Proponents of independent non-physician practice make a dangerous assumption


An excerpt from Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.

On a sunny Tuesday in March 2015, the steps of Capitol Hill were draped in white as nurse practitioners from across the United States descended on the nation’s capital. Their long white coats flapping, and stethoscopes draped around their necks, the lobbyists marched with determined steps.

The organizer of the event, the American Association of Nurse Practitioners, called it a record day. Nurse practitioners had scheduled more than 250 visits with legislators.  Their message to lawmakers was clear: Nurse practitioners are just as good—or better—than physicians. Further, if it were legal for nurse practitioners to practice autonomously, the country would save money while also increasing access to health care in physician shortage areas —a promise with tremendous appeal to those in public office.

The nurse practitioners had a compelling argument. The cost of the 15,000 hours of training required of physicians before being permitted to practice medicine is much higher than the minimum 500 hours required of nurse practitioners. At the same time, lobbyists showed lawmakers studies that appeared to indicate that nurse practitioners were just as safe and effective as physicians, despite this difference in training and experience. So, why pay for the high cost of medical school and residency for physicians when nurses can be trained in less time and for less money?

Lawmakers listened attentively to these arguments. Representatives with large rural constituencies were particularly intrigued by the idea that nurse practitioners could increase access to health care in underserved areas. After all, economists were once again predicting a physician shortage, and nurse practitioners promised to fill that void.

By 2019, legislators in 23 states and Washington DC were convinced. Despite opposition from physician and patient advocacy groups, lawmakers in these states granted nurse practitioners the right to provide medical care to patients without physician supervision. That same year, North Dakota became the first state to allow physician assistants to practice independently.  Corporations and private equity markets were delighted. Instead of paying top dollar for fully trained physicians, these organizations now had the green light to hire less expensive nurse practitioners. Retail pharmacies across the nation rushed to install nurse practitioners into mini-clinics on every corner. Hospitals began to staff emergency departments and intensive care units with “doctors” of nursing. University medical centers even began to utilize nurse practitioners to teach medical students and resident physicians. Noting the success of nurse practitioners, other groups began to follow suit, with physician assistants, pharmacists, and psychologists lobbying for expanded practice rights.

Unfortunately, most Americans have remained dangerously unaware of this revolution in health care. Being treated by a non-physician is not on the radar of the average patient, most of whom assume that anyone in a white coat is a physician. If patients do wonder about being treated by a non-physician, they are reassured that their nurse practitioner or physician assistant is “just as good” as a doctor, an idea reinforced by multi-million-dollar direct-to-patient advertising campaigns. But is care by nurse practitioners and physician assistants really as good as that of physicians?

Non-physician advocacy groups point to studies that claim that nurse practitioners and physician assistants can provide care for patients safely and effectively. Indeed, some studies have shown that non-physicians can and do provide quality care when working in teams with physicians, following clear medical protocols. However, there are absolutely no credible scientific studies that support the safety and efficacy of non-physicians practicing without physician supervision. None.

This is a bold statement, but it is unequivocally true. While medical literature headlines and abstracts may imply that the non-physician practitioners being studied were providing care “independently,” the fine print reveals otherwise. A detailed reading of each article makes it clear that in every single study, physicians were available for consultation and supervision when non-physician practitioners ran into trouble. Proponents of independent non-physician practice are making a dangerous assumption: that if a non-physician can practice safely with physician supervision, as studies seem to indicate, then they should be able to practice equally as safely without physician involvement.

Rebekah Bernard is a family physician. Niran S. Al-Agba is a pediatrician. They are the authors of Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.

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