Perils of replacing physicians with non-physician providers

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Rebekah Bernard, MD, a family physician at Gulf Coast Direct Primary Care in Fort Myers, Florida. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

The United States is facing a physician shortage.[i]  Efforts are being made to increase physician training programs through Graduate Medical Education (GME) funding, with bills H.R. 2267 and S. 1301 slowly winding their way through the political process. In the meantime, some organizations see the physician shortage as a golden opportunity to increase the production of non-physician healthcare providers, including nurse practitioners (NP) and Physician Assistants (PA). 

Dr. Bernard

Nurse practitioner organizations have been particularly active in promoting a nursing role in the health system, encouraged by the Institute of Medicine’s 2011 Future of Nursing report, which called for a radical change to health care delivery in the United States with a push towards higher levels of nurse education to achieve “full” nurse partnership with physicians.[ii] Nursing schools rallied to the call by creating a goal of increasing baccalaureate trained nurses and doubling the number of nurses with a doctorate degree by 2020.[iii]

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Unfortunately, this focus on increasing nursing scope of practice has led to several dangerous consequences. The first adverse effect of increased NP production is a decline in bedside nurses, one of the most critical components of our healthcare system.   

Bedside nurses are the cornerstone of quality medical care delivery across healthcare settings.  The United States is facing a nursing shortage, due to a combination of factors: the aging of the population, retirement of experienced nurses and the transition of nurses from bedside to a provider role.

The first way that increasing nurse scope of practice is affecting bedside nursing is that as nursing programs encourage more advanced training, fewer students are entering associate level training.[iv]  Associate level (ADN) registered nursing degrees are two-year programs, available through community colleges, which offer a shorter and less expensive track toward becoming a nurse.  Students can work and attend school at the same time, and can enter the workforce after two years of study, rather than four.  

Next:" Simply substituting one for another isn’t the answer"

Yet despite the push toward four-year degrees for nurses, the State of Nursing 2016 study noted that the two-year ADN graduates were often better prepared to care for patients with more real-life experience obtained during training. In the study, BSN graduates reported that “compared to their associate-prepared peers, bachelor-prepared nurses are ill equipped with practical bedside skills.” While BSN grads did not feel as well-prepared to practice clinical nursing, they valued their baccalaureate program “as a stepping stone to larger roles, including graduate school or positions in management”[v] – not bedside nursing.

The second way that scope of practice is causing critical shortages in essential bedside nursing care is the rapid expansion of BSN to NP programs. In an article on why nurses are leaving the bedside, nurse Brie Gowan says that “fewer nurses are staying in the trenches” and instead are “pursuing higher education off the bat.”[vi]

Finally, the increase in nursing scope of practice is causing a serious shortage in nurse educators. Doctoral nurses are more likely to enter clinical practice than academia, a far less lucrative career track, which is leading to a decrease in training of bedside nurses. 

Of one thing there is no doubt: We need more nurses, and we need more physicians. Simply substituting one for another isn’t the answer.

The next article will discuss nursing scope of practice, and the rapid increase in nurse practitioner training programs. 

[i] https://news.aamc.org/for-the-media/article/gme-funding-doctor-shortage/

[ii]http://hdl.voced.edu.au/10707/249309

[iii] https://nursejournal.org/articles/the-future-of-nursing-infographic/

[iv] https://www.nursinglicensure.org/articles/adn-program-future.html

[v] http://www.nursing.org/wp-content/uploads/2015/10/Nursing.org_.State-of-Nursing_2016.pdf

[vi] http://briegowen.com/2016/04/11/why-nurses-are-leaving-the-bedside/