NPs and PAs claim that they can provide care at an equal level to physicians for the majority of medical problems seen in a primary care practice and to some extent this may be true. Medical practice, however, is not simply caring for simple, common problems. One of the critical aspects of providing primary care is have a sufficiently broad fund of knowledge and clinical experience in training to be able to distinguish between a simple problem and a more serious one, both of which can present in the same way. We know common conditions can present in unusual ways and that serious problems can present very subtly.

Physicians undergo four years of extremely comprehensive, in-depth education in medical school, which includes a great deal of teaching in physical diagnosis as well as treatment, and then have to undertake a minimum three years of post-graduate residency training, all of it in direct patient care, to become a primary care physician. Nursing and PA schools do not provide nearly the emphasis on physical diagnosis and treatment because the curricula is directed to patient care, a very different focus. Pre-nursing education is so much more superficial than for pre-medical students in college that those courses are not acceptable if the nursing student wishes to upgrade to pre-medical studies. My daughter encountered this when she switched from nursing to pre-med. Nursing and PA students receive much less comprehensive education in the basic medical sciences- anatomy, physiology, biochemistry, microbiology, pharmacology, pathology, histology- than medical students. A graduate nurse practitioner or physicians assistant, ready to go out and practice has less education and clinical experience than a 4^th year medical student.

Is this to say we don’t need NPs and PAs. No! They have a legitimate and important function to extend the reach of physicians and assist in patient care, under the supervision of a physician. What they do not have is equivalency with physicians to practice independently and all the legislation to the contrary won’t change that.

A couple of recent examples will illustrate why I say this. A colleague who is a family physician, and an excellent diagnostician, recently saw the elderly mother of another physician for mild shortness of breath and right-sided chest pain. Everything checked out on her examination and lab work but something did not feel right. He sent her to the hospital emergency department with a presumptive diagnosis of pulmonary embolism, a highly lethal condition, and this was confirmed. His ability to sift through an extensive list of possibilities and his experience raised his level of suspicion and probably saved her life. I doubt that a NP or PA would have picked up on this.

In my own practice, I recently had impressed on me the difference between an advanced nursing degree and a medical degree. I have used certified registered nurse anesthetists (CRNAs) for years and have great respect for them. I would be happy to have one administer my own anesthesia. I had a patient with neurofibromatosis, an uncommon medical condition, on whom I was performing necessary surgery. The certified, registered nurse anesthetist (CRNA), a very good one, by the way, was putting the patient to sleep with the anesthesiologist supervising. He told the CRNA to watch the patient’s blood pressure since neurofibromatosis is associated with pheochromocytoma, a tumor that can release epinephrine (adrenalin) and cause a hypertensive crisis. I had learned this years ago in medical school but forgotten it and the CRNA was unaware as well. It just emphasized to me the difference between a real anesthesiologist and even a good CRNA.

What is behind this push? I suspect it is several factors. What is objectionable about the current system of NPs and PAs serving as physician extenders? One claim is that NPs and PAs will tend to go to underserved areas. I have never seen any data to suggest this is so. Never discount financial incentives. One factor may be something I have written about before, the Dunning Kruger effect https://www.bosshardtandmarzek.com/blog/confidence-is-overrated-the-dunningkruger-effect.html No, advanced nursing degrees and PA degrees are not equivalent to medical school education and residency.