Years of training.
When considering the potential negative effects on quality and safety of proposed scope of practice changes that would give nurse practitioners more latitude to practice independently, that is the place to start.
Nurse-practitioner programs generally last two to four years, however, some nurse practitioners can get their degree in as little as 18 months after becoming an RN. Online-only programs are allowed.
Physicians, by contrast, must complete four years of medical school to earn a degree as an MD (a doctor of medicine) or a DO (doctor of osteopathic medicine). There are no online medical schools.
Meanwhile, nurse practitioners have no residency training requirement, whereas physicians must complete three to seven years of residency and fellowship training depending on which specialty they pursue.
And while nurse practitioners are essential and valuable members of physician-led health care teams, they will tally just 500–750 patient-care hours in training. By comparison, physicians rack up at least 16 times as many patient-care hours. Between medical school clinical rotations and residency, physicians get between 12,000 and 16,000 hours of patient-care experience.
It’s no surprise that 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.
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.
Not all nurse practitioners get “a sound, thorough, in-person education,” said Teresa Camp-Rogers, MD, a staff emergency physician at South Central Regional Medical Center in Laurel, Mississippi.
“Some NPs receive subpar training. There are NP schools with 100% acceptance rates. Some NP schools have open-book exams. A handful of NP schools, called direct-entry NP schools, will accept applicants even without a nursing degree. Some programs can be completed in as little as 18 months.”
Given the duration and lack of rigor in this nurse-practitioner training, “it is not surprising that it is common to see missed diagnoses, incorrectly written prescriptions, and delays in care among patients cared for by NPs,” said Dr. Camp-Rogers, an AMA member who is associate editor of the Journal of the Mississippi State Medical Association.
As noted in an AMA explainer (PDF), physician training is comprehensive and requires studying all aspects of the human condition—biological, chemical, pharmacological and behavioral—in the classroom, laboratory and through direct patient care.
“We don’t just learn one quick fact about a disease and its most common presentation,” Dr. Camp-Rogers said. “In order to keep patients safe, we learn every single facet of a disease and the less common presentations.”
Physician training also is hands-on and involves rotating through different specialties during the final two years of medical school, working side by side with licensed physicians. By contrast, the training that nurse practitioners get is abbreviated, given that nurse practitioners can complete a master’s or doctoral degree in two to three years.
In addition, nurse practitioners may have limited hands-on training, with 60% of nurse-practitioner programs offered completely or partially online, the AMA explainer says.
Critically, nurse-practitioner training—in stark contrast to physician education and training—has virtually no standardization for obtaining practical experience in patient care. The type of patient care experiences nurse practitioners get will vary widely from student to student, and the breadth and depth of clinical experience is not guaranteed at the individual level.
While both physicians and nurse practitioners make mistakes, “the difference between the physician error and the nurse practitioner error is simple, but significant. It has to do with assuming the NP mastered enough content and clinical experience in their shortened training,” Dr. Camp-Rogers said.
Another huge difference with an unmistakable impact on care is in the area of residency training. After earning their medical degrees, physicians go on to residency programs for three to seven years of additional training in a select surgical or medical specialty.
In addition, newly graduated physicians move from direct supervision to progressively increased responsibility in guided preparation for independently practicing medicine, the AMA notes. All U.S. residency programs are highly standardized, and they must be accredited by the Accreditation Council for Graduate Medical Education, offering graded and progressive responsibility.
And what residency training is required for nurse practitioners to graduate or earn licensure?
When it comes to physicians, Dr. Camp-Rogers said, patients can be assured that physicians have the knowledge and experience needed to reliably provide quality care and keep patients safe. For nurse practitioners, by contrast, patients cannot take solace in knowing whether they were “ever taught the content to begin with,” Dr. Camp-Rogers said, noting that nurse practitioners take only one, 150–200 question board exam.
Moreover, the national certifying exam that nurse practitioners must pass is in a specific area of focus—based on the type of program from which the NP graduated—but they are not required to practice in that area. That means a nurse practitioner certified in primary care can practice in cardiology, dermatology, neurology, orthopaedics and other specialties without any additional formal education or training.
Physicians, meanwhile, must pass a multiyear series of nationally required, standardized exams. These rigorous exams start in the second year of medical school and continue throughout residency. In addition to standardized exams after each core rotation, MDs take three United States Medical Licensing Examinations and DOs take three Comprehensive Osteopathic Medical Licensing Examinations. And after completing an accredited residency in a select specialty and establishing licensed practice, physicians may obtain board certification in various specialties to further demonstrate their mastery of knowledge in a specific field of medicine.
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.
If you doubt that, Dr. Camp-Rogers advises you to consider the infamous example of Alexus Ochoa-Dockins, a 19-year-old college athlete who tragically died as a result of misdiagnosis of a pulmonary embolism by the family nurse practitioner who treated her in the emergency department. There are emergency departments across the U.S. staffed only by nurse practitioners.
Indeed, a study published in the Journal of Nursing Regulation found that over one-third of family nurse practitioners had not interpreted results from diagnostic tests in more than 10 cases. Of the nearly 4,000 family nurse practitioners surveyed for the study, almost 60% said their training was done fully or mostly online. A majority (53%) of the family nurse practitioners in training said that they—not faculty—were responsible for locating and securing preceptors to supervise them during clinical rotations.
Research that supports limiting inappropriate scope of practice expansions for nurse practitioners is abundant.
For example, 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.
“The nurse practitioner schools and lobbyists are saying that nurse practitioners are safe to go out there and practice just like doctors much of the time,” Dr. Camp-Rogers said, “but there's no proof that they were taught how in the first place.”
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 fighting scope creep.
And find out more with the AMA about how expanding nurse practitioner scope of practice (PDF) leads to higher costs, more referrals, higher emergency department use, and lower patient satisfaction than care provided by physicians.