Todd Shryock

The American Association of Nurse Practitioners (AANP) will tell you that nurse practitioners (NPs) are qualified to handle primary care. They point to a long history of successfully caring for patients and a host of studies that back up their claims of quality. For most of that history, NPs were under the supervision of physicians. Now, however, many states allow NPs to practice independently, and some physicians are worried that NPs are not properly prepared and that patients don’t understand the differences between an NP and a physician.

“Alex,” not her real name and who requested anonymity for fear of workplace reprisal, was an experienced nurse who wanted to provide greater care for patients and went to school for her nurse practitioner certificate. Upon graduation, she was so uncomfortable with the idea of seeing patients based on the training she received that she decided to attend medical school and is now a physician.

Looking back, she is disturbed by what she heard and saw while getting her NP training. “They told us we were just as good as doctors and that we had more experience than the residents,” she says.

When asked if NPs are qualified upon certification to see patients without physician supervision, Alex is emphatic in her answer. “How could they be qualified to do that? Their level of training is variable. It is not standardized, with no consistency between institutions. How can they practice with just a nursing background?”

She described her NP training as far less rigorous than her physician training. In her NP training, working as a nurse sometimes could be counted toward clinical hours, and some clinical experience was simply shadowing others, with little or no accountability or requirements to present cases or patient work-ups.

“There were some really good rotations, but they were still nothing like the experience you get as a medical student and definitely not compared to what you get in residency,” she says. “Some NP students I see rotating are just observing, not doing procedures, are not accountable for making educated decisions for care or working through their thought process for differential diagnosis or how to prescribe for treatment. For some schools, they are literally just watching and standing in the background.”

The training requirements for NPs and physicians are disparate: According to the Primary Care Coalition, the difference in training hours between a family practice doctor and an NP is about 15,000 to 20,000 hours, and NPs have no residency requirement.

Despite this chasm, 26 states allow NPs to practice without physician supervision compared with two states for physician associates (PAs), despite PAs having more training than NPs in both didactic and clinical hours.

This broadening scope of practice for NPs has created friction between the professions. The AANP has a page on its site to anonymously report negative statements made about the NP role in the media, and its advocacy page promotes support for several bills that would grant NPs greater freedom of practice, terming any limitations on NP scope as “outdated.”

On the physician side, Physicians for Patient Protection advocates for physician-led care, and physician-centered professional groups like the American Medical Association share reports that show the advantages of physician-led care versus that of NPs or PAs. And on the website 

, physicians anonymously share stories to expose “midlevel provider incompetence in the fight to ensure patient safety and preserve physician-led, physician-supervised medicine” — as an illustration of how deep the frustration runs.

NPs and PAs can’t have full practice authority in a state unless the state legislature authorizes it. Experts say one part of the argument in favor of that is expanding access to care. The Association of American Medical Colleges predicts a primary care shortage of up to 48,000 physicians by 2034, and in many rural areas, the shortage is already being felt. The salaries of NPs and PAs are about half that of primary care physicians, according to most salary surveys, and with state legislators looking to save money and make their constituents happy, full practice authority is a popular legislative choice.

Familiarity also works in the NP’s favor, experts say. According to the AANP, 82% of adults report either being treated by an NP or knowing someone who has. Because patients are familiar with NPs, patients have a high comfort level with them, as evidenced by the 90% of patients who support policies and legislation that remove barriers to NP practice, according to the AANP.

“The greatest advocates for (full practice authority) are the nation’s patients, who have demonstrated overwhelming support for the high-quality health care NPs deliver,” says AANP President April N. Kapu, D.N.P. “States that adopt full practice authority have rapidly improved patient access to care, streamlined care delivery and protected patient choice.”

