When I first started to work at CHAS I was surprised to find out that I wouldn't actually have an office and I would probably be moving from one desk to another depending on what space was available. In my previous offices I always had my own desk with drawers that I put things in that I would use to take care of patients, a bookshelf to hold my favorite texts, wall space to put up pictures of family and copies of diplomas and medical licenses. I worked with RN's who would assist with procedures and could give intravenous treatments. I shared on-call responsibilities with a number of other doctors with nearly the same experience I had. At CHAS we use medical assistants instead of RN's, who can do many but definitely not all of the things RN's can do and have less independence than my previous nurses. (We did get a nurse finally but we share her and she has very different responsibilities.)
The biggest difference is that CHAS is primarily served by Nurse Practitioners and Physician's Assistants as the providers rather than MD's. There are a few MD's, but it is really difficult to recruit MD's for our practice. There are more Nurse Practitioners and PA's in the job market and they are apparently less picky about certain things. They also have fewer years of training than doctors and took on less responsibility in the process of getting their degrees. Some have many years of experience, having been nurses before but none had the baptism by fire that is common for MD's. (I recall as an intern taking care of a whole medical floor of acutely ill patients in the hospital, getting 4+ new admissions from the emergency department and making decisions completely unsupervised countless nights, presenting the cases in the morning to the attending physician and working until sign-off at 6 PM the next day.) I don't recommend the baptism by fire thing, but it does teach you medicine. That scenario was repeated, with gradually increasing levels of experience, for 3 years before I was released to practice independently.
So right out of training I had some skills. Not to say that a person needs to be able to juggle the needs of sick and dying hospital patients in order to take good care of clinic patients. Nevertheless there is a difference in the backgrounds of NP/PA's and MD's, related to level of responsibility and sheer hours of patient contact as the main decision maker. That said, the backgrounds of mid-level practitioners can be more helpful to outpatients than that of certain MD's. Studies do not show that MD's do a better job of taking care of patients in community clinics that NP's or PA's.
More NP's and PA's are licensed each year than MD's. Looking through various internet sources, it appears that over 36,000 new NP's and 20,000 PA's are licensed each year and new physician graduates add up to fewer than that, around 20,000. MD's and DO's (Doctor of Osteopathy, a pathway very similar to MD) actively practicing medicine number a bit over 1 million in the US. NP's and PA's add up to just under 500,000, since those two certifications have not existed for as long.
An MD or DO degree takes 8 years to complete after finishing high school (a college degree then 4 years of medical school), and is followed by a required residency program that takes 3-7 years depending on the specialty. When I did it, there were no restrictions on the number of hours we spent at work during our clinical years and residency, which meant that we spent vast amounts of time in the hospital. Weekends had virtually no meaning after the first 2 years. It is incredibly competitive to get in to medical school, so students need to have stellar grades and scores and have done a few extra things that show how super special they are just to be admitted. Residency is also competitive: some people complete their MD only to fail to get a residency. This is a huge hurdle to starting practice as a doctor and a colossal waste of time, money and talent.
Becoming a doctor in the US is an unnecessarily difficult process.
The British system, followed by many other countries in the world, involves getting a Bachelors degree in medicine. This degree requires around 6 years after high school and leads to a degree as a physician and surgeon. It is possible to practice medicine after that, though I believe most people do a residency. After being qualified to be a physician they are called "doctor" though they do not have a doctorate degree. It is possible to do further academic or scientific work and gain a doctorate in medicine or science, but that is not common or required.
A nurse practitioner in the US usually gets a four year Bachelors degree in nursing (occasionally 2 years if it is an accelerated program), spends a few years being a nurse (sometimes many years) and then does the 2-4+ year program to be an Advanced Practice RN. This can lead to a practice as a midwife, nurse anesthetist (like an anesthesiologist) or a family practice NP. Physicians assistants finish a regular undergraduate degree (Bachelor of arts or sciences), usually does some kind of medical or science related job for a few years, then applies to a program that takes 2 years to complete. Both NP's and PA's can do residency programs before going to work.
The AMA (American Medical Association) is involved in advocacy for physicians to various agencies, including federal and state governments. I just recently saw that their focus this year involves pushing back against "scope creep." By this they mean trying to make sure that nurse practitioners can't practice independently of doctors. There are 26 states (including Idaho, where I practice) that are considered "full practice" states for nurse practitioners. They can open their own clinics and can practice and prescribe independently. There are still some restrictions, including hospital work and (strangely) prescribing certain durable medical goods. The AMA continues to lobby enthusiastically against more states joining the "full practice" majority.
I recently read an opinion piece by Robert Doherty in the Annals of Internal Medicine. Mr. Doherty worked for decades at the American College of Physicians in health policy and knows his stuff. His essay "In the These Uncaring Times, Will Physicians Lead Us Back to our Better Angels?" holds nothing back in encouraging doctors to be involved in the fight against discrimination against vulnerable and disadvantaged people, to work harder, even to be involved in civil disobedience. He feels the US is regressing, with corporate profits made more important than "the dignity, health and lives" of Americans. He mentions that we need do more to reduce harm to patients, rather than focus on issues such as "scope of practice." Working on scope of practice means pushing back against the power of nurse practitioners and is what the AMA is doing.
The clinics where I work rely heavily on NP's and PA's to provide primary care to our patients. Without them, CHAS would simply be unable to function. In my position as an internal medicine consultant, I review many charts and observe many practice styles. There is huge variability in the level of competence and completeness and also in the complexity of patients. I am in awe of some providers' care and other times things are clearly missed or done wrong. Sometimes I notice that I have missed something that another provider would have noticed. Care is obviously better when providers are able to ask each other questions, and when they have diverse backgrounds. It is good when MD's are part of a mix of providers. But it has been extremely difficult to recruit MD's for our clinics. Specialty care, such as gastroenterology, rheumatology, neurology, oncology and surgical subspecialties is almost always provided by MD's outside of our clinic. Our patients often wait in excess of 6 months to see these specialists, which is both dangerous and embarrassing. The cardiologists in our area use nurse practitioners to manage patients with heart disease and we are generally able to get these patients in much more quickly because at these offices there is adequate staffing. In our community there are simply not enough MD's.
So what should we do about the increasing numbers of NP's and PA's providing care for patients? I think we should welcome them, support them, mentor them and learn from them. We MD's should have a more humble perspective, realizing that the US system is different than most of the rest of the world and that our very arduous educational path for producing doctors has not created a system that is more effective and equitable than places that do it differently.
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