Proponents of independent non-physician practice make a dangerous assumption [PODCAST]

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“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?”

Rebekah Bernard is a family physician. She is the co-author of Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.

She shares her story and discusses the article that she co-authored, “Proponents of independent non-physician practice make a dangerous assumption.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Rebekah Bernard. She is a family physician, and she co-wrote the KevinMD article “Proponents of independent non-physician practice make a dangerous assumption,” and she’s the co-author of the book Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare. Rebekah, welcome to the show.

Rebekah Bernard: Thank you for having me.

Kevin Pho: So we’ll get into your article and book in a little bit, but first off, can you share your story and your journey to where you are today?

Rebekah Bernard: I’d love to. I’m a native Floridian and the daughter of two registered nurses, and my journey was shaped by the onset of my mother’s severe mental illness, which began when I was about 12 years old. Because we lived in a rural underserved area and we were of depressed socioeconomic means, her health care was really limited, and her disease progressed to the point where she wasn’t able to work, and she actually required my help to take care of my three younger siblings.

Fortunately, I was able to attend college through financial aid and scholarships, and then I was accepted to medical school with a National Health Service Corps scholarship. So following medical school and residency in family medicine, I went to work in a rural underserved area. I did that for six years. I loved the work, but I found myself really frustrated by the bureaucracy and the barriers that were put up to taking care of patients. I also was really not happy with the way that I was treated as a physician, nor my fellow clinicians, by the administration there, something that I’ve heard from other people in federally qualified centers.

So I decided that I needed to make a change. I tried out a for-profit health system, but what I learned was that the same experiences and problems that I had in a government setting were really the same in a corporate setting. So I decided that I really needed to open my own practice. I converted that to direct primary care about five years ago. What I love so much about it is that it allows me to continue to provide underserved care. Most of my patients are uninsured, but I can do this in a way that eliminates all the administrative burdens that you get when you involve a third-party payer, like an insurance company or a government payer.

Kevin Pho: And for those in my audience who don’t know what a direct primary care practice is, can you explain what that is?

Rebekah Bernard: Yeah, direct primary care doctors eliminate a third-party payer, or a middleman, from the arrangement, and patients pay directly to the doctor for their services. Most of them are set up through a monthly membership, and the average cost of a DPC practice across the country is about $77 a month. So for that amount, patients receive virtually unlimited visits from their doctor. They can usually text and email. It’s just a different model of health care that is usually quite rewarding for physicians, and it offers great patient care as well.

Kevin Pho: And how’s your practice going, especially during the pandemic?

Rebekah Bernard: It’s been surprisingly resilient, actually. I lost fewer patients to attrition. Usually every month, we have some patients that drop their membership because they’re moving or they get health insurance or for various reasons, but I’ve lost fewer patients during the pandemic than ever before. I think it’s because patients are afraid, because they know they need someone if they do get sick, but they also like the access that we offer. We were already set up to offer telemedicine and web-based visits. We do a lot of things virtually anyway. So the model really works well. As awful as these times are, this model is pretty resilient for primary care.

Kevin Pho: All right, let’s transition into your book and article. You co-wrote the article “Proponents of independent non-physician practice make a dangerous assumption.” Now, for those who haven’t read that article, can you just walk my audience through it and maybe share the story of why you decided to co-write it?

Rebekah Bernard: The article is an excerpt from the book Patients at Risk. I really never thought about the issue of non-physicians in practice until a few years ago. I had supervised nurse practitioners and physician assistants when I worked in the federally qualified health center, but no one really taught me how to do that or explained anything about the model to me.

A few years ago, I joined an online group called Physicians for Patient Protection. I don’t even know how I got added onto it, but it was a group of doctors that were talking about some of the challenges that they were seeing and some of the impact on patient care that was occurring because of physicians being replaced. I believe what we’re seeing is such an increase in the corporatization of health care. Many companies are taking advantage of independent practice, or in non-independent practice states, they’ll force physicians to supervise so that they can hire an increased ratio of non-physician practitioners and sometimes pay them less. It’s become a real problem in medicine, and I started to become aware of that.

