Physicians dominated 20th-century American medicine, but not from the start. In his landmark book, Paul Starr explained how a ragtag, “weak traditional profession of minor economic importance” transformed into a sovereign profession controlling healthcare delivery.
By the end of the century, fearing a surplus, doctors successfully lobbied to prevent growth in medical schools and residency programs. Consequently, as the US population expanded, the number of physicians stagnated.
Today, the US has fewer physicians per capita (2.6 per 1,000) than most developed nations (average 3.6 per 1,000). Given an aging, sicker population, the country is short 125,000 physicians and is projected to lack nearly 200,000 by 2037.
NPs And PAs Are Filling The Gap
As the medical profession was rising, two new clinical professions quietly emerged. In 1965, the University of Colorado started the first nurse practitioner program to expand care access. Duke University launched the inaugural physician assistant program that same year. For decades, the number of NPs and PAs increased gradually. Since 2000, these professions have exploded.
Today, America’s 280,000 NPs and 145,000 PAs comprise one-third of the clinical workforce. They provide over a quarter of healthcare visits, far exceeding any other country. And they are among America’s fastest-growing professions, poised to provide a higher proportion of care over time.
Is NP And PA Care Equivalent To Physician Care?
After college, physicians complete four years of medical school and three to seven years of residency and fellowship (7-11 years total), amassing 12,000-16,000 patient care hours. NPs are (traditionally) registered nurses who complete one to three additional years of training, with 500-1,000 patient care hours. PAs complete two to three years of training, with 2,000 patient care hours.
Bruce Lee said, “Under duress, we do not rise to our expectations but fall to our level of training.” Yet despite significantly different training, most studies have found physicians, NPs, and PAs provide similar-quality care. (There are some exceptions.)
A counterargument is that quality is challenging to measure. In many ways, it is an “I know it when I see it” phenomenon.
Dr. Rebekah Bernard, a vociferous critic of independent NP practice who has written two books on the subject, argues, “There are absolutely no randomized, controlled trials examining the safety and efficacy of care provided by unsupervised nurse practitioners treating ‘typical’ patients.”
After two-plus decades of practicing medicine, I find it hard to generalize. In my experience, most NPs and PAs are good-to-great, but some are not. The same is true of physicians.
We Must Ask Different Questions
I recently discussed this with Lusine Poghosyan, a Columbia University nursing and health policy professor. She rhetorically asked, “Why would we train various professionals completely differently and expect them to practice the same way?”
I agree. With NPs and PAs firmly established as key healthcare providers and given ongoing workforce shortages, we must ask questions beyond whether their care equals physician care.
First, how can various clinicians best meet the population’s health needs? Though we tend to emphasize differences, NPs, PAs, and physicians have overlapping scopes of practice.
Jennifer Orozco-Kolb, PA-C and Chief Medical Officer at the American Academy of Physician Associates, told me, “PAs are not trying to be physicians. We are trying to do what we are trained to do: care for our patients and communities.”
Second, how do we ensure all professionals are well-prepared to practice? This is most important for new NPs and PAs with limited clinical experience, particularly NPs graduating from purportedly shoddy, online, for-profit schools.
NPs and PAs typically form collaborative relationships with physicians, gaining autonomy over time. Roderick S. Hooker, a retired PA and a widely published health services researcher, invoked the “See One, Do One, Teach One” model common in medicine. A growing number of organizations offer postgraduate residency and fellowship programs.
Third, how do we optimally configure practices? For example, when should patients see a physician, an NP/PA, or a team? When is physician oversight necessary?
While states technically determine the scope of NP and PA practice, provider organizations decide their actual roles. For example, hospital privileging is not associated with scope of practice laws. Similarly, NP and PA roles vary more within states than between them.
Organizations can define roles based on clinical problem types. NPs and PAs are suited to manage well-defined “structured problems” that are solvable using protocols (e.g., uncomplicated UTIs and hyperlipidemia). Yet, without the right experience, they may struggle with poorly defined “unstructured problems” lacking known solutions (e.g., refractory depression and penetrating Crohn’s disease). Of course, novice physicians may face similar difficulties.
A related dimension is clinical discipline. NPs and PAs often fill primary care shortages. However, primary care’s broad range of conditions makes it far more complex than most people appreciate. Some NPs and PAs may be better suited to develop more narrowly focused, deeper expertise in specialty care.
Ultimately, we must trust organizations to decide how to incorporate various clinicians. This means accepting that some may employ NPs and PAs as labor arbitrage to maximize profits. It also means empowering patients to decide the type of clinician they see.
Looking Ahead
Clinicians can be territorial. Physicians (rightfully) feel their extensive training earns them unparalleled practice privileges. NPs and PAs (rightfully) sometimes feel underappreciated and even disrespected. Putting emotions aside, to serve America’s sicker, aging population, we need all hands on deck.
How should these professions evolve?
Dr. David Chan, a hospitalist and Berkeley health economist, explained, “In many settings, we have physicians and non-physicians performing the same job. This begs the question of whether the physicians are overtrained or the non-physicians are undertrained for that job.”
While there is no clear answer, each profession must continually examine its training process, asking questions like: How much pre-clinical work is relevant to clinical practice? Typically, cultivating learning skills is more important than mastering basic science principles.
To what extent is training about learning versus signaling capabilities? While medical schools are highly selective and PA schools are selective, many NP schools accept 100% of applicants.
How much clinical exposure is necessary? There is no substitute for actual experience.
And how should training and practice change as artificial intelligence spreads throughout medicine? AI is already changing how clinicians access medical knowledge and process clinical information. Some AI tools are even starting to outperform clinicians in prediction tasks.
Moving forward, recalling facts and making predictions will be less valuable. More critical will be clinicians’ ability to ask the right questions, contextualize information, apply sound judgment, and care compassionately. These changes will shift roles and further blur the boundaries between physicians, NPs, and PAs.
Acknowledgments: I thank Rebekah Bernard, David Chan, Rod Hooker, Jennifer Orozco-Kolb, Lusine Poghosyan, Polly Pittman, and Chris Turitzin for discussing this topic with me.
Disclosure: I advise WovenX Health, which provides virtual NP and PA staffing for specialty care practices.
