A surreptitious conflict is brewing in our health clinics and hospitals — a tug of war between doctors and advanced-practice providers (APPs): nurse practitioners, physician assistants and nurse anesthetists.
As a physician, I am witnessing these rising tensions more frequently. Both parties are getting territorial about their space in medicine.
Why do some of us feel so strongly about claiming superiority? Why do we insist on marking our rung in the hierarchical ladder? Well, it’s complicated. The answer lies somewhere between concerns over quality of patient care, destabilization of our role in the healthcare structure and insecurities about financial futures.
Professions Created Out of Necessity
Nurse practitioners and physician assistants emerged as occupations in the 1960s to mitigate shortages in the U.S. primary care workforce. Presently, approximately 290,000 nurse practitioners and 125,500 physician assistants practice across all sites of care in the United States. They have prescribing privileges (including for controlled substances) and can practice independently without a supervising physician in many states.
In 2016, the actively licensed U.S. physician-to-population ratio was around 295 physicians per 100,000-population. In other words, there were only 29.5 physicians in patient care per 10,000 civilians. No wonder most of us feel “burnt-out” and overworked. Our truncated time during patient visits adds to this disillusionment.
Within the last 50 years, the number of active U.S. physicians has increased dramatically. In early 2020, the total number of American physicians was just over one million. Yet this increase is insufficient to adequately meet the needs of our population, now around 331 million.
Dr. Bonnie Lee Guerin, director of the breast cancer program at Overlook Medical Center in Summit, N.J., explains one part of this current dynamic in healthcare: “With aging baby boomers, it is unrealistic and difficult for highly trained physicians to adequately fill the needs of all of our population.”
Healthcare costs have been rising for decades. NPs and PAs mitigate these costs, and play a key role in the nation’s future — they can provide medical care at a reduced cost, which is pivotal as baby boomers increasingly need more services, and costs associated with Medicare and Medicaid continue to rise.
Dr. Guerin makes a shrewd observation: A challenge that adds to the friction between docs and APPs is that, for many physicians, there has been relatively little, if any, training on how to incorporate NPs and PAs into their practice.
“I would predict that, for many physicians, they don’t really even understand the difference between NPs or PAs, and how they can best be utilized,” Dr. Guerin said. “We were never trained on how they could enhance our practice.”
It Takes Two to Tango
Despite the skewed doc-civilian ratio, many physicians continue to question APP’s role in medicine. The animosity is fueled by both sides. The American Association of Nurse Practitioners (AANP) vehemently opposes the use of terms “mid-level provider” and “physician extender” in reference to nurse practitioners. They claim that patient outcomes for NPs are comparable or better than that of physicians (per a study published in “Journal for Nurse Practitioners” in 2013).
That is difficult to digest given the differences in training between doctors and APPs. Quality of care might be similar among NPs, PAs, and physicians for routine patient presentations, but not so for complex or ill patients, or those with nuanced needs.
Did you know there is an annual “Doctors Day” to celebrate physicians? This year, it was marked by free meals, token gifts and a flurry of social media posts. Honey-coated posts celebrating our heroic efforts during the pandemic. Also acerbic posts — why this day should be reserved for the “real” doctors: Medical and Osteopathic.
It’s a Big Sandbox
There is plenty of work for us all. Nurse practitioners and physician assistants represent a growing aspect of primary care in the United States and represent a workforce essential to operations in both inpatient and outpatient settings.
A salient feature of a successful healthcare model is that we must all be transparent about our education, training, credentials and certification. Lumping everyone under “Providers” can be misleading. We should be open to discussing challenging cases and collaborate to deliver care that utilizes each profession’s unique skills and expertise. Most importantly, we must respect one another, which is essential to providing quality, interdisciplinary care to our patients.
It is undeniable that physicians train longer and harder than extended providers. We have expertise and specialize in our fields. However, we don’t want to be the mean girls of medicine. The presence of APPs in American healthcare is not a sojourn. They are here to stay. We need to evolve and refine our current, rather uncouth, dynamic with them.