Around that same time, I read Niran Al-Agba’s article that she wrote on KevinMD about 20,000 hours making the difference. I had the chance to meet her at a meeting in Washington, D.C., and we connected and started talking about this issue, and we decided that it was important enough that we needed to write a book. Because the truth is, there’s absolutely no book out there that addresses the impact of non-physician practitioners. Even books on health care reform, like An American Sickness, none of them even mention the issue of non-physician practitioners. And yet it’s something that’s really important for patients to be aware of.

Kevin Pho: So what exactly are the clinical impacts of non-physician practitioners practicing independently?

Rebekah Bernard: What we’re seeing is these corporations especially, but also academic centers, are firing physicians across the country and replacing them with nurse practitioners, really cheerlead to save money. The impact of that is that patients are losing a chance to see a physician. You know, I’m a big believer in patient choice, and if a patient wants to see a nurse practitioner or a physician assistant for their care, I think that’s great. However, if they would like to see a physician, they should have that option, and that doesn’t always happen.

In our book, we tell a very tragic story about a 19-year-old young woman who had a pulmonary embolus, and she was taken by ambulance to an emergency department, not in a rural area, just outside of Oklahoma City. But when she got there, there was no physician on staff; there was only a nurse practitioner working alone. The health system that employed this nurse practitioner was a multibillion-dollar corporation that went out of its way to staff with only nurse practitioners. Sadly, the patient ended up dying after 11 hours of futile treatment. She was finally transferred and properly diagnosed, but she succumbed. The problem that I see is that this patient and her family had no idea that she was not being treated by a physician. They were under the impression that a physician was supervising their care.

This is happening across the country, and patients are really losing the opportunity to have physician-led care, and only patients can be the ones to make a change, because government entities are passing independent practice across the country, in nearly half the states. The entire Veterans Administration now allows unsupervised practice by nurse practitioners. North Dakota became the first state to allow independent practice by physician assistants.

The truth is, there is a big difference in our training and education. There’s a minimum of 500 clinical hours that nurse practitioners must complete. For physician assistants, it’s about 2,000 hours, and it’s estimated that physicians have a minimum of 15,000 hours. So it’s kind of unrealistic to expect that you would get the same level of care. And the truth is that studies do not show that the care is the same. You hear all the time from proponents of non-physician practitioners that studies show that they provide the same care; sometimes they’ll even say it’s better. But if you review the literature, the Cochrane database was the largest study, and they could only find 18 studies over 50 years that were good enough to analyze. Of those, every single study involved clinicians that were being supervised by a physician. So the truth is that there are studies that show nurse practitioners and physician assistants can provide great care when they’re working in teams with physicians, but there are no studies that show that independent practice is safe or effective.

Kevin Pho: Now, the studies that advanced practice practitioner proponents point to, where are they getting that data from?

Rebekah Bernard: Yeah, they do have data that shows that they do a great job when they’re working with physicians. But what happens is they extrapolate that out, and that’s where the title of the article that I submitted to you comes in, which is that they’re making a dangerous assumption. They’re saying, “Well, if we can practice well when doctors are involved, then we should be able to do equally as well independently.” And the truth is, there’s no data to back that up.

Kevin Pho: Now, are there any studies that show that they provide worse care? Medical liability lawsuits, for instance?

Rebekah Bernard: Well, there are studies that show that non-physician practitioners order significantly more lab tests and more radiology tests. In fact, nurse practitioner prescribing or ordering of X-rays has increased 444 percent in the last 10 years, whereas physicians’ ordering of X-rays has decreased. They prescribe more medications, including more opioids and more antipsychotic medications. They refer more often, and they have been found to have lesser-quality referrals. They also perform more biopsies, more unnecessary skin biopsies, than physicians. So there is data that’s accumulated that shows some of these concerns.

Kevin Pho: Now, we have a shortage of physicians when it comes to primary care, and especially in rural areas, it’s very difficult to find a physician who practices primary care. Given those circumstances, do you not see a little bit of a role for advanced practice practitioners to practice independently in areas where primary care physicians simply aren’t available?

Rebekah Bernard: It would be a role if they would do it, but unfortunately, the data shows that states that have allowed independent practice have not seen an increase in practitioners into those areas. In fact, the number one clinician type that works in rural medicine is family physicians. They did a large pilot study in 2012. The government spent, I think it was, $1,290,000 trying to encourage nurse practitioners to enter into primary care and rural care, and what they found was that only a tiny minority of the graduates from that program chose that type of practice. Most of them went into hospital care.

Unfortunately, we’re seeing that nurse practitioners are increasingly not choosing primary care, for the same reason that doctors are not as interested in doing it. And physician assistants have always been more specialty-dominated. So the argument that these practitioners will serve this important role is a good argument if it were true. Unfortunately, it has not panned out to be the case.

Kevin Pho: Now, is that also true for urban areas? Because anecdotally, in more desirable areas and more urban areas, there’s also a shortage of primary care physicians. What does the data show there?

Rebekah Bernard: You know, I don’t know the exact data on the urban areas. I do know that there’s a significant overlap. The American Medical Association has practice mappers for every state, and you just see there’s a complete overlap of nurse practitioner and physician practices. So we’re basically working in the same areas, and we’re not necessarily seeing that nurse practitioners are fulfilling more of an underserved role.

Kevin Pho: Now, across the country in terms of legislation, you mentioned North Dakota allowing advanced practice practitioners to practice independently. What about the other states?

Rebekah Bernard: Right now, North Dakota is the only state that allows physician assistants to practice independently, but Maine is on the cusp of it. Because of COVID-19, quite a few states did allow temporary expanded practice rights, and I don’t know if that’s still going on everywhere. I’m assuming that may increase, because we’re now seeing another increase in COVID-19 cases.

Kevin Pho: And what do you anticipate the next five to 10 years to bring?

Rebekah Bernard: I think it really depends on patients. I think that patients are starting to see what’s happening. In fact, I get a lot of emails. It’s interesting, because I get, of course, some hate mail and people that are unhappy with what I’m saying, but I actually get a lot more supportive emails from nurse practitioners and physician assistants, and also patients, who are saying this model is really just corporations and certain groups that are profiteering off of these professions. So the only thing that will change is if patients demand that physicians be involved in their care. So what will happen just depends on how people respond, and I think my job is really just to get the word out so that people can make their own best choice.

I don’t think that going to legislators is something that’s really effective, because I don’t feel that they really understand, and they’re mostly focusing on quick fixes. So, you know, this sounds like a good idea, but they’re not necessarily that interested in the realities and the fact that to train a physician is difficult. It is expensive, and we’re not creating enough physicians.

You know, the United States ranks 24th out of 28 similar nations in number of physicians per capita and in the creation of new physicians. The only countries that are worse than us are Poland, Canada, which is interesting, South Korea, and Mexico. So we don’t have enough physicians. We’re also the country that utilizes non-physician practitioners the most, and of course, we’re the country that has one of the highest rates of health care spending. So I would argue that increasing the number of physicians, especially in primary care, will actually save our country money, and we know that it decreases mortality, and that’s where we need to put our efforts.

Kevin Pho: So in your view, what should the next steps be?

Rebekah Bernard: The next steps are to increase the training of physicians and increase residency programs, and there might be some way to make those programs a bit shorter. The European model, of course, instead of doing four years of college and four years of med school, has a more abbreviated two years of college and then four years of medical school. Perhaps residency programs could be a smidge shorter.

You know, it’s so interesting, because California just passed a law that physicians are not allowed to get a license until they’ve completed three full years of residency, but yet the governor just signed a law that nurse practitioners can practice independently. So it’s really interesting that physicians require that full three years. But perhaps that’s something that could be made less. We know that residency funding has been frozen since 1997. That’s many, many years without an increase in funding to train more physicians. So clearly, we need to invest in physician training so that we can provide care to patients.

