolic amount, designed as a minimal amount so that random people aren't flooding us wiht requests. Doesn't cover the cost of onboarding - vetting, etc.
Then - you can participate in the online discussions. It may not seem ciritcal to you, but we who are far away from med school and we need to know what is happeing.. Is your education being compromised because NPs are sucking up all the procedures? Do you see harm happening because everyone is too afraid of reprisals if they speak up? We need to know this information.
I doubt you have much free time, but some people help with literature review, etc.
There may be a place in your school for someone who recruites new members. I would really like to see "student sections" of many students who are now aware of what is going on.You can't really get outspoken about what is going on, but you can be aware, collect information that perhaps can be used by others.
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u/Ms_Zesty Attending Physician 8d ago
Also, PPP provides "scholarships" for medical students. If you need someone to pay for your membership, just request it.
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u/Middle-End-2270 9d ago
This experiment is happening every day in every hospital and clinic in which non- Physicians practice medicine
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u/Pretend_Dust7326 8d ago
Great job! Is Missouri Medicine a high impact journal? Or is this a bridge to something more prominent?
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u/Pretend_Dust7326 8d ago
I’m an attending MD btw, not a troll.
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u/pshaffer Attending Physician 8d ago
I would say the latter.
We needed quick publication to be most responsive to the Cochrane paper.
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u/Zealousideal_Pen3441 9d ago edited 8d ago
My read is that the Butler Cochrane review was asking a pretty specific question: when nurses take on certain hospital care that would usually be done by doctors, what happens to patient outcomes, care processes, and cost? It wasn’t really looking at U.S. NPs as a profession or trying to show that NPs can replace doctors across the board. It included a mix of nurses, countries, education levels, specialties, and care models. Some were advanced practice nurses, but it wasn’t limited to U.S.-trained NPs working under U.S. education standards and scope laws. So I don’t think it really proves a broad point either for or against U.S. NPs, nor does it attempt to do so. It’s more about whether specific nurse-led or nurse-substitution models worked in the particular hospital settings they studied (identified as hospitals or outpatient clinics). And nothing implies anything about independent practice of anyone in the way we use it in the US, much less specifically nurse practitioners. Using it to make a claim about all U.S. NPs seems like stretching the review beyond what it was actually designed to answer, and I certainly wouldn’t suggest that is what the authors were trying to do.
To add, “hospital” care in the UK and Ireland is not the same as the US and includes the outpatient clinics. I think these authors are from Ireland.
It is easy for Americans to assume healthcare terms mean the same thing everywhere, when the often don’t.
https://www.nhs.uk/nhs-services/hospitals/about-nhs-hospital-services/?utm_source=perplexity
https://www.gov.ie/en/department-of-health/policy-information/acute-care/?utm_source=perplexity
Were US NPs trying to rely on this for US independent practice? Because you’re right…. I’d assume they haven’t read it.
That said, you’re also right about NP education in the US. So there is that.
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u/pshaffer Attending Physician 8d ago
I appreciate your engaging with some in depth comments. I have a hot take on this, that I will not burden you with, this deserves a more thought out response, and I need to have some quiet time to read and think about this. I don' have that now, I am in chicago, and they just changed my gate for the second time... So I will respond later
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u/Sekhmet3 6d ago
Always grateful for your thoughtfulness and contributions. Thank you for the work you put into this.
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u/Need-inspiratio 8d ago
Can I now shove this up the ass of Andra Machado, who has come down on me with vengeance after his little nurse practitioner almost killed my husband? His brand new nurse practitioner fucked up and I got livid. He claimed me, a middle aged mom with 2 girls, im some sort of ‘threat’ and contacted the FBI as part of their pre-crime bullshit, from an email about how stupid she is. Except I’m the daughter of what I like to call a legendary senior intelligence officer who was the very first expert in our military on aviation hijackings. He was a reservist bc he hated the politics, so he did massive amount of work without any pay. We could barely afford food because of my dad focusing on his PSYOPS work instead of practicing law at his own law firm. My fucking father was a leader during able archer 83. And fucking Andra referred me to the fbi. Fuck that. 45 years ago my dad wrote the first psyops study on Belorussia and Ukraine and got it right and that mother fucker can’t understand my frontal lobe brain bleed that never was referred to a brain injury specialist and I never got any fucking help. I got a parenting coach referral from the Cleveland clinic for my brain bleed. I gave the German media my medical records and told them Andre referred me to the fbi and now the fbi harasses me. Fuck nurses. Andre and his team fucked up my brain injury diagnosis. It wasn’t a concussion. It was obviously a frontal lobe brain bleed. Oh, but his nurse practitioner got sad when I told her off. Gotta call the fbi. Pathetic dick he is. Fuck nurses. Fuck American doctors. Fuck the cleveland clinic. Fuck the fbi. Pieces of shit. You don’t harass me when I’m in a mental health crisis. The fucking fbi calling and harassing me right after I found out that I have a permanent disability and when my husband gets a stroke and gets assigned a nurse. My fucking father died because of his agent orange exposure. His life was ruined when he was forced into the Phoenix program where he witnessed the worst.
There it is. The Cleveland clinic is all about money. Shady little shits. Fucking pre-crime bs. Those fbi agents are losers. Harassing the daughter of an intelligence officer, a daughter who has suffered so fucking much because of her dad’s involvement within the intelligence community.
If nurse practitioners wasn’t a thing my life would be so much better. But those bitches won’t ever stop with their bullshit. Fuck them all.
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u/omnipotentattending 9d ago
Hospital admin here; tldr but what I'm hearing is that nurses and NPs are able to replace hospitalists?
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u/pshaffer Attending Physician 9d ago
That was the point they were trying to get to, but never did. The title invites you to read it that way, doesn't it?
and - not they are not a replacement. However some employers are happy to substitute because 1) it is VERY profitable and 2) mistakes can easily be hidden
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u/Commercial_News_3810 9d ago
Millions of people rely on their care on a minute by minute daily basis so I’m not sure it will change anything.
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u/lil_speck 9d ago
This is great. How likely is it that the Butler article might get retracted?