The Doctor Is Out, But the Advanced Practice Provider Can See You Now

This article originally appeared in the Huffington Post on July 17, 2014.

By Sofia F. Garcia

People trust nurses: they were again voted the most honest and ethical profession. Yet, buoyed by typecasting, there are challenges to expanding their roles as the Affordable Care Act is implemented. Nurses' image as handmaidens to physicians persists, despite the Institute of Medicine's recommendations that they should "practice to the full extent of their education and training." That span can be especially broad for nurse practitioners.

They and physician assistants are rising in numbers and ranks to augment patient care, especially in underserved communities. A study published last year illustrated that increased use of nurse practitioners and physician assistants could significantly lessen the projected primary care physician shortage. Their expanded roles could also dramatically reduce costs, according to a recent report.

But many patients do not know what nurse practitioners and physician assistants do. In addition to examining and educating patients, they order and interpret laboratory tests, and some prescribe medications. Nurse practitioners receive advanced degrees and clinical training, and physician assistants complete two-year programs modeled on medical school. Still, they are often disparagingly called "mid-level providers." That term is falling out of favor but its continued use contributes to the notion that these advanced practice providers do not provide high-level care.

In fact, a review of studies spanning 18 years showed that care provided by nurse practitioners in concert with physicians is comparable and sometimes better than care solely by physicians. Further, research has indicated that nurse practitioners and physician assistants tend to provide more patient education than do physicians.

What do patients think?

Nearly half of the health care consumers in a 2012 survey endorsed that nurse practitioners or physician assistants can provide comparable care to physicians, but only 8 percent reported using one as their primary care provider. When wait time is a factor, things change. Half of the consumers in an Association of American Medical Colleges survey preferred physicians for primary care but 60 percent were willing to be treated sooner by an advanced practice provider.

Working as an academic researcher in oncology, another area bracing for physician shortage, I study ways advanced practice providers can deliver care to the unprecedented and growing number of cancer survivors. The oncologists and advanced practice providers with whom I collaborate report that patients react positively to nurse practitioners and physician assistants when their care expectations have been managed properly. This is particularly the case when trusted oncologists introduce advanced practice providers.

Not all physicians are as supportive. Two-thirds of respondents in a survey of over 500 primary care physicians believed they provide better service than nurse practitioners. Despite lack of clear evidence, the American Medical Association and other physician groups cite safety concerns along with their profession's additional training in their lobbying against independent practice by nurse practitioners. Perhaps obviously, they favor them working in physician-led teams.

Physician shortages and the Affordable Care Act are pushing state legislatures and health insurance providers to consider scope of practice and reimbursement for advanced practice providers. Certainly, physicians will continue to play principal roles with the benefit of their extensive training, and efforts to attract medical students to specialties facing shortages should continue. But it is likely that advanced practice clinicians will prosper given they are more affordable and can fill shortages more quickly because their training is shorter.

The reality is that 19 states allow independent practice by nurse practitioners. New legislation in Kentucky, Texas and Ohio has broadened their duties and that of physician assistants. This affords great opportunity to gather data on the quality of care they provide. It is incumbent on those determining these providers' roles to do so based on available evidence rather than stereotypes, biases, and turf-war or solely fiscal arguments.

As health care transitions to new delivery models, providers from different professions must educate patients about the services they are regulated to safely and effectively provide. Concurrently, all of us as patients would do well to make informed decisions about the providers we see based on the fit between their established qualifications and our needs -- not knee-jerk reactions to their titles.

- Sofia F. Garcia is an assistant professor of medical social sciences and psychiatry and behavioral sciences at Northwestern University.