On July 8, 2019, the American Academy of Emergency Medicine wrote a letter to the American Medical Association, asking the organization to create a public campaign to support physician-led care.
Noting concerns over the recent media crusade to promote nurse practitioner care to patients, including the American Association of Nurse Practitioners “We Choose NPs” campaign, the letter asks the American Medical Association to combat the messaging being sent by nurse practitioners, which “suggests that [nurse practitioner] care is equivalent or better than that of a physician.”
The letter notes that “NPs and other midlevel providers do not have the training required to sufficiently care for patients independently,” and should be supervised by physicians as part of a medical team to protect patients.
Within two days, the American Association of Nurse Practitioners responded, demanding that the emergency medicine group retract its letter, which it claimed sought to “undermine the NP profession and devalue the health care needs of patients nationwide.” Furthermore, the group called for more autonomy and independence for nurse practitioners, citing “50 years of research” demonstrating equivalent outcomes to care by physicians.
Indeed, research has shown that nurse practitioners can provide quality care to patients — but only when working as part of a physician-led team.
The bottom line is that every single high-quality published study demonstrating safety and efficacy of nurse practitioners, beginning with the Burlington trial of 1974, has been performed in a setting of physician oversight and collaboration. Even in studies where nurse practitioners were practicing “independently,” nurse practitioners have always been allowed the opportunity to consult and seek advice from a supervising physician.
Using data from studies of nurse practitioners working under physician supervision to demand independent practice is a flawed practice, as there is no proof that nurse practitioner care without physician oversight is either safe or effective.
The call for independent nurse practitioner practice is of concern in an era in which the standards for training have become less rigorous.
In the past, most nurse practitioners entered the profession after years of clinical nursing experience and after participating in hands-on clinical training with an experienced nurse practitioner or physician preceptor. Today, many direct-entry nurse practitioner programs abound, which allow non-nurses with a bachelor’s degree in any field to become nurse practitioners in just 24 months — without a day of nursing experience.
With an explosion of more than 400 nurse practitioner programs in the United States, it is not difficult to be accepted, with at least nine nurse practitioner programs boasting 100% acceptance rates. Programs offer a variety of options, including accelerated courses that allow nurses to become nurse practitioners in under a year, with one program clocking in at just 10 months.
Nurse practitioner students complain that finding a clinical preceptor is increasingly difficult, and some have resorted to paying headhunters to find a place to gain experience, which may amount to no more than shadowing.
Patients should have a choice of who they see for their health care. But many patients are unaware of the differences in training and education between physicians and non-physician practitioners. The lines are further blurred when nurse practitioners are identified by terminology traditionally assigned to medical physicians. Patients may assume that they are seeing a physician when their nurse practitioner is labeled as a doctor (of nursing) or is listed as being “board-certified.”
In some cases, patients are not being given a choice. Many corporations are now hiring nurse practitioners to practice “independently” after attending school 100% online and completing just 500 hours of clinical experience shadowing a doctor or nurse practitioner.
The American Academy of Emergency Medicine is right. Physicians must undertake a public relations campaign to remind patients that physicians train for an average of 15,000 hours before being permitted to practice independently. Nurse practitioners average 500 to 1500 hours and physician assistants, who unveiled their own media campaign, “Your PA Can Handle It,” train for 2,000 hours.
Grassroots efforts to advocate for physician-led care are growing. Groups including Physicians for Patient Protection and the Hospitalist’s Union have released videos and patient information guides. The Texas Primary Care Coalition released a white paper showing the gaps in training between physicians and non-physician practitioners. And the American Medical Association has made efforts to educate the public, including a 2018 campaign for Truth in Advertising.
But more needs to be done. As the largest organization representing physicians, the American Medical Association must join with other physician groups to formulate a comprehensive plan to promote physician-led care.
In addition to detailing their medical training and expertise, physicians must also work to regain patient trust. Physicians must remind patients that nurse practitioners and physician assistants don’t hold the monopoly on “holistic” practice and listening to patients. Entire fields of medicine, including the osteopathic medicine profession and the specialty of family medicine focus on disease prevention, wellness and forging strong relationships with patients.
Patients need to know that the days of paternalism in medical education are long gone, and that physicians are now trained to partner with patients for shared decision-making. But in order to implement this new model of care, physicians will also need help breaking the chains of a system that rewards seven-minute visits and pays more for procedures than for preventive care.
Independent medical practice must only be earned through years of rigorous, standardized medical school and residency training. Anything less does patients a disservice. And patients deserve better.