I worry. A storm is brewing within the normally collaborative and professional family of medicine as nurse organizations and other non-physician associations advocate in state legislatures across the country to be allowed to practice independently and without restriction or supervision. While I understand their motivation for advocating for their profession, I fear the unintended consequences of this move that will ultimately undermine public confidence in the entire medical system.
I have had and partnered with many nurses (NPs) and Physicians (PAs) throughout my career, many of whom are very capable of seeing patients independently – after years of experience. I’ve also seen firsthand that most recent graduates are far from willing to practice outside of a structured environment with mentors and experienced physicians.
In addition, I have criticized the inadequate surveillance requirements that have been in place for decades, which neither protect the public nor aim to improve the knowledge or skills of those under surveillance. Essentially, supervision should be the version of advanced training that residencies are for physicians.
As a GP I fully understand that I have to prove my competence. When I entered the practice, as it still is today, doing obstetrics or treating complex hospitalized patients in my hospital was not standard practice for GPs, nor was such training assured by simply completing an education. (There is a difference between experiential and hands-on training).
Despite my training as a resident, I had to consult and be supervised to prove my knowledge and ability, and eventually I was given full obstetrical privileges and admission privileges in the intensive care unit and the coronary care unit. It felt humbling, but with time and wisdom I realized it did more for my specialty and my own standing in the medical community.
Traditionally, state medical boards are established to license physicians and regulate the practice of medicine. They are required to establish minimum standards for the practice of medicine in the state, broadly defined as diagnosing and treating diseases, prescribing drugs and performing surgery. Almost without exception, states have moved from their own certification exams to mandating physicians for every part of the comprehensive three-part U.S. medical licensing examination; part three is taken during the first year of residency training and licensure comes after completing one year of post-medical school residency training.
New doctors can then get their medical license, but almost all of them complete a residency before entering independent practice. With state legislators granting full independent practice to advanced practice nurses and PAs and each board licensing their own, we are on track to have multiple standards for medical practice. I am concerned that the long-term effect of this move will manifest itself over time and, unfortunately, in the courts.
I am also concerned about the increasing lack of public transparency regarding the training and qualifications of the clinician caring for them. There is a trend among many hospitals and other corporate clinics to staff their emergency care centers, primary care clinics with NPs or PAs, often without an on-site physician.
While the motivation appears to be greater staff availability and lower costs, there is concern about whether new hires in these locations are ready for such an independent practice. I believe that the public still expects a physician’s care as the primary option when seeking care, especially in the emergency department or emergency care unit. If that is no longer the norm, the public should be made aware of this.
There is more to unpack about the physician workforce, NP and PA, as well as many aspects of the growing conflict within the home of medicine. we at Medical economics® will begin to examine the conflict and delve deeper into educational differences, data on the claim that specialist nurse care equals physician care, and whether the growing number of nurse specialists and PAs solve our geographical dispersion problem. We’ll also look at who is hiring NPs and PAs, the economic drivers of this movement, and emerging examples of places and policies that ensure patients receive the best possible care from these practitioners.
L. Allen Dobson Jr., MD, FAAFP, is a general practitioner and editor-in-chief of Medical economics®.
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