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.

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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.”

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  • It couldn’t have been said better. “Not Enough isn’t adequate “. We need as many state licensed quality people we can educate and can be reeducated and honor the people that they serve. Without these midlevel practitioners we couldn’t deliver on the promise of dedicated care and the diligence of our best medical care.

  • I trust a practitioner as much as I do a doctor in fact my grandchildren go to practating dr. and they are terrible NP are 100% better..

  • I appreciate greatly the balance with which this article was written. Independent practice does not mean practicing beyond one’s training. It does not mean practicing in a bubble without collaborating or consulting. It does not mean abandoning the team approach. It does not mean ignoring or negating the continued importance and unique contributions of allopathic and osteopathic medical expertise. It is autonomy. That’s what FPA should stand for IMO, Full Practice Autonomy. Let advanced practice providers autonomously practice to the FULL extent of their training without artificial and unscientific boundaries, regulations and encumbrances. More importantly, providers of EVERY discipline, need mechanisms to improve the weaker and remove the persistently negligent or maleficent clinicians.

    • You absolutely hit the nail on the head. APRNs are ready and willing to take on this responsibility and all of us know the point where we have to get a physician involved. We do not feel that we replace physicians, we just do not feel everyone needs to see a physician for every healthcare concern. We are not performing surgery, taking care of brittle diabetics, or dealing with advanced cardiac issues.

      If anything, it would FREE UP RESOURCES and allow physician’s schedules to stop being clogged up with low-risk patients and allow them to treat the higher acuity patients as they should be!!!!

  • If mid levels such as PAs, PTs and nurse pracs want to practice independently, then I say go for it. As long as they are subject to the same maintenance of certification/board certification requirements that physicians are. The mid levels have been smarter than doctors in terms of getting reimbursed for call and other “incidentals.” More power to ’em.

    Dr. Prasad’s comments in his book on vertebroplasty are unfortunate. In our practice, where we perform Balloon Kyphoplasty, we have had excellent results. So much so, that patients who have fractures at additional levels return for the procedure and often seek us out to care for them primarily in this regard.

    • I believe his point is that there are “midlevels” in all disciplines. As well as many “high levels” and some “low levels”. Regardless of the “alphabet soup” of credentials and certifications.

    • I disagree. Nurse practitioners do not practice on the medical model of care and that is a huge misconception physicians have about our profession. Nurse Practitioners should be regulated by the Board of Nursing, not the Board of Medicine. You seem to have this assumption that nurse practitioners will be treating anyone and everyone that walks into the clinic regardless of complexity. There is nothing further from the truth nor is that taught in any NP program. Part of our education and training is learning the limitations of our practice abilities and when to get a physician involved.

      Physicians do the same thing now. You won’t have a primary care physician in most cases treating an exceedingly complex cardiovascular disorder. They will be referring the patient to a cardiologist.

      Physicians are not unique animals in knowing when to let a patient go.

  • I echo your thoughts, comments and observations. I have received the best care including the most complete physical examination by NPs many, many, many times–so much so that I seek out care from NPs exclusively now. I don’t understand the fear of allowing these providers to practice to the full extent of their training, certification and experience.

    • As I review what I have written, I see what a mess healthcare has become. I am hoping the training for NPs is optimum, but I am fearful that it isn’t.
      If you nave found an exemplary individual, stick with them is all I can say.
      Some, perhaps many docs have a smug, comdescending attitude. They will never do well because they do not LISTEN to their patients. They fail to even listen to anyone who has medical training. As a lab professional, they don’t listen to me either. For example, my friend suffered for months with diarrhea and nausea. I suggested something wrong with her water source. She to.d her doc. Her doc pooh-poohed the thought and did not test her stool for bacterial or parasitic infestation as I suggested . Well, she took the lowly lab professional’s advice and stopped drinking her well water. She was well in two weeks! I could share at least 50 of these incidences. Thanks Karen for your thoughts. I suspect many patients have stories to tell.

  • Mr Kumar, as Dr PRasad has said, not all are superstars. There will be those who will always strive for excellence (as they should) in whatever discipline they have chosen. After over 40 yrs in the medical field I have seen both. I have seen physician decisions which make me shake my head in disbelief. The best patient care will only occur when all healthcare professionals work as a team, learning to respect each role as a key component to the greater good.

  • Dr Prasad makes it sound like most primary care physicians are mediocre. Is OHSU that bad? Plus I was not aware that all Nurse Practitioners were excellent. I guess they are better trained than doctors. In addition, Dr Prasad states that doctors “forget ” all their basic sciences, plus who really needs it to see patients…
    I cannot believe this wave of anti-intellectualism has reached our medical shores.

