Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Pathways to Independent Primary Care Clinical Practice

How Tall Is the Shortest Giant?

Dewan, Mantosh J. MD; Norcini, John J. PhD

doi: 10.1097/ACM.0000000000002764

Patients can be treated by a physician, a nurse practitioner (NP), or a physician assistant (PA) despite marked differences in the education and training for these three professions. This natural experiment allows examination of a critical question: What is the minimum education and training required to practice primary care? In other words, how tall is the shortest giant? State licensing requirements, not educational bodies, legislate minimum training. The current minimum is 6 years, which includes 27.5 weeks of supervised clinical experience (SCE), for NPs. In comparison, PAs train for 6 years with 45 weeks of SCE, and physicians for at least 8 years with 110 weeks of SCE. Initial, flawed studies show equivalent patient outcomes among the professions. If rigorous follow-up studies confirm equivalence, the content and length of medical education for primary care physicians should be reconsidered. Unmatched medical school graduates, with 7 years of training and 65 weeks of SCE, more than the required minimum for NPs, deserve to practice independently. So do PAs. If equivalence is not confirmed, the minimum requirements for NPs and/or PAs should be raised, including considering a required residency (currently optional). Alternatively, the scope of practice for the three professions could be defined to reflect differences in training. There is an urgent need to set aside preconceived notions and turf battles, conduct rigorous independent studies, and generate meaningful data on practice patterns and patient outcomes. This should inform optimal training, scope of practice, and workforce development for each invaluable primary care clinical practitioner.

M.J. Dewan is interim president and SUNY Distinguished Service Professor, Upstate Medical University, Syracuse, New York.

J.J. Norcini is president and CEO, Foundation for the Advancement of International Medical Education and Research, Philadelphia, Pennsylvania.

Editor’s Note: Invited Commentaries on this article by E.J. Warm and B. Kinnear, and by C. Whitehead and E. Paradis appear on pages 937–939 and pages 940–942, respectively.

Funding/Support: None reported.

Other disclosures: M.J. Dewan receives royalties from American Psychiatric Publishing, Inc.

Ethical approval: Reported as not applicable.

Data: The authors received permission from the National Resident Matching Program to use data from the 2017 and 2018 Results and Data reports.

Correspondence should be addressed to Mantosh J. Dewan, Office of the President, Upstate Medical University, 750 E. Adams St., Syracuse, NY 13210; telephone: (315) 464-3105; email:

© 2019 by the Association of American Medical Colleges