The training debate

The American Association of Nurse Practitioners (AANP) will tell you that nurse practitioners (NPs) are qualified to handle primary care. They point to a long history of successfully caring for patients and a host of studies that back up their claims of quality. For most of that history, NPs were under the supervision of physicians. Now, however, many states allow NPs to practice independently, and some physicians are worried that NPs are not properly prepared and that patients don’t understand the differences between an NP and a physician.

“Alex,” not her real name and who requested anonymity for fear of workplace reprisal, was an experienced nurse who wanted to provide greater care for patients and went to school for her nurse practitioner certificate. Upon graduation, she was so uncomfortable with the idea of seeing patients based on the training she received that she decided to attend medical school and is now a physician.

Looking back, she is disturbed by what she heard and saw while getting her NP training. “They told us we were just as good as doctors and that we had more experience than the residents,” she says.

When asked if NPs are qualified upon certification to see patients without physician supervision, Alex is emphatic in her answer. “How could they be qualified to do that? Their level of training is variable. It is not standardized, with no consistency between institutions. How can they practice with just a nursing background?”

She described her NP training as far less rigorous than her physician training. In her NP training, working as a nurse sometimes could be counted toward clinical hours, and some clinical experience was simply shadowing others, with little or no accountability or requirements to present cases or patient work-ups.

“There were some really good rotations, but they were still nothing like the experience you get as a medical student and definitely not compared to what you get in residency,” she says. “Some NP students I see rotating are just observing, not doing procedures, are not accountable for making educated decisions for care or working through their thought process for differential diagnosis or how to prescribe for treatment. For some schools, they are literally just watching and standing in the background.”

The training requirements for NPs and physicians are disparate: According to the Primary Care Coalition, the difference in training hours between a family practice doctor and an NP is about 15,000 to 20,000 hours, and NPs have no residency requirement.

Despite this chasm, 26 states allow NPs to practice without physician supervision compared with two states for physician associates (PAs), despite PAs having more training than NPs in both didactic and clinical hours.

This broadening scope of practice for NPs has created friction between the professions. The AANP has a page on its site to anonymously report negative statements made about the NP role in the media, and its advocacy page promotes support for several bills that would grant NPs greater freedom of practice, terming any limitations on NP scope as “outdated.”

On the physician side, Physicians for Patient Protection advocates for physician-led care, and physician-centered professional groups like the American Medical Association share reports that show the advantages of physician-led care versus that of NPs or PAs. And on the website www.midlevel.wtf, physicians anonymously share stories to expose “midlevel provider incompetence in the fight to ensure patient safety and preserve physician-led, physician-supervised medicine” — as an illustration of how deep the frustration runs.

Why states are setting NPs free

NPs and PAs can’t have full practice authority in a state unless the state legislature authorizes it. Experts say one part of the argument in favor of that is expanding access to care. The Association of American Medical Colleges predicts a primary care shortage of up to 48,000 physicians by 2034, and in many rural areas, the shortage is already being felt. The salaries of NPs and PAs are about half that of primary care physicians, according to most salary surveys, and with state legislators looking to save money and make their constituents happy, full practice authority is a popular legislative choice.

Familiarity also works in the NP’s favor, experts say. According to the AANP, 82% of adults report either being treated by an NP or knowing someone who has. Because patients are familiar with NPs, patients have a high comfort level with them, as evidenced by the 90% of patients who support policies and legislation that remove barriers to NP practice, according to the AANP.

“The greatest advocates for (full practice authority) are the nation’s patients, who have demonstrated overwhelming support for the high-quality health care NPs deliver,” says AANP President April N. Kapu, D.N.P. “States that adopt full practice authority have rapidly improved patient access to care, streamlined care delivery and protected patient choice.”

She points out that in Arizona, which granted full practice authority in 2001, the NP workforce doubled across the state and grew 70% in rural areas within five years of adopting it. In North Dakota, which adopted full practice authority in 2011, the NP workforce grew 83% within six years of adopting it. Nebraska, she says, adopted full practice authority in 2014, and the NP workforce grew in 20 state-designated primary care medically underserved areas within five years. The vast majority (89%) of NPs train in primary care, according to AANP statistics.

But not all states may be hitting those highs. A report by the Oregon Center for Nursing that looked at NP state licensing renewal forms found that only about 25% were in primary care in 2018.

On the PA side, Jennifer M. Orozco, PA-C, president of the American Academy of Physician Associates, points to a 2020 study that appeared in JAMA that shows the number of PAs practicing in rural areas increased by more than 49% from 2009 to 2017 while the number of physicians only increased 14%.

Davis Patterson, Ph.D., director of the Washington, Wyoming, Alaska, Montana, Idaho Rural Health Research Center at the University of Washington School of Medicine in Seattle, says that research into national trends shows that family physicians are more concentrated in rural counties than in urban counties on a per capita basis, which is not true for internists and pediatricians, who are far more concentrated in urban areas.

“NPs and PAs, though more concentrated in urban than rural areas, have a more even distribution than pediatricians and internists,” Patterson says. “In addition, the NP and PA workforces are growing fast relative to physicians, so even if not as concentrated as family physicians in rural areas, their sheer numbers and increasing numbers can help fill rural gaps.”

