Why Physician Assistants and Nurse Practitioners Need Supervision, Say Physician Groups

The ongoing expansion of responsibilities for physician assistants and nurse practitioners is renewing opposition from physician groups.

Efforts to expand the roles of physician assistants and nurse practitioners are expected to accelerate this year over the objection of physician groups.

The National Commission on Certification of Physician Assistants expects reform of scope of practice, supervision, and delegation of authority legislation to be a top trend regarding physician assistants this year. Advocates of loosening restrictions on physician assistants and nurse practitioners claim the reforms can boost productivity, lower cost of care, and improve access to healthcare services.

For example, recent research found physician assistants and nurse practitioners provided equivalent care for diabetes patients, and the American Academy of Physician Assistants has reported that PAs increase access to care.

"PAs expand access to care in rural areas: 15% of Americans live in rural areas; AAPA data indicates that 12% to 15% of PAs overall—and 20% to 25% of PAs in primary care—practice in rural areas, compared with 10% of MDs," the AAPA reported.

The American Medical Association (AMA), which represents more than 200,000 member physicians, opposes relaxing rules that require physician assistants and nurse practitioners to practice under the supervision of a doctor.

"Independent practice and team-based care take healthcare delivery in two very different directions. One approach would further compartmentalize and fragment healthcare delivery, while team-based care fosters greater integration and coordination," an AMA spokeswoman told HealthLeaders.

Carmen Kavali, MD, of Kavali Plastic Surgery and Skin Renewal Center in Atlanta, and a board member of Physicians for Patient Protection in Massapequa Park, NY, says PPP has taken an even harder line on the relaxing of restrictions for PAs and NPs.

"There are absolutely patient safety concerns associated with NP and PA care. We don't diminish the fact that physicians make mistakes, of course, but the type of mistake is often very different from those of non-physician practitioners. We have had many physicians and patients share stories with us of missed diagnoses and misdiagnoses by NPs and PAs, as well as excessive and inappropriate testing, prescribing, and treatment," Kavali says.

PPP is a grassroots physician organization spawned on social media in 2016 and formed officially in August 2018. "Our mission is to ensure physician-led care for all patients and to promote truth and transparency in healthcare, particularly in healthcare credentialing," she says.

PPP reality check

Physicians are far more well-prepared to manage patient care than non-physician practitioners, Kavali says.

"The educational differences are vast between physicians and NPs and PAs. A primary care physician completes medical school and three years of residency with around 15,000 hours of patient evaluation and treatment, beyond the 'book learning' hours. Today, an NP can attend NP school with no prior nursing experience and complete online education with as few as 500 clinical shadowing hours. A PA finishes PA school with about 2,000 clinical hours."

The educational differential between physicians and non-physician practitioners has important implications for how care is delivered, she says.

"Because it is hard to know what you don't know, and because many patients present with potentially confusing and confounding symptoms, a physician should see all initial patient consults, develop the diagnoses, then formulate the treatment plan(s), which can then be carried out seamlessly by an NP or PA. Simply co-signing a chart without laying eyes on the patient is not adequate supervision."

PPP is particularly concerned over the relaxation of practice restrictions on NPs, and the organization rejects contentions that NPs can solve clinician shortages in rural areas, increase access to care, and lower cost of care, Kavali says.

"Here's the reality—in states where nurse practitioners have had independent practice, they are not going rural. For example, in Arizona the nurse practitioners have had independent practice unsupervised since 2001, and in 2017 there were fewer than 11% of nurse practitioners in rural areas of the state. They are not going rural more than anyone else is for the same reasons. As far as costing less, NPs order more tests, order more radiographs, and order more labs. For basic chronic disease care, they spend more annually than primary care physicians do."

PPP is trying to help the AMA to turn the regulatory tide regarding the supervision of NPs and PAs, she says.

"We are trying to educate legislators and members of the public. A nurse practitioner was never intended to replace a physician. This is not about turf. This is not about territory. This is about truth, transparency, and patient safety," Kavali says.

AMA guidance for physician assistants

The AMA has adopted several recommendations for the supervision of physician assistants by physicians.

• Physicians should bear ultimate responsibility for coordinating and managing patient care, with appropriate input from physician assistants
   
• Physicians should supervise physician assistants in all care settings
   
• Physicians and physician assistants should set mutually agreed-upon guidelines for physician assistant participation in patient care
   
• Physicians should be available to consult with physician assistants at all times, either in person or through remote communication
   
• Physicians and physician assistants should regularly review all delegated patient services
   
• Physicians should clarify and familiarize supervising methods with physician assistants

"The American Medical Association encourages physician-led healthcare teams that utilize the unique knowledge and valuable contributions of all clinicians to enhance patient outcomes. Physician assistants and nurse practitioners are valuable members of this team, and patients win when each member of their healthcare team plays the role they are educated and trained to play," the AMA spokeswoman said.