Misleading at Best: A Critical Appraisal of "Nurse-Physician Substitution in Hospital Settings"

A recent Cochrane review concluded that nurse-led care results in little to no difference in outcomes compared with physician-led care in hospital settings. These findings have been widely interpreted as evidence supporting substitution of nurses for physicians.

To evaluate the studies included in the Cochrane review and determine whether the evidence supports independent nurse substitution for physicians in hospital settings.

We conducted a structured analysis of the 82 randomized controlled trials included in the review, examining clinical setting, patient acuity, level of supervision, and type of intervention.

Only 10 of 82 studies evaluated inpatient hospital care, all involving stable or selected patient populations within physician-led or supervised systems. An additional 11 studies addressed low-acuity emergency or preoperative settings. The remaining majority consisted of outpatient, protocol-driven care for stable conditions, often with explicit physician oversight. No study evaluated independent nurse-led management of hospitalized patients or intensive care settings. Many studies assessed task-specific interventions, additional services, or structured follow-up rather than equivalent clinical roles.

The evidence cited does not support independent substitution of nurses for physicians in hospital settings. Instead, it supports the effectiveness of protocolized, delegated care within physician-led teams. While addressing physician workforce shortages is important, maintaining quality and safety requires preserving physician-led models of care.