She points out that in Arizona, which granted full practice authority in 2001, the NP workforce doubled across the state and grew 70% in rural areas within five years of adopting it. In North Dakota, which adopted full practice authority in 2011, the NP workforce grew 83% within six years of adopting it. Nebraska, she says, adopted full practice authority in 2014, and the NP workforce grew in 20 state-designated primary care medically underserved areas within five years. The vast majority (89%) of NPs train in primary care, according to AANP statistics.

But not all states may be hitting those highs. A report by the Oregon Center for Nursing that looked at NP state licensing renewal forms found that only about 25% were in primary care in 2018.

On the PA side, Jennifer M. Orozco, PA-C, president of the American Academy of Physician Associates, points to a 2020 study that appeared in JAMA that shows the number of PAs practicing in rural areas increased by more than 49% from 2009 to 2017 while the number of physicians only increased 14%.

Davis Patterson, Ph.D., director of the Washington, Wyoming, Alaska, Montana, Idaho Rural Health Research Center at the University of Washington School of Medicine in Seattle, says that research into national trends shows that family physicians are more concentrated in rural counties than in urban counties on a per capita basis, which is not true for internists and pediatricians, who are far more concentrated in urban areas.

“NPs and PAs, though more concentrated in urban than rural areas, have a more even distribution than pediatricians and internists,” Patterson says. “In addition, the NP and PA workforces are growing fast relative to physicians, so even if not as concentrated as family physicians in rural areas, their sheer numbers and increasing numbers can help fill rural gaps.”

Orozco says that forcing PAs to be tethered to a physician can limit care when a physician isn’t in the area. She said in one case, a rural physician who had contracted with a PA moved out of the region, and there was no other physician in the area providing the same services the PA had been providing. The patients affiliated with that PA could no longer receive that care because there was no supervising physician, even though the patients had been working with the PA for years.

Christopher Garofalo, M.D., a family medicine physician and member of Physicians for Patient Protection, says it’s true that patients do want better access, quicker access and more convenient access to primary care. “I would argue that they want that of their physicians,” he says. “That’s like saying, ‘I want to be able to fly wherever I want, so just put the co-pilot in there.’ We wouldn’t allow that even if consumer demand wanted it, so I don’t know why they allow it in medicine. If the argument is that even with expanded access there aren’t enough physicians, then my answer to that is we need to train more physicians.”

Garofalo says NPs and PAs are important to medicine but more transparency is needed so that patients understand what type of professional they are seeing.

“There are nurse practitioners who go out and get their doctorate degrees so they can now call themselves doctors, and they feel that’s OK to do in a clinical setting,” Garofalo says. “They don’t think it’s confusing, that patients know who they’re seeing, but they really don’t.”

Some states are taking measures to make sure patients are aware of what type of health professional they’re receiving care from. The New Jersey Health Care Transparency Act, passed in 2021, requires providers to inform patients of their credentials when seeing patients in person or when advertising their services. Indiana restricts the use of certain medical specialty designations to a physician; for example, NPs who are a certified nurse anesthetist could not call themselves a nurse anesthesiologist.

“Terms such as anesthesiologist, ophthalmologists, cardiologists are going to be restricted to only physicians in an effort to curb confusion and so patients know exactly who they are seeing,” says Garofalo. “I applaud those states that are doing that, and more should do it.”

Orozco agrees that it’s important for patients to know what type of medical professional they’re seeing and that PAs have always been in favor of being transparent with patients.

When asked about transparency and the confusion between doctors and NPs, Kapu says, “Based on the results of our own research, patients have a strong understanding of the role of nurse practitioners.”

Another transparency issue that some physicians point out is that patients don’t understand the standard-of-care differences between doctors and NPs.

“If you are doing the job of a nurse, you should be held to the standard of nursing practice,” says Niran S. Al-Agba, M.D., co-author of “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.” “If you are working independently in an urgent care center as a physician-equivalent filling the job of a physician, I think you should be held to the same standard as a physician. Or the patient should be told, ‘You’re seeing a nurse practitioner. If she makes a mistake, she’s only required to know what a nurse knows. Do you want to see a doctor or see a nurse?’ So either transparently let the patient know or hold NPs to the same standard.”

