I recently found a spot on my arm that worried me. My regular dermatologist was not available for an appointment as fast as I wanted, so I decided to check out a new dermatology clinic in my town. I got an appointment for the next day, but when I looked up the credentials of the practitioner with whom I was scheduled, I found she was a nurse practitioner, not a physician. I cancelled the appointment as I was distrustful of an organization that did not disclose that I was signing up for an appointment with a nurse practitioner. Had I been told I was not seeing a physician, I probably would have kept the appointment. At any rate, the experience prompted me to look into the training and practice of nurse practitioners and physician assistants (now referred to as “physician associates)–something I have been meaning to do for some time.


Nurse practitioners (NPs) are registered nurses who have completed an NP-focused graduate program. To practice, they have to pass a national certifying exam.

Physicians associates (PAs) have a bachelor’s degree and then undergo a three year PA program with heavy emphasis on clinical training. They too must pass a national certifying exam.

In about half the states, NPs can render care independently, with no physician supervision. PAs require a greater degree of physician supervision, although their association is working to gain greater practice autonomy.


The need for primary care clinicians in the US is a big reason that the movement to NPs and PAs has prospered, as experts in the physician workforce predict an ever greater shortage of physicians. The most alarming statistic is that, currently, 95 million Americans lack access to primary care. In 2004, there were 106,000 NPs, whereas there are 355,000 today. In 2010, there were 89,019 PAs; today there are 159,000. In comparison, there are almost one million practicing physicians in the US, about 40 percent of whom are primary care providers.

Quality of Care

As a primary care physician (retired), I have been circumspect about NPs and PAs, as they simply do not have the amount of training physicians undergo. In researching this blog entry, I was ready to call for studies that compared the quality of care rendered by NPs and PAs compared to physicians. In fact, there are many, and many of them are of high quality. In randomized trials, quality control parameters such as glucose control in diabetics and blood pressure control demonstrated no difference between NPs and physicians. Prescribing preventive measures such as vaccines and mammograms also showed no difference. Importantly, patient satisfaction with NPs was no different from physicians’ ratings.

The Future

Given the inability to receive timely care, many patients have begun to accept non-physician care. Wanting to avoid long waits for an appointment with a physician, they often turn to immediate care clinics that are staffed by NPs and/or PAs. Major pharmacy chains are getting into the primary care business too, and given that PAs and NPs earn less than half of primary care practitioners ($115,390 and $111,680 per year, respectively), profit without physicians is greater. And quality does not appear to be compromised.

Given the research data I have cited, I wonder whether I was overtrained. Regardless, it is clear the direction the clinical care workforce is taking–a phenomenon that is being largely driven by patients. And there appears to be no reason to think this trend compromises healthcare.

Most of the information in this post came from the “Medical Economics Journal,” V99, Issue 9, September 2022. It is readily accessible to anyone online.

By the way, my spot was “nothing.”


  1. Peter Beatty says:

    My feeling about “physician extenders” is that they tend to be algorithm-driven which is ok if the problem they’re dealing with is routine . To avoid mistakes, Atul Gwande thinks that most situations should ge algorithm-based. But having spent most of my professional life dealing with non-routine issues, I worry that complex stuff might not get the thought it deserves and needs for a satisfactory outcome with physician extenders (with notable exceptions).

  2. Anonymous says:

    Informative and well-written as usual. One more point: just this week the NYT covered the extremely high rate of burnout among MDs. We’re certainly going to need all those new NPs and PAs, and not only in health care deserts.

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