It’s not uncommon for patients to spend more time with physician assistants (PAs) and nurse practitioners (NPs) than their actual primary care doctors. This trend has sparked controversy among physicians and patients alike. While so-called “mid-level providers” like NPs and PAs are undoubtedly essential for filling gaps in the healthcare system, there is some concern that these men and women are tasked with responsibilities that are beyond the scope of their training and expertise.
America’s Growing Physician Shortage
Physicians are in increasingly short supply, and this is a problem that will continue to worsen. Data published by the American Association of Medical Colleges (AAMC) project a shortage of between 46,900 and 121,900 physicians by 2032, including both primary care doctors (between 21,100 and 55,200) and specialty care doctors (between 24,800 and 65,800).
“The nation’s population is growing and aging, and as we continue to address population health goals like reducing obesity and tobacco use, more Americans will live longer lives. These factors and others mean we will need more doctors,” AAMC president and CEO Darrell G. Kirch, M.D., explained in a press release. “Even with new ways of delivering care, America’s doctor shortage continues to remain real and significant.”
Angela Golden, DNP, FNP-C, FAANP, president of the American Association of Nurse Practitioners from 2012 to 2014, doesn’t see this as an issue. “There is a healthcare provider shortage all over the United States,” she points out. “Since 80 percent of nurse practitioners practice in primary care, we are an excellent source for health care.”
Confusion and Concerns Surrounding “Mid-Level Providers”
Outside of general medical care, consumers are sometimes worried that doctors delegate too many specialized tasks to NPs and PAs. These health care providers are trained in using and interpreting a wide range of diagnostic tools to diagnose and treat acute, episodic and chronic conditions, therefore it can be difficult to ascertain where their expertise begins and ends.
In fact, the American Association of Nurse Practitioners (AANP) cites the use of outdated terms like “mid-level provider” and “physician extender” to refer to NPs as a major source of confusion. Similarly, the American Academy of PAs (AAPA) stipulates that these terms are not only offensive to PAs, but they also do not reflect the collaborative relationship these health care professionals have with physicians.
Referring to NPs and PAs as mid-level providers also suggests that they provide a mediocre quality of care or work within a clearly defined hierarchy of health care professionals, neither of which are generally true. The delivery of high-quality health care depends upon effective collaboration and communication among all members of a patient’s care team.
Understanding the Differences Between Medical Credentials
First, it’s essential to understand what distinguishes a physician from other health care professionals. Just because a provider doesn’t have “M.D.” or “D.O.” following their name doesn’t mean they are not capable of offering quality care, according to Golden.
Nurse Practioners (NPs)
NPs are a type of advance practice registered nurse (APRN). In addition to the initial four-year nursing program to become a professional registered nurse (RN), NPs must complete a master’s degree or doctoral degree. In their graduate studies, NPs choose to focus on treating certain populations and providing specific types of care. For example, a family nurse practitioner (FNP) with a specialization in primary care treats both children and adults in an outpatient setting like a family medical practice. On the other hand, an adult-gerontology NP who specializes in acute care treats adults of all ages in inpatient settings like hospitals and nursing homes.
NPs must also go through a national certification process and obtain state licensure. Some NPs may choose to pursue a sub-specialty like orthopedics, palliative care, emergency medicine, cardiology or surgery, some of which require specialized certification exams. On average, NPs complete anywhere from 500 to 720 hours of patient care throughout the initial training and education process. Nurse practitioners must also undergo periodic peer reviews and clinical evaluations, participate in continuing education courses, and meet recertification requirements every five years.
Physician Assistants (PAs)
PAs have similar requirements, but there are some notable differences. NPs study advanced nursing techniques that focus primarily on patient-centered care, which is why they choose a patient population to specialize in. PAs receive education and training that follows the medical model and is therefore more disease centered. As a result, PAs are considered medical generalists, although they may choose to pursue specialties like dermatology, surgery or emergency medicine.
Physician assistants typically complete at least a master’s degree from an accredited program and over 2,000 clinical practice hours. A PA must pass the national certification exam to apply for their state license and practice care. A minimum of 100 continuing medical education hours are required every two years as well as a recertification exam every 10 years for PAs to maintain their national certification.
There are definite differences between doctors, NPs and PAs. Kathryn Boling, M.D., a primary care physician with Mercy Medical Center in Lutherville, Maryland, started out as an NP before going to medical school. “Physicians are better trained,” Dr. Boling admits, citing the extensive residency period that doctors are required to go through after their years of schooling and the fact that far more physicians undergo specialized training.
When it comes to educational differences, a physician must complete a bachelor’s degree, a post-graduate degree in a doctoral program (M.D. or D.O.), and a residency, totaling an average of 11 years of schooling. Some doctors even pursue fellowships in subspecialties like geriatrics or cardiology that tack on even more years of training. In the end, a family physician must provide a total of 10,000 to 12,000 hours of patient care in the process of completing their education.
Scope of Practice for NPs and PAs
Since NPs and PAs are highly educated and receive extensive clinical training, they can execute a diverse array of medical care tasks in various settings. They can order and conduct diagnostic tests and lab work, perform in-office procedures, prescribe medications, and diagnose and treat health conditions like high blood pressure, injuries, infections and diabetes.
Depending on the regulations of the state in which they’re practicing, NPs and PAs either work under the direction of or in collaboration with physicians. However, professional associations for both NPs and PAs have been urging states to change their laws and allow these providers greater autonomy.
Comparing Quality of Care
The fact that NPs and PAs spend more quality time with individual patients often facilitates candid communication. Thus, these providers can gain valuable insight into patients’ specific care needs. “We have years of experience working with patients one on one and developing critical listening skills,” notes Margaret Dean, a gerontological NP and assistant professor of nurse practitioner studies at Texas Tech University Health Sciences Center.
In fact, a 2017 study published in Medical Care compared the care quality of nurse practioners, physician assistants and primary care physicians. The results showed that care provided by all three types of clinicians was largely comparable. However, when compared with patients who visited physicians, patients who visited with NPs or PAs were more likely to receive more health education/counseling services.
As healthcare providers look for creative ways to meet the needs of an aging population, patients and caregivers will need to use common sense when it comes to deciding whether a care provider is safe and effective regardless of his or her title. Older adults are prone to putting doctors on a pedestal, but such deference can be detrimental to their care if they blindly trust an M.D. or won’t take direction from an NP.
“Patients are smart,” says Dr. Boling. “They can usually tell if their provider—whether an NP or M.D.—is a good fit and cares about them. If they have an NP or PA that is attentive and takes good care of them, then they should trust that person.”
In the end, the quality of care a patient receives determines whether a healthcare provider is a good match. If a patient’s needs are too specialized or complex, any type of medical professional should be comfortable with asking for assistance or providing a referral to another provider who is better suited to handle the case.
Sources: 2019 Update The Complexities of Physician Supply and Demand: Projections from 2017 to 2032 (https://www.aamc.org/system/files/c/2/31-2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf); New Findings Confirm Predictions on Physician Shortage (https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage); Use of Terms Such as Mid-level Provider and Physician Extender (https://www.aanp.org/advocacy/advocacy-resource/position-statements/use-of-terms-such-as-mid-level-provider-and-physician-extender); PAs & NPs: Similarities & Differences (https://www.aapa.org/download/60509/); Chart: Doctors top health care providers in education and training (https://thedo.osteopathic.org/2019/06/chart-doctors-top-health-care-providers-in-education-and-training/); A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians’ Patterns of Practice and Quality of Care in Health Centers (https://journals.lww.com/lww-medicalcare/Abstract/2017/06000/A_Comparison_of_Nurse_Practitioners,_Physician.11.aspx)