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The never-ending battle for money and turf among the US healthcare professions continues to rage and, of late, appears to be heating up. In particular, the American Medical Association (AMA) has increasingly taken the fight to both advanced practice RNs (APRNs) as well as physician assistants/associates (PAs), but others, including healthcare economists and policy researchers, also have used selective data from published studies to mischaracterize the contributions of PAs.1,2 Signals indicating a rise in anti-NP and PA sentiment also includes essays from physicians lamenting the decline in their prestige and authority, and physician concerns about the quality of the education and practice capabilities of APRNs.3-5 Hostile commentaries about PAs are not new, as Dehn pointed out, noting that “PAs are frequently misrepresented and misunderstood by health workforce researchers,” a point that remains problematic for the profession today.6

Much of the healthcare services research performed on nonphysician healthcare providers combines NPs and PAs as study subjects. Collectively, most of these studies show clinical performance in key areas such as productivity, quality, and cost to be similar to physicians, particularly in primary care.7 However, there often are problems in the true determination of collective conclusions studies that mix APRNs and their independent practice activities with PAs whose practice is more closely linked with collaborating physicians. One such recent example relates to a paper published in a state medical society journal that reports the collective contributions to care of a community population.8

More than 15 years ago, in an effort to extend the delivery of primary care services to its community, the Hattiesburg (Miss.) Clinic started hiring NPs, and to a lesser degree, PAs to staff the clinic.8 The study authors noted that the shortage of physicians was then so serious that the clinic established PAs and NPs to function independently with separate primary care panels, side-by-side with their collaborating physicians. The clinic intended for PAs and NPs to have their own panels in relationship with a collaborating physician; PAs and NPs would see fewer complex patients and provide similar quality of care, stabilize costs, and meet patients' expectations for satisfactory care. The outcome measures combined NP and PA performance data and showed that in terms of quality, physicians had better scores particularly in immunizations (influenza, pneumococcal, PCV-13 vaccine use); fairly close scores in cancer screening (breast, colon); and slightly better scores in hypertension, diabetes, and lipid management.8 Spending was $43 per member per month higher for Medicare patients with an NP or PA primary care provider (PCP) compared with those who had a physician PCP.8 For patient satisfaction, scores were relatively similar between physicians and PAs and NPs across six domains measured by Press-Ganey patient satisfaction questions. The authors of the report acknowledged that “if not for the addition of over 100 nurse practitioners and physician assistants to Hattiesburg Clinic over the last 15 years, our organization could not have provided services to thousands of patients who might have otherwise gone without care.”8 They go on to add that “[PAs and NPs] are a crucial part of the care team; however, based on a wealth of information and experiences with them functioning in collaborative relationships with physicians, we believe very strongly that nurse practitioners and physician assistants should not function independently.”8

An accompanying editorial in the same issue as the Batson and colleagues paper, a physician editor noted that the educational differences between NPs and physicians are the important factor in maintaining physician leadership of the primary care team.9 The editor indicated that the substantial educational differences between NP and physician leads physicians to oppose full-practice authority for NPs in that state and observes that “abbreviated education does not garner independence.”9

The AMA wasted no time in using the outcomes of the Hattiesburg Clinic to condemn the independent practice of primary care by NPs and to stress the primacy of physician-led medical teams.1 In most of the communications, the small number of PAs involved was not mentioned, and PAs and NPs were the collective target of the objections by the responding physician groups.

In another instance, a recent paper written by a healthcare economist titled “Increased reliance on physician assistants: an access-quality tradeoff?” asserted that the increased use of PAs in the US healthcare system could pose a healthcare policy dilemma.2 The authors, Walia and colleagues, raise the question: Are the economic benefits that accompany increased PA contributions to healthcare delivery offset by a decline in quality? In their description of “quality,” they stated that “increased reliance on PAs is expected to increase the prevalence of medical diagnostic error and defensive medicine,” and go on to assert that “there is statistically significant evidence that physicians outperform PAs in minimizing diagnostic and treatment malpractice.”2 The authors draw on this statement in support of their overall conclusion, inferred throughout the article, that PAs provide lesser quality of care than physicians and thus increase malpractice liability.

