NP and PA Set for Imminent Consultation
Modern medicine in 20th-century America was ruled by physicians, but their dominance didn't start at the get-go. In a groundbreaking piece, Paul Starr discussed how a rough-around-the-edges, economically insignificant traditional medical profession somehow managed to seize control over healthcare delivery.
By the millennium's end, the doctor gang was concerned about a glut in competition. Thus, they effortlessly persuaded decision-makers to limit the growth of medical schools and residency programs, resulting in a standstill in the number of physicians as the U.S. population increased.
Today, the good old US of A lags compared to most developed nations when it comes to physicians per capita, with only 2.6 doctors for every thousand folks, while the average is 3.6. With an older, sicker populace, the nation is short an estimated 125,000 doctors and anticipates another 80,000 deficiency by 2037.
NPs and PAs: The Subtle Risers
As the medical profession gradually climbed the ladder, two new clinical professions quietly surfaced. In 1965, the first nurse practitioner program was launched at the University of Colorado to enhance care access, and Duke University debuted the initial physician assistant program at the same time. For years, the number of NPs and PAs expanded slowly, but since the year 2000, these roles have skyrocketed.
With around 280,000 nurse practitioners (NPs) and 145,000 physician assistants (PAs) in the U.S., these professionals establish a firm one-third of the clinical workforce. They attend to over a quarter of all healthcare visits, making more than any nation on the planet. And they are among the fastest-growing professions, destined to assume an even higher share of the careload over time.
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Equivalent Care: NP vs. PA vs. Physician?
After graduating from university, physicians undergo a grueling quartet of years of medical school followed by three to seven years of residency and fellowship (seven to eleven years in total), all culminating in 12,000 to 16,000 hours of patient care. Nurse practitioners (NPs), on the other hand, are typically registered nurses who complete one to three additional years of training for about 500 to 1,000 hours of patient care. Physician assistants (PAs) finish two to three years of training for roughly 2,000 hours of patient care.
Bruce Lee famously said, "Under pressure, we don't rise to our own expectations, but rather to our level of training." Despite their vastly varying education, most studies have found that physicians, NPs, and PAs provide similar-quality care. Although there are exceptions.
A counterargument arises that gauging quality of care is a tricky business. Many times, it's an "I know it when I see it" situation.
Dr. Rebekah Bernard, a staunch critic of independent NP practice who's written two books on the subject, argues, "There are absolutely no randomized, controlled trials examining the safety and efficacy of care provided by unsupervised NPs."
After more than two decades in the medical field, I've found it difficult to make sweeping generalizations. In my experience, most NPs and PAs are great, but some are not. The same goes for physicians.
The Right Questions: A Necessary Shift in Focus
I recently had a chat with Lusine Poghosyan, a health policy professor at Columbia University. She wisely asked, "Why would we train different professionals so differently and expect them to practice the same way?"
I agree. Given that nurse practitioners and physician assistants have established themselves as crucial healthcare providers in the face of ongoing workforce shortages, it's about time we started asking questions beyond whether their care is equal to that of physicians.
First, how can various practitioners best meet the population's health needs? Although we tend to emphasize differences, NPs, PAs, and physicians have overlapping scopes of practice.
Jennifer Orozco-Kolb, PA-C and Chief Medical Officer at the American Academy of Physician Associates, said, "PAs are not trying to be physicians. We're trying to do what we are trained to do: care for our patients and communities."
Second, how do we ensure all professionals are well-prepared to practice? This is most critical for new NPs and PAs with limited clinical experience, particularly NPs graduating from allegedly subpar, online, for-profit schools.
NPs and PAs typically form collaborative relationships with physicians, gaining autonomy over time. Roderick S. Hooker, a retired PA and a widely published health services researcher, invoked the "See One, Do One, Teach One" model common in medicine. A growing number of organizations offer postgraduate residency and fellowship programs.
Third, how do we optimally configure practices? For instance, when should patients see a physician, an NP/PA, or a team? When is physician oversight necessary?
While states technically determine the scope of NP and PA practice, provider organizations decide their actual roles. For example, hospital privileging is not associated with scope of practice laws. Similarly, NP and PA roles vary more within states than between them.
Organizations can define roles based on clinical problem types. NPs and PAs are suited to manage well-defined "structured problems" that are solvable using protocols (e.g., uncomplicated UTIs and hyperlipidemia). Yet, without the right experience, they may struggle with poorly defined "unstructured problems" lacking known solutions (e.g., refractory depression and penetrating Crohn's disease). Of course, novice physicians may face similar challenges.
A related dimension is clinical discipline. NPs and PAs often fill primary care shortages. However, primary care's complexities are often underestimated due to the vast array of conditions it encompasses. Some NPs and PAs may be better suited to develop more narrowly focused, deeper expertise in specialty care.
Ultimately, we must trust organizations to decide how to incorporate various clinicians. This means accepting that some may employ NPs and PAs as labor arbitrage to maximize profits, and it also means empowering patients to decide the type of clinician they see.
Strides Ahead
Medical professionals can be protective of their turf. Physicians feel that their lengthy training warrants unmatched practice privileges. NPs and PAs, at times, feel undervalued and even disrespected. Emotions aside, serving our nation's sicker, aging population necessitates the involvement of all hands on deck.
What's next for these professions?
Dr. David Chan, a hospitalist and Berkeley health economist, explained, "In many settings, we have physicians and non-physicians performing the same job. This prompts the question of whether physicians are overtrained or non-physicians are undertrained for that job."
While there is no simple answer, each profession must constantly examine its training process, considering questions like: How much pre-clinical work is relevant to clinical practice? Typically, cultivating learning skills is more important than mastering basic science principles.
To what extent is training about learning versus signaling capabilities? While medical schools are highly selective, a significant number of NP schools accept all applicants.
How much clinical exposure is necessary? There's no substitute for real-world experience.
And how should training and practice evolve as artificial intelligence enters the medical realm? AI is already changing how clinicians access medical knowledge, process clinical information, and make predictions. In fact, some AI tools are even outperforming clinicians in specific prediction tasks.
As we move forward, let's remember that recalling facts and making predictions will be less important. More valuable will be clinicians' ability to ask the right questions, contextualize information, exercise sound judgment, and show compassion. These changes will shift roles and further blur the boundaries between physicians, NPs, and PAs.
Acknowledgments: I thank Rebekah Bernard, David Chan, Rod Hooker, Jennifer Orozco-Kolb, Lusine Poghosyan, Polly Pittman, and Chris Turitzin for discussing this topic with me.
Disclosure: I advise WovenX Health, which provides virtual NP and PA staffing for specialty care practices.
- By the end of the 21st century, the collective workforce of nurse practitioners (NPs) and physician associates (PAs) effectively formed a third of the clinical workforce in the United States.
- NPs and PAs attend to more than a quarter of all healthcare visits, surpassing any nation in the world in the number of visits handled.
- Despite their varying education, most studies have found that NPs, PAs, and physicians provide similar-quality care, albeit with exceptions.
