By: Servando Sanchez Jr., MD
I am a PGY4 resident completing my training in psychiatry with the goal of going on to provide high quality mental health care to people who need it. Throughout my training, I have worked with a variety of people with different roles in the healthcare team. I have learned much from both the physicians and non-physicians with whom I have worked. However, as I have gained more knowledge and experience, I have realized the importance of having healthcare teams led by physicians. In the US, advanced practice providers (APPs) have gained broader scopes of practice and, in the majority of states, are able to practice independently. In this essay, I will share information about some differences between physicians and APPs and will share a personal experience that have informed and reinforced my belief that healthcare teams should be physician led.
First, I would like to address the expansion of APPs in the US. We are currently dealing with a physician shortage that will likely worsen unless we make changes to the system of educating and training physicians. In their paper, Zhang et al. explained that based on supply and demand trends, more than 30 states in the US will face physician shortages by 2030 (Zhang et al. 2020). This prediction indicates we will not meet the healthcare needs of our population with physicians alone. Likely as a result, legislation has passed such that utilizing APPs has become part of the solution. I think that we need to re-evaluate this decision and discuss what role APPs will be filling within our healthcare systems.
As APPs have obtained more autonomy and independence, studies have attempted to examine how they perform in comparison to physicians. However, as Al-Agba and Bernard mention in their book Patients at Risk, these studies have not compared independently practicing APPs versus physicians. In these studies, APPs have had supervision by a physician or had a physician available for consultation (Al-Agba and Bernard 2020). Thus, what the studies have truly compared is the care from an APP who has supervision and/or can consult with a physician versus care from a physician alone. An area often studied is the cost of care provided by APPs vs physicians; results are mixed. A systematic review completed in 2019 found that the majority of studies available at that time supported APPs to be cost-effective providers for medication management, but they had mixed results when it came to cost-effectiveness for diagnostic procedures and laboratory testing (Abraham et al. 2019). Further, an examination of cost data for the Hattiesburg Clinic’s accountable care organization in southern Mississippi showed that care provided by non-physician providers working on an independent patient panel was more expensive than care delivered by physicians (Batson et al. 2022). In terms of actual health outcomes, results are also mixed. A 2018 study compared Medicare beneficiaries whose primary care provider (PCP) was an APP vs those who saw a physician PCP. This study showed that patients assigned to APPs for primary care had fewer preventable hospital admissions, readmissions, and fewer ED visits while those managed by physician PCPs more often received recommend treatment for chronic disease management and cancer screenings (Buerhaus et al. 2018). Taken as a whole, I believe the data supports that APPs can provide adequate care in specific settings and when appropriately supervised by physicians. However, I have reservations about the current scope of practice APPs have obtained and worry they do not have the ability to practice safely in many settings. The education and training APPs receive is not equivalent to the education and training of a physician. Physicians complete graduate education and post graduate training that includes over 10,000 hours of patient care. APPs typically complete only graduate level education and training that includes several hundred to 2,000 hours of patient care (Scope of Practice 2023). With such a clear difference in our education and training, it is not surprising that a physician and an APP can see the same patient and give different recommendations for treatment.
As a PGY4 psychiatry resident, I have already experienced firsthand several situations in which I have seen poor quality or blatantly inappropriate care provided by APPs. I do not mean to imply that all APPs provide such care, but I want to emphasize this can occur when an APP practices without adequate training or appropriate supervision. Rather than mention every situation I have encountered, I will discuss only one. During an initial psychiatric evaluation for a patient establishing care at our clinic, I completed a medication review. I immediately noted that the patient was taking an inappropriate and dangerous combination of medications. The patient reported they had been seeing an APP for medication management of their mental health conditions but felt they were not improving. This APP prescribed the patient a controlled Z-drug for sleep, a benzodiazepine for anxiety, two antipsychotic agents, and two serotonin agents. Furthermore, a review of our state’s prescription drug-monitoring program revealed that the patient was taking an opiate pain medication prescribed by a different clinician. The combination of a Z-drug, a benzodiazepine, and an opiate pain medication is overtly dangerous and could be lethal, especially if a patient were to combine any of these medications, let alone all three, with any amount of alcohol. Looking at the antipsychotic and serotonin agents, none was at the maximum FDA recommended dosages. The patient verified that they had not been on higher doses of these medications, which implies the APP had not first attempted to maximize the benefit of the mediations by increasing the dose. Instead, the APP added new medications that increased the overall mediation burden and increased the risk for interactions and side effects. At that initial visit, I worked with the patient to decrease the doses of the controlled medications as a risk minimization strategy, and we agreed to taper and stop some of these medications over time. This patient and I were able to simplify their medication regimen by increasing the doses of some mediations and stopping others completely. We were ultimately able to get symptoms under better control with fewer medications, and thus with a safer medication interaction profile.
Although this story may not represent all cases in which APPs provide healthcare, it is important to recognize this type of situation has occurred and will likely continue to occur. Based on the growing demand for healthcare services in the US and the inability of our current system to train the needed number of physicians, I understand the desire for other types of medical professionals to take on the role of physician. However, my experiences, and the similar experiences of others, show the level of training physicians receive through medical school and residency is far greater than the training APPs receive in their programs. Rather than continue the current trend of increasing the autonomy of APPs, I think we should be looking at how to incorporate APPs into healthcare teams led by physicians. I believe that in this manner we could meet the demand for healthcare services while also ensuring APPs have adequate supervision and receive appropriate and ongoing training.
References
Abraham, Cilgy M et al. “Cost-Effectiveness of Advanced Practice Nurses Compared to Physician-Led Care for Chronic Diseases: A Systematic Review.” Nursing economic$ vol. 37,6 (2019): 293-305.
Al-Agba, Niran, and Rebekah Bernard. Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare. Universal-Publishers, Inc, 2020.
Batson B, Crosby S, Fitzpatrick J. Targeting Value-based Care with Physician-led Care Teams. Journal of the Mississippi State Medical Association. January 2022, Vol. LXIII, No. 1, pp. 19-21. https://ejournal.msmaonline.com/publication/?m=63060&i=735364 &p=21&ver=html5
Buerhaus, Peter PhD, RN, FAAN, FAANP(h)*; Perloff, Jennifer PhD†; Clarke, Sean PhD, RN, FAAN‡; O’Reilly-Jacob, Monica MA, MS, FNP-BC§; Zolotusky, Galina MS§; DesRoches, Catherine M. PhD∥. Quality of Primary Care Provided to Medicare Beneficiaries by Nurse Practitioners and Physicians. Medical Care 56(6):p 484-490, June 2018. | DOI: 10.1097/MLR.0000000000000908
“Scope of Practice: Education Matters.” American Medical Association, 31 Aug. 2023, www.ama-assn.org/practice-management/scope-practice/scope-practice-education-matters.
Zhang, X., Lin, D., Pforsich, H. et al. Physician workforce in the United States of America: forecasting nationwide shortages. Hum Resour Health 18, 8 (2020). https://doi.org/10.1186/s12960-020-0448-3
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