April 23, 2019
Beyond MDs: Nurse Practitioners, Physician Assistants, and Midwives

Beyond MDs: Nurse Practitioners, Physician Assistants, and Midwives

by Berkeley Wellness

If your doctor is part of a large practice, you have probably encountered other kinds of health-care providers during your appointments—white-coated professionals who are not MDs (Medical Doctors) or DOs (Doctors of Osteopathy), but who may consult with patients, provide health information, do exams, diagnose illnesses, and write prescriptions (in some states). Some may do nearly everything a doctor (more accurately called a physician) does and may even serve as primary care providers for patients.

These non-physician clinicians, as they’re sometimes called (other terms include advanced practice providers and advanced practitioners), can be a boon for patients. You may get faster access and quicker answers. If you call the office when the physician cannot speak to you, a nurse practitioner or physician assistant may answer your questions and give you test results. You’re also likely to encounter these providers at urgent care centers or walk-in clinics.

Amid rising physician shortages in the U.S., especially in rural and underserved areas, the population of non-physician providers is booming: In 2018, there were 234,000 nurse practitioners in the U.S., compared with 140,000 in 2010, according to the American Association of Nurse Practitioners. The number is projected to reach 280,000 by 2026. A 2018 report from the Health Care Cost Institute found that, while visits to primary care physicians sagged by 18 percent between 2012 and 2016, visits to nurse practitioners and physician assistants rose by 129 percent in the same period.

Who are these providers? What is their training? And how does the care you receive from them compare with what you get from your physician? Here’s a look at three types of non-physician providers you may encounter in primary care and specialized medical practices, plus a sampling of research comparing their care to that of physicians.

Nurse practitioner

Nurse practitioners (NPs) are registered nurses with advanced education (master’s or doctorate degree) plus clinical training. They are licensed or credentialed by the state(s) in which they practice and must also pass a national certification exam. Some 87 percent are certified in an area of primary care, such as family medicine, gerontology, women’s health, and pediatrics. They may also be certified in specialty areas such as cardiology and acute care medicine.

In 23 states, nurse practitioners can practice independently. In all others, they work under the supervision of, or in consultation with, a physician. As of 2017, the VA allows advanced practice registered nurses, including nurse practitioners, to practice independently in all of its national medical centers, regardless of individual state laws.

Scope of Practice: A Hot Debate

Physician groups oppose the idea of advanced practice nurses treating patients independently, citing concerns for patient safety. Nurses' associations counter that physicians are carrying on a turf war that puts profits ahead of patients.

Physician assistant

Physician assistants (PAs) work with physicians, usually in group practices in doctors’ offices or hospitals, seeing patients and carrying out tasks similar to those of nurse practitioners. They have a medical sciences education and clinical training, and must pass a national certification exam. Some programs now offer a doctorate degree in the field.

About 20 percent of physician assistants work in primary care, according to a 2016 report from the National Commision on Certification of Physician Assistants; the rest work in specialty areas, most commonly surgery, emergency medicine, and internal medicine subspecialties like cardiology, oncology, or gastroenterology. More than 130,000 physician assistants are currently certified in the U.S., according to the American Academy of PAs.

Certified nurse midwife, Certified midwife

A certified nurse midwife (CNM) is a registered nurse who provides obstetric care and other women’s health services, such as performing well-woman exams, prescribing contraceptives and other medication, and providing patient and parenting education. CNMs work in a variety of settings, including hospitals, group obstetrical practices, or community health centers. Some work as independent providers.

A related provider, the certified midwife (CM), is not a nurse but must pass the same national certification exam as a certified nurse midwife. Both groups have a graduate degree in midwifery plus clinical training. About 12 percent of vaginal births in the U.S. were attended by a certified nurse midwife or certified midwife in 2014, the last year for which national data were available, according to the American College of Nurse-Midwives.

Comparing outcomes

Research has generally found that nurse practitioners and physician assistants provide comparable care to that of physicians, within their respective areas (or "scopes") of practice. Plus, they deliver health care at lower cost than physicians and help make medical offices and hospitals function more efficiently.

A study in the Annals of Internal Medicine in 2018 looked at data from almost 400,000 patients with diabetes treated at more than 500 Veterans Affairs (VA) primary care facilities nationwide. The investigators found that patients had similar outcomes whether they were cared for by a nurse practitioner, physician assistant, or physician. The studied outcomes included systolic blood pressure, LDL (“bad”) cholesterol, and HgbA1c, a measure of long-term blood sugar control.

In a Cochrane review published in July 2018, the authors looked at 18 studies that compared nurses, including nurse practitioners, to doctors for the delivery of primary care. They found that for patients with chronic conditions, as well as those with certain urgent or ongoing complaints, nurses “probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients.”

Another study, published in 2018 in PLOS One, looked at the role of midwives in improving maternal and infant health outcomes. It found that states in which midwives were “highly integrated” into the health care system had higher rates of vaginal delivery and breastfeeding, and lower rates of cesarean section, preterm birth, low-birth-weight infants, and newborn death, compared to states with the least integration of midwives (for example, due to very restrictive laws limiting their scope of practice). The relationship held even after researchers controlled for race, an important variable since African American women in the U.S. have much higher rates of maternal and neonatal death than non-black women. States with the highest levels of midwife integration included Oregon, Washington, and New Mexico. The lowest levels were in Mississippi, Alabama, and Ohio.

Also see A Team Effort.