Lacy R. Leduc, J.D., an associate in the medical malpractice group Roetzel & Andress in Cleveland, says that the standard of care for physicians is what a reasonable physician would do under the same circumstances, whereas an NP will be compared with other NPs, even if they are practicing primary care independently like a physician.

PAs are slightly different. “For a PA, the supervising physician is always responsible, whereas with an NP, unless state law says otherwise, they are responsible for their own decisions,” says Leduc. “(NPs) are always going to be judged by their peers based on education and training, and they never had the same education and training as a physician.”

There’s also the question about malpractice rates. If NPs are practicing primary care without doctor supervision, will an increase in malpractice cases against NPs cause an increase in physician rates, since they’re doing the same job?

The short answer is no, according to Laura Kline, MBA, senior vice president of business development for The Doctors Company, a medical malpractice insurance provider, which views them as a separate category. Separate rates and rules will be filed with each state’s department of insurance, so there will be a physician and surgeon filing that captures their data and then a distinct set for NPs and PAs practicing independently.

“If we’re seeing an increase in claims for this separate category of advanced practice clinician, then we’ll adjust the rates in that specific filing,” says Kline. “As we go to market with this stand-alone product offering, the rates are about on par with the rates (being paid) under the physician and surgeon policy. But over time, having more autonomy creates greater exposure for them.”

Claims data for NPs with full practice authority may prove over time they are putting patients at greater risk, as some physicians argue, or these data may show NPs are equivalent to physicians when it comes to primary care decisions, albeit at a lower standard of care.

“There are a lot of people who think there are shortcuts to being able to practice medicine, except that the model for practicing and training for medicine has been in place since the ‘Flexner Report,’ which has its own historical issues but has really guided us well for the last 100 years or so,” says Garofalo. “It established there are four years of medical school and at least three years of residency, up to seven, depending on your subspecialty. There are a lot of nurse practitioners who feel that their experience as an RN actually somewhat qualifies them as being trained appropriately, despite the fact that they learn a nursing model. But that’s not medicine.”

Alex agrees. “As a nurse, you can always kick the decision-making can down the hall to the physician; as a physician, you can’t do that,” she says. “NPs should not be autonomous. They are practicing and claiming board certification — but it’s from a nursing board. They are not certified by a medical board.”

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As nurse practitioners gain more practice freedom, advocates for physician-led care debate the training differences.

The NP training debate

Primary care is all about taking care of patients and trying to keep them healthy through prevention and early detection.

But who is qualified to provide primary care and who does it in a way that is most cost effective, safe and efficient for patients? Nurse practitioners say study results illustrate that they are just as good or in some instances better at caring for patients than physicians. Similarly, physician associates list studies with results showing they are equally effective as primary care givers.

But physicians will argue they have the most training and hands-on experience, are the only ones who should be overseeing a patient’s care and — when all factors are taken into consideration — provide the best care at the best price.

“There are a lot of nurse practitioners who feel that their experience as a registered nurse qualifies them as being trained appropriately, despite the fact that they learn a nursing model and don’t learn medicine,” says Christopher Garofalo, M.D., a family medicine physician and member of Physicians for Patient Protection, a group that advocates for physician-led care. “In fact, there are some schools of nurse practitioners that allow them to get credit for having been a nurse on the floor for X number of years. So what they think is appropriate training, at least according to the criteria we have set out for medicine, is not.”

Both the American Association of Nurse Practitioners (AANP) and the American Academy of Physician Associates (AAPA) maintain a list of studies to validate both their cost and effectiveness claims. These studies were published in an array of medical journals, span different years and were from different researchers and health systems or populations (see sidebar for the full list).

