Physicians, NPs Disagree on Expanded Practitioner Role

Tinker Ready

May 15, 2013

Primary care physicians and nurse practitioners (NPs) disagree sharply on whether an expanded role for NPs will result in better care or lower costs, according to a survey of 972 clinicians, performed by Karen Donelan, ScD, from Mongan Institute for Health Policy, Massachusetts General Hospital, and Harvard Medical School, Boston, and colleagues.

More than 66% of surveyed physicians agreed that physicians provide a "higher quality of examination and consultation" than NPs, but less than a quarter of the surveyed NPs agreed. Although 77.0% of NPs said their expanded role would reduce costs, just 31.1% of physicians predicted a costs savings, and 19.1% said the move would increase costs.

The findings, published in the May 16 issue of the New England Journal of Medicine, were based on a survey conducted by researchers at Massachusetts General Hospital and the Institute for Medicine and Public Health at Vanderbilt University, Nashville, Tennessee.

The researchers surveyed representative samples of 957 nurse practitioners and 957 primary care physicians. Of those, 505 physicians and 457 NPs completed the survey.

The researchers conclude that "primary care physicians are unlikely to embrace policy recommendations aimed at further expansion of the roles and supply of nurse practitioners." In particular, physicians' concerns about the likely effect of an expanded workforce of NPs on several aspects of healthcare quality need to be addressed in discussions of strategy for the development of the US healthcare workforce, the researchers conclude.

One reason for the disagreement may be variation in training requirements for NPs, said Reid B. Blackwelder, MD, a family physician in Kingsport, Tennessee, and president-elect of the American Academy of Family Physicians.

"The education, training, and the experience of nurse practitioners varies dramatically from state to state, whereas the training of family physicians and physicians in general is consistent, regardless of medical school or state," he said.

The researchers specifically refer to the 2010 Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health. That report endorsed a number of measures that ranked low among physicians in this survey, including equal pay for the same services. Only 3.8% of physicians believed in equal pay for services, but 64.3% of NPs said they should be paid the same fee as physicians who provide for the same service, according to the current article.

The 2 groups came closer to agreeing on a few issues. Most agreed that having more NPs would speed access to care (72.5% of physicians and 90.5% of NPs). In addition, the majority agreed it would improve access to care (52.2% of physicians vs 80.7% of NPs).

However, patient safety was an area of dispute: About 21% of physicians said that the increased use of NPs would improve safety for patients, but another 31.2% predicted the nurses' expanded role would make safety problems worse.

Jan Tower, PhD, the senior policy advisor for American Association of Nurse Practitioners, said she was not surprised by the findings.

"Nurse practitioners are competent in what they do," she said. "Physicians are hesitant about us."

She agreed with the recommendation for more professional education so the 2 groups can better understand each other. Dr. Tower also said the study is unclear as to how many of the physicians who responded actually worked with NPs.

"The people who are most concerned about us are people who haven't worked with us," she said.

Dr. Donelan has disclosed financial relationships with various organizations. Full conflict-of-interest information for the article is available on the journal's Web site. Dr. Tower and Dr. Blackwelder have disclosed no relevant financial relationships.

N Engl J Med. 2013;368:1898-1906.

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