I used to enjoy taking pictures with a heavy camera that required careful assessment of light, motion, and the surroundings before taking a picture. I would adjust the lens, focus, and snap numerous shots. Sometimes there would be unexpected motion or change in the lighting that would ruin the picture. When I was done, I had to wait for the film to be developed several days later to find out the results of my efforts. Sometimes I might come up with two or three photographs I really liked.
But when cell phones with their built-in cameras came along, the convenience of being able to always have my camera with me meant I could capture images that I would previously have missed. Initially, the detail on cell phone photos was limited and I would still bring along my “real” camera for special occasions. But bit by bit, as cell phone cameras became better and better, those occasions became fewer and fewer until now I don’t even know where that camera is. As it gradually improved, the cell phone camera became a disruptive innovation for photography and reduced the need for other cameras, gradually replacing them for many people.
Similarly, in health care, various health professionals have replaced physicians in many clinical settings. Christensen et al1 have described how nurse practitioners (NPs) and physician assistants (PAs) are disruptive innovations; they offer services once provided only by physicians. Christensen’s idea of a disruptive innovation is that of a product that is typically less expensive and initially appeals to the lower end of the market, where there is less competition. There it gains a foothold and gradually improves and expands into the middle and upper parts of the market, ultimately squeezing out the competition. As I read the article by Dewan and Norcini2 in this issue of Academic Medicine, which compares training models of physicians, NPs, and PAs, I wondered whether the training approaches themselves are also disruptive innovations that might change physician-education models. In that case, what should those changes be?
Two Disruptive Innovations in Health Care
Christensen et al, in looking at the evolving practices of NPs and PAs, explained:
It is in physicians’ interest to embrace this change. Rather than fight the nurse practitioners who are invading their turf, primary care physicians should move upmarket themselves using advanced diagnostic and therapeutic technologies to perform many of the services they now refer to costly hospitals and specialists.
In the intervening 19 years since Christensen et al published their article, NPs and PAs have proliferated and expanded beyond their historical origins in primary care into many specialties in medicine, supplementing the physician workforce. Auerbach et al3 have shown that between 2010 and 2016, the increase in the number of NPs and PAs (79,000) exceeded the increase in the number of physicians (58,000). They estimated that between 2016 and 2030, two-thirds of added clinicians would be NPs and PAs. Cawley and Hooker4 note:
PAs are trained in 2.5 years at one fourth the cost of a physician and begin producing patient care 4 years before a physician is independently functioning.… PA quality of care appears indistinguishable from that of physician-delivered services.
They explain that the salary differential between a PA and a family physician is approximately 45%, even though the PA sees a range of patients whose diagnoses represent 85% to 90% of the diagnoses of a family physician’s patients. Igelhart5 notes that NP programs require only 500 to 700 supervised clinical hours beyond an initial bachelor of science nursing degree and a completed master’s degree (although currently many programs now require a doctorate) for a student to qualify as an NP. Unlike PAs, whose scope of practice is determined by their physician supervisor, NPs can practice independently in some states, with the scope of practice determined by the state. Because PAs and NPs can be seen as disruptive innovations in many areas of health care, they have faced resistance from physician groups and state policymakers, who raise concerns related to training, quality of care, and the safety of patients.
Differences in Duration of Training
Dewan and Norcini2 note PAs’ and NPs’ briefer duration of training compared with that of physicians, note the similar quality of care they provide, and ask whether it is time for a reassessment of current physician training models, including their duration. They state that
the vast majority of primary care physicians (internal medicine or family practice) have spent 11 years in training, with 225 weeks (4.5 years) of supervised patient contact, when the minimum legislated for clinical practice is 6 years and 27.5 weeks (half a year).
They cite numerous studies that suggest equivalence in outcomes of care provided by NPs, PAs, and physicians and suggest that if patient outcomes are indeed equivalent,
there must be a serious reevaluation of the length and especially the content of medical training…. On the other hand, if this equivalence does not hold up, then we need to use data to revise the minimum requirements…. This may include increased [supervised clinical experiences] (which even now is a rate-limiting step in many programs) or requiring an NP or PA residency, which are currently unregulated, voluntary, and last just one year.
In other words, Dewan and Norcini appear to be asking whether PAs and NPs represent disruptive innovations to the physician training model as well as to the care model. If we can train advanced practice clinicians in less time than it takes to train physicians and with a different curriculum and achieve approximately the same results, should we consider altering physicians’ curricula and the duration of their training to more closely resemble those used for PAs and NPs?
Emanuel and Fuchs6 have also raised questions about the duration of physician training, noting:
Years of training have been added without evidence that they enhance clinical skills or the quality of care. This waste adds to the financial burden of young physicians and increases health care costs.
They suggest that medical training could be reduced by 30%. Lucey et al7 have suggested possible ways to shorten medical education through adopting competency-based, time-variable training, and Andrews et al8 have described innovative transitions from medical school to residency in pediatrics as an example of how medical education could be shortened using a competency framework.
Analysis of Arguments for Reducing Duration of Physicians’ Training
While all of these proposals suggest a reexamination of the duration of medical education and possibly its curricula, they do so using different arguments. Dewan and Norcini base their argument on the many years of successful training of NPs and PAs and the published literature that examines quality of care measures of NPs and PAs compared with those of physicians and that suggests similar results. Lucey et al and Andrews et al base their argument on competency-based education models that recognize individual variability in achieving competency and the potential for some students, if given the chance, to do so in less time than is currently required. Emanuel and Fuchs base their argument on lack of evidence for the time requirements of the current educational system and the examples of reductions in each phase of medical education that already exist, which they propose could be more widely adopted. In the rest of this editorial I explore these arguments and their implications for future health professions education.
