Doctors—especially those who practice primary care and gerontology— are in increasingly short supply, so it's not uncommon for patients nowadays to spend more time with physician assistants (PA) and nurse practitioners (NP) than an actual MD.
This trend has sparked controversy among physicians and patients alike. While so-called "mid-level" providers" (NPs and PAs) are undoubtedly essential to fill the gaps left by the current drought of doctors, there is some concern that the responsibilities being shouldered by these men and women aren't appropriate, given their level of training and expertise.
"There is a healthcare provider shortage all over the United States," points out Angela Golden, DNP, immediate past president of the American Association of Nurse Practitioners. "Since 80 percent of nurse practitioners practice in primary care, we are an excellent source for healthcare."
Yet others are concerned that doctors delegate too many specialized tasks to mid-level medical professionals.
A recent analysis of Medicare beneficiary data found that, in 2012 alone, PAs and NPs performed more than four million different dermatological procedures (e.g. doing biopsies of and destroying minor skin lesions).
"Mid-level providers were originally envisioned to provide primary care services in underserved areas," note co-authors Brett Coldiron and Mondhipa Ratnarathorn in their article in "JAMA Dermatology." But the Cincinatti-based dermatologists caution against expanding the responsibilities of these essential healthcare professionals too quickly, saying "It would be prudent to temper widening the scope of practice of mid-level providers that are not solely limited to primary care, and may involve procedures for which they may not have formal training."
The medical Jacks-and Janes-of-all-trades
What does this mean for patients and their families?
First, it's essential to understand what separates a mid-level provider from a full-blown physician. Just because a healthcare worker doesn't have an MD next to their name doesn't mean they are not capable of offering quality care, according to Golden. NPs, for example, are required to obtain a doctoral or master's degree, attend a four-year nursing program and go through a national certification process. They also undergo periodic peer reviews and continuing education courses. PAs have similar requirements.
As a result, NPs and PAs can execute a diverse array of medical care tasks. They can order and conduct diagnostic tests and lab work, perform in-office procedures, prescribe medications, and diagnose and treat health conditions such as high blood pressure, injuries, infections and diabetes. Depending on the regulations of the state in which they're practicing, mid-level providers either work under the direction of, or consult with a physician.
The fact that NPs and PAs spend more quality time with individual patients often makes it easier for patients to be honest with them. Thus, they are able to obtain valuable insights about a patient's specific care needs. "The main benefits is the years of working with patients one-on-one and developing critical listening skills," says Margaret Dean, a geriatric NP and assistant professor of nursing with the Texas Tech School of Medicine. "The ‘personal space' issue is not a concern for a nurse who is used to getting in and being close to that patient. That closeness allows us to support the patient to open up."
"Nurse practitioners are quality and effective providers of primary care, with 50 years of research that has demonstrated this," says Golden. While their true strength lies in the realm of primary care, some NPs and PAs also receive specialized training in an area such as gerontology and women's health.
But there are definite differences between doctors and nurses. Kathryn Boling, MD, a primary care physician with Mercy Medical Center in Lutherville, Maryland, started out as an NP, before becoming a doctor. "Physicians are better trained," Boling says, pointing to the extensive residency period that doctors are required to go through after their years of schooling, and the fact that far more physicians undergo highly-specialized training in a specific area of practice.
When speaking about the difference in quality of care provided by NPs versus doctors, she says "Like any profession, there are people who are great and there people who are not so great. I will say that, in my experience, the percentage of good physicians is quite high—higher than the percentage of good NPs and PAs."
Identifying a high-quality care provider
So how do you know if you (or an older family member) are in good hands with an NP or PA?
As healthcare providers look for creative ways to attend to the needs of an ever-aging population, patients and caregivers will need to use common sense when it comes deciding whether a care provider is safe and effective—regardless of his or her title. Older adults in particular are prone to putting doctors on a pedestal, but such deference can be detrimental to their care if they blindly trust an MD, or won't take direction from an NP.
"Patients are smart," says Boling. "They can usually tell if their provider—whether NP or MD—is good and cares about them. If they have an NP or PA that is caring and takes good care of them, then they should trust that person."