On Non-Physician Physicians

In her book The Smartest Kids in the World, Amanda Ripley explains how the Finns developed the best educational system in the world according to international testing standards (PISA testing). About 25 years ago Finland gave up on a system very much like “No Child Left Behind” and instead adopted a very simple reform in which teachers had to come from the top 20% of their academic elite. As in the U.S. most Finnish teachers had previously come from the bottom half of those applying for college per the national entrance exam (similar to our SAT). To pull this off teachers had to be paid more, and they were. It took about two decades, but these brighter teachers figured out how to teach in such a way that the students adopted the critical thinking skills measured by the PISA. Finland has surpassed even South Korea which compels its top students to spend about twice as much time in the classroom every day. So what does this have to do with medicine?

In American medicine we are rapidly adopting the Finnish approach, but in reverse. We used to call nurse practitioners (NPs) and physician assistants (PAs) “physician extenders”, but no more. In most states nurse practitioners are now allowed to practice independently without the supervision of a doctor. The PAs are extending their education by 2 years to acquire a PhD that will allow them to do the same. Total education for an NP is 8 years, but 2 of those years are dedicated to research. Total education for a PA is currently 6 years, hence the need for extension if they are to convince state legislators that they can practice independently. Total education for a family practice doctor is 8 years plus a 3 year residency that is devoted to clinical training; it is in this residency that the doctor really learns how to practice medicine. NPs have convinced lawmakers that they can fill the shortage of primary care doctors on the cheap. It costs much less to to train them and their lower salaries can be used in negotiation to undercut the salaries of doctors. So with NPs and PAs practicing independently, we do not have to pay primary care doctors as much or more than specialists to draw medical school graduates away from specializing.

This problem does not exist in Europe where most doctors are in primary care and only a small percentage specialize. In the U.S. about 85% of physicians are specialists, and specialist lobbies distort the income scale to the detriment of primary care. This perpetuates the lack of primary care doctors as most medical students follow the money, particularly as they come out of school with a debt load of about $200,000. So how will this development with NPs and (ultimately PAs) affect medicine in America?

To be continued ….

– Gary Gallo, MD