COMMENTARY

Independent Nurse Practitioners and Physician Assistants: A Doc's View

John M. Mandrola, MD

Disclosures

January 22, 2020

For a century or more, only doctors practiced medicine. This era is over.

Almost hidden in section 5 of the executive order from President Trump on protecting and improving Medicare are two rule changes that upend the current way in which nurse practitioners (NPs) and physician's assistants (PAs) deliver medical care.

According to the nonprofit Practicing Physicians of America (PPA), section 5 will not only eliminate supervision of NPs and PAs but will also lead to pay parity, or, more accurately, "reimbursement parity." Medicare dollars, and eventually all third-party payments for care, would be leveled across physicians, NPs, and PAs.

This Is Provocative—On Many Levels

The first thing to say is that change is here. My practice includes one NP for almost every two physicians. Nearly every other group of physicians in the hospital has hired NPs or PAs to see patients. This growth mirrors data from the US Bureau of Labor Statistics, which projects a 30% growth in NPs over the next decade.

You don't have to be a health economist to understand the growth. It's less costly to employ NPs or PAs instead of a doctor. What's more, adding less experienced clinicians in the current fee-for-service model is a feature, not a bug. Less experienced clinicians (no matter the type, NP or MD) order more tests. While payment models may change, right now, for most health systems, testing generates revenue.

Many of the doctors I have spoken with, and comments in the Twitter thread following the PPA's tweet, express concern that NPs and PAs do not have the training necessary to function as doctors. Physician-writer Sandeep Jauhar, MD, laid out the standard arguments against independent NP or PA practice in the New York Times.

To be sure, the difference in training is vast. In our group, an NP who does consultative cardiology may have graduated from a 2-year training program after 4 years of college. A cardiologist spends 4 years in medical school after college, followed by 3 years in internal medicine and then another 3 years (minimum) doing only cardiology.

Are Nurses Up to the Task?

Despite differences in training, the evidence looks good for NPs. US, British, and Dutch randomized controlled trials (RCTs) comparing independent NP-led care to physician-led care in primary care settings all found similar to better outcomes in the NP arm. A 2014 Veterans Affairs Evidence Brief found no differences in the care of NPs compared with that of doctors in seven parameters.

Trials from specialty clinics confirmed equivalence of care for nurse-led vs physician care in patients with dyspepsia, diabetes, inflammatory arthritis, bronchiectasis, and HIV. Finally, a Cochrane review of 18 RCTs concluded that "care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence)."

One of my favorite RCTs showed that nurse-led care for patients with atrial fibrillation led to lower rates of cardiovascular (CV) hospitalizations and CV mortality compared with physician-led care. (One caveat is that the initial visit in the nurse-led arm was collaborative with a doctor.)

Comments

Whether or not this executive order gets enacted, it's only a matter of time before NPs and PAs reach independence.

Many doctors are being replaced with people with far less training. Procedural fields, such as my field of electrophysiology, may be protected—for now. But think about it: the procedural part of medicine is the easiest part. The two letters after my name have little to do with my ability to move a catheter or tie good knots.

Groupthink among doctors holds that our replacement by people with less training will lead to Armageddon. That's because doctors make causal connections from our years of training/suffering to our ability to help people. We think the same way because we endured the same training.

Doctors do great things, but perhaps the empirical data showing parity of NP care are no fluke.

Let me try to persuade you that independent practice will likely make little difference in patient care.

My case turns mostly on how much a single doctor influences outcomes. I used to think it was a lot. Patients reinforce this belief with their misplaced causal judgments: "You've kept me alive for all these years."

One of the seminal days of my career happened when John Lloyd, MD, a senior pulmonologist, now retired, sat me down for a chat about an essay I wrote on the hubris of medicine. Lloyd believed that doctors don't control outcomes as much as they think they do. He told the story of two patients with sepsis whom he treated in the same way: one he expected to live but died; the other he expected to die but lived.

The more I practice, the more I understand Lloyd's wisdom. I see it nearly every day: many patients get better on their own, despite us. Many patients fall into an easy protocol—say, chest pain, dyspnea, or atrial fibrillation. With basic training, a motivated person quickly gains skill in recognizing and treating everyday problems.

Consider that the most important part of getting the right diagnosis is having the emotional intelligence to listen to the patient. Really listen. I've seen esteemed doctors take terrible histories. Emotional intelligence is learned more on the playground than in medical school.

And the key part of any physical exam is what the patient looks like on general appearance. Interns learn this skill in a matter of months. An NP who was a bedside nurse already knows it.

Technology also closes the gap. Point-of-care ultrasonography (POCUS), which can be self-taught, will soon supplant most of the physical exam. With POCUS, an NP or PA could recognize a pericardial effusion just as fast as a doctor. It's early days, but artificial intelligence holds promise in assisting clinicians. Biomarkers, such as high-sensitivity troponin, make it harder to miss important diagnoses.

The smartphone and its digital connectivity have made the years I spent in medical school memorizing facts more about perseverance than being a good doctor. And social media now allows any clinician to get curbside advice from global experts.

Patients, too, have access to medical information. The Internet doesn't make one a clinician, but the asymmetry in knowledge between patient and clinician has narrowed.

Team-based care also changes things. In days of old, one doctor directed care. Now, most patients in the hospital are sick enough to receive care from a team. Why can't NPs and PAs coordinate this type of care as well as a doctor?

Two Final Points

The rise of NPs and PAs offers great opportunities to study a new model of care. Randomize one emergency department to independent NP/PA care vs one with supervised care. Same with hospital wards or teams.

If further data uphold the equivalence of NP/PA care, the medical establishment must change the anachronistic model of medical education. Spending months on basic biology, such as the Krebs cycle, is dumb. (I could look up the Krebs cycle, but I have never had to.)

Forcing a person who wants to be an electrophysiologist to spend years on the medical ward treating alcohol withdrawal or pneumonia, or months doing rotations on obstetrics, psychiatry, and surgery, seems equally useless.

Conclusion

Doctors forget much of what they learn in medical school.

It matters not. Most of what makes a good clinician is caring. Caring enough to learn the important stuff; caring enough to listen; caring enough to look at all the patient data; and caring enough to reach out for help. The type of degree you have does not bear on this.

I could be wrong—we surely need more studies, but I don't believe independent NP or PA care will cause harm. I love being a doctor. It's a job with great meaning. I am unsure, however, how much all that training mattered.

Finally, doctors have long held a monopoly on medical practice. The medical guild protects us—mostly through convincing the public and lawmakers that there is a need for certification and control of the supply of doctors.

But what if there was a truly free market—one in which outcomes, not degrees, were what mattered?

Could we convince people to support our higher salaries? We will soon find out.

John Mandrola practices cardiac electrophysiology in Louisville, Kentucky, and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence. 

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