    • @Deepak Kumar, Dr. Prasad’s never implies that “most primary care physicians are mediocre” or “that all Nurse Practitioners were excellent.” On the contrary, he wrote,

      “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.”

      He further wrote,

      “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.”

      So it appears it is your bias that yielded such an unbalanced interpretation from a well-balanced piece. Evidence of that bias is where you sarcastically write, “I guess they [NPs] are better trained than doctors.” Dr. Prasad never attempts to compare the depth of training between the two disciplines. Furthermore, you accuse him of stating, “doctors “forget ” all their basic sciences, plus who really needs it to see patients…” What Dr. Prasad ACTUALLY said was,

      “I know many doctors who have long forgotten most of this pathology….I am not sure that a more intimate understanding of the biology of disease inherently leads to better decisions for patients.”

      That’s very different from your interpretation. You end by writing, “I cannot believe this wave of anti-intellectualism has reached our medical shores.” Insults add nothing to this conversation. It only exposes the insecurities of the insult-er. I hope you, and others with similar sentiment, reconsider your actual motives.

  • Physician’s will always rule all aspects of healthcare, even when they are not directly involved $$. For example, in laboratory medicine, there are many brilliant individuals, medical lab scientists, that could run a quality lab without physician oversight ( the Pathologist MD). Yet, this is not allowed. For example, my colleagues and I could test patient specimens independently to rule out illness per a NP or MD referral. Most Paths get paid to oversee a lab, but they do nothing but collect the money. One prime example would be tickborne infections. Most labs no longer microscopically review bloodsmears. Within 2 days we would have a presumptive, if not a definitive Dx. We would refer to a PC or NP for treatment. Today, this dx would take weeks at a high cost and a delay in treatment. Makes no sense. A patient could see a NP, then get blood tested with us. Medical lab scientists, like Nurses, or NPs have medical training and are “certified”. I have 7 (now retired) colleagues who together could set up a competent Hematology lab. We would miss nothing: leukemia, lymphoma, hemoglobinopathies, blood parasites, various anemias, Hemophilia and other bleeding disorders. Although current labs have MD oversight, they miss far too much. Too many samples, too few slides reviewed. too few people doing the work. I don’t think we are headed in the right direction. We are headed to corporate medicine where it is all about the money and nothing more.

    • Carol, you are obviously very much a fan of almost anyone providing healthcare simply because someone has said they can. The truth is that the excessive testing that Nurse practitioners order when they are in charge of patients is only the tip of the iceberg. Some of the rest of the iceberg is the excessive referrals and consults that they order from specialists. The sad truth is that these mid-level providers are more likely to bow to the trial lawyers’ idea of what medicine should be, defensive and therefore wasteful. Btw, this is also the reason for your “needless” pathologist MD oversight of laboratories. They are there because of liability, because their degree and their prestige is the only sufficient reservoir in which to dump blame. Nurses aren’t sued as much as doctors, not for any other reason than they do not represent enough money in insurance and otherwise for trial lawyers to target. So, your attempts to remove the fattest prey both in prestige and monetarily from the liability of a laboratory oversight will be met with rabid opposition, not so much from the doctors as from the predators, the trial lawyers.

    • Dear Comcerned
      That’s a very interesting take on the matter. Although I am not a fan of “almost anyone”. In my own profession quality training has plummeted. As the laboratory’s on site educator for university students’ studying of laboratory medicine, I am shocked at the number of students who are poorly prepared. Yet, the university expects that I can teach Hematology and Coagulation practices in 2 weeks! A similar time frame has been set for Chemistry, Microbiology, Blood Bank & others. The learning process has been stream-lined to spend more time on books instead of the needed practical experience so crucial. Note that theory and practice are both important, and I have always provided both.
      I do understand the liability part, but what is disturbing is that many, if not most overseers, in my years of experience, pay little attention unless there is a problem pointed out by a colleague. Do they then say, I didnt approve? “She or he disobeyed my orders”. Without more than a cursory scan, they approve procedure manuals with a signature. Rarely, do they READ the text. A prime example, although not a hospital lab, is the State lab of Massachusetts where a chemist (not a medical chemist) falsified data. The overseer did not properly review practices. As in many hospital labs, the overseers are too busy with their own private practices. (supported by the hospital), to be concerned. Pathologists review tissue samples for a fee. They are not all educated in Clinical pathology (hospital). They collect a handsome salary however. All n’ all, the condition of current medical training and caregiving is disturbing. Budget cuts undermine every area where patients are apt not to notice. Yet, the top administrators enjoy a lucrative job. The excessive referrals you mention, in my opinion, occur when the NP, or even an MD are unsure of what is going on with the patient. Hence a training issue again. And as you implied fear of litigation and medical waste. Perhaps in the future things will change for the better. The pendulum always swings too far one way before it equilibrates. Thanks for your comments.

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