Why family physicians are a threat to themselves

In recent months, AAFP President Reid Blackwelder has been editorializing and debating what they see as the encroachment of nurse practitioners (NPs) and other “mid-level providers” (physicians are, presumably, “upper-level”) on the practice territory of family physicians (FPs). Dr. Blackwelder has repeatedly said that NP and physician roles are “not interchangeable.” The AAFP’s position on this issue seems to be resistance to the increasingly common decisions by state legislatures to free NPs of physician oversight. Dr. Blackwelder and the AAFP are misallocating their energies and resources – NPs are not a threat to family physicians. We are a threat to ourselves.

Two vignettes serve to illustrate my point. First, a recent news headline (“Hospital Lifts Ban on Non-Specialists Delivering Babies“) announced that, after a long fight, a Texas FP finally got privileges to deliver babies. This is news? Sadly, yes. Second, while eating at one of my favorite restaurants recently, the waitress and I got to talking about her search for a doctor for her little boy. She knew I was a family doctor, but she was surprised to find out that I, too, take care of children, deliver babies and see patients in the hospital.

What do these anecdotes have to do with the AAFP’s quest against NP independent practice and protection of FP identity?

It is not nurse practitioners or physician assistants who have denied family physicians privileges to practice obstetrics, to do C-sections, to do endoscopy, to practice conscious sedation and to do minor surgeries – in other words, to practice the full scope of family medicine. It is our “partialist” (a delightfully accurate term that needs more circulation) colleagues who see us as a threat to their “turf” (and income) who have restricted our credentials and ability to practice.

It is not nurse practitioners or physician assistants who have done such a poor job shaping and marketing our image as “comprehensivists” that laypeople are surprised to learn that FPs take care of children, deliver babies, practice emergency medicine, do minor office procedures, and see hospitalized patients. It is we who have voluntarily given up our scope of practice in many areas, who are surrendering our hospital, obstetrical and surgical practices either in the name of an easier lifestyle or because of pressure to see more patients per day.

The AAFP is a subset of dinosaurs protesting the approaching meteor. In 2014, millions of Americans will gain health insurance and flood the primary care market. There simply will not be – there cannot be – enough FPs to fill the gap. NPs will serve that necessary role, and do an excellent job. Hundreds of thousands of Americans will soon identify NPs and PAs as their primary doctor. It will happen, it already has happened. There is no way the AAFP can prevent it.

Furthermore, as the family medicine skill set deteriorates, as the trends continue that fewer FPs do obstetrics, endoscopy, minor surgeries and hospital medicine, our practical skill sets (regardless of the oft-quoted “hours of training” differential) will asymptotically approach those of our NP colleagues. To the patient in the exam room, there will soon be no discernible difference between their self-limited family physician or their well-trained nurse practitioner. They just want a primary care clinician who can do a good job – and very soon, either one of us will.

If my professional organization, the AAFP, wants to know who is eroding the identity, role and practice spectrum of family physicians, they need not look at NPs. They need only look in the mirror.

Paul D. Simmons is a family physician.

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