This Doc Still Supports NP/PA Led Care … With Caveats

John M. Mandrola, MD


January 24, 2022

Two years ago, I argued that independent care from nurse practitioners (NPs) and physician's assistants (PAs) would not have ill effects on health outcomes. To the surprise of no one, NPs and PAs embraced the argument; physicians clobbered it.

My case had three pegs: one was that medicine isn't rocket science and clinicians control a lot less than we think we do. The second peg was that technology levels the playing field of clinical care. High-sensitivity troponin assays, for instance, make missing myocardial infarction a lot less likely. The third peg was empirical: studies have found little difference in MD vs non-MD–led care. Looking back, I now see empiricism as the weakest part of the argument because the studies had so many limitations.

I update this viewpoint now because healthcare is increasingly delivered by NPs and PAs. And there are two concerning trends regarding NP education and experience. First is that nurses are turning to advanced practitioner training earlier in their careers—without gathering much bedside experience. And these training programs are increasingly likely to be online, with minimal hands-on clinical tutoring. 

Education and experience pop in my head often. Not every day, but many days I think back to my lucky 7 years in Indiana learning under the supervision of master clinicians—at a time when trainees were allowed the leeway to make decisions … and mistakes. Then, when I joined private practice, I continued to learn from experienced practitioners.

It would be foolish to argue that training and experience aren't important.

But here's the thing: I still don't see average health outcomes declining as a result of the rise in NPs and PAs. And even if I did, it wouldn't matter. The rise in nonphysician care will not be undone, at least any time soon.

I will make three points: first I will bolster two of my old arguments as to why we shouldn't be worried about non-MD clinicians; then I will propose some ideas to increase confidence in NP and PA care.

Healthcare ≠ Health

On the matter of how much clinicians affect outcomes, a recently published randomized controlled trial performed in India found that subsidizing insurance care led to increased utilization of hospital services but had no significant effect on health outcomes. This follows the RAND and Oregon Health Insurance studies in the United States, which largely reported similar results.

We should also not dismiss the fact that despite the massive technology gains over the past half-century in digital health and artificial intelligence, and increased use of quality measures, new drugs and procedures, and the mega-medical centers, the average lifespan of Americans is flat to declining (in most ethnic and racial groups). Worse than no gains in longevity, perhaps, is that death from diseases like dementia and Parkinson disease are on the rise.

A neutral Martian would look down and wonder why all this healthcare hasn't translated to longer and better lives. The causes of this paradox remain speculative, and are for another column, but the point remains that—on average—more healthcare is clearly not delivering more health. And if that is true, one may deduce that much of US healthcare is marginal when it comes to affecting major outcomes.

It's About the Delta

Logos trumps pathos. Sure, my physician colleagues can tell scary anecdotes of bad outcomes caused by an inexperienced NP or PA. I would counter that by saying I have sat on our hospital's peer review committee for two decades, including the era before NPs or PAs were practicing, and I have plenty of stories of physician errors. These include, of course, my own errors.

Logos: we must consider the difference between non-MD–led care and MD-led care.

My arguments from 2020 remain relevant today. Most medical problems are not engineering puzzles. Many, perhaps most, patients fall into an easy protocol—say, chest pain, dyspnea, or atrial fibrillation. With basic training, a motivated serious person quickly gains skill in recognizing and treating everyday problems.

And just 2 years on, technology further levels the playing field. Consider radiology in 2022—it's easy to take for granted the speed of the CT scan, the fidelity of the MRI, and the easy access to both in the US hospital system. Less experienced clinicians have never had more tools to assist with diagnostics and therapeutics.

The expansion of team-based care has also mitigated the effects of inexperience. It took Americans longer than Canadians to figure out how helpful pharmacists could be. Pharmacists in my hospital now help us dose complicated medicines and protect us against prescribing errors.

Then there is the immediate access to online information. Gone are the days when you had to memorize long-QT syndromes. Book knowledge—that I spent years acquiring—now comes in seconds. The other day an NP corrected me. I asked, Are you sure? Boom, she took out her phone and showed me the evidence.

In sum, if it were even possible to measure the clinical competence of care from NP and PA vs physicians, there would be two bell-shaped curves with a tremendous amount of overlap. And that overlap would steadily increase as a given NP or PA gathered experience. (The NP in our electrophysiology division has more than 25 years' experience in heart rhythm care, and it is common for colleagues to call her before one of us docs. Rightly so.)

Three Basic Proposals Regarding NP and PA Care

To ensure quality of care, I have three proposals.

It has always seemed strange to me that an NP or PA can flip from one field to another without a period of training. I can't just change practice from electrophysiology to dermatology without doing a residency. But NPs and PAs can.

My first proposal would be that NPs and PAs spend a substantial period of training in a field before practice--a legit apprenticeship. The duration of this period is a matter of debate, but it ought to be standardized.

My second proposal is that if physicians are required to pass certification exams, so should NPs. (PAs have an exam every 10 years.) The exam should be the same as (or very similar to) the physician exam, and it should be specific to their field of practice.

While I have argued (and still feel) that the American Board of Internal Medicine brand of certification is dubious, the fact remains that physicians must maintain proficiency in their field. Requiring NPs and PAs to do the same would help foster specialization. And while I can't cite empirical evidence, specialization seems super-important. We have NPs at my hospital who have been in the same area for years, and they exude clinical competence.

Finally, I have come to believe that the best way for nearly any clinician to practice medicine is as part of a team. (The exception being primary care in rural areas where there are clinician shortages.)

On the matter of team care, I've practiced for a long time, but nearly every day I run situations by a colleague; often this person is an NP. The economist Friedrich Hayek proposed that dispersed knowledge always outpaces the wisdom of any individual. That notion pertains well to the increasing complexities and specialization of modern medical practice.

A person who commits to learning one area of medicine, enjoys helping people, asks often for help, and has the support of colleagues is set up to be a successful clinician—whether the letters after their name are APRN, PA, DO, or MD.

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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