The Doctor Or Nurse Practitioner Will See You. Does It Matter?

Amid a critical shortage of physicians throughout the U.S. and an increase in the number of nurse practitioners with doctorates, nursing groups are pushing to expand what certain nurses can do without doctors’ supervision. Many state legislatures are doing the same. At the same time, doctors want nurse practitioners and physician assistants to continue to operate under their oversight. They maintain that granting full autonomy to healthcare providers with less rigorous training could put patients at risk.

In terms of health outcomes it can matter to patients whether an NP or medical doctor sees them. And this depends on the particular clinical setting in which patients find themselves, the stage of care and the degree of complexity of their case. Is it a primary or specialty care setting? Does it involve taking a medical history? Conducting a physical examination? Establishing a differential diagnosis? Formulating a treatment plan? Following up by evaluating outcomes and possibly doing more testing?

Given that the rate of physician graduates lags far behind that of NPs and PAs, increasingly people will be treated by non-physicians if they’re not already. Reinforcing this trend is the money government programs, health insurers, hospitals and clinics believe they can save by hiring more NPs and PAs and fewer physicians. In parts of the healthcare system, such as the Medicare program, NPs in particular are seeing considerable increases in their reimbursement rates while doctors experience decreases in real dollar terms, adjusted for inflation.

An NP is a registered nurse with advanced education and training. NPs who earn doctorates are sometimes referred to as “doctor.” The doctorate of nursing practice is the highest degree available in the field of nursing.

There are many medical tasks that can be delegated to NPs, particularly in primary care. Nonetheless, the higher the degree of complexity of a situation in which a patient presents at the clinic or hospital the more physicians are needed. This is because a progressively sophisticated skill set is involved. And while NPs can play a vital role in the multiple steps from a physical exam to follow-up, they may be best suited to follow algorithms for a known, established diagnosis and care protocol, according to Philip Shaffer, a diagnostic radiology specialist. Medical doctors have proven proficiency in all relevant procedures patients must go through from their initial presentation in the office to monitoring, which he believes makes them an indispensable part of any clinical practice team.

Pennsylvania’s Bill To Grant NPs “Full Practice Authority”

The Pennsylvania state legislature is currently considering a house bill that would allow “well-qualified certified registered nurse practitioners to treat patients without a collaborative agreement with physicians.”

Previously, in 2023, the State Senate passed a piece of legislation designed to “lower costs and expand access to healthcare in the state,” which included a “compromise” that would require NPs to practice for three years and 3,600 hours under a collaborative agreement with two physicians. After completing this transition-to-practice period, NPs would have “full practice authority” and would no longer be obliged to obtain contracts with doctors.

Supporters assert that NPs are “already trained to take care of patients.” Accordingly, needing doctors to sign off once the three year period is over is in their view an unnecessary impediment and limits access to healthcare. Proponents also cite studies that suggest lower cost of care for patients managed by NPs, as compared to those managed by physicians across inpatient and office‐based settings.

On the other hand, critics argue that having ongoing stipulated agreements with physicians ensures that patients have rapid access to a medical doctor. This may be particularly relevant for patients who haven’t yet gotten a proper diagnosis or corresponding treatment plan, or when the degree of case complexity is such that it goes beyond the expertise of the NP.

If the legislation passes, Pennsylvania will join 27 states and the District of Columbia that grant NPs full practice authority. Having such independent authority implies that NPs would be permitted to diagnose, prescribe and treat without physician oversight once the three year period of joint collaboration is over.

Full practice authority means different things to different states. Several states, such as Oregon, have comparatively few prerequisites. Their scope of practice laws appear especially lax, as there isn’t a required three year period of practicing under a physician’s supervision prior to becoming independent. Moreover, where NPs who set up independent practices can branch out to beyond primary care—for instance, pediatrics, women’s health, dermatology and addiction medicine—varies by state with respect to regulatory stipulations.

Training Differences Between NPs and Physicians

Nurse advocates argue that non-physician providers are just as good as physicians in the primary care setting. Nurse Journal even asserts that NPs are educated to provide the “same care as doctors.”

But there are significant differences in the education and training between, say, family physicians in primary care, and NPs. For one thing, the duration of medical training for physicians far exceeds that of NPs, as does the depth and breadth of their preparation.

Before they can practice independently, all medical doctors must spend four years in medical school with classroom instruction as well as clinical rotations across various specialties. Then there’s a three to seven year period in which all physicians must engage in an on-the-job training program called residency. By the end of the program, physicians accumulate between 10,000 and 20,000 hours of clinical practice training in medicine.

On the other hand, typically PA and MP degrees take less than two years to complete, educational curricula are not standardized and classes can in some instances all be taken online. At the point of certification, NPs have amassed between 500 and 2,000 hours of clinical training.

Clinical- And Cost-Effectiveness Of NP-Led Care

It’s said by nurse advocates that NPs focus on preventing diseases with a “holistic” approach to care, by promoting the health and well-being of the whole person. In addition, they can manage a chronic disease patient’s overall care through follow-up, which is generally focused on monitoring key metrics, lifestyle modifications and medication therapy management aimed at improving adherence to prescription drug regimens.

Researchers in Canada examined an NP-led clinic model of primary healthcare services in which physicians were present in a consulting role and concluded that such clinics could successfully support patients with chronic disease.

And in a Health Affairs study, researchers found that the use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs. Here, as in the Canadian study cited above, the so-called patient-centered medical home model being looked at includes a team of caregivers—NPs, PAs and doctors—that provides care to patients in a coordinated fashion. While physicians were usually not the first point of contact, they were involved as either the head of the team or as an overseer to be consulted at critical junctures during a patient’s treatment pathway.

A systematic literature survey of multiple studies conducted worldwide on NP- versus physician-led care indicates a mixed bag in terms of which had better clinical-and cost-effectiveness numbers. Researchers note that while care guided by “advance practice nurses”—NPs, in the U.S. context—provide cost-effective medication management, the results weren’t as good for laboratory testing and diagnostic procedural care.

Furthermore, a series of other publications have shown that when NPs are on their own there tends to be increased diagnostic imaging, antibiotic prescribing and overall prescriptions, all of which don’t necessarily correlate to better care.

Not having physician supervision or collaboration can lead to higher costs, as a three-year Veterans Health Administration study on emergency care by the National Bureau of Economic Research demonstrates. Researchers found that lengths of hospital stays increased by 11%, 30-day preventable hospitalizations went up by 20% and the cost of emergency department care rose by 7%, when comparing NPs who delivered care in the absence of a doctor to care provided by emergency physicians.

Given the sheer number of studies out there it’s impossible to draw a definitive lesson that would apply across the board. But where there is a consensus view it pertains to disease management or structured treatment plans for patients who have a chronic disease or multiple conditions. The medical professional association American Managed Care Pharmacy details how such programs can achieve the most optimal outcomes when NPs and PAs work as part of multidisciplinary collaborative teams that include physicians.

Americans seeking healthcare are increasingly likely to get it from people who aren’t medical doctors. Evidence indicates that NPs can provide safe and effective medical care, but that physician partnership and oversight are crucial.