Let nurse practitioners work independently

Efforts by many states to increase the reach and scope of nurse practitioners — letting them see and treat patients by themselves — have spurred a backlash, mostly among doctors. These physician critics argue that the gap between nurse practitioners (NPs) and doctors is as wide as the Grand Canyon. Their objections seem to focus largely on theoretical differences between NPs and physicians. They also seem to ignore the simple reality: In many parts of America, there just aren’t enough health care providers for all patients.

Critics of letting NPs run their own independent practices say that NPs can be competent and helpful, but can never substitute for the experience and judgment of doctors. Doctors, they argue, have trained for years in the pathology of disease, the little cellular changes that drive illness (or at least that drive our latest models of it), while nurses seldom ruminate on these details. Of course, I know many doctors who have long forgotten most of this pathology. But even if this were true, I am not sure that a more intimate understanding of the biology of disease inherently leads to better decisions for patients.

Sometimes in medicine, biological understanding by itself leads to a treatment plan. But these are usually instances when patients fall outside of well-established treatment paradigms, clinical trial data, or decision trees. In such cases, knowing the intricacies of pathology surely makes doctors feel more comfortable with making decisions, but I am not aware of evidence showing that such decisions are routinely correct.

In fact, biologic thinking can lead to excessive confidence in therapies that only might work. Such confidence can preclude considering and offering patients alternative choices. Failing to offer alternatives in the setting of uncertainty is the cardinal sin of modern medicine, a violation of shared decision-making.

Critics also cite the very limited data showing that nurse practitioners order more tests than doctors. However, they underplay the fact that the difference is slight, and that this is just one of many of things we do in caring for patients.

In their quest to find some fundamental difference between nurse practitioners and doctors on average, I suspect that critics make the common mistake of overlooking the fact there is far more variation within each group than between them. Many seasoned nurse practitioners may have more experience than junior physicians. Good NPs may order tests more judiciously, provide better informed consent, and make better decisions than mediocre physicians.

I have worked with excellent health care providers and terrible ones. Their titles and the alphabet soup of letters on their white coats offer little giveaway to their understanding of disease or how well they care for patients. I know many nurses, research nurses, nurse coordinators, physician assistants, nurse practitioners, and physicians who are flawless clinicians. They operate at the top of the game when it comes to knowledge of illness, bedside matter, attention to detail, judgment, intuition, and experience.

We in health care work with such individuals in total confidence that nothing will fall through the cracks. When you come across such a person in your life, you beg them to never switch jobs, and rely on them for years.

At the same time, I have worked with doctors-in-training and physicians who are less than superstars, guilty of odd decision making, showing tentative or mistaken judgment, exhibiting poor bedside manner, and displaying confidence out of proportion to their ability.

When it comes to caring for my patients or the people I love, I would eagerly trade three mediocre physicians for one excellent nurse practitioner.

Ultimately, the reality is that there are excellent physicians and excellent nurses, and the best of each can operate independently, competently, and gracefully. The worst of each likely needs supervision or remediation.

Instead of drawing divisive lines based on our training or credentials, we ought to find ways to identify and improve the poor performers in each group, without constraining the stars. Concluding that all doctors are great and all nurses just average is as misguided as judging someone’s intellect by the college he or she attended. We need to embrace expanding full practice authority to NPs. The need for this is pressing, and clinging to delusions that one professional title guarantees competence while another entirely precludes it is irrational and harmful.

Vinay Prasad, MD, is assistant professor of medicine and senior scholar in the Center for Ethics in Health Care at Oregon Health & Science University and coauthor (with Dr. Adam Cifu) of “Ending Medical Reversal: Improving Outcomes, Saving Lives.”