Orozco says that forcing PAs to be tethered to a physician can limit care when a physician isn’t in the area. She said in one case, a rural physician who had contracted with a PA moved out of the region, and there was no other physician in the area providing the same services the PA had been providing. The patients affiliated with that PA could no longer receive that care because there was no supervising physician, even though the patients had been working with the PA for years.

Christopher Garofalo, M.D., a family medicine physician and member of Physicians for Patient Protection, says it’s true that patients do want better access, quicker access and more convenient access to primary care. “I would argue that they want that of their physicians,” he says. “That’s like saying, ‘I want to be able to fly wherever I want, so just put the co-pilot in there.’ We wouldn’t allow that even if consumer demand wanted it, so I don’t know why they allow it in medicine. If the argument is that even with expanded access there aren’t enough physicians, then my answer to that is we need to train more physicians.”

A double standard?

Garofalo says NPs and PAs are important to medicine but more transparency is needed so that patients understand what type of professional they are seeing.

“There are nurse practitioners who go out and get their doctorate degrees so they can now call themselves doctors, and they feel that’s OK to do in a clinical setting,” Garofalo says. “They don’t think it’s confusing, that patients know who they’re seeing, but they really don’t.”

Some states are taking measures to make sure patients are aware of what type of health professional they’re receiving care from. The New Jersey Health Care Transparency Act, passed in 2021, requires providers to inform patients of their credentials when seeing patients in person or when advertising their services. Indiana restricts the use of certain medical specialty designations to a physician; for example, NPs who are a certified nurse anesthetist could not call themselves a nurse anesthesiologist.

“Terms such as anesthesiologist, ophthalmologists, cardiologists are going to be restricted to only physicians in an effort to curb confusion and so patients know exactly who they are seeing,” says Garofalo. “I applaud those states that are doing that, and more should do it.”

Orozco agrees that it’s important for patients to know what type of medical professional they’re seeing and that PAs have always been in favor of being transparent with patients.

When asked about transparency and the confusion between doctors and NPs, Kapu says, “Based on the results of our own research, patients have a strong understanding of the role of nurse practitioners.”

Another transparency issue that some physicians point out is that patients don’t understand the standard-of-care differences between doctors and NPs.

“If you are doing the job of a nurse, you should be held to the standard of nursing practice,” says Niran S. Al-Agba, M.D., co-author of “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.” “If you are working independently in an urgent care center as a physician-equivalent filling the job of a physician, I think you should be held to the same standard as a physician. Or the patient should be told, ‘You’re seeing a nurse practitioner. If she makes a mistake, she’s only required to know what a nurse knows. Do you want to see a doctor or see a nurse?’ So either transparently let the patient know or hold NPs to the same standard.”

Lacy R. Leduc, J.D., an associate in the medical malpractice group Roetzel & Andress in Cleveland, says that the standard of care for physicians is what a reasonable physician would do under the same circumstances, whereas an NP will be compared with other NPs, even if they are practicing primary care independently like a physician.

PAs are slightly different. “For a PA, the supervising physician is always responsible, whereas with an NP, unless state law says otherwise, they are responsible for their own decisions,” says Leduc. “(NPs) are always going to be judged by their peers based on education and training, and they never had the same education and training as a physician.”

There’s also the question about malpractice rates. If NPs are practicing primary care without doctor supervision, will an increase in malpractice cases against NPs cause an increase in physician rates, since they’re doing the same job?

The short answer is no, according to Laura Kline, MBA, senior vice president of business development for The Doctors Company, a medical malpractice insurance provider, which views them as a separate category. Separate rates and rules will be filed with each state’s department of insurance, so there will be a physician and surgeon filing that captures their data and then a distinct set for NPs and PAs practicing independently.

“If we’re seeing an increase in claims for this separate category of advanced practice clinician, then we’ll adjust the rates in that specific filing,” says Kline. “As we go to market with this stand-alone product offering, the rates are about on par with the rates (being paid) under the physician and surgeon policy. But over time, having more autonomy creates greater exposure for them.”

Claims data for NPs with full practice authority may prove over time they are putting patients at greater risk, as some physicians argue, or these data may show NPs are equivalent to physicians when it comes to primary care decisions, albeit at a lower standard of care.

“There are a lot of people who think there are shortcuts to being able to practice medicine, except that the model for practicing and training for medicine has been in place since the ‘Flexner Report,’ which has its own historical issues but has really guided us well for the last 100 years or so,” says Garofalo. “It established there are four years of medical school and at least three years of residency, up to seven, depending on your subspecialty. There are a lot of nurse practitioners who feel that their experience as an RN actually somewhat qualifies them as being trained appropriately, despite the fact that they learn a nursing model. But that’s not medicine.”

Alex agrees. “As a nurse, you can always kick the decision-making can down the hall to the physician; as a physician, you can’t do that,” she says. “NPs should not be autonomous. They are practicing and claiming board certification — but it’s from a nursing board. They are not certified by a medical board.”

Coming next month, part 4 and the conclusion of the series:

The future of health care: Who will be the main provider of primary care?