New-Age American Health Care System (Part 2)

In Part 2 of a discussion from the Student National Medical Association (SNMA) Conference in Louisville, KY this past weekend, Bryant Cameron Webb and I discussed changes to the practice of medicine. 

Medical Practice

If there indeed is a physician shortage, why spend over 7 years training someone to fill that void (4 years of medical school and at least 3 years of residency training) when other clinicians can be trained in less time? Nurse practitioners (NPs) and physician assistants (PAs) take a fraction of the time to train relative to physicians and produce similar outcomes in certain studies.

There are approximately 155,000 nurse practitioners and over 75,000 physician assistants in practice today. In fact, NPs are among the fastest growing clinician group entering the field of primary care. This becomes important considering the talks of doctor shortages and the looming expansion of Medicaid under the Affordable Care Act ().

Are PAs and NPs efficient substitutes for physicians? Although a lot of anecdotes might state that NPs and PAs mights pose risk to patients, much of the published data supports the idea of clinical equivalence between these different health care providers. But according to Dr. Bryant Cameron Webb, who has researched the issue thoroughly, the strength of the data behind some of these studies comparing the effectiveness of nurse practitioners to physicians is questionable.

It is here where there is often disagreement between physicians and nurse practitioners. Although there is amble data supporting the use of NPs as primary care providers, some would say that the data is far too limited in scope to allow NPs to replace physicians outright as the nation’s go-to primary care providers. Nevertheless, the Kaiser Family Foundation and the  both argue that NPs should be allowed to practice at the top of their license.

What does this mean for medical students? If you happen to be going into primary care, you could find that as NPs gain independence, primary care doctors will have direct competition for patients with nurse practitioners.  As it stands today, in 23 states and the District of Columbia NPs can already practice independently of physicians. There will be increasing pressures for state legislatures – which dictate whether NPs can practice independently, with a written agreement with a physician, or under strict supervision of a physician – to loosen regulations to accommodate access to care for their constituents.

Medical students interested in primary care need to know whether or not they will practice in a state with a competitive or a collaborative approach with NPs. Physician assistants, on the other hand, always must have a supervising physician with which to work. Thus, PAs and physicians naturally collaborate more easily without threat of a “turf battle.”

Might states that have allowed NPs to practice at the top of their license without physician supervision see fewer primary care physicians over time? Only time will tell. But until the financial incentives that drive physicians toward procedures and specialization are corrected, primary care will continue to suffer.