By Maureen O’Hara Padden, MD, MPH, FAAFP
It’s no secret that our country is facing serious healthcare challenges. Between a shortage of medical professionals at all levels, to the rising costs of care, there are many ideas and opinions out there on how to solve these challenges.
One such solution approved by the Florida legislature in March 2020 was a scope of practice expansion, allowing Advanced Practice Registered Nurses (APRNs) to practice medicine autonomously in some circumstances. The argument was that enabling APRNs to practice medicine independently, without any requirement for collaboration with a physician, would provide additional patients with access to healthcare and reduce costs.
While it makes sense in theory, removing the primary care physician from the care team can lead to delays in care and even higher medical care costs for the patient.
A closer look at scope of practice expansion
Over the years, the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP) have studied states where independent practice is allowed in various capacities to examine how scope of practice expansion impacted healthcare costs, access to healthcare, and the quality of care that patients received in contrast with states that require physician collaboration.
When looking at patient access to care, an examination by AAFP of Washington’s healthcare provider shortage, a state which allows Nurse Practitioners to work independently, revealed a continued health professional shortage in nearly 70% of Washington’s counties.
A recent AMA study showed that care provided by APRNs was more expensive than care delivered by physicians, was more likely to result in unnecessary prescriptions and diagnostic imaging, and resulted in unnecessary referrals.
In contrast, care delivered by a physician-led collaborative team – with the entire care team working together to care for the patient – results in more effective delivery of high-quality, efficient care that gives the patient the best outcomes.
The physician-led care model
When we look at why physician-led care teams are so effective, it comes down to the physician’s extensive medical education and clinical training, as required by rigorous national standards set by the Accreditation Council for Graduate Medical Education.
After undergraduate school, medical students spend four years learning concepts regarding the entire human body before undertaking residency training in their specialty to further understand and treat a patient’s full range of medical conditions. We learn to work collaboratively with medical assistants, nurses, technicians, and physician consultants to maximize the value added to patient care. At a minimum, physicians complete seven years of training after earning their bachelor’s degree, totaling more than 15,000 hours of medical clinical training.
In comparison, an APRN completes two to three years of training after nursing school, followed by 500-720 total hours of medical clinical training. According to Florida law, an APRN is then qualified to enter independent practice.
Looking at the education and training requirements for a physician versus an APRN, an APRN fulfills six percent of the training, education, and experience required of a physician. Understanding the differences in medical professional training and education, the most appropriate, safe, and affordable care setting for patients is a physician-led, collaborative team-based approach to care.
The physician-led care model in practice
I worked in the Navy for 30 years where physicians, APRNs and Physician Assistants (PAs) worked collaboratively by design to provide the highest quality of care for patients. This symbiotic relationship consistently led to improved quality of care and reduced costs through avoidance of unnecessary subspecialty visits.
APRNs always had ready access to consult with their collaborative physician whose scope of practice was broader. This allowed the team to manage many issues the APRN might have otherwise referred to specialty care.
Since my retirement from the Navy, I have continued to practice with both PAs and Nurse Practitioners in my clinical practice. Team-based care, involving physicians, ARNPs and PAs, allows providers of varied experience and training to collaborate on providing the right care to each patient based on experience and scope of practice. It avoids delay in care, as a patient may wait weeks or months to see a subspecialist for care outside the APRN’s scope of practice or comfort level. But when working alongside a physician with a broader scope of experience and training, the patient can be cared for quickly.
The expanded training and experience that physicians receive is irreplaceable when a patient’s symptoms are complex, and the diagnosis is not clear. Many things don't require that level of training but if you are the person whose clinical scenario does, collaborative care in a physician-led team could make a difference. I respect and love working side by side with my PA and APRN colleagues. There is a place for all of us in healthcare and as a team, we can continue to provide outstanding care to our patients.
About Maureen Padden, MD
Maureen Padden, M.D. is a board-certified family medicine and obesity medicine physician.
Following her 30-year career in the Navy, she has continued clinical practice as a family
physician and serves on the board of directors for the Florida Academy of Family Physicians. The
views expressed are those of the author and do not represent the Department of the Navy or the
Department of Defense.