Last month, amidst the chaos brought into the medical community by COVID-19, a Twitter battle among healthcare professionals ensued. The controversy began when a medical student tweeted a graph depicting the differences in clinical education between physicians, physician assistants (PAs), and nurse practitioners (NPs). The graph showed that by the time they graduate from medical school, physicians have accrued approximately 6,000 hours of clinical education—even before any additional required years of residency training. Physician assistants acquire approximately 2,000 hours of clinical education prior to graduation and nurse practitioners between 500 to 1,500 hours. The range of graduating nurse practitioner experience (500-1500 hours) is because nurse practitioner programs lack the same standardization required of medical school and physician assistant programs, resulting in variable clinical exposure and competency.1
Along with the graph was a message stating that:
- Graduating medical students have more clinical training hours than either PAs or NPs
- National organizations supporting PAs and NPs have leveraged the COVID-19 pandemic to further their argument for “full practice authority (FPA)” (a.k.a. independent practice or practice without supervision)
Although the medical student also included the message that all members of the health care team have a valuable role in caring for patients, non-physicians on Twitter were outraged.
Rather than responding to the message with a fact-based argument, furious non-physicians attacked the medical student directly, threatening his career, reputation, and credibility. One PA even threatened to send a screenshot of the message to every medical school in the country to prevent the medical student from being accepted into residency training.
This attack was deeply disturbing to Natalie Newman, M.D., an emergency medicine physician and vocal advocate for patient protection, who took to Twitter to defend the student. Newman has seen these types of “vicious, bullying attacks” on medical students, residents, and fellows on social media many times, and believes that the corporate practice of medicine is the root of the problem. In replacing physicians with nurse practitioner and physician assistants, Newman notes that corporations have created a “false equivalency between physicians and non-physicians, blatantly disregarding the unique role that each discipline contributes to the medical team.”
Although corporations and some non-physician practitioners would like the public to believe that all medical professionals are interchangeable, the truth is exactly what the medical student posted: physicians have far more hours of clinical training than nurse practitioners and physician assistants.
Non-physicians were angered not only by the citation of training hours, but also by the medical student’s accusation that nurse practitioner and physician assistant leaders have politicized the COVID-19 pandemic to gain practice independence. But the truth is that in the last several months, nurse practitioners and physician assistants gained large increases in scope of practice in multiple states based on the argument that physician supervision requirements were holding them back from being able to help out in the health crisis. These groups continue to use the pandemic to gain practice independence across the country.
For example, the AAPA unveiled the hashtag: #InItToPivot, implying that physician assistants are ideally positioned to move into new roles in health care. This hashtag is typically accompanied by the more common #PAsAreTheSolution and #PAsNeedFullPracticeAuthority circulating through various public posts. In these posts, physician assistants insist that they are ready and willing to work in any medical specialty without the need for additional training. For example, a PA who works in dermatology can theoretically “pivot” to become a critical care or emergency room PA just by taking on a new title and pay. While this ability might seem most opportune in the current all-hands-on-deck climate, the truth is that this practice can be dangerous to patients, particularly if independent practice is allowed.
Physician assistants and nurse practitioners often insist that they must be permitted to practice “at the top of their license.” But what if physicians made the same argument? State medical licenses do not limit medical practice to a specific specialty. In fact, medical licenses are required only to “practice medicine and surgery.” However, most physicians only practice in their specialty after completing an additional three to seven years of training following medical school. A cardiologist does not suddenly decide to be a psychiatrist—even though their medical license does not prohibit them from doing so. A geriatrician does not one day choose to advertise as a pediatrician. Not because they cannot, but because they know their limitations and realize that this type of practice is dangerous. It is for this reason that physicians undergo additional years of training in any specialty in which they wish to practice, which includes standardized assessments and examinations.
There is no quick “pivot” in medicine—because patient safety comes first.
It takes more than 11 years to become a fully trained physician, capable of practicing independently. There are no shortcuts. Fellow physicians and medical trainees must be courageous enough to speak the truth about physician-led care, even though they may face attacks from adversaries. Concomitantly, PA and NP colleagues should try to understand the limitations in their education and, when engaging in this much needed discussion, they should take care to avoid using personal attacks and threats. In the end, our goals should be identical: protection of and care for our patients at the highest level.
1.) 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