Docs vs NPs, PAs: How AMA Made Scope Creep Fight Uglier

Alok S. Patel, MD


December 18, 2020

This transcript has been edited for clarity.

In a spirit of productive debate, I want to talk about something that's making the rounds on social media and internet threads everywhere: expanded scope of practice and how the American Medical Association (AMA) triggered so many NPs and PAs while getting support from physicians.

Over the past year, healthcare teams have gone above and beyond on the COVID-19 front lines. When we work together as a team, patients get the best possible care.

Beneath the stories of collaboration is an ongoing push for more autonomy for NPs and PAs. This has led to some doctors saying that although every member of a healthcare team is vital, patient care should ultimately be physician-led.

About a month ago, the AMA sent out a tweet that caused a ruckus. I'm going to read it for you. It says, "Patients win when each member of their health care team plays the role they are educated and trained to play. That includes care led by physicians — the most highly educated, trained and skilled health care professionals."

They deleted a tweet right before this that had a Scrabble-like tile image directly calling out NPs, PAs, and CRNAs. Both tweets included #StopScopeCreep.


As a result of this tweet, the American Association of Nurse Practitioners (AANP) wrote an open letter to the AMA, asking them to stop the disingenuous attacks on NPs. Their letter cited patient satisfaction surveys and argued that NPs may be able to fill the physician shortage gap.

The American Academy of Physician Assistants (AAPA) also wrote a statement, straight up calling the concept of "physician-led patient care and training" outdated. Their letter also stated that PAs provide high-quality care and have similar health outcomes as physicians.

Now, one important note is that both statements included very important reminders of the vital role that both NPs and PAs have played during our pandemic response. I think we can all agree on that.

But when organizations use wording such as "choose an NP," physicians don't see this as teamwork; they see it as competition, made possible by an expanding scope of practice.

NPs have full practice authority in 22 states.


Over the past few years, there have been several reports of NPs replacing board-certified physicians in certain practices — not because it's better care, but because it's a cheaper salary for a hospital or a clinic to pay.

PAs may not be that far behind. The AAPA is advocating for several changes, including, and I quote, "to repeal the requirement that physicians should be responsible for PA-provided care." Translation: PAs want more autonomy.

Physician organizations recognize the significance of every healthcare professional, but they all say that neither NPs nor PAs have the training needed to replace physician-led care.

Both the grassroots organization Physicians for Patient Protection (PPP) and the AMA cite differences in training. For example, the average doctor clocks in around 15,000-20,000 hours by the time they finish residency, whereas some NPs can graduate with around 500-1000 hours. It's a big difference. Both organizations also argue that expanding NP autonomy may actually increase healthcare costs, could lead to some patient safety concerns, and wouldn't actually fix the rural access problem.

Regarding practicing in a rural or underserved area, the AANP says that many NPs choose one of these two options and fill in the physician shortage gap. On the other hand, PPP and the Primary Care Coalition present data saying the opposite. They say that primary care doctors are more likely to work in underserved areas, not NPs.

Read both sides and tell us what you think. By the way, we seem to talk about the physician shortage often. Why don't we talk about fixing that problem? We need more residency programs.

Personally speaking, I work with some brilliant, dedicated, compassionate NPs and PAs. Some of them are just outright annoyed by these accusations of "scope creep." I tell them to go speak out against their agencies, representatives, or anyone saying that they should be allowed to replace physicians.

We're supposed to be a team; answers to shortages in healthcare access are not shortcuts. I leave you all with a few questions to stir the pot:

  • What do you think of the AMA's tweet and #StopScopeCreep?

  • What do you think is going to happen post-COVID regarding scopes of practice for NPs and PAs?

  • What do you want to see happen?

Please comment below.

Alok S. Patel, MD, is a pediatric hospitalist, television producer, media contributor, and digital health enthusiast. He splits his time between New York City and San Francisco as he is on faculty at both Columbia University/Morgan Stanley Children's Hospital and the University of California San Francisco Benioff Children's Hospital. Alok hosts The Hospitalist Retort video blog on Medscape.

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