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Efforts by many states to increase the reach and scope of nurse practitioners — letting them see and treat patients by themselves — have spurred a backlash, mostly among doctors. These physician critics argue that the gap between nurse practitioners (NPs) and doctors is as wide as the Grand Canyon. Their objections seem to focus largely on theoretical differences between NPs and physicians. They also seem to ignore the simple reality: In many parts of America, there just aren’t enough health care providers for all patients.

Critics of letting NPs run their own independent practices say that NPs can be competent and helpful, but can never substitute for the experience and judgment of doctors. Doctors, they argue, have trained for years in the pathology of disease, the little cellular changes that drive illness (or at least that drive our latest models of it), while nurses seldom ruminate on these details. Of course, I know many doctors who have long forgotten most of this pathology. But even if this were true, I am not sure that a more intimate understanding of the biology of disease inherently leads to better decisions for patients.


Sometimes in medicine, biological understanding by itself leads to a treatment plan. But these are usually instances when patients fall outside of well-established treatment paradigms, clinical trial data, or decision trees. In such cases, knowing the intricacies of pathology surely makes doctors feel more comfortable with making decisions, but I am not aware of evidence showing that such decisions are routinely correct.

In fact, biologic thinking can lead to excessive confidence in therapies that only might work. Such confidence can preclude considering and offering patients alternative choices. Failing to offer alternatives in the setting of uncertainty is the cardinal sin of modern medicine, a violation of shared decision-making.

Critics also cite the very limited data showing that nurse practitioners order more tests than doctors. However, they underplay the fact that the difference is slight, and that this is just one of many of things we do in caring for patients.


In their quest to find some fundamental difference between nurse practitioners and doctors on average, I suspect that critics make the common mistake of overlooking the fact there is far more variation within each group than between them. Many seasoned nurse practitioners may have more experience than junior physicians. Good NPs may order tests more judiciously, provide better informed consent, and make better decisions than mediocre physicians.

When it comes to caring for my patients or the people I love, I would eagerly trade three mediocre physicians for one excellent nurse practitioner.

I have worked with excellent health care providers and terrible ones. Their titles and the alphabet soup of letters on their white coats offer little giveaway to their understanding of disease or how well they care for patients. I know many nurses, research nurses, nurse coordinators, physician assistants, nurse practitioners, and physicians who are flawless clinicians. They operate at the top of the game when it comes to knowledge of illness, bedside matter, attention to detail, judgment, intuition, and experience.

We in health care work with such individuals in total confidence that nothing will fall through the cracks. When you come across such a person in your life, you beg them to never switch jobs, and rely on them for years.

At the same time, I have worked with doctors-in-training and physicians who are less than superstars, guilty of odd decision making, showing tentative or mistaken judgment, exhibiting poor bedside manner, and displaying confidence out of proportion to their ability.

When it comes to caring for my patients or the people I love, I would eagerly trade three mediocre physicians for one excellent nurse practitioner.

Ultimately, the reality is that there are excellent physicians and excellent nurses, and the best of each can operate independently, competently, and gracefully. The worst of each likely needs supervision or remediation.

Instead of drawing divisive lines based on our training or credentials, we ought to find ways to identify and improve the poor performers in each group, without constraining the stars. Concluding that all doctors are great and all nurses just average is as misguided as judging someone’s intellect by the college he or she attended. We need to embrace expanding full practice authority to NPs. The need for this is pressing, and clinging to delusions that one professional title guarantees competence while another entirely precludes it is irrational and harmful.

Vinay Prasad, MD, is assistant professor of medicine and senior scholar in the Center for Ethics in Health Care at Oregon Health & Science University and coauthor (with Dr. Adam Cifu) of “Ending Medical Reversal: Improving Outcomes, Saving Lives.”

  • As a former student at OHSU, I heard Dr Prasad lecture and thought he was generally well informed and fair in his assessment of evidence based medicine, though he does seem to enjoy controversy for controversy’s sake. To hear a fellow physician claim that the only difference between medical school and mid-level training is the amount of physiology minutiae acquired is just … puzzling and shocking. The most obvious difference is the 3+ years of highly supervised post graduate training that every MD, even Family Medicine, has to endure. MS3 and residency years are where the magic happens. That is what gives a physician the ability to truly practice independently. Is Dr. Prasad in favor of abolishing residency for all PCPs? If not, I really don’t know what he is intending to say with this statement. So disappointing.

