Are Doctors a Threat to Their Own Occupation?

Yes, according to Dr. Paul D. Simmons and he does not mince words. His final paragraph quite accurately sums up the whole argument, “If my professional organization, the AAFP (American Academy of Family Physicians), wants to know who is eroding the identity, role and practice spectrum of family physicians, they need not look at NPs. They need only look in the mirror.”


According to Dr. Simmons, in recent months, AAFP president Reid Blackwelder has been up in arms about what he sees as the encroachment of nurse practitioners (NPs) and other mid-level providers on the practice of family physicians. Dr. Blackwelder has repeatedly said that NP and physician roles are “not interchangeable.”


I do take delight is his term for specialist – partialist. These partialists are the ones that have slowly pushed the family physicians out of their practices by limiting what they are trained to do. Yes, it is not the NPs that have denied family physicians privileges to practice obstetrics, to do C-sections, to do endoscopy, to practice conscious sedation and to do minor surgeries – in other words, to practice the full scope of family medicine. The culprit according to Dr. Simmons are their colleagues who see us as a threat to their “turf” (and income) who have restricted our credentials and ability to practice.


Dr. Simmons continues, “It is we who have voluntarily given up our scope of practice in many areas, who are surrendering our hospital, obstetrical and surgical practices either in the name of an easier lifestyle or because of pressure to see more patients per day.”


Then he addresses the impending physician shortage by saying that there will not be enough family physicians to fill the gap. NPs he says will serve in that necessary role and do an excellent job. It will happen, it already has happened, and there is no way for the AAFP to prevent it. Good for Dr. Simmons.


This is also the reason I have written about the American Telemedicine Association calling for national licensing which medical associations and state medical boards are in full opposition. Then I also blogged about doctor bashing because this is happening because doctors will not make referrals when they are not current in an area. With the impending shortage of physicians, patients are going to become frustrated. If the frustration becomes large enough, the manure will hit the fan and the doctors opposing NPs, PAs, and pharmacists, plus other doctors who are qualified and could work across state lines may just find themselves hurting for patients. I hope this does not happen, but I would not bet against it. I just say let these doctors shoot themselves in the foot. Maybe the pain in one end will bring some sense to the other end.

Will States Allow NPs to Practice?

I can just imagine the physicians on many State Medical Boards choking on their tongues when they read this article in Medscape. The title is “Reducing State Restrictions on NPs Boosts Primary Care Supply.” Unless the Obama administration delays other provisions of the Patient Protection and Affordable Care Act, many states will be in serious problems for lack of primary care physicians. Yet, many of these same State Medical Boards are working overtime to prevent expansion of NPs rights, PAs rights, and limit telemedicine across state borders.


On January 1, 2014, millions more people are expected to gain coverage under the Affordable Care Act, and they will be seeking services from primary care physicians who, in most cases, already have full schedules. One way to meet this supply problem is to relax regulations on nurse practitioners (NPs) and allow them to independently provide basic primary care, as already happens in many rural states that have had difficulties attracting physicians. An additional help would be letting PAs practice with NPs and open the borders for telemedicine.


Arizona, Iowa, Oregon, Maine, and Washington allow the highest levels of NP autonomy, and California, Florida, Massachusetts, Michigan, and Texas have the highest levels of NP restrictions. It would seem prudent for the rural areas of California and Texas that they should reduce the restrictions, but the state medical boards wield a lot of power in those states. Oklahoma, Georgia, Texas, and Louisiana have the highest number of uninsured people and the largest shortage of primary care physicians, therefore how will they be served to take advantage of the ACA.


Then we have this from Medscape, promoted by the Graham Center Policy, and published online in the August 15 issue of American Family Physician. It claims that allowing NPs and PAs will only help a little in the coming physician shortage. Their finds indicate that the data shows that only about half of NPs (52.4%) and PAs (43.2%) work in primary care, with the others choosing subspecialty areas. Even these numbers will help in the physician shortage, if states will relax their restrictions for NPs and PAs to be able to practice. It is unfortunate that the numbers of those that would be available to practice in primary care is not stated.


The authors do indicate that relying on NPs and PAs to solve the problem of a growing shortage of primary care physicians may not be an option. The authors continue that policy makers should not abandon policy solutions designed to increase the number of primary care physicians, NPs, and PAs.


Will state medical boards choke on this as well? Probably, as they do not want NPs and PAs to be able to practice independently.


I was able to receive the full copy of the abstract mentioned in the first Medscape article and it is interesting. I will quote minimally from it, “Several factors contribute to the current and projected shortage of primary care providers in the United States. These include overall population growth, population aging, an expected large increase in the number of people with health insurance, and a decade-long decrease in the number of medical school graduates choosing primary care as a career. Increasing the role of NPs as primary care providers can be an important approach to increasing primary care capacity.


I expect more articles over the next few months as we count down to January 1, 2014. Therefore, I expect to write more on this topic.