The other (IMO very critical) factors this doesn't address is the relationship between midlevel providers and MDs, and the shift towards away from primary-care providers and specialists treating their patients during hospitalization to hospitalists treating patients during hospitalization.

30 years ago, the patient likely would have seen their family doctor, who would have caught the symptoms of sepsis (just like the midlevel nurse practitioner did), and then directly admitted the patient into the hospital themselves, and cared for the patient during their admission.

I grew up with a father who was a primary care physician in a rural community. If one of his patients required admission to the local hospital, he'd admit them directly. It was normal that on Saturday and Sunday mornings, then-6-year-old-me would tag along as he rounded through his patients in the hospital. He'd manage their care, talk with them about their symptoms and progress, and make whatever changes to their orders that were necessary.

If he was out of town, he'd hand them off to one of his partners, and return the favor when they were out of town.

Now, that model is rare for a couple reasons. First, because primary care physicians are overworked, and don't relish the extra (often unpaid or severly underpaid) responsibility of caring for patients while they're hospitalized.

Second, because primary care physicians are now being replaced with midlevel providers, like the nurse practitioner in this case. Unlike physicians, midlevels often either don't have admission privileges (in some states), or have admission priveledges that require that the patient be under the care of a physician after admission (in other states).

The result is the creation of a relatively new specialty in medicine, the hospitalist, who is responsible for the care of admitted patients while there in the hospital.

There's lots of evidence to show that this is generally a good thing for patient care, and definitely for quality of life for primary care providers. There's a physician on-duty 24/7/365 to care for hospitalized patients who specializes in care in that setting. But, as this case points out, it's not a system that's immune from flaws.

There's also an imbalance of power and liability created by the introduction of a midlevel provider.

While midlevel providers are an important and necessary part of providing primary care in our current medical system (though, in my personal opinion we should focus much more than we do on increasing our capacity for training physicians), their introduction does create a power and liability imbalance in our medical system.

I expect that if the patient had been seen by an MD, who called the hospitalist and said "this patient is septic and needs to be admitted", the hospitalist would have been more likely to take their recommendation at face value. They would be getting a recommendation from a peer, with the same level of education and training as them, instead of a provider with less training and experience.

Additionally, in cases like this, physicians carry an outsized responsibility for liability compared to midlevel providers.

I don't bring any of this up to excuse the hospitalist invoved in this case. But it seems to me that this is a very clear case brought about by recent trends in the way we practice medicine in this country, that deserves further examination along those lines.