When asked about what the overall results of these studies say about the cost and quality of NP care, Bryan Black, vice president of communications, AANP, said, “The question about the effectiveness of NP care has been asked and answered numerous times over the last four decades. Consistently, peer-reviewed, independent research demonstrates that nurse practitioners provide high-quality, cost-effective care.”

AAPA President Jennifer Orozco had a similar response. “Time and time again, research has supported what we as physician assistants (PAs) have always known: PAs provide compassionate, high-quality care to patients. As part of one of the fastest-growing professions in health care, PAs provide critical access to care for millions of patients every year. These studies also demonstrate that oftentimes PA-delivered care costs less for the patient than physician-delivered care,” she said.

She referenced results of a 2021 metastudy where of the 39 studies examined, 18 found PA care better than that from a physician and 15 found it comparable.

Garofalo says some of the results presented by both groups can be misleading.

“Quality of care studies can get a little bit tricky because that’s a very broad range,” Garofalo says. “Depending on the paper, it can mean patient satisfaction — are patients more satisfied with NPs versus an M.D. or D.O.? It can also mean process measures — did (the doctors) get more patients in to have their diabetes measured over a year than the nurse practitioners did?”

He says results from outcome studies are the most important ones because they measured if the doctor or NP/PA was able to make a difference in the patient’s health.

“When you look at a lot of the literature that the nurse practitioners point to, they will tell you that their studies show they provide equal or better care than physicians,” Garofalo says. “However, most, if not all, of those studies are either process measures or patient satisfaction; they are not outcome studies. And one more thing to note about all those nurse practitioner studies: They have all been done while nurse practitioners have been supervised, not unsupervised. So you cannot make the leap that says, ‘We provide better care when we’re supervised, therefore, we provide better care when we are not supervised.’ ”

Garofalo also points out that the studies are not randomized, meaning the NPs may be getting the patients with less-complicated diagnoses and physicians are treating the more complex cases.

The study Garofalo says that is the best comparison is the Hattiesburg Clinic study, which looked at the cost effectiveness of NPs and PAs compared with physicians. The results at the 300-physician clinic showed that advanced practice providers (APPs) cost patients an average of $120 more than physicians, and because of this, the clinic now has patients see only doctors as their primary care provider with APPs in a supporting role.

But both the AANP and AAPA argue results of this study are flawed.

“The Hattiesburg article is a summary of an internal program evaluation from a single clinic in a restricted practice state, a state where it is against the law for an NP to practice without a collaborative relationship with a physician,” Black says. “It presents only descriptive analysis and comparison. It isn’t a study.”

He points out there are no data related to the total sample size in each provider group, and no standard deviations, among other issues.

“Ultimately, the findings of this internal program evaluation cannot be generalized or extrapolated to address questions of NP cost-effectiveness or quality of care compared (with) physicians for several reasons, including but not limited to: it didn’t analyze the data to allow for a direct comparison of M.D./D.O. to NP, it doesn’t meet the basic requirements for statistical evidence, and it lacks the rigor of traditional cost-effectiveness research,” Black says. He also notes that the study did not differentiate between NPs and PAs.

Likewise, the AAPA also has issues with the study results.

“Twice as many physicians saw 13 to 16 times more patients in the same time period,” Orozco says. “This calls into question issues related to visit attribution.”

In addition, Orozco says the study does not show co-managed teams as a standalone comparison group, only physician-led versus APP-led teams. “They even stated that the patients who were co-managed had the best quality of care and cost outcomes,” she says. “In fact, when we examined data for patients who were co-managed in primary care, being defined as alternating visits between physician and APP, those patients had the best quality and cost outcomes of all.”

Orozco also had issues with the conclusion that physicians rated higher across six domains and the narrowness of the cost analysis. The physician ratings were only 0.03 better, which Orozco says is not a meaningful difference. She also says the cost analysis was not representative because researchers only looked at patients who did not have end-stage renal disease and patients enrolled in non-nursing home Medicare accountable care organizations. She notes that the 2021 metastudy results showed that PA-led care costs were found to be lower than those of physician-led care in 29 of the 39 studies.

