When a Nurse Is as Good as a Doctor
Across the country, nondoctor health care professionals—usually nurse practitioners (NPs) and physician assistants (PAs)—are turning up in a range of medical settings. We see those so-called advanced practice providers most often in primary care and family medicine practices, but they also work as specialists in hospitals and retail clinics, and more. In rural areas, they may be the only health care providers who are regularly available.
Their ranks are growing fast. In the past 10 years, the number of licensed NPs in the U.S. has almost doubled to 205,000. Between 2003 and today, the number of certified PAs grew from about 43,500 to more than 102,000.
One major reason: Demand for doctors, especially family physicians and internists, is outstripping supply. The Association of American Medical Colleges expects a shortage of up to 31,100 primary care doctors and up to 63,700 other physicians by 2025.
Advanced practice practitioners can make up the shortfall. But can they give you the care you need? And how does the care compare with what you’d get from a doctor?
What they do, what they don’t
PAs and NPs are handling many tasks that were once the exclusive domain of doctors: They can write prescriptions in every state. In 21 states and the District of Columbia, NPs can practice autonomously. Some NPs and PAs substitute for residents at academic medical centers.
But there are differences between them and doctors. One distinction: What advanced practice practitioners are permitted by law to do can vary from state to state and even from hospital to hospital. For example, NPs can’t prescribe controlled substances in Florida. In some states, a supervising physician needs to be on site when a PA treats you; in other states, it’s not necessary. Nationwide, an NP’s or PA’s authority to admit you to a hospital is up to the hospital.
Training differs, too. Doctors and PAs train under the so-called medical model (though primary care doctors have about 23,000 hours of education and training, PAs have around 3,000). That teaches physicians to “work through a diagnostic process that directs the questions you ask, the physical you perform, the diagnostic studies and treatments,” says Reid Blackwelder, M.D., chair of the American Academy of Family Physicians’ board of directors. Nurse practitioners are educated under the nursing model, which stresses health promotion and education.
Ultimately, what an NP or PA does in your doctor’s office will depend on his or her experience, the setting, and the speciality, notes Marc J. Moote, PA-C, chief physician assistant at the University of Michigan Health System in Ann Arbor. “Often, each physician/PA/NP team will decide the best use of everyone’s skills on the health care team, and this can vary from practice to practice,” he adds.
6 big benefits
NPs and PAs are indispensable in handling everyday problems such as sore throats or urinary tract infections, freeing primary care doctors to handle more complex conditions, says John Santa, M.D., medical adviser to Consumer Reports. They can also prescreen patients, make hospital rounds, do follow-up care, monitor treatment, manage chronic conditions, and have a place in specialty care as well. “They can be very good at the history taking, reviewing a patient’s records, and coordinating everything the specialist needs,” Santa adds. What’s more, many PAs work as surgical assistants. Though seeing an advanced practice practitioner is unlikely to lower your co-pay, it can help reduce overall health costs. Other benefits may include:
Shorter waits for appointments. Merritt Hawkins, a health care search and consulting firm, found that in 15 metropolitan areas, new patients wait, on average, 18.5 days to see a cardiologist, dermatologist, family physician, obstetrician/gynecologist, or orthopedic surgeon. But with more providers in the office, the PA or NP can see a patient if the doctor can’t.
A team approach. Having an NP or PA on staff makes some aspects of team-based health care more feasible. He or she can check a cough, cut, or sprain, and ensure vaccinations and blood pressure and cholesterol checks are done. A 2013 review in the Journal for Nurse Practitioners reported comparable blood glucose and blood pressure levels in people cared for by NPs as in people seen by doctors.
Convenient care. NPs and PAs staff some walk-in clinics at drugstores. So if you develop a urinary tract infection, for example, you can get the care you need ASAP.
Faster emergency-room treatment. Canadian researchers have found that in ERs with NPs and PAs on duty, people without life-threatening symptoms were twice as likely to be treated within 15 to 60 minutes.
Help with chronic conditions. Once you and your physician decide on a treatment, a PA or NP can make sure it’s going smoothly, for example, that your blood glucose levels are well-controlled.
APPs are especially helpful for seniors with chronic illnesses. A study in the Journal of the American Geriatrics Society noted that older patients managed by both an NP and a physician had higher quality care for dementia, falls, and urinary incontinence than those treated only by a physician. Co-management “is most appropriate for conditions that require a lot of close monitoring, patient engagement, and education,” says study co-author David B. Reuben, M.D., chief of the division of geriatrics at the David Geffen School of Medicine at UCLA.
Lower risk of hospital readmission. Leukemia patients in the hospital for chemotherapy cut their stays by about 6 days and were less likely to be readmitted within 14 days when cared for by PAs instead of doctors in training, according to a small study in the Journal of Oncology Practice. A 2013 study in the Journal of Thoracic and Cardiovascular Surgery found that when PAs make home visits to heart surgery patients as part of a PA home care program, it lowered 30-day readmissions by 25 percent.
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When to stick with a doctor
More research is needed to definitively assess when seeing a doctor might be preferable to seeing an NP or PA. Advanced practice practitioners have the know-how to play a primary role in diagnosing and treating common ills and an auxiliary role managing complex ailments, says Marvin M. Lipman, M.D., chief medical adviser to Consumer Reports. “Doctors are good for those 5 to 10 percent of patients whose symptoms don’t add up and need more detailed investigation,” he notes.
NPs and PAs say they can handle more than routine tasks. “It’s a misconception to assume they can’t diagnose or manage complex care,” Moote says.
That said, some research suggests physicians may be more skilled in some areas. For example, one 2013 study found that family physicians who referred patients to a medical center better understood what the symptoms might suggest and were more likely to order the right tests than NPs and PAs. The doctors’ referrals showed “a much more logical approach,” says William Mundell, M.D., assistant professor of medicine at the Mayo Clinic in Rochester, Minn. “They were getting closer to the diagnosis.”
Another key question: How many tests are different types of providers ordering? Recent research in JAMA Internal Medicine found that NPs and PAs tend to order slightly (less than 1 percent) more imaging tests than primary care physicians for similar Medicare patients.
The takeaway: All of those providers have an important place in health care. Make sure that you see the right one for you at the right time.
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