Scope of Practice

Medical training and scope of practice: 3 keys everyone must know

Timothy M. Smith , Contributing News Writer

Nonphysician providers are vital members of the health care workforce. Nurse practitioners, physician assistants, pharmacists and nurse anesthetists all extend the healing touch of physicians and make care accessible to more patients.

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The AMA has achieved recent wins in 5 critical areas for physicians.

Still, there’s no ignoring or replacing the training and expertise of physicians. Yet this is what some lawmakers have permitted in recent years—allowing nonphysician providers to operate without physician supervision or collaboration—sometimes with dreadful health outcomes for patients and higher overall health care costs.

In fact, physician education is the keystone of the health care system, which is why the physician-led health care team is so vital to ensure the delivery of high-quality, safe care.

Fighting scope creep is a critical component of the AMA Recovery Plan for America’s Physicians.

Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. The AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety.

Take nurse practitioners and physician assistants, for example. Most need just two years of graduate-level education—compared with a physician’s four—and neither is required to do a residency or fellowship, whereas MDs and DOs need at least three years of residency; many do seven years or more.

In addition, by the time a nurse practitioner gets to practice, they may have as few as 500 total patient care hours (PDF) whereas a physician assistant will have 2,000 (PDF). Compare either of those with a physician’s 12,000–16,000 hours.

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Patients are aware of these disparities too. Over 90% of patients say that a physician’s years of education and training are vital to optimal patient care, especially in the event of a complication or medical emergency. And 62% (PDF) of U.S. voters say patients are most likely to be harmed from scope of practice changes. Meanwhile, only 3% say that having a physician involved in specific treatments, such as anesthesia, surgery and other invasive medical procedures is not important.

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Scope-of-practice expansion for nonphysician providers often raises costs and harms quality of care. For example, x-ray ordering has been shown to be more than 400% higher among nonphysicians. On top of that, a recent study found 6.3% of nurse practitioners and 8.4% of physician assistants prescribe opioids to more than half of their patients, compared with just 1.3% of physicians.

In addition, it is often thought that allowing nonphysicians to practice without physician involvement will increase access to care in rural and underserved areas. But the AMA mapped the locations of primary care physicians and nurse practitioners nationwide in 2013, 2018, 2020 and 2022, and each time found physicians and nurse practitioners tend to practice in the same areas of a state no matter the state’s scope-of-practice laws.

Find out in detail why education matters to medical scope of practice, with information on:

  • Nurse practitioners compared with physicians.
  • Physician assistants compared with physicians.
  • Nurse anesthetists compared with anesthesiologists.
  • Psychologists compared with psychiatrists.
  • Naturopaths compared with physicians.

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Amid doctor shortage, NPs and PAs seemed like a fix. Data’s in: Nope.

A three-year study of emergency departments in the Veterans Health Administration found nurse practitioners delivering care without physician supervision or collaboration increased lengths of stay by 11% and raised 30-day preventable hospitalizations by 20% compared with emergency physicians. It also found that assigning just 25% of emergency cases to nurse practitioners resulted in a net cost of $74 million annually.

And an earlier study of more than 33,000 Medicare patients at Hattiesburg Clinic, a private multispecialty clinic in Mississippi, showed similar results. Using 2017–2019 CMS cost data, its authors found that if all patients were followed by nurse practitioners and physician assistants, costs would be $28.5 million higher annually.

They also found that four of the five highest-cost providers were nurse practitioners; patients who saw a nonphysician as their primary care provider had higher rates of ED use than patients who saw an MD or a DO; and physicians performed better on nine of 10 quality measures, even showing double-digit differences in flu and pneumococcal vaccination rates.

Learn more with the AMA about great resources that set the record straight for policymakers on scope of practice. The AMA is one of the only national organizations that has created hundreds of advocacy tools for medicine to use when supporting physician-led care.