Setting the record straight on nonphysician practice
By Rebekah Bernard, MD
An article I wrote opposing the physician assistant (PA) profession’s proposed name change and move towards independent practice set off a firestorm of debate with over 1,400 comments, including personal attacks on my character, training, and even appearance. It also earned a rebuttal from the combined forces of the AANP and AAPA, lambasting me for ‘attacking’ and ‘demeaning’ their professions.
While many commenters advised me to ‘educate myself’ on nurse practitioner and physician assistant training, they were likely unaware that the book I co-authored, Patients at Risk, published by an academic press that required independent editorial scrutiny, includes an extensive literature review with over 500 citations, as well as interviews with NPs, PAs, patients, attorneys, and physicians who were NPs or PAs before attending medical school. [i]
What we learned while investigating the medical literature was shocking: while the AANP and AAPA insist that “decades of research confirm the high quality of PA- and NP- delivered healthcare,” they fail to include one critical detail—that every single study they cite involved some degree of physician oversight. In fact, there is no scientific evidence that nonphysicians can independently practice medicine safely and effectively without physician involvement.
For example, the most comprehensive meta-analysis of nurse practitioner care found only 18 studies out of 8,885 that were of adequate quality to analyze, and of these, just three of the eighteen were performed in the United States. The average duration of these studies was fourteen months, and most studies were designed for nurse practitioners to follow specific algorithms, with high risk or complicated patients almost always excluded from study. Importantly, none of the studies supporting nurse practitioner care involved unsupervised nurse practitioners – all participants had access to consultation with a physician.[ii] (The study that came the closest to excluding physicians was published by Mary Mundinger more than twenty years ago, but a careful review of her book and interviews reveals that the supposedly independent NPs in the study were each assigned a physician mentor and received an additional nine months of training with medical residents before beginning the study.[iii])
Commenters took umbrage to my statement that NP training has become haphazard, and yet, according to nursing literature, there is a “lack of consistent standards in nurse practitioner practice, education and nomenclature.”[iv] Further, over the last twenty years, NP education has shifted from well-established brick-and-mortar schools with high standards for acceptance to over 400 programs that compete fiercely for student tuition dollars. Many of these programs boast 100% acceptance rates, accelerated programs, and online training. Many NP students work full-time while attending school. In 2019, landmark NP researcher Mary Mundinger herself expressed concern about the state of NP education, noting that 85% of the 553 nurse doctorate programs established at the time of review focused on administrative and leadership training rather than clinical expertise.[v]
Despite comments that I underestimated the number of clinical hours required of NPs, the most recent NP guidelines confirm that 500 clinically supervised hours are the minimum for certification,[vi] with the average program requiring 686 hours for graduation.[vii] Unfortunately, students are having increased difficulty in finding adequate preceptorship for even these minimum hours,[viii] with a recent review of nursing education literature noting that 50% of NPs surveyed were not fully prepared for the work they were expected to handle, especially “in the areas of independent decision making, time management, complex care, prescribing, billing/coding, and interdisciplinary communication.”[ix] NPs themselves do not believe that this is enough education or training, reporting a lack of competence in evidence-based practice[x] and a desire for improved educational content, clinical experience, and competency testing.[xi]
Critics of my article argued that I failed to acknowledge nursing experience gained before entering into the NP role. They are likely unaware that over sixty ‘direct entry’ programs now allow anyone with a bachelor’s degree in any subject to earn a nurse practitioner degree without previous nursing experience. But whether nursing experience makes a significant difference in preparation for the NP role is debatable, with some studies showing no relationship between prior RN experience and NP role transition.[xii]
Based on the many supportive comments from physician assistants, many are equally appalled by the direction that their leadership is taking. But by co-penning a rebuttal with AANP leadership, the AAPA has chosen to double down on their move towards independent practice.
It is unfortunate that anyone who points out the differences in medical training or emphasizes the importance of truth and transparency among healthcare practitioners is faced with a barrage of insults and accusations of being negative and divisive. By squelching dialogue and debate, NP and PA leaders are doing a disservice to their professions, which, like the field of medicine at the time of the Flexner report, are due for a major overhaul to ensure patient safety.
[i] Al-Agba N, Bernard R. Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare. Universal Publishers; 2020.
[ii] Laurant M, van der Biezen M, Wijers N, et al. Nurses as substitutes for doctors in primary care. Cochrane Database of SystRev. 2018;(7):CD001271. doi: 10.1002/14651858.CD001271.pub3
[iii] Mundinger, M. (2014). Path to nursing excellence: the Columbia experience. Springer Publishing Company.
[iv] Gardner, G. Dunn, S. Carryer, J. and Gardner, A. (2006). Competency and capability: imperative for nurse practitioner education. Australian Journal of Advanced Nursing 24(1):pp. 8-14.
[v] Mundinger, M. O., & Carter, M. A. (2019). Potential Crisis in Nurse Practitioner Preparation in the United States. Policy, politics & nursing practice, 20(2), 57–63. https://doi.org/10.1177/1527154419838630
[vi] National Task Force, (2016). The National Task Force on Quality Nurse Practitioner Education, Criteria for Evaluation of Nurse Practitioner Programs, 5th Edition. Washington, DC. https://www.nonpf.org/page/14.
[vii] Bray, C.O., & Olson, K.K. (2009). Family nurse practitioner clinical requirements: Is the best recommendation 500 hours? Journal of the American Academy of Nurse Practitioners, 21, 135–139.
[viii] McInnis, A., Schlemmer, T., Chapman, B., (January 31, 2021) “The Significance of the NP Preceptorship Shortage” OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 1, Manuscript 5.
[ix] Ljungbeck, B, Sjögren Forss, K, Finnbogadóttir, H, Carlson, E. “Content in nurse practitioner education – A scoping review.” Nurse Education Today. 2021, Volume 98. https://doi.org/10.1016/j.nedt.2020.104650.
[x] Melnyk BM, Gallagher-Ford L, Zellefrow C, et al. The First U.S. Study on Nurses’ Evidence-Based Practice Competencies Indicates Major Deficits That Threaten Healthcare Quality, Safety, and Patient Outcomes. Worldviews Evid Based Nurs. 2018;15(1):16‐25. doi:10.1111/wvn.12269
[xi] Hart A and Macnee C. “How well are nurse practitioners prepared for practice: results of a 2004 questionnaire study.” Journal of the American Academy of Nurse Practitioners. 2007, Vol. 19, No. 1, p. 37.