Is this the end for primary care physicians?

Even if NPs and PAs do order more tests and cost patients more money, that doesn’t necessarily help physicians, says Niran Al-Agba, M.D., co-author of “Patients At Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare

“If you think of yourself like a hospital CEO, and you could pay someone you employ to do the same job as a doctor for less, and yet they made you more money because they ordered more tests, more CTs, more labs — it’s a no brainer, you are not going to keep the physician,” Al-Agba says.

Although payers may be incentivized to keep costs low, Garofalo says the integrated nature of today’s health system works against that. “A lot of systems tend to benefit when they do more procedures, when they have more testing, when more specialists are seen,” he says. “So even if nurse practitioners, as in the Hattiesburg study, order more testing and refer to specialists more often, that unfortunately does mean more revenue for certain parts of the health care system, so that part may not be incentivized to lower costs.”

Value-based care, which pays more for positive patient outcomes and efficient use of health care dollars, uses data to reward the best stewards of payer funds, and experts predict it will eventually be a driving force in health care. But a recent report from the Medical Group Management Association shows that less than 7% of primary care income is generated from value-based care contracts.

April Kapu, president of the AANP, says that nurse practitioners thrive in a value-based environment because of their focus on prevention and treating the whole patient, but that current barriers hold them back.

“One example is the need to modernize state legislation nationwide to allow NPs to practice to the top of their profession and to eliminate costly physician contracts,” Kapu says. “Another is a need to create better tools and resources for NPs leading small and independently owned practices to transition to value-based care while navigating the financial risks associated with administering a new reimbursement model.”

Orozco says PAs also do well when allowed to practice to the top of their license in a value-based care setting. “They increase access to care, they improve patient outcomes, patients don’t have to wait months for an appointment and they don’t have to drive three or four hours to get to a high-quality provider who can help take care of them,” she says. “When you have that consistent continuity of care and improved efficiency in the health care system, those patient outcomes and patient satisfaction scores will improve.”

Garofalo and Al-Agba both point out that this isn’t about a fight over patients, as there are plenty to go around, but about who should be directing primary care for them.

“This isn’t a turf war,” Garofalo says. “Nurse practitioners have their role and they belong in our health care system, but they should be where they are, where there training allows them to be. The nurse practitioners like to say, ‘We should be allowed to practice at the top of our license,’ and I have yet to hear anybody give me a definition of what ‘the top of our license’ means. What they mean to say is, ‘I should be able to practice independently and basically do what I want to do,’ but that doesn’t necessarily mean that they are trained to be able to do that.”

He says that part of the problem with the trend toward NPs and PAs taking more primary care roles is that a lot of people think primary care is easy, so they think it’s fine to have a nonphysician do it.

“Primary care physicians deal with the largest swath of patients out there,” Garofalo says. “It’s not easy to go from taking care of an 80-year-old who’s there for a physical, followed by a 3-year-old who needs a splinter removed, followed by a prenatal patient who’s halfway through her pregnancy, followed by a 25-year-old who just learned they have a brain tumor. So just the very notion that our society thinks, ‘Oh, just let NPs do primary care because it is easy’ is just wrong.”

With the growing cost difference and public acceptance of NPs and PAs providing primary care, Al-Agba doesn’t see a bright future for primary care physicians.

“The long-term ramification is going to be that they are going to take over the jobs in hospitals and urgent care clinics in the next 10 years,” Al-Agba says. “You will not see a doctor in an urgent care clinic or an emergency department any longer, and you also won’t see one in the hospital once you’re admitted. The NPs and PAs are more economical for the big private equity hospitals and other owners, and they generate more money for those entities. What’s the future? Very few doctors employed or working in hospitals, and then the second piece of that, which is really sad, is it will cost patients more for basic care.”

Orozco says the aging population is outstripping the ability of any one profession to keep up with its health care needs and that something has to change. “Let’s work together and seek to understand one another,” she says. “Let’s try to take care of all these patients and stop arguing with one another, because at the end of the day, all we want is for patients to be healthier and for our economy to be healthier. But we can’t do that when we’re against one another, so let’s partner together and start figuring out how to move forward with these teams so that we can provide better care.”

A list of studies from the American Association of Nurse Practitioners showing the effectiveness of nurse practitioners can be found here:

https://www.aanp.org/advocacy/advocacy-resource/position-statements/quality-of-nurse-practitioner-practice

A list of studies from the American Academy of Physician Associates showing the effectiveness of physician associates can be found here:

The Hattiesburg Clinic study that shows care from NPs and PAs costs patients more money can be found here:

https://ejournal.msmaonline.com/publication/?m=63060&i=735364&p=20&ver=html5

How does quality compare between NPs, PAs and physicians? It depends on who you ask.

NPs, PAs or physicians: A question of quality

 took a close look at value-based care and how practices approach it. The study was presented at MGMA 2022 conference in Boston.

One of the most surprising is that 63% of respondents had less than one quarter of their practice’s revenue based on performance in 

, despite expert predictions for years that value-based care would soon supplant fee-for-service. Only 15% of respondents said that more than half of their revenue was from value-based care contracts.

Despite the slow uptake, 67% agreed that value-based care was beeter in the level of quality care provided to patients, but 46% said fee-for-service is better for the ease of practice management. The biggest challenges identified to adding more value-based care contracts was a lack of staff resources, lack of control over patient care-seeking behavior, and lack of control over other providers.

, 74% had added staff, while 71% added technology to assist with the shift. This technology was usually (82%) data analytics/reporting or population health management (57%). Staff changes were most likely to be care coordination (72%) or care management (67%) additions.

When paid resources were added, nearly half (47%) of those surveyed indicated that staff provided the greatest positive impact on patient health outcomes based on return-on-investment. Technology was second with 21%, with patient engagement (17%) and social determinants of health considerations (3%) ranking next.

The MGMA-Humana study shows that despite predictions to the contrary, not much practice revenue is tied to value-based care for most physicians

MGMA 2022: Study finds most respondents agree value-based care is better for patient care quality

Many primary care physicians might say they are. After all, they have spent years building relationships with patients, sometimes treating multiple generations of the same family and learning as much about their private life as their medical history during office visits. Who better to give a diagnosis than someone who knows not only the patient’s ailments but where and how they live, and what nonmedical factors might be affecting their overall health?

But other primary care doctors know this nostalgic view of patient care is heading the way of house calls and the little black bag. Gone are leisurely discussions with patients aimed at pinpointing root causes of health issues. Now, there are corporate RVU goals, patient quotas and productivity spreadsheets. Time for patients is spent instead with electronic health record screens, administrative paperwork and computer systems that often cannot communicate across departments, let alone across the street.

To make matters worse, there simply are not enough primary care physicians. The American Association of Medical Colleges predicts a primary care shortage of between 17,800 and 48,000 doctors by 2034, and those estimates were made before COVID-19 drove some doctors into early retirement or other professions (40% of physicians reported feeling burned out before the pandemic). In addition, by 2034, the U.S. population is expected to increase by 10.6% with a projected 42.4% increase in those 65 or older — the people most likely to need care. More than 2 in 5 physicians will be 65 or older in the next decade, further thinning the doctor ranks.

America already trails most countries in doctors per capita. As of 2019, the U.S. average was 2.64 doctors per 1,000 citizens compared with the global average of 3.37 — an improvement from 1993 when the U.S. number was 2.4.

The result, predictably, is that the patient loses. Monthlong waits to see a primary care physician, rushed appointments, increasing costs taking money out of patient paychecks, and rising copays add up to frustration with the health care system.

Patients want a quick appointment to find out whether their case of the sniffles is anything to worry about; they do not want to be told they cannot see a doctor soon because they are caught up in the macroeconomics of the country’s inefficient health care system.

So, what happens? The patient takes charge. “Patient” is just a medical term for “consumer,” and today’s consumer does not want to wait.

“There’s a big focus on convenient care,” says Tom Florence, president, permanent physician placement, AMN Healthcare/Merritt Hawkins, a health care search firm. “A lot of patients, particularly younger patients, don’t want to wait around in the physician’s office, so fewer younger adult patients even have a regular family practice doctor. They want everything now.”

This demand is driving retailers like CVS and Walmart to get into the primary care game by opening clinics. The consumer wants medical care without a wait, and big corporations and private equity see an opportunity. Inevitably, someone will fill the gaps created by the shortage of primary care physicians.

So, who is in charge of primary care? The consumer, and that has led to a surge of nonphysicians willing to provide such care, often with little or no supervision from doctors thanks to increasing public pressure on legislatures to act.

In 2004 there were 106,000 nurse practitioners (NPs). Today there are 355,000, a growth rate of 235%. For physician assistants (PAs), in 2010 there were 89,019. Today there are 159,000, a growth rate of 79%.

With a shortage of primary care physicians leaving more than 90 million people without access to primary care, according to the Health Resources & Services Administration, it is not surprising that NPs and PAs are filling the gap and being sought to do so.

Retailer clinics are trying to provide more primary care access, but Florence says, “They’re doing a lot of that work through nurse practitioners or PAs.”

The same is often true for urgent care clinics. One startup, Mitesco, which owns The Good Clinic chain in Minnesota and looking to expand nationally, is staffed only by NPs — something it touts in news releases, saying they allow “equal care while cutting costs 25%.”

Mitesco is not alone. Florence says professional searches last year for NPs and PAs slightly exceeded those for primary care doctors for the first time, and searches for NPs were higher than for any other position. “Retail clinics, urgent care, a lot of telehealth are starting to trend toward specifically looking for advanced practice care candidates,” he says. “That’s more about the dollars and cents of it, meaning if we (the urgent care) hire a staff member who costs less, then our expenses are less costly, (and) then this becomes a more profitable venture for whoever is doing the hiring there.”

Despite increased demand for NPs and PAs, Florence says primary care physicians need not worry about a lack of job opportunities. “Family medicine was our No. 1 search for 14 years in a row up until last year; now it’s No. 2,” he says. “I do see a trend where the convenient care lens is a little more tilted toward an advanced practice candidate, whereas hospitals and health systems, generally speaking, prefer to have a physician in place and utilize advanced practice to help.”

The surge in NPs and PAs should not be surprising; both professions were founded as a means of providing more primary care. The first class of PAs graduated in 1967, with all four members having been Navy hospital corpsmen who had considerable medical training during their military service, according to the the American Academy of Physician Associates (AAPA). The PA concept gained federal acceptance and backing as early as 1970 as a creative solution to the physician shortage.

“PAs have been practicing primary care for over 50 years,” says Jennifer M. Orozco, PA-C, president of the AAPA. “I think where PAs fit in is they are often a patient’s primary care provider, just as physicians are, just as sometimes NPs are. Even with all that, we still have more than 95 million patients in the U.S. (who) lack access to primary care … and we have this growing need of chronic health conditions that need to be addressed, from diabetes to obesity. There’s no plethora of problems that are going to go away.”

NPs got their start in the late 1960s because more primary care services were needed for underserved populations. “NPs bring a comprehensive perspective to primary care,” says April N. Kapu, D.N.P., president of the American Association of Nurse Practitioners (AANP). “NPs assess patients, order and interpret diagnostic tests, make diagnoses and initiate and manage treatment plans, including prescribing medications. Today, 82% of adults report they’ve been treated or know someone who has been treated by an NP, and a vast majority of health consumers — nine out of 10 patients — support policies and legislation that remove barriers to NP practice and strengthen patient choice in the selection of a health care provider.”

Although there is some specialization among NPs, almost 89% choose primary care as their area of focus.

As their members’ roles have expanded, the AAPA and AANP have worked to shape their public image as more independent professionals and not just someone on a doctor’s staff. For example, in 2008, AANP petitioned pharmaceutical and health care product companies to use provider-neutral language in consumer print and broadcast advertisements. It has also invested in public relations efforts to change public perception of an NP’s role in the health care system. In late 2020, the AAPA voted to officially change the professional title to “physician associate” rather than “physician assistant” to better convey a PA’s ability to manage patients’ care autonomously.

NPs have full practice authority — meaning they do not require a supervising physician and can see patients on their own — in 26 states, whereas physician associates have full practice authority in just three states, even though their clinical requirements exceed those of NPs.

To become an NP, the person must have a bachelor’s degree in nursing, be a registered nurse, graduate from a master’s program with either a Master of Science in Nursing or a Doctor of Nursing Practice degree, and then pass the National NP Board Certification Exam. The graduate can then apply for state licensure. Most licenses must be renewed every two years, typically with continuing medical education credits of between 20 and 30 hours required annually, depending on the state. National certification by the AANP lasts five years.

PAs need a master’s degree from an accredited PA program, which requires supervised clinical experience in family medicine, emergency medicine, internal medicine, surgery, pediatrics, women’s health (prenatal and gynecologic care) and behavior and mental health care. Programs take three academic years and include classroom instruction and more than 2,000 hours of clinical rotations with an emphasis on primary care in ambulatory clinics, physician offices and acute or long-term care facilities. Once the degree is earned, they must take the Physician Assistant National Certifying Exam. To maintain certification, PAs must complete 100 hours of continuing medical education credits every two years and take a recertification exam every 10 years.

Requiring lower levels of training than physicians concerns some doctors. Physicians have tens of thousands of hours of training, with much more of it being hands-on experience.

“It’s not just the hours, but it’s the quality of their education, particularly nowadays, with many NPs simply graduating from an NP school that is completely online,” says Christopher Garofalo, M.D., a family medicine physician and member of Physicians for Patient Protection, which advocates for physician-led care and transparency around who provides it. “So, all their learning is online and there is no experiential learning. When they do get out into the clinics, if they even get out into a medical setting, the requirements for them are minimal, if at all. Yet when they come out, they essentially want to practice independently, just like a physician.”

The online schools have diminished the quality of nurse practitioners, says Niran Al-Agba, M.D., a pediatrician and co-author of “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Health Care.”

“Nurse practitioners a decade ago or beyond were phenomenal colleagues with a phenomenal education,” says Al-Agba. “They were required to have, in general, five years of hands-on nursing experience, and it was, ‘OK, I’ve worked for five years in the (intensive care unit) or in a clinic, now I’m going to get my master’s education at a brick-and-mortar school.’ Now, you don’t even need to work as a nurse at all, and the first patient you see could literally be after your nurse practitioner degree practicing independently.”

She adds that being honest with patients about credentials and education level is paramount. “Because it’s too late to put the full-practice authority genie back in the bottle, I think we should be really clear about our roles and be clear about our identification,” says Al-Agba.

That’s something Orozco says PAs try to do. “We’ve been very clear who we are and what we do. We’re also very clear that we work closely with physicians, nurses and other members of the team so that (patients) know this is a team-based environment.”

Kapu says physicians must accept change. “The key is for all of us to recognize that health care is changing, and old-style hierarchical models are being replaced to put patients, not a single health care profession, at the center of the health care team. We have a shared obligation to modernize these outdated structures and we invite our physician colleagues to join us in achieving this goal for the benefit of our patients.”

Nurse practitioners and physician assistants keep taking on more primary care responsibilities, often without supervision of a doctor

Are PAs and NPs replacing primary care physicians?

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