What happens when you analyze 30 million patient visits by Advanced Practice Providers (PAs and NPs)? You discover that they care for the same types of patients as physicians and achieve equivalent or better results.
In 2019, two MDs teamed up for a critical review of 30 research papers on the quality of care provided by physician assistants and nurse practitioners. Their editorial was published in The American Journal of Managed Care. Drs. Sarzynski and Barry do a pretty good job reviewing the literature on patient outcomes but they make a common mistake within the first few paragraphs.
I Could While Away the Hours…
“In contrast to NPs and PAs, a typical family physician completes 15,000 hours of clinical work over 5 additional years of training [compared to 2 years for PAs and NPs], including residency.” While it’s true that MDs have a higher threshold for minimum training requirements than PAs, comparing a new grad MD to a new grad PA is not an honest endeavor. The MD and PA that start their training at the same time will both have 7 years of experience by the time the MD finishes med school and a typical 3-year residency.
They do correctly state, however, that 3 or more NPs could be trained for the price of 1 MD and in a fraction of the time. This is a salient point–the role of PAs and NPs is not to replace the well-trained physician, but rather to address the shortage created by an overly elaborate system.
In the US, medical students traditionally attend a 4-year medical school after 4 years of college. Although this is changing with the advent of 3-year medical school and accelerated BS/MD programs, also referred to as “guaranteed admission” programs, American physicians spend more time in school than physicians from around the world. In most other countries a medical degree is a 5-6 year MBBS (Bachelor of Medicine, Bachelor of Surgery). Drs. Sarzynski and Barry concede that an overhaul of US physician education is warranted.
What reasoning do the authors give then for their implicit preference for MD training? The “ability to generate differential diagnoses” and “provide care for complex patients”. I guess they missed the article in the prestigious journal Chest a few years earlier showing that PAs and NPs caring for critically ill ICU patients had lower predicted mortality scores and lower mechanical ventilation rates than patients treated by physicians alone. Don’t they know that some physicians actually train alongside PAs?
Out of Context, Out of Mind
While the article is largely supportive of expanded roles for physician assistants and nurse practitioners, the few articles they use as counter-points are not thoroughly explained. For example, they cite a 2015 review of telemedicine visits to suggest that Advanced Practice Providers (APPs) prescribe more antibiotics than physicians. They fail to report, however, that Emergency Medicine Physicians were also included in this group of “over prescribers”. They also fail to mention that the prescribing habits of APPs were largely based on two individual PAs! Yet at the same time, the authors of the telemedicine article acknowledge that the two PAs had a greater level of electronic communication with patients through the EMR messaging system suggesting that they “may be uncovering and treating a larger variety of symptoms that would be otherwise unaddressed.”
A more recent study, entitled “Comparing physicians and PAs as solo providers in a rural ED” was published in JAAPA in July 2021. This study evaluated ED metrics from a critical access hospital in Arizona. Analysis of 26,000 patient encounters was performed with only minor variances in PA and physician metrics. Transfers, 72-hour returns, and death rates for PAs were all similar to those of physicians. The short answer? No clinically meaningful difference between physicians and PA-led care was discovered.
The next article Sarzynski and Barry cite supposedly suggests that PAs and NPs compensate for deficits in training by ordering more diagnostic tests. Left at that, the statement sounds pretty damning, right? They conveniently fail to provide any actual data. The 2014 JAMA article referenced actually states that advanced practice clinicians ordered imaging in 2.8% of cases while primary care physicians ordered imaging in 1.9% of cases. That’s a difference of 0.3% per patient! In layman’s terms, this means that about 1 out of every 300 patients that saw an APP had some sort of imaging study that they might not have had had they seen a physician. Statistically significant? Perhaps. Clinically significant–I don’t think so. PS: Imaging utilization was no different for new patients seeing either an APP or a physician but this wasn’t reported either.
The third and final cited article by Sarzynski and Barry to counter the overwhelming evidence that PAs and NPs provide excellent care was a 2015 article from The Journal of the American Geriatrics Society. The stated findings in the editorial by Sarzynski and Barry was that Advanced Practice Providers referred more patients with diabetes to specialty care than did primary care physicians. Not only is this a questionable metric (older diabetic patients tend to have multiple comorbidities) but they failed to report the following: “Nurse practitioners were similar to PCPs or slightly lower in their rates of diabetes mellitus guideline-concordant care. NPs used specialist consultations more often but had similar overall costs of care to PCPs.” So, same or slightly lower adherence to guidelines with more team-based care and equivalent overall cost? Hardly incriminating.
Your PA Can
Sarzynski and Barry do make several excellent points with which I wholeheartedly agree:
- NPs and PAs should practice to the fullest extent of their education and training (this is the official stance of the Institute of Medicine)
- Competency-based medical education, along with greater responsibility for NPs and PAs, can help improve the shortage of primary care physicians
- Interestingly enough, this only works when “state licensing boards … adapt to the idea that medical school may be completed in less than 4 years.”
- PAs and NPs often serve as primary care providers to underserved patients.
- The diversity of APPs prior experiences enhances care.
- Most PA schools require applicants to have between 1,000 and 3,000 hours of hands-on patient care experience.
- Policy reforms should reflect each professional’s competencies, not antiquated state laws.
- We must consider patients’ preferences about receiving primary care services.
- 94% of patients are willing to see a PA vs an MD
- Physicians and APPs must collaborate to improve the delivery of primary care.
- Physicians and APPs must respect one another.
And my personal favorite:
- Physicians’ arguments about quality are largely unfounded.
- NP and PA-led care is indeed comparable to that of primary care physicians (except, in this study, PAs and NPs were also more likely to offer health education and counseling).
Overall, Drs. Sarzynski and Barry do a fine job recognizing the value of PAs and NPs in medicine but their misrepresentation of research supposedly critical of advanced practice providers leaves something to be desired.