MDs vs. NPs in Primary Care . . . The Conflict Continues

Advanced-practice nurses (including nurse practitioners [NPs], clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives) have become commonplace within the U.S. healthcare delivery system since their inception in the 1960s. Now, the clinical workforce is estimated to include >180,000 NPs, approximately 35% of whom provide primary care. But how do NPs and physicians view their respective roles? Researchers analyzed responses to a survey (conducted from November 2011 to April 2012) of 505 primary care physicians and 467 NPs to evaluate their attitudes about healthcare delivery, compensation, and collaboration. Questions included topics such as scope of practice, hours worked, compensation, and attitudes toward NPs in a primary care role.

Three quarters of NPs believed that they were practicing to the full extent of their training and education. Fully 82% of NPs (vs. 17% of physicians) agreed with the statement that NPs should have the authority to lead medical homes. Two thirds (64%) of NPs (vs. 4% of physicians) believed that they should receive equal pay for the same services. Two thirds (66%) of physicians believed that they provided higher quality of care than NPs; 75% of NPs disagreed with this statement.

These results, taken together with an accompanying Health Policy Report, provide insight into the evolution of the NP's role in the face of economic and political influences. NP certification programs were initially developed — and continue — to fill a healthcare gap for a largely uninsured, underserved population. These “certificate-prepared” NPs work in large clinics serving both urban and rural populations. With the projected shortage of primary care physicians (an estimated 33,100 by 2015), NPs again occupy an ideal position to address a healthcare deficit.

Today's NP is a formally educated clinician: In addition to being a registered nurse, the NP graduate must now have — at minimum — a master's degree in nursing and should hold national certification in a practice domain. Doctor of Nursing Practice (DNP) programs are burgeoning. Many NPs are trained as primary care providers in family, adult, or pediatric care. The Institute of Medicine (IOM), in a 2010 report, supported the mission to eliminate barriers to advanced-practice nursing, stating that nurses should be free to “practice to the full extent of their education and training.”

With the assistance of the Federal Trade Commission (FTC), the IOM sought to promote advanced-practice nursing as a safe alternative to physician-delivered care. The American Medical Association (AMA) disapproved of this effort, accusing the FTC of “aggressive advocacy.” The Robert Wood Johnson Foundation drafted a document entitled “Common Ground: An Agreement between Nurse and Physician Leaders on Interprofessional Collaboration for the Future of Patient Care,” coauthored with representative leaders of national physician and nursing organizations. However, the AMA, upon learning of the document's existence, garnered support from the American Academy of Family Physicians, and American Osteopathic Association, and the American Academy of Pediatrics to withdraw support from the dialogue, essentially halting the document's progression.