Over the past 3 decades, the low malpractice liability of PAs in clinical practice has become well established.10-12 The most comprehensive of the studies on this topic used data from the National Practitioner Data Bank (NPDB) and consistently concluded that PAs (and APRNs) have lower levels of malpractice liability relative to their physician colleagues.10-12

Walia and colleagues cited a recent study conducted by several PA medical legal experts and researchers and use these data to support the erroneous assumption that “the truncated training period of PAs relative to physicians contributes to a higher average diagnostic error rate, which in turn contributes to higher use of defensive medicine.”2 Brock and colleagues, authors of the Medical Care Research and Review study, point out that this analysis was based on a 10-year record of data from the NPDB and indicates the opposite of the conclusions of Walia and colleagues.11 Walia and colleagues drew on a table in the Brock article that delineates in descending order the reasons cited for malpractice litigation for physicians and PAs. Brock did not indicate nor compare the prevalence of malpractice litigation or adverse licensure actions between physicians and PAs. Although it is true that diagnostic and treatment categories are more prevalent reasons for malpractice incidents for PAs than physicians, the liability research indicated that per provider, PAs experienced significantly fewer malpractice incidents and adverse licensure actions than physicians from 2005 to 2014.10 Furthermore, payments for PA malpractice incidents were about half that of physician malpractice payments during the same period.11 This data analysis revealed similar findings to a study published in 2009 that examined NPDB data for a 17-year period from its inception in 1991 to 2007.10 In the 2009 study, PA liability was less than that of physicians per capita.10

Responding PAs continued to argue that the entire premise of the Walia paper is that PA practice results in a higher use of defensive medicine. Had the authors treated the Brock and colleagues study fairly, they would have pointed out that this newer research points to the reduction of malpractice incidence and adverse actions when PAs are added to a physician practice. Walia and colleagues failed to include data in the categories in which PAs, using Walia and colleagues' own verbiage, “outperformed physicians in minimizing malpractice.” These malpractice categories include surgery, obstetrics, patient monitoring, anesthesia, and behavioral health.13

Based on the mischaracterization of the data noted, the paper fails to establish an access-quality tradeoff. The quality of care of PAs has been demonstrated in dozens of studies and has been described as “indistinguishable” from physician levels of care.14

These issues of data interpretation exaggeration and/or frank misrepresentation are not isolated occurrences and are only the latest examples. In the healthcare professions turf wars, skeptics in one healthcare professions group or another tend to use research findings based on small-scale studies to broadly generalize findings to their advantage. Physician groups of late, as noted, have become more vocal and, as in the Hattiesburg Clinic instance, used such tactics to advance their message (“physician-led teams”). Physicians in general, who not long ago held dominance over the entire healthcare field, are predictably responding to what they perceive to be encroachment on their turf. Encouraging a more measured dialogue among the healthcare professions and their organizations, based on mutual agreement regarding the fair interpretation of research findings, would help to lower the temperature of the rhetoric and model real team-based behavior.

1. Robeznieks A. Amid doctor shortage, NPs and PAs seemed like a fix. Data's in: nope. www.ama-assn.org/practice-management/scope-practice/amid-doctor-shortage-nps-and-pas-seemed-fix-data-s-nope? Accessed May 24, 2022. 2. Walia B, Banga H, Larsen DA. Increased reliance on physician assistants: an access-quality tradeoff. J Mark Access Health Policy. 2022;10(1):2030559. 3. Balon R, Morreale MK. Demise of a physician. Ann Clin Psychiatry. 2022;34(1):1–3. 4. Mosley M. Physicians must restore the integrity of medicine. Emerg Med News. 2022;44(5):3–5. 5. Al-Agba N, Bernard R. Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare. Irvine, CA: Universal Publishers, Inc.; 2020. 6. Dehn RW. Missing the mark: why is some research on PAs just wrong. JAAPA. 2014;27(12):9. 7. Halter M, Drennan V, Chattopadhyay K, et al. The contribution of physician assistants in primary care: a systematic review. BMC Health Serv Res. 2013;13:223. 8. Batson B, Crosby S, Fitzpatrick J. Mississippi frontline—targeting value-based care with physician-led teams. J Miss State Med Assoc. 2022;63:19–21. 9. Camp-Rogers T. The importance of the physician led team. J Miss State Med Assoc. 2022;63:17–18. 10. Hooker RS, Nicholson JG, Le T. Does the employment of physician assistants and nurse practitioners increase liability. J Med Licensure Discipline. 2009;95(2):6–16. 11. Brock DM, Nicholson JG, Hooker RS. Physician assistant and nurse practitioner malpractice trends. Med Care Res Rev. 2017;74(5):613–624. 12. Fred W, Weinstock M, Darracq M. Physician assistant malpractice trends in emergency medicine [abstract]. Ann Emerg Med. 2021;78(4):S7. 13. Nicholson JD, Hooker RS, Cawley J. Reply to Walia B, Banga H, Larsen D. Increased reliance on physician assistants: an access-quality tradeoff. J Market Access Health Policy. 2022; in press. 14. Lassi ZS, Cometto G, Huicho L, Bhutta ZA. Quality of care provided by mid-level health workers: systematic review and meta-analysis. Bull World Health Organ. 2013;91(11):824–833.