- Experts say nurse practitioners are taking the place of doctors in many urgent care clinics and emergency rooms.
- Nurse practitioners say they provide quality healthcare, sometimes as good as a physician can offer.
- Doctors and medical groups say nurse practitioners don’t have the training or knowledge to diagnosis and treat serious medical conditions.
In June, Amber Price, MD, founder and chief pediatrician at Willow Pediatrics and Lactation in Chicago, was contacted by a lactation consultant from the University of Chicago who asked if Price had donor breast milk available for purchase.
The consultant told Price she had a 5-day-old baby boy who had lost 17 percent of his birth weight and was unable to transfer milk from the breast since birth due to an undiagnosed tongue-tie.
Price was immediately concerned and asked if the baby had been evaluated by a physician.
The lactation consultant said the baby had been seen earlier in the day by a nurse practitioner at an outpatient clinic who sent the family to lactation.
Price asked to speak to the mother and told her she wanted to examine the baby for no charge before providing them with any breast milk.
The family agreed. Immediately upon seeing the baby, Price said it was clear that he was severely dehydrated and in grave danger.
“The baby had numerous signs of dehydration, including a sunken fontanel — the soft spot on top of the head — dry lips, a weak cry with no production of tears, lethargy/poor tone, poor skin turgor, and uric acid crystals in the diaper,” Price told Healthline.
Price phoned the nurse practitioner who had seen the baby to discuss her clinical assessment.
“I asked her what findings in a medical history and physical exam would be concerning for dehydration in a 5-day-old exclusively breastfed baby, but she was unable to articulate a medically correct answer,” Price said.
“I also requested to speak with her supervising physician but was told that he was unavailable. I later found out that he was on vacation at the time of this incident,” she added.
When the test Price ordered showed a dangerously high sodium level as well as numerous other electrolyte abnormalities, Price phoned the family to let them know their baby needed to be admitted into the hospital as soon as possible for treatment.
“The baby was near death and was misdiagnosed by the nurse practitioner,” Price said. “This was wrong on so many levels. Nurse practitioners are literally practicing medicine without a medical license, and nothing is being done about them.”
Price adds, though, that she knows “many nurse practitioners that are very capable when they work within their scope of practice.”
The baby, Travis Love, is now fully recovered. The baby’s mother, Lenora Love, told Healthline she’s deeply grateful that Price stepped in.
“Dr. Price saved my baby’s life,” Love said. “Before I met Dr. Price, we had no clue what was going on with our baby. Being in the hospital was a scary and emotional experience for me and my husband. This experience makes me think about how some of these nurses act, as if they are doctors.”
A nurse practitioner is an advanced practice registered nurse (APRN) who has additional training and responsibilities for administering patient care than registered nurses (RNs).
For many years, nurse practitioners have provided important care to patients.
In recent years, nurse practitioners have been successful in lobbying many state legislatures to increase their scope of practice.
Due in part to an ongoing nationwide physician shortage and, many experts say, the increasing corporatization of U.S. healthcare, nurse practitioners are more frequently seeing patients and diagnosing them without a doctor’s supervision.
Nurse practitioners have what’s called “full practice authority” in 22 states as well as in the District of Columbia.
This means that in these locales, they don’t have to work under the supervision of a doctor.
Proponents say nurse practitioners (NPs) bring a unique and welcome approach to patient care, and that their training qualifies them to take on additional duties that are usually left to physicians.
“There are ERs and ICUs in this country now that are staffed by NPs without a physician on site,” Price said. “For instance, they can start off working in dermatology, then the following month take a job in urgent care. In contrast, a physician must be residency trained to order to practice their field of medicine.”
Price explains that nurse practitioner and physician assistant training programs were developed in order to train individuals to function under the supervision of physicians, thus extending the ability of the physician to provide service to a greater number of patients.
“Their role was to take on duties that did not require the expertise of a physician,” Price said. “Studies over the past 50 years concerning quality and safety have not looked at the impact of NPs practicing independently without proper supervision.”
Sophia Thomas, a nurse practitioner and the president of the American Association of Nurse Practitioners (AANP), says nurse practitioners have been providing primary, acute, and specialty healthcare for more than 5 decades.
“One of the trends we are seeing is that patients are using on-demand healthcare clinics like urgent care, and that challenges getting into primary care has resulted in an increase in the need for same-day urgent care,” Thomas told Healthline.
“Urgent care centers provide same-day care for issues that can’t wait. The majority of visits are for issues routinely managed in primary care, and some urgent care clinics offer casting, suturing, or IV medication,” Thomas said.
All of these are within the broad graduate education of nurse practitioners and within the scope of current national certification, she adds.
When asked if it’s acceptable for a nurse practitioner to work alone in an urgent care with no physician available, Thomas says yes.
“The question of quality and safety around NP care has been asked and answered by more than 50 years of rigorous evaluation,” she said.
Thomas says nurse practitioners are well qualified and equipped to provide urgent care for people in free-standing nurse practitioner–owned practices or as part of multidiscipline groups.
“NP-staffed clinics have led the way in urgent care over the last decade and helped define patient-centered care by meeting same-day healthcare needs for millions of Americans,” she said.
Thomas explains that a nurse practitioner may refer a person to a specialist for further treatment or back to the person’s primary care provider for follow-up.
“Patients who suspect possible heart attacks, strokes, and life threatening conditions should not go to any urgent care regardless of the provider staffing the urgent care,” she said. “Patients should expect to see a range of healthcare providers during any given trip to urgent care or the ER.”
“The expertise in today’s healthcare workforce means that clinicians, like NPs, physicians, and PAs [physician assistants], have overlapping knowledge and skills to evaluate, diagnose, prescribe,” Thomas added.
“This overlap means that not all patients need to be seen by a physician and allows the healthcare system to safely and effectively care for more patients with less wait time,” she explained. “That overlap and flexibility is good news for everyone.”
But a growing chorus of physicians and medical organizations nationwide, including the American Medical Association, don’t agree this trend is in the best interest of healthcare.
And they’re pushing back.
Doctors in general have been reluctant to speak out on this issue, in part because this can cost them their job.
But multiple doctors interviewed by Healthline for this story — some on the record, some not — insist that nurse practitioners are being used too often beyond the scope of their training.
Doctors say there’s little incentive among profit-seeking companies, especially urgent care facilities, to keep paying doctors when they can hire nurse practitioners and substantially cut costs.
Amy Townsend, a family physician from Bridge City in southeastern Texas, says this is putting patients in danger.
“Nurses are not physicians. The training is as different as night and day,” Townsend told Healthline. “Bottom line? Profits and ego are being put ahead of patients.”
Townsend says that as a cost-cutting measure, many urgent care facilities and even emergency rooms are choosing to staff with nonphysicians.
“The rigorous training of physicians during their 4 years of medical school and 3-plus years of residency makes them experts in medical care,” she said. “Nonphysician practitioners such as NPs and PAs have a fraction of the training of a board certified physician, and patients have a right to know the realities of these differences in training.”
Even if a nurse spends 20 years in the profession, Townsend said, “They never learn the basic science, the pathophysiology, or the clinical reasoning to independently and accurately make a diagnosis. These are things that can only be learned with the rigors of medical school and residency.”
Townsend says it’s easier and less expensive to replace doctors with lesser-trained midlevels who help the financial status of the owners.
Price notes there’s no standard to achieve nurse practitioner certification, since educational requirements vary from program to program and from state to state.
Townsend recently joined the board of directors of Physicians for Patient Protection (PPP), a group of physicians, residents, and medical students whose mission is to ensure physician-led care for patients and advocate for truth and transparency regarding healthcare practitioners.
Townsend says PPP has collected from frontline physicians more than 500 stories of misdiagnoses or mismanagement of patients by nurse practitioners in the past 2 years.
In most of these situations, Townsend says, there was no supervising physician present or consulted.
“We are working to organize this data to show that much more research is needed to support claims that NPs have adequate training to practice medicine independently,” Townsend said. “Specifically, research needs to focus on diagnostic skill and accuracy in diagnosing undifferentiated patients.”
Townsend says she’s worked with many fine nurse practitioners, but she believes the profession is now overstepping its boundaries.
“Patients are being harmed, and it is contributing to the astronomical costs of healthcare in our country,” she said.
Thomas says research backs up her organization’s assertion that nurse practitioners provide quality care.
“It’s what researchers in over 50 years of research have determined,” she said. “NP care is as good or better than the care provided by other healthcare professionals. This quality of care has been noted by the Institute of Medicine, the Congressional Budget Office, and in many studies.”
Thomas points to a study by Peter Buerhaus of Montana State University that was published by the American Enterprise Institute (AEI).
Buerhaus’ study found that a large and growing body of research shows nurse practitioners’ care to be as good as, or better than, the care provided by primary care physicians.
AEI supports the further loosening of state restrictions on nurse practitioners as a solution to the primary care doctor shortage in the United States.
In the report issued last year, Buerhaus wrote that nurse practitioners are “uniquely prepared to address the healthcare needs in rural areas and could likely do so at a fraction of the cost of their physician counterparts. Loosening state restrictions on NPs could save both money and lives without sacrificing healthcare quality.”
The Mayo Clinic and several other medical institutions have come to a different conclusion.
A 2013 Mayo Clinic
Researchers studied 160 patients referred by nurse practitioners and physician assistants and a random sample of 160 patients referred by physicians.
The quality of referrals to an academic medical center “was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation,” the study concluded.
“We found that the quality of pre-visit care and patient referrals to general internists at a tertiary medical center, on the basis of a validated assessment by academic faculty members, was higher for physicians than for NPs and PAs,” the study concluded.
Price says that there simply are no solid studies or evidence that nurse practitioners provide equivalent care.
“None of the studies have been randomized control trials. All studies have been done by nurses, and most have extremely poor methodology,” she said.
The
The AMA has consistently held the position that while nurse practitioners are a valuable part of modern healthcare, they’re best suited as part of a physician-led healthcare team that uses the unique knowledge and valuable contributions of all clinicians to enhance patient outcomes.
“Nurse practitioners are valuable members of this team and patients win when each member of their healthcare team plays the role they are educated and trained to play,” the AMA told Healthline in a statement.
“Innovative physician-led team models used by some of the nation’s top healthcare systems across the country are achieving improved care and patient health, while reducing costs. Independent practice and team-based care take health care delivery in two very different directions,” the AMA stated.
The AMA also told Healthline that it opposes the independent practice of nurse practitioners because it would further “compartmentalize and fragment healthcare delivery; while team-based care fosters greater integration and coordination.”
The AMA said it’s working to alleviate a flaw in the distribution of physicians that’s responsible for shortages in many states.
“We support multiple methods to help ease existing and predicted shortages, including increasing residency slots to train physicians in medically underserved areas, developing programs to help inactive and retired physicians re-enter clinical medicine, and expanding medical class sizes and the number of U.S. medical schools,” the AMA said.
The AMA, along with the Association of American Medical Colleges, supports the Liaison Committee on Medical Education (LCME), which has approved 20 new medical schools in the past decade and supported increasing the size of existing medical school classes to increase the number of physicians in training by 30 percent.
The AMA has said that while nurse practitioners and other midlevel medical workers are an important part of the medical team, they’re not a substitute for physicians in diagnosing complex medical conditions.
Lynda Lane, who attended medical school at Roslyn Franklin Medical School in Chicago, has been a primary care board certified physician since she opened her private practice 32 years ago.
She says that having more nurse practitioners as primary care providers will “only lead us to less diagnostic specificity” and cause more harm to patients.
In her practice, Lane told Healthline, they “frequently see and correct mistakes made by nurse practitioners and other midlevels at urgent care clinics.”
To obtain her credentials, Lane says she completed 4 years of medical school and 3 years of residency training.
“This is quite a bit different than the training that nurse practitioners receive. It is more detailed and more comprehensive in scope,” she said.
One of the biggest differences between training for nurses and training for physicians, Lane says, is the perspective and sophistication of the training.
“While nurses are trained to see one patient for a long period of time in their training, doctors are trained to see multiple patients and make very sophisticated diagnoses,” she said.
Lane says it’s important for nurse practitioners to triage people in the ER or in an urgent care setting, “but I do not think it is fair to the patient to have this done without physician supervision.”
In Chicago, Lane says, many of the urgent care centers are staffed by professionals who aren’t medical doctors and thus are paid less.
“My patients often go to these centers and are unsatisfied with the treatment they receive,” she said.
“The patient then retreats to my office for help. If an antibiotic is given for a viral infection, for example, it is useless and can possibly cause a reaction. This has happened more than once to my patients,” Lane said.
The increased role for nurse practitioners has become a hot button issue in state legislatures and in Washington, D.C.
President Trump’s recent executive order for senior health has the support of nurse practitioners but has been met with petitions and widespread criticism.
Dozens of medical organizations oppose the verbiage in Section 5 of the order, which pertains to the scope of practice in medicine and which opponents say will make a bad situation worse by replacing more physicians with nurse practitioners.
Last week, the AMA sent a
“We are highly concerned this language requires the Secretary of Health and Human Services to propose a regulation to eliminate or weaken current Medicare supervision requirements of non-physician professionals,” said the letter, which was co-signed by dozens of state and federal medical and physician organizations.
The AMA said in the letter that supervision requirements of nurse practitioners and other midlevels are a “critical safeguard to ensure the health and safety of Medicare patients and the cornerstone of the widely adopted team-based approach to health care.”
Also last week, Texas Medical Association President David Fleeger, MD, urged President Trump and Azar to remove the language from the order that expands the scope of practice of nurse practitioners and other nonphysician practitioners.
“Due to the vast differences in their education, skills, and training, health care professionals with various degrees and licenses are not interchangeable,” Fleeger wrote in his letter.
“Physicians appreciate the value that all members of the health care team can deliver for our patients. But physicians, who shoulder the ultimate responsibility for patient health and safety, are the only ones who can or should lead and supervise the other members of our health care team,” he said.
Fleeger also wrote that the broad language in Section 5 ignores critical facts.
“Physicians spend six to 11 years in highly organized training after earning an undergraduate degree, vs. two to three years for advanced practice registered nurses (APRNs), two to three years for physician assistants (PAs), and four years for chiropractors and optometrists.
“Physicians must undergo 12,000 to 16,000 hours of clinical training before they can begin practice, vs. 500 to 1,500 hours for APRNs, 2,000 hours for PAs, and 80 weeks for podiatrists.
“The practice of medicine is fundamentally different from nursing, or podiatry, or chiropractic, or optometry. While physicians may delegate certain tasks and duties to those other practitioners in appropriate situations in accordance with their licenses and competencies, only the physician is responsible for each patient’s entire well-being,” Fleeger said.
Thomas says that nurse practitioners take great pride in their profession.
“As the voice of NPs, we play a significant role in educating patients about nurse practitioners and the high-quality care they provide,” she said.
“Generally speaking, NPs introduce themselves to their patients using their professional credentials,” Thomas said.
In fact, Thomas said, “NPs comply with HIPAA [Health Insurance Portability and Accountability Act of 1996] and wear name tags or lab coats that include their professional designation.”
But Thomas adds that the AANP doesn’t endorse those requirements, which she says are “advanced by organized medicine in order to diminish the NP role. That would force providers to announce that they ‘aren’t physicians’ as a requirement to provide healthcare to their patients.”
But Townsend says people have the right to know whether or not the person who walks into the examination room to treat their medical condition is a physician.
“And if that person is not a physician,” Townsend said, “there is an obligation to disclose that information to the patient.”
Townsend says the historical makeup of a healthcare team is rapidly evolving and can be difficult for many patients and doctors to understand or accept, just like medical illnesses can be difficult to understand or accept.
“We need to educate patients in order for them to make informed decisions,” she said, “just like we educate them on other treatment options.”