  • I agree that in no way are nurse practitioners as capable of independent practice as medical doctors given their much less rigorous training and experience. With greater years of experience and training they could be capable. Operating with physician oversight for enough training is more responsible. The selection process and standards of training for nurse practioners are so much lower in general that years of oversight are necessary.

  • Excellent article with great points and crucial perspective. Research consistently shows that outcomes are the same- and sometimes better- for nurse practitioner care. Nurse practitioners have proven that they can deliver outstanding care. NPs are available to fill critical care gaps, especially in our underserved populations. Hopefully, big organizations like the AMA and AAFP will wake up and smell the ether. Source:

  • I don’t even know where to begin. APRNs have 500-900 hours of supervised training before they’re out on their own. Compare that to 10k-30k a physician will have. APRNs also do not have a residency, an experience most physicians will tell you that really taught them how to practice. Many NP schools are 100% online and some have 100% acceptance rates because they are 100% for profit. Some schools are now taking nurses that have freshly graduated from nursing school with no prior experience as a nurse. At least one state has fought and won equal pay for MDs and NPs and so they may not be saving money in the future (a big argument used). Our shortage of physicians has more to do with the government not funding more residency programs than it does people trying to get into Med school. Have you ever heard the saying “you don’t know what you don’t know?” Well, I have, and sometimes understanding the detailed pathophysiology DOES help you make better decisions and I don’t understand what line of thinking could ever suggest less knowledge is equal or better. Really? I don’t think so.

    • I have seen this echoed in many places, however, when most of the research suggests that both patient outcomes are equivalent to that of physicians, and in many cases, patient satisfaction is superior. The research I have found to the contrary is sparse and in many cases statistically insignificant. I would like to see more research backing this sentiment, and comparing independent versus supervised APRN outcomes, and/or those working in group practices with physicians versus those with their own “shingle”. Even in cases where “supervision” is required by law, this can mean many different things in practice- from a simple signing of protocols to direct oversight.

  • As a physician who was previously a nurse practitioner, I can say without reservation that letting NPs or PAs practice independently is a bad idea. The training for NPs simply does not provide the depth of knowledge or the same decision making process as the training process for physicians does. The most sobering thing about going to medical school after being a NP or PA is realizing how much one doesn’t know what one doesn’t know.

    NPs and PAs have valuable role in health care, but practicing without involvement of physicians is not one of them. The training is NOT equivalent. You cannot take someone who went to an 18 month online NP program without any previous nursing experience, and 500 hours of clinical time which is often merely shadowing at best, and claim they are equivalent to a physician with 4 years of medical school, with a minimum of 3000 hours of clinical time in the third year alone, who then must do at least 3 years of residency at 80 hours a week and say they are equivalent. They aren’t. This is like saying “let a crop duster pilot fly a jumbo jet”

    The fact that some of the best NPs are better than some of the worst physicians does not change the fact that NPs are not physicians.

    If it is your contention that they are the same, why not do away with medical school and residency altogether and let everyone who wants to be a “provider” go to online NP school and be done in 18 months with less debt, no need to worry about the residency match, and immediate employment? I notice you didn’t call for that because I suspect that you realize that medical education still has value

  • This is exactly whats wrong with medicine. People who have climbed up the ladder want to pull it from those behind them. It takes 11 years to train an FM/IM doctor, his/her entire life’s efforts and savings go into the education so they can perhaps save a life someday.
    If NPs with their choppy online schooling which comes to 3% of an MD/DOs can do the same thing, why would anyone sacrifice so much to master their trade?
    If its your loved one why wouldn’t you want them to see the most well-trained person in their field?

    Why should anyone settle for a backup?

    NPs not only order more tests, they also prescribe more opioids, do more biopsies, give out more antibiotics and have no interest in settling in rural areas.
    This is ridiculous to the point that arguing against it will make you lose brain cells.

  • Unfortunately in California we are woefully understaffed. The FNP’s and the PA’s render service with a MD,DO, and the service that they provide is subject to change. I had a FNP that was overly generous with MU agonists and CVS wouldn’t dispense her Rx’s. PA’s are not qualified to diagnosis . State law differs.

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