The evolving models of primary care: More harm than good?

The legislation proposals aimed at allowing physician assistants and nurse practitioners to act independently and deliver primary care services in place of physicians is a change in health care that we may face with an impending primary care physician shortage. It is an important topic for patients and physicians to discuss since ultimately those two groups will be impacted most by this change. Patients should be concerned with the quality of care they would be receiving without a physician’s expertise and training. New physicians should consider the possibility of having to face greater competition for business. Medical students may face an environment where the government is less willing to increase residency training programs for the growing number of medical school graduates if the availability of primary care services has seemingly been addressed.

As physicians, we have the utmost respect for the contributions nurse practitioners and physician assistants make, and they undoubtedly add great value to patient care. However, there is one thing that cannot be denied and that is a lack of training. This is where the problem lies. Nurse practitioners receive 5-7 years of education compared with 11 years of education for a primary care physician (and additional years for specialists).  Training and clinical hours required to become a family physician total 21,700 hours compared with 5,350 hours for nurse practitioners. In fact, there have been many first-hand accounts of nurse practitioners that had gone back and went to medical school and who have seen both sides.

For example in a recent AAFP telephone news conference, LaDona Schmidt, MD was interviewed on the topic of the difference between nurse practitioners and physicians.  Dr. Schmidt states, “I didn’t know what I didn’t know until I went through 7 more years of training,”since she was a nurse practitioner before she went back to become a physician. Dr. Schmidt also commented on how she was surprised how difficult medical school was given her previous training.  She goes on and says that it wasn’t until she completed medical school and residency that she realized “how much I did not know about the underlying causes of disease processes.”

The additional training a physician goes through allows for detailed analysis of multi-organ systems and complex patient conditions. The American Academy of Family Physicians articulates this point well in saying that “family physicians are trained to provide a complex differential diagnosis, develop a treatment plan that addresses multiple organ systems, and order and interpret tests within the context of the patient’s overall health condition.  Nurse practitioners and physician assistants, on the other hand, are specifically trained to follow through on the treatment of a patient after a diagnosis and to implement protocols for chronic disease management.” Thus, a team-based system would seem to provide a higher quality of care rather than a greater number of non-physician practitioners.

The problem, however, is that our health care system is facing a shortage of primary care physicians. The proper planning to accommodate the growing elderly population was not done and now it seems that in an attempt to find a solution for lack of planning, the government is considering allowing nurse practitioners and physician assistants to assume the role of primary care physicians. The big question is whether assuming this role independently will cause more harm than good? It’s important to consider. Since most of the data that shows the high quality of patient care received by nurse practitioners and physician assistants have been under physician-led practices, it is difficult to promote this change with any confidence.

A few studies have been performed in Europe, but I have yet to find the conclusive results. A study out of Netherlands was projected to be completed in 2015 and remains inconclusive at this time. Therefore, we should proceed cautiously and utilize evidence-based and collaborative models of care.  The promotion of team-based care should serve the population as greater numbers of both physicians, nurses and physician assistants are trained who will be able to grow this team-based approach.

Sarah Barber is a physician.

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