What's ruining medicine for physicians: Replacing primary care physicians with NPs/PAs

At the end of every year, Medical Economics publishes a list of the top challenges facing physicians. This list is generated by surveying our physician readers.

For this year’s list, we decided to recast the question. Instead of asking what challenges physicians face, our editorial staff wanted to hone in on what issues annoy and frustrate doctors and get in the way of what’s truly important: Treating patients and running practices.

And so we asked physicians in a poll: “What ruining medicine for physicians?”

In our list of the nine issues ruining medicine for physicians, the goal is not to dwell on the negative aspects of working as a physician. Instead, we wanted to show our readers that they share common challenges when dealing with the vexing issues facing primary care in today’s complex healthcare environment. Each piece also offers practical solutions that physicians can start using in their practices today.

#5 Replacing primary care physicians with NPs/PAs

The number of new nurse practitioners (NPs) and physician assistants (PAs) continues to outpace the number of new physicians nationwide, causing some concern among primary care doctors. There are more than 248,000 NPs currently licensed to practice in the United States, up from about 120,000 in 2007, according to the American Association of Nurse Practitioners. An estimated 85.5 percent of new graduates have been trained in primary care.

Similarly, the number of physician assistants has grown exponentially, from just four in 1967 to more than 115,000 in 2018, according to the American Academy of Physician Assistants. Slightly more than 30 percent of PAs work in family medicine. 

Both professions are projected to grow more than 30 percent by 2026, creating frustration among doctors who fear being replaced by lesser-trained professionals in providing  primary care.

“One of the biggest concerns we have is the development of diploma mills-NPs in particular are being churned out of online programs,” says Rebekah Bernard, MD, board member of Physicians for Patient Protection, an advocacy group for physician-led healthcare. 

She adds that there is no standardized education for NPs and PAs, so knowledge and training can vary widely among graduates. “The gap in required education is staggering-physicians aren’t allowed to practice until we have trained for about 20,000 hours, while NPs may have 1,000.”

Yet NPs are often promoted by health systems and nursing programs as being “just as good” as doctors and are now allowed to practice independently in 23 states. 

The push for more non-physician providers in primary care is coming not just from healthcare organizations looking to reduce costs, but from patients who want more convenient access to providers. These patients often lack respect for the amount of training it takes to be a physician and want instant answers and quick care, and a nurse practitioner at a retail clinic can often provide that, even though it may incur a higher risk, says Bernard. 

“The biggest thing with a new NP is they don’t know what they don’t know,” she says. “They don’t have the experience, and really don’t realize how quickly something can go wrong.”

Doctors working for health systems can be assigned supervisory duties over non-physician providers who may or may not have appropriate training, putting physicians who are already short on time in a position of having to assume liability for supervising them. 

“There’s no oversight on hiring or how helpful they might be, but doctors are expected to supervise them or they’ll be let go,” says Bernard. “Physicians should be extremely aggressive if doing true supervision and not just sign off on charts. Understand their knowledge base and there should be true collaboration.”

Bernard says collaboration is the key. Laws should limit what NPs or PAs can do on their own, and they should always have to work under the supervision of a physician.