The argument of Dewan and Norcini rests on two assumptions. The first is that the quality of care provided by practicing PAs and NPs is equivalent to that of physicians, and the second is that equivalent quality of care in practice means that the educational outcomes were also likely equivalent. There is some evidence supporting the first assumption, although it is limited by studies that are underpowered to test for equivalence. Laurant et al9 in a 2005 systematic review found “no appreciable differences between doctors and nurses in health outcomes for patients, process of care, resource utilization or cost.” But the authors also noted that only one study in their analysis was powered adequately to assess equivalence of care. McCleery et al10 in a 2014 systematic review comparing the quality of care given by advanced practice nurses and physicians also found no differences but noted that the strength of evidence was low. Because PAs work under the supervision of physicians, comparisons of independent practice quality with physicians similar to comparisons done with nurses were not possible. While the existing studies related to the quality of care provided by independently practicing NPs may be useful to encourage pilot programs and support increased scope of independent practice, they cannot definitively answer the question about the equivalence of quality of care.
The second assumption, about whether we can draw inferences about the quality of education from the quality of practice studies, is more challenging. PAs and NPs commonly receive intensive supervision and education after graduation from a physician or group, akin to an apprentice relationship. Thus, the performance measured in clinical studies likely reflects the years of on-the-job training they received as well as what they learned in their formal training programs. It is impossible to know how much of their performance is due to their formal education and how much is due to what they learned later in practice. A comparison of equivalence of education would require comparative testing at the completion of formal training, not after years of practice. Unlike physicians, PAs and NPs do not routinely enter a required residency, which has an organized curriculum, assessment, and formalized supervision and feedback. Their clinical experience is variable depending on the practice setting they initially enter and the teaching skills of the other health professionals around them.
Physicians follow their medical school training with a residency in a specialty of medicine for a minimum of three years and as much as six or more years. During that time they progress from a state of limited capability to increasing competence. Li et al11 have shown that milestone scores for pediatric residents increase annually and that almost 80% of 550 graduating third-year pediatric residents received a milestone rating of ≥ 3 (on a 5-point scale) in all 21 subcompetencies. Medical school graduation, like PA and NP graduation, is a starting point on the progression toward clinical competence that occurs during residency, and the increasing milestone scores during residency demonstrate that progression.
My experience in supervising newly graduated PAs, NPs, and medical students is that none are ready to practice independently. That is why an entrustment framework that incorporates clinical experience with patients and allows clinical supervisors to make judgments about the level of supervision needed—based on the severity of the illness and the individual resident’s experience—provides a useful way to assess the progress of residents.12 Li et al showed that even third-year residents may not achieve competence at the highest levels before graduation. I suspect that PAs and NPs follow a similar progression of gradually increasing knowledge and skills as they work under the supervision of physicians. They just do it directly after graduation, while physicians do it during residency and in a more formal way. The suggestion that any trainee—NP, PA, or physician—is ready for independent practice upon graduation without being supervised by either an experienced physician in practice or in a residency is not supported by the literature. Supervision by a practicing physician is built into the PA- and physician-education models but not necessarily into the NP model. However, Dewan and Norcini suggest that NPs and PAs are competent for independent practice upon graduation at a level similar to that of resident graduates in their analysis, which was based on licensing requirements. I know of no evidence, including the use of licensing requirements, that supports such an assertion, but that does not invalidate the questions they have raised.
Power and Interprofessional Collaboration
Part of the difficulty in comparing PAs and NPs with physicians is the historical difficulty of having unbiased conversations about the questions of independent practice quality. Historically, PA and NP training grew out of concerns about unmet primary health care needs of many underserved populations and the recognition of possible alternatives to physicians, such as returning military medics who had cared for injured soldiers in the field as extensions of military physicians. Initially, PA and NP training was conceived of as having PAs and NPs as part of a team with physician supervision and ongoing education. However, the relationship between physicians, PAs, and NPs soon included struggles over power and independence. Haddara and Lingard,13 in a discourse analysis of publications from 1960 through 2011 about interprofessional collaboration, identified two themes: evidence of improving patient care through interprofessional collaboration and concerns about power relations between the health professions. Paradis and Whitehead14 have also identified power issues as a current and ongoing problem in interprofessional education and practice. Discussions about the meaning of studies of health professions education must include a recognition of the historical challenges of interprofessional collaboration related to power and how power dynamics can interfere with the analysis of evidence and development of health policy. This will be particularly important as new economic and political factors enter discussions about the future workforce needs of the country.
Implications for Future Health Professions Education
With all of the above in mind, I have three suggestions.
Find opportunities to improve clinical education through collaboration
First, there are many important reasons to review current medical education curricular content and duration, including the potential to learn from the experience of more than 50 years of PA and NP educational programs. Such a review should be focused on how medical education can better meet the goals of the health system and of our students and on the potential of competencies to help achieve educational priorities. As part of such a review, we need to recognize that while NP and PA training is shorter than physician training, some of that difference is due to a lack of required residency education for PAs and NPs, which was not as important when NP and PA training began as it is today. Current health care requires additional training beyond initial formal training and increasingly requires subspecialty education. As health professions education increasingly adopts a competency framework, I propose that some form of residency education beyond initial training, or a more formal competency-based apprenticeship, become a part of NP and PA training, which could increase training duration. Changes in NP and PