>Which NP's don't have as much of, since they didn't go to (or complete) med school?

This is a very politically sensitive question. I'll answer bluntly, because yay for pseudonymity - no one will answer you this bluntly in real life anymore.

The road to NP is a bachelors in nursing, being a nurse for a little bit (increasing numbers of programs don't require nursing time, so as to be more competitive with PA programs) followed by some (fairly easy) grad courses, followed by being an NP. In some states this requires supervised practice; in others, it leads to independent practice. As an aside, "supervised practice" isn't - hospitals hire NPs to be cheap manpower that does an end-run around physicians, so they use them to their maximum and, in effect, they end up unsupervised.

Nursing is not "doctoring light," it is its own thing (keeping an eye on patients, administering medication, taking vitals, measuring ins and outs, changing dressings) so while it provides exposure to the clinic, it does not provide exposure to clinical reasoning. You pick up things like "CTPA to catch a pulmonary embolism," basically enough to do monkey-see monkey-do medicine, but again ... not to reason. So you miss exceptions, you miss uncommon things, you miss subtle things, you miss contingencies. Honestly, docs that go to malignant residencies (residencies that just use trainee physicians as cheap bodies rather than trainees) end up something similar.

NP courses do not make up this difference even a little bit. Columbia's school of nursing is a big proponent of NPs being the equivalent of physicians. They attempted to administer the first of three physician licensing exams to their NP students and the pass rate was less than half that of the worst med schools in the country.

An NP is basically an under-educated medical student. And a medical student is someone too ignorant to be allowed near a patient - that's what residency training is for.

PAs are substantively similar. Their coursework is a lot more similar to med student coursework, but they skip out on the back half of med school. Some PA programs are three years and cover at least some clinical reasoning; some are just a bit over two years, and don't cover any at all. They also don't do residencies.

So, basically: if you wouldn't want a freshly graduated medical student on his first day of residency treating you, you don't ever want an NP or PA being in charge of your care.

And they often are. Hospitals not-infrequently hire a doctor to act as a malpractice license, and then they stock up so many PAs under the doc that the doc never actually has the chance to supervise.

In practice, I do prefer PAs. For social and political reasons, NPs often end up working closely with other nurses and NPs, and PAs tend to end up working more with the physicians (despite, at least fresh out of training, the two being completely interchangeable). The NPs end up spending their time with people that can't teach them any clinical reasoning, whereas the PAs get taught alongside the med students and residents. Even though the PAs usually don't spend an extra 40 hours a week studying like a med student or cramming like a resident, they at least pick up some stuff during their shifts.

It's not the med school that really makes the difference. It's the residency. Med school is what gives physicians the ground level knowledgebase to go spend four or more years working 80+ hours a week (plus studying) intensively training. Mid-levels have less training, it's true, but the key difference is that they have no residency. Even hours worked are apples-to-oranges: an NP shift is about knocking out paperwork, a first year resident shift is about seeing all the patients and knowing all the things because your attendings will constantly be hounding you about them and you'd better know your assitis from your elbowitis, you'll be writing treatment plans and they'll be ripping them to pieces (or, hopefully, not).

The other thing is just personality. The people who are driven to study their asses off day-in and day-out for a decade are not the same people who get a bachelors in nursing and go take blood pressures and hand out pills. It's an enormously different pool of people. NP becomes about getting independence and a pay-raise, but it draws from the average nurse crowd.

Bottom line: when physicians and mid-levels and healthcare executives get sick, they go to physicians. That people who aren't insiders get mid-levels foisted on them is a crime against the public. "You don't know any better, and we don't have a better way of making our profit margins, so you get people who aren't educated enough, aren't trained enough, and aren't supervised or held accountable to look after you. Of course, if you've got money and you know the system, you can have a real doctor."

(There are some mid-levels I love. They tend to be the ones who have worked in one little niche forever, and take their shit super seriously, and go out of their way to study and read like they're physicians. I most often see this in critical care PAs. I fucking love them.)

No one in healthcare is allowed to say this anymore. Hospitals need mid-levels in order to make profit margins. Insurers want you seeing mid-levels (they actually advanced the term 'providers' to muddy the water between physicians and non-physicians) in order to minimize healthcare costs. Any doc who says any of this out loud is "not a team player" (read: getting in the way of our minimizing our expenses).

I'm not an old-school doc, either, talking out of nostalgia and bias. I'm a second careerist who came to medicine after working at the executive level in health insurance, often working on cooperative agreements with large physician groups. I've seen this from the other side.

As for clinic incentives: I don't know. Any incentives against sending the patient to the ED would apply even moreso against sending them to admit to another hospital's inpatient service, so that doesn't make sense. Especially since the other hospital was in another hospital system, so it's not like her hospital would get dinged for the cost of a readmission or something. And, as you say, if she wasn't concerned, why bug two doctors? If she was concerned, why not send them to the ER?

My suspicion is this: he's a shit clinician. People who can't reason about what they're seeing don't tend to stick by their guns, because they're already making decisions by gut and habit. So, he saw a sick patient and got concerned and made some calls. He wasn't taken too seriously because the labwork was probably not too dire and/or he didn't report all the relevant values and/or because he came off like an idiot, so the "just take my word for it, this patient looks like shit" line that I'll buy from someone whose clinical judgement I trust got ignored. So, two docs told him the patient didn't sound like they needed inpatient care. And because they learned medicine by monkey-see monkey-do to begin with, and they didn't have enough clinical reasoning to make a cogent argument to themselves as to why they'd ignore the monkeys, went against their own judgement.

It's easy to overpower someone's judgement if they don't have judgement to begin with, just habit and gut feeling.