Should We Use Nurse Practictioners and Physician Assistants as Doctors?


  "I can't help quoting you, cause everything that you said rings true." - About Morrissey.

Doctor Aaronson is the OTHER oracle of Omaha

Doctor Aaronson, Omaha, Nebraska's OTHER Oracle. Dr. Michael Aaronson is a kidney physician specializing in Nephrology and hypertension.

First, I’ll describe the concept of a paradigm shift and revolutions in the context of weight loss. (Adapted from my book The Spider Diet). Second, I’ll apply my view of the utility of nurse practitioners (NP) and physician assistants (PA) to the future practice of medicine. My proposed model is a revolutionary one requiring a paradigm shift in current medical thinking.

People use the word paradigm for almost anything. The term has become watered down and cliche over the last few years. We prefer to use the word judiciously. A paradigm shift is a radical change in thinking about something. Thomas Kuhn wrote The Structure of Scientific Revolutions in 1962. Kuhn “argued that science does not progress via a linear accumulation of new knowledge, but undergoes periodic revolutions that he called ‘paradigm shifts,’ in which the nature of scientific inquiry within a particular field is abruptly transformed (Wikipedia).”

“The Perpetual Dieter! (available on mp3 audio)” case study exemplifies a revolution in the way that we think about food consumption. We think differently about what we call a healthy choice. Only a few years ago people felt recommending a low carbohydrate diet was insanity. Doctors always recommended fruits and vegetables, focusing on carbohydrates.

Advocates of low carbohydrate diets recommend complex carbohydrates and stand by their beliefs. Any “outside of the box” thinking is disparaged. Why does this occur? People who spend their entire lives defending a theory refuse to acknowledge new evidence. People have trouble saying they may be wrong; they resist doing so.

Eventually the evidence becomes so overwhelming that doctors change their way of thinking (paradigm shift). The new theory becomes the standard. Doctors’ recommendations change over time as new research becomes available. Studies have suggested that low carbohydrate diets can help people lose weight [Foster and others. N Engl J Med. 2003 May 22;348(21):2082-90].

Opponents of the newer ways of thinking continue refusing to accept the evidence. Eventually, these pundits are no longer heard. They are not allowed a soap box to be contrarian (taking the opposing viewpoint). They usually retire. However, this process takes time. There may be some instances where your physician is using older, outdated ways of thinking. You as a consumer of health care must decide what type of physician you are looking for. Some physicians are cutting edge; others are more conservative, slow to change.

Proponents for the paradigm shift focus on the new. Students are taught as though the current paradigm has been the correct way of thinking forever. Hence the problem with textbooks. New editions are new compilations of evidence based on current theories. If a certain fact doesn’t fit, that fact is marginalized in the text so that the current theory prominently stands.

When a patient comes in with a heart attack and is not following traditional eating methods, people may blame the patient for causing his or her health problems. Perhaps there are other attributable causes. What is the patient’s cholesterol level? What is the patient’s glucose? What is the patient’s blood pressure?

However, some ideas are truly fads, not paradigm shifts. Have you heard of the marching diet? You exercise by marching in place. This process can be done anywhere (working, at home watching television, and supervising your kids). There is a compact disk of marching music and a companion DVD that teaches you alternative marches. These items are available for purchase on the internet. What is that you say? You have never heard of the marching diet? You haven’t heard of the marching diet because we just made it up! People are coming up with some crazy diet regimens that are questionable at best. Please do not waste your money on fad diets that do not work and cause frustration for the already frustrated dieter….

Now let’s “radically shift” the thinking to the nurse practitioner and physician assistant team model of health care delivery

Some people have opined that instead of using NP/PAs we should increase the number of doctors by lowering the standards for allowing an individual to be a physician in America. Unfortunately, this strategy isn’t going to fix the problem. There would be more availability in the United States to physicians, but there would be less ability and arguably poorer outcomes.

First, NP/PA’s are NOT physicians. The good news is that they don’t need to be. That’s what I do. Well trained NP/PAs complement the physician so that more world class care can be delivered to patients. In other words, NP/PAs assist the doctor.

The revolutionary change in health care that must occur is acceptance of the use of nurse practitioners / physician assistants. These providers are essential components of health care delivery and will play an important role in the future of medicine. Both patients and doctors who disapprove of the use of nurse practitioners need to unlearn what they have learned and realize a paradigm shift is occurring in the medical community. Only those who embrace this model will survive. For those who believe that this way of thinking is a “fad” because other models of care in the past were a fad will eventually see that this change is inevitable. The change is an evolutionary one.

While in North Dakota, I had the pleasure of working with 2 phenomenal physician assistants. From an efficiency and quality perspective, we were extremely productive; the patients received great care; and there was uber-quality. Please note the following proposal is the “ideal” situation in which most of the recommendations I make are based on experiential practice. They work! Healthcare systems should try to achieve the following noting that the nurse practitioner / physician assistant (NP/PA) revolutionary model simultaneously helps the doctor, the system, and the patient:

  • The nurse practitioner / physician assistant is the first point of contact. They help gather data.
  • Nurse practitioners, from a doctor’s perspective and a patient’s perspective, facilitate a patient encounter so that the physician can more effectively see patients without sacrificing quality. Rushed physicians make mistakes.
  • Many physicians want more time with their patients. What I think we really want is quality time, not quantity time.
  • The doctor, with the background knowledge gleaned from the NP/PA, can ask more focused questions. Also, the doctor can spend more time with the patient on the plan of care.
  • All patients the NP/PA sees in the hospital are reviewed with the physician. The doctor sees every patient every day.
  • With respect to the clinic setting (outpatient):
  • Every new patient in the clinic that is seen by the NP/PA is also seen by the physician.
  • Follow up patients can be seen by the NP/PA without a physician if the problem is chronic and is within the scope of practice of the NP/PA.
  • Since the physician trains the NP/PA, one can argue that substituted judgment occurs, so that the NP/PA treats the patient as the physician would.
  • The patients get more total time with the provider team.
  • Therefore, the patients get more education and more care.
  • During the physician’s absence, the patients can see the NP/PA allowing for continuity of care.
  • There are more provider “eyeballs” thinking about the patient and knowing the wants and desires of the patient allowing for the “art of medicine.”
  • NP/PAs help physicians prioritize allowing physicians to go where they are needed the most.
  • NP/PAs help coordinate care so the patients can be moved through the system more quickly.
  • NP/PAs help to create a standard of care in the community because they work with different doctors in the practice. The hypertension expert and the dialysis expert teach the NP/PA the latest cutting edge information, and then the NP/PA can pass the information on to the other providers. This helps to ensure that evidence based, best practice medicine occurs.
  • Did you know that patients who agree to see a NP/PA are likely to be seen sooner for a non-emergent evaluation? Patients who are treated sooner don’t get sicker, and they do better.
  • NP/PAs can help enhance access to care. They can also help facilitate communication between the patient and the practice. They educate. They explain. They teach!

Here is the concern I have heard from patients and other physicians: what if the NP/PAs do not know their limitations?  Will they be practicing outside of their scope of practice? I think that NP/PAs need to be reviewed quarterly to ensure that they are practicing within their scope of practice. Peer review and provider excellence committees help to identify any concerns. I have seen this happen with a NP/PA, and when it did, appropriate procedures were taken so that the person went back to practicing within his/her scope of practice. Please note that doctors abide by these same rules. For example, you don’t want a podiatrist in charge of your kidney dialysis, and you certainly do not want me in charge of your podiatry concerns!

Another concern I have heard from primary care physicians is that they fear that the NP/PA is making all the decisions, when the primary care physician wants the specialist to make the decisions. I have worked in the NP/PA model, and I can tell you that the patients seen in the model had access to my, the specialist physician’s, brain. Also, every patient seen by the NP/PAs was reviewed by the end of the day in some capacity by me or my partner. The model, when designed correctly, works quite well.

Also, I predict in the future, primary care physicians will use this model as well. There will be 2 – 4 NP/PAs for each primary care doctor. The doctor will circle from patient to patient making sure that any “must not miss” diagnosis is made. I don’t have actual statistics, but I opine that the doctor “shortage” can be averted using this model and will become an industry standard.

Question 1: Should the NP/PA model be “forced” on a patient or primary care provider?
No. The opportunity is voluntary. However, many people don’t want to wait for availability, especially if the difference is days versus weeks. With customer feedback (ie, the patient evaluating both the NP/PA and the MD in that setting), there are checks and balances in place to ensure adequate NP/PA quality control.

Question 2: Does the NP/PA’s salary in your model come out of the doctor’s salary?
No. Medical home and other futuristic models of health care require maximal efficiency while improving cost and maintaining quality. If the NP/PAs take from the physician so that the physician loses income, there will be resistance to uptake. The doctor needs to make money during this process. This allows for physician incentive for quality as opposed to penalty. For those who subscribe to an RVU model, a portion of the NP/PA RVU goes to the physician. That way people are working together and everyone wins. The physician still sees some patients without the help of the NP/PA. The most challenging diagnostic patients should be seen exclusively by the physician. One could argue this patient type represents about 20% of the specialist’s practice.

Question 3: will there be a delay seeing the doctor?
Using this method, you may have to wait for the doctor to complete the visit. During this time you may get your blood drawn, read about your condition, and prepare any additional questions you might have for the physician. For a follow up visit, if the problem is within the scope of nursing practice, you may not have to see the doctor. At the end of the day however, the case should be reviewed by the physician. If there are any changes that need to be made, you can expect a call the next day.

Question 4: Can an effective computer based electronic medical record (EMR) do the work of an NP/PA?
Computers are not people! They cannot do the work of a NP/PA. Computers cannot replace human intuition, hunches, or nuances. Computers, for example, cannot “smell” the alcohol on a person’s breath and other subtle clues a provider uses to diagnose a patient.

In conclusion, the need for medical providers is omnipresent. A critical shortage is near. People need health care. We must achieve this goal using NP/PAs! Using the 3 P’s: person, product and process, there is an available procedure to achieve this goal. We must be willing to change our way of thinking in preparation for the medical delivery revolution of the future and include NP/PAs as an integral part of the team.

*Special thanks to Tara Whitmire, APRN for her insight on NP/PA practice. Tara is currently studying to become a Doctor of Nursing Practice (DNP). A DNP degree is an advanced nursing degree. Doctors of Nursing Practice take on leadership roles in the community. They put research into practice following best practices guidelines and focus on process.





by request