By Rebekah Bernard, MD

In Gabrielle Masson’s recent article, “One Thing That Should Be on CMOs’ Priority List,” The Leapfrog Group’s CEO Leah Binder expresses concern that due to staffing shortages during the COVID19 pandemic, some hospitals have brought in physicians who are not board-certified or lack specialty training in critical care. She emphasizes the importance of having highly trained and qualified physicians in intensive care settings for patient safety. On behalf of Physicians for Patient Protection, we agree wholeheartedly with the spirit of this viewpoint, but feel that several issues require elaboration.

Regarding physician board certification, we fully agree that every physician should complete initial board certification, however, there are increasing concerns about the recertification and ‘maintenance of certification’ (MOC) process. In a perfect world, board certification status would be a valid measure of a physician’s qualifications to practice and their diligence in staying current. Unfortunately, board recertification in its current form does not measure either of these things, focusing on a physician’s knowledge at one point in time and ability to prepare for an exam rather than measuring their judgment and ability to apply knowledge. As a result, many well-trained and experienced physicians are choosing to drop American Board of Medical Specialties (ABMS) recertification in favor of the National Board of Physicians and Surgeons (NPBAS), which meets all national accreditation standards for health plans.  We urge employers to join the many hospitals that already accept both recertification pathways for physicians.

More importantly, while the article focuses on the employment of physicians who are not board-certified in critical care, it fails to acknowledge the more pernicious process playing out in ICUs, emergency departments, and other care facilities throughout the country: the replacement of physicians by non-physician practitioners with minimal training and oversight. Specifically, the use of nurse practitioners (NPs) and physician assistants (PAs) in ICUs, often without physician supervision or even a physician on-site, presents a serious risk to patient safety both during a pandemic and in the future.

The use of non-physician practitioners is frequently justified as a strategy to expand access to affordable medical care in the setting of physician shortages. However, as the article points out, there exists an inevitable tradeoff between accessibility and quality. To be licensed to practice medicine, physicians must complete a minimum of 15,000 hours of clinical training and pass multiple standardized examinations.  Physician assistants graduate with about 2,000 clinical hours, and nurse practitioners with a minimum of 500 clinical hours. The nurse practitioner role is also complicated by changing trends in NP training. While in the past nurse practitioners typically had extensive nursing experience before becoming nurse practitioners, there are now more than 400 NP training programs that include accelerated, online training, 100% acceptance rates, and “direct entry” programs that allow anyone with a bachelor’s degree in any subject to become an NP in under three years.

If a fully trained physician without critical care certification is considered inadequate to care for intensive care patients, how then can it be considered safe to allow NPs and PAs, with far less training, to fill that same role?

The Leapfrog Group espouses the importance of transparency in healthcare, and we agree that patients must know who is providing their care, as well as their training and credentials. While the concerns presented in the article are valid, the issue is far deeper and warrants further attention.

Rebekah Bernard MD is a family physician in Fort Myers, FL and a board member of Physicians for Patient Protection, a group that advocates for physician-led care and truth and transparency among healthcare practitioners. Mark Lopatin MD is a retired rheumatologist and member of Physicians for Patient Protection. He is the author of Rheum for Improvement: The Evolution of a Healthcare Advocate.