And of course, I’d love to see more emphasis on ways to encourage physicians to choose primary care and to work in underserved areas. There are motivators. For me, working with the National Health Service Corps was one of the reasons I chose primary care and rural work. I think if you can make it easier for doctors to do this kind of job, they want to be able to provide that kind of care.

Kevin Pho: We’re talking to Rebekah Bernard. She’s a family physician. She co-wrote the KevinMD article “Proponents of independent non-physician practice make a dangerous assumption,” an excerpt from the book that she co-authored, Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare. Rebekah, in your view, what is the ideal role for advanced practice practitioners in medicine?

Rebekah Bernard: Studies show that nurse practitioners and physician assistants can provide excellent care when they’re working in close teams with physicians. We know that nurse practitioners do a great job with education. They can spend time with patients. Patients love them because they listen. I would hope that physicians do too, but sometimes, because of limitations in time and systemic burdens, we aren’t always able to show patients how much we really care, and that’s something we need to change. But I would say that working together as teams, with the physician as the leader of the health care team, because they do have the most training and knowledge, is the best way to work together.

Kevin Pho: From my limited experience, that’s generally the view of a lot of advanced practice practitioners that I talk to. No one really disagrees with that. Now, where are you finding pushback against that model?

Rebekah Bernard: The AANP, the American Association of Nurse Practitioners, strongly promotes what they call full practice authority. In fact, like you said, I’ve heard as well from many nurse practitioners who say, “We don’t want to be forced to be autonomous. We want to work together.” But there is definitely a strong push toward independence.

For example, in 2019, at the close of the AANP annual meeting, it hosted a lecture by Margaret Fitzgerald, who is a nurse practitioner educator and has her own research company. She had a slide at the end. It had a smiley face with a zipper for the mouth, and it said, “Sometimes the strongest voice is silent.” Her message was that if you’re opposed to full practice authority, you need to keep your mouth zipped, because you could actually harm the profession.

So the AANP is clearly sending a message that they do not want anyone speaking out against autonomous practice, to the point where they also put a reporting link on their website: If you hear someone talking negatively about the profession or about full practice authority, you can anonymously report them to the AANP authorities so that they can take action. So that is where I think the pushback is, and I think the AANP is doing a big disservice to the profession by pushing in this direction.

Kevin Pho: One of the more recent trends that I’m seeing is nurse practitioner degrees at a doctorate level, doctors of nurse practitioners. So what’s your opinion of those, and do they play a role?

Rebekah Bernard: Well, studies show that 85 percent of all DNP programs are non-clinical, which means that they’re getting training in administration, research, and leadership. So if they are clinical degrees, then certainly they can add to a nurse practitioner’s experience, but the reality is that most of them are non-clinical. So now we have nurses that are being called doctor, and PAs as well; they have a doctorate in medical science as well. I fear that it can be confusing to patients, who don’t always know who the doctor is anymore, and it may not necessarily improve their care if this is a non-clinical degree.

Kevin Pho: And my final question, Rebekah: What’s your take-home message that you want to leave with the KevinMD audience?

Rebekah Bernard: The message is that we are health care teams. We need to work together, but we need to make sure that we’re practicing safely and effectively, because these are patients’ lives on the line. And patients will need to educate themselves. Unfortunately, Americans are very good at researching before we buy things. We get Consumer Reports, review sites. So unfortunately, we’re going to have to take that same approach when it comes to health care, and we’re going to need to start asking questions and making sure that we’re getting the type of care that we want and need for ourselves and for our families.

Kevin Pho: And how can people find your book?

Rebekah Bernard: Please visit our Amazon site, which has it, and you can also find us at Barnes and Noble. So it’s Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.

Kevin Pho: Rebekah, thank you very much for your time and insight, and thanks again for being on the show.

Rebekah Bernard: Thank you for having me.

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