Scope of Practice

“Are you a doctor?” Why a straight answer is harder to come by

Tanya Albert Henry , Contributing News Writer

AMA News Wire

“Are you a doctor?” Why a straight answer is harder to come by

May 10, 2024

The number of nurse practitioners (NPs) and physician assistants (PAs) continues to rise in the U.S., and the associations representing them continue to push state legislatures for permission to practice without physicians’ supervision.

Scope of practice expansion advocates argue that these nonphysician providers are just as good as physicians. But evidence from the past half century fails to provide conclusive evidence that nurse practitioners and physician assistants can provide safe and effective medical care without physician oversight, according to AMA member and Florida family physician Rebekah Bernard, MD.

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Moreover, many states lack truth-in-advertising requirements for all health professionals to clearly and accurately identify themselves in all writings, advertisements and other communications and wear—during patient encounters—a name tag that clearly identifies the type of license they hold. Together, this has led to what Dr. Bernard sees as a rise of nonphysician providers posing as “imposter doctors.” She has outlined the issue in her most recent book, Imposter Doctors: Patients at Risk

Rebekah Bernard, MD

In addition to sharing stories in which patients were harmed because they did not get the proper care when they were treated by a nonphysician provider, Dr. Bernard’s book details data showing just how much less training nurse practitioners and physician assistants get compared with physicians. She also highlights studies showing that replacing physicians puts patients at risk. She co-wrote, with Niran Al-Agba, MD, a previous book called Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Health care.

Going beyond the data, Dr. Bernard’s book offers perspectives from nurses and physicians of how patients are endangered when nonphysician providers practice beyond their training, and examines the role of profit has too often been put before the interests of patient safety. In an interview, she expanded upon these and other themes.

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Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. The AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety.

AMA: Is there one thing that surprised you the most—and you believe would surprise your physician colleagues—that you learned while you were researching this book?

Dr. Bernard: The history of how we ended up in this situation—that it is a policy situation and that if we wanted to have more physicians, we could do that. I didn't realize the things that happened in the 1980s ... we had the freezing of medical schools, a moratorium on new medical schools and then even the freezing of residency positions. By 1997, Congress passed the Balanced Budget Act that froze residency funding.

Then there were reports saying there actually was not going to be a physician surplus. Instead, there's going to be a physician shortage. By the time that this is realized, how do you stop a moving train? We already have all of this policy that's slowing down the production of physicians. And at that point, lawmakers say, "Let's fill the gap and let's get more NPs and PAs.” ...

I find it just amazing when you look at the numbers of physicians, we've sat at about a million doctors, more or less, for the last decade or two, and yet the number of NPs was 90,000 in 2010, and now it’s at 385,000.

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AMA: One story from the book that really stands out is that of a Louisiana emergency physician Louisiana who was fired after refusing to admit an ED patient to the care of an unsupervised nurse practitioner. How can physicians fight back when they believe patient care is unsafe?

Dr. Bernard: We really need more awareness, because if it's just you trying to fight the system—that's just not going to go very far. These systems are complex and nuanced. We need to involve people who understand all these nuances, like attorneys and intellectual experts on health care policy, to help.

And I think the media is a very big part of this. It comes down to really increasing awareness and I think it's starting to happen. I'm seeing more ProPublica pieces and other investigative watchdogs that are starting to report on this. The only way that change will happen is if there's enough pressure. Again, this is like stopping a moving train. And, so, it's going to take a lot of work and a lot of pressure.

AMA: How can physicians be proactive in these situations and protect themselves and patients?

Dr. Bernard: I'm still so shocked by the number of physicians that truly do not understand the educational background and training of nurse practitioners and just make the assumption, "Oh, well, they're just like a doctor. Oh, they know just as much."

So, first, physicians need to understand the differences in the training. They need to really understand what the scientific data says about care and not just read the headlines and say "Oh, NPs provide great care." They do, but that's when they have careful physician supervision. ... I think that physicians need to take that supervisory role very seriously. If they agree to do that, then they need to do it properly, or not do it at all.

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AMA: You write about how the rise of nurse practitioners and physician assistants’ practicing without physician supervision is contributing to a two-tiered health care system. Can you talk about the impact on efforts to advance health equity? 

Dr. Bernard: This is one of the biggest challenges and problems that I see, and part of it is government policy. Back in 1977, the Rural Health Clinic Services Act mandated that a nurse practitioner, physician assistant or certified nurse midwife must be available to provide patient care for at least 50% of the time the clinic operates.

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When I worked at a federally qualified health center with extremely sick patients, many had not had any health care and their cases were so complicated. As a family physician, a new graduate, I was constantly researching, trying to figure out how to help patients, especially with limited resources. I remember talking to my boss and saying, "We really need another doctor." And he said, "Well, we do, but we can't hire another doctor, because we have to hire another NP or PA." ...

Every patient deserves to have access to a physician or physician-led care. And a lot of times, you hear this argument that, "Well, it's for access. It's for rural areas." Well, why are rural patients less valuable than urban patients? And are community health center patients less entitled to high quality health care? To me, that is a social justice issue. If you want to get patients care by a physician, you can incentivize physicians to go to those areas.

AMA: Is there anything physicians can do to help empower patients to understand the level of education of the person who's providing their care?

Dr. Bernard: When we're talking with our patients, we can let them know. For example, as a primary care doctor, when I'm referring my patient to a specialist, if they don't see a physician—or at least a physician isn't involved in that visit—I'm going to let my patient know that that's not acceptable. In fact, I'll tell them that ahead of time. That’s not to say an NP or a PA can't see the patient and then present it to the physician and work together. That's perfectly fine.

But if I send someone to a specialist and they come back to me and I say, "Well, I just saw the NP and there was no physician involvement," and they keep seeing the NP every time, I have a big problem with that. And I explain to the patient why. I explain to them the difference in training, and that if I'm not sure what's wrong with them, I expect you to see someone that knows more than I do about that subject—who went to medical school and did additional training in that field. I know it's uncomfortable to have these conversations, but again, it's for empowering patients and letting patients make an educated decision.

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