Keep health care decisions in the hands of physicians

A growing number of independent health care providers in the United States are practicing medicine without any oversight by an experienced physician. Many patients are unfamiliar with this trend and sometimes unaware whether their own medical clinician is a real doctor.

Virginia and 22 other states license nurse practitioners to diagnose and treat the sick in a freestanding setting without any physician supervision. At a time when health care has become so complex, this level of medical practice has created a lower standard of care for some.

For years doctors have successfully worked together with physician assistants (PAs) and nurse practitioners (NPs) in the same practice site. It is a collaborative approach in which NPs and PAs evaluate patients commensurate with their training while physicians who monitor their proficiency are readily available for consultation in complicated cases.

This is a very common organizational design today in many primary care and medical specialists’ offices. It enhances a patient’s encounter by increasing efficiency and is the best utilization of PAs and NPs skills.

But for a segment of nurse practitioners, being a member of a physician-led medical team is not a satisfactory arrangement.

In the final decades of the 20th century, nurse practitioners’ professional organizations sought legislation to expand their scope of clinical care and responsibilities beyond their traditional role as physician extenders. The goal was clear: practice independently without a doctor’s surveillance and be paid directly for their services.

To achieve this aspiration, lobbyists advanced the notion that unrestricted nurse practitioners would increase access to health care for the underserved rural areas. In addition, advocates asserted NPs would be less costly and of equal caliber to physicians. This dialogue resonated with many politicians.

A federal law granted nurse practitioners payment from Medicare. Their role was further enhanced in the Affordable Care Act, and currently licensure for autonomous practice is a reality in nearly 50% of states.

A state license, however, does not authenticate that independent nurse practitioners’ function at an equivalent level of clinical expertise as doctors. No credible studies have been performed that substantiate the efficaciousness of medical care provided by nurse practitioners in a setting that does not have physician supervision.

Since there is no national licensure test for nurse practitioners, there are variable criteria from state to state to obtain a license to practice autonomously.

A major concern is that stand-alone nurse practitioners do not possess the broader expertise necessary to identify and treat complicated multi-system conditions. A newly graduated NPs hours of clinical instruction is equivalent to a third-year medical student. A physicians’ greater in-depth training provides a more pronounced capability to solve complex diagnostic dilemmas.

Free-standing nurse practitioners have not appreciably increased access to medical care for underserved citizens. Current surveys of geographic distribution are telling: only 5.5% practice in remote rural locations.

Unfettered nurse practitioners have not reduced overall costs. Studies have found that health care providers with less education and training are more likely to increase health care expenditures.

They have a lower threshold to refer to specialists, use more laboratory tests, order unnecessary diagnostic imaging and prescribe more drugs than physicians.

The COVID-19 epidemic has highlighted how intensive care unit doctors collaborate with highly trained nurses and other experienced medical personnel to treat this complicated infection. At that heightened level of care, physician expertise is the driving force behind the positive outcomes achieved for these very sick patients.

Outside the hospital, in the frontline practice of medicine, expert skills and training are no less important. The increased presence and burgeoning utilization of less qualified non-physician independent practitioners is diluting the level of modern health care to segments of the population.