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The effects of nurse practitioners replacing physicians


Unsupervised non-physician providers put patients at risk when working outside their scope of practice.

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Across the country, corporations and government agencies are replacing physicians with nurse practitioners (NPs). While these entities argue that they have been forced to hire nurse practitioners due to a supposed physician shortage, the truth is that physicians are being systematically fired and replaced by lesser qualified clinicians on the basis of profit. This short-sighted trend is dangerous for several reasons.

Lack of informed consent and patient choice

Patients are inherently vulnerable and have little choice but to place their trust in the treating medical team. Most Americans trust the training of physicians, and report that they prefer to be treated by a physician. Due to the right of informed consent, all patients deserve to be informed that they are being treated by a non-physician practitioner. 

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With the increasing replacement of physicians by non-physician practitioners, some of the most vulnerable patients are losing the opportunity see a physician-or may be unaware that the caregiver is not a physician. For example, federally-funded rural health clinics treating socioeconomically disadvantaged patients are mandated by law to employ at least one non-physician practitioner-either nurse practitioner or physician assistant. Our nation’s veterans are now being treated by unsupervised nurse practitioners at VA clinics and hospitals across the country.  

Rationing health care by restricting access to physicians and substituting lesser trained practitioners is very much a question of social justice. This is particularly poignant considering brand-new revelations that that medical algorithms-treatment guidelines followed NPs-may be biased and impact quality of care for certain patients. 

Patient harm

Although advocates claim that studies show that NPs can provide comparable care to physicians, they fail to acknowledge that this research has always been done with supervised NPs. The truth is that there are absolutely no studies that show nurse practitioner safety and efficacy when practicing independently

Moreover, most of the studies that purport to show NP safety have been of low quality, often following healthy patients over very short time frames, with one often-cited study having a time frame of only two weeks. These studies were not appropriately designed to show whether nurse practitioners, especially practicing independently, can safely and effectively care for patients over the course of a lifetime in a primary care role.

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In fact, newer studies have revealed concerning gaps in the quality of care of some nurse practitioners, including poorer quality referrals to specialists, increased diagnostic imagingincreased prescriptions -like increased antibiotic prescribing -and higher opioid prescribing.

Strained by the demand for more graduates, training programs for NPs are accepting less qualified applicants and no longer requiring nursing experience (or even a nursing degree) to become a nurse practitioner.  

Mary Mundinger DrPh, a nurse practitioner researcher, has also called NP training programs into question, pointing out that only 15 percent of all nurse practitioner doctorate programs provide adequate clinical training, with 85 percent focusing on nonclinical education.

Lack of repercussions for quality of care issues

Despite legislation allowing unsupervised nurse practitioners the right to to provide medical care to patients, case law has repeatedly demonstrated that NPs are not held to the same legal standard as physicians in malpractice cases. 

NPs answer to their individual board of nursing, rather than the board of medicine. There are questions regarding the ability of these nursing boards to safely oversee nurse practitioners, with examples of patient harm being ignored by nursing boards.

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Organizations are not being held responsible when they hire nurse practitioners to work outside of their scope of training. For example, the most common type of NP is a family nurse practitioner, trained to work in an out-patient setting. NPs who wish to work in a higher acuity setting such as a hospital must complete an acute care program. Because of the confusion even within the nursing system regarding the types of NP certifications-there are 183 different nursing certifications-organizations often fail to properly credential NPs to work in the appropriate setting, with little to no repercussions.  

When any medical provider-physician, nurse practitioners or physician assistant-works outside the scope of their education and training, patients are at risk. By treating physicians and nurse practitioners as interchangeable, organizations are following a dangerous path that will ultimately lead to patient harm.

Rebekah Bernard, MD is a family physician and board member of Physicians for Patient Protection

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