This is particularly the case in primary care, where several trends are leading to even more intense turf wars. Newly graduating physicians continue to avoid primary care, preferring the higher-paying specialties and subspecialties. Similar trends are occurring among PAs, but for both groups the specialty trend is being driven by high student debt and poor reimbursement for primary care. Seeing an opening, NPs are seeking to increase their profile in primary care by establishing their entry-level degree at the doctoral level and amending state practice laws to permit a wider practice scope.
In the turf wars, the professions often choose to identify specific features of their practice that appear to give them particular advantages or greater degrees of effectiveness over the others. Since physician practice has dominated healthcare delivery for the past century, other professions often seek to compare their practice effectiveness against the physician "standard" and note, for example, that the care they deliver is just as safe and effective as physician care.
The Myth of More Time
One of the most common assertions, one that seems to have existed for decades and has been perpetuated by the professions and their organizations, is the canard that NPs and PAs spend more time with their patients compared with physicians.
In my work as an educator and speaker, I regularly encounter student groups and professional audiences, all of whom tend to have the impression that spending more time with patients is one of the signature characteristics of NPs and PAs alike. When I ask applicants why they seek to become a PA, they invariably state that it is because they want to spend more time with patients. The perception seems to be ubiquitous.
Having spent much of my professional life in research and academics, I can state flatly that no study definitively shows that PAs spend more time with patients than do physicians, and that the NP literature on the topic is weak and circumstantial at best.
Studies often cited by the NP profession1,2 in support of this assertion, as well as a comprehensive review of the literature summarized and published by the U.S. Agency for Healthcare Research and Quality,3 show that NPs have patient outcomes, effectiveness and safety equivalent to that of primary care physicians3 but show little evidence supporting that more NPs spend more time with patients.
Does Time Spent Equal Quality?
The question arises that even if NPs and PAs actually do spend more time with patients, what exactly does this indicate? It is possible that the length of the visit, while perhaps appreciated by the patient, does not translate into an effective clinical encounter. Spending more time with the patient may be an overrated index of the patient care encounter. Does spending more time really mean that the care provided was in any way more effective or safe or resulted in a high-quality outcome? It is possible that the longer time questioning the patient may reflect a clinician's lack of experience or capability to solve the patient's problem.
Finally - and this is the core reason that I'm skeptical about the notion of NPs and PAs spending more time with patients - I sense that in our fragmented, highly monetized healthcare system, NPs, PAs and physicians have a defined timeframe to see the patient, particularly in private practices or managed care settings.
Economic pressures affect all healthcare providers, and it seems an unusual luxury for any of us to be given an unlimited time in which to see the patient. I'm sure there are exceptions, but I remain dubious.
That we actually do spend more time with patients is a convenient and useful myth that has thrived for decades. It enhances our image but is built on a fragile foundation.
1. Horrocks S, et al. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324(7341):819-823.
2. Avorn J, et al. The neglected medical history and therapeutic choices for abdominal pain: a nationwide study of 799 physicians and nurses. Arch Intern Med. 1991;151(4):694-698.
3. O'Grady ET. Advanced practice registered nurses: the impact on patient safety and quality. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008:chap 43. AHRQ publication 08-0043.