Second Opinion: Sorting Out the Players

June 1, 2007

A Virginia psychiatrist on nonphysician providers.


Would you put a high school football player on a professional NFL team and expect him to perform well at that level? Would you consider that player an “equal” and afford him all the respect and deference due to his highly trained, professional teammates? Unlikely. Despite his athletic prowess, he will still require assistance and oversight from the more advanced and skillful players.

From a physician’s perspective, nonphysician providers are analogous to this young football star. Yes, many have talent and knowledge to contribute to the world of medicine. Their training, however, is irrefutably shorter - and less intense - than that of physicians, who, after spending many years training, find more clarity in how much they don’t know. This is necessary for a clinician to train himself to forgo the superficiality of a first clinical impression and to be skillful and comfortable with his judgment amid ambiguity. And so, nonphysician providers are aptly named “physician extenders.” No more, no less.

In theory, nonphysician providers work under the auspices of a supervising physician. In fact, I have yet to meet one who does not require a physician’s skill as backup. Only about half of those that I have worked with recognize this limitation and accept it without argument. Many of my physician colleagues have also witnessed this firsthand.

In reality, the demands of practicing medicine in today’s world leave physicians with insufficient time to sustain constant supervision of nonphysician providers while performing all of our own duties. The fault here lies with the current state of our medical system, not with the physician extenders.

However, most nonphysician provider organizations have capitalized on this reality gap by mounting skillful and robust political campaigns, calling on state legislatures to reduce the physician supervision requirement as much as possible. They’ve met with some disturbing success. In Arizona, for example, nurse practitioners do not have to be supervised by a physician at all. They can even perform surgery if they so desire, as they are “supervised” and “licensed” by their own independent board.

Why would anyone want to perform surgery without the proper training or skill? We at the national and state levels have stopped asking this question because the answer stems from the natural human desire for autonomy and self-determination.

In business, when people spy an open market niche, they usually go for it. Understandable. So what’s wrong with it in this instance? The health of patients may be compromised.

The nonphysician provider learning environment itself contributes to the confusion by espousing inappropriate career goals. Physician assistant students who have rotated on my service have frequently remarked that their faculty tells them they are “on par with fourth-year medical students.”

A decisive, clearly delineated statement about where nonphysician providers fit into the stratified field of medicine would help, but the various sides have not been able to reach an agreement. And the discord has only intensified in recent times.

Certainly, nonphysician providers fill a critical gap in our medical system. Their work - in the proper scope - is both needed and deeply appreciated by physicians and patients alike. But there must be clear, immutable rules governing their clinical limits. The public’s health and safety are at stake.

David B. Durham specializes in preventive medicine and psychiatry in Roanoke, Va. In the ongoing debate about the role of nonphysician providers, he has served a number of national and state leadership organizations. His comments are his own and do not necessarily reflect the views of Physicians Practice.

This article originally appeared in the June 2007 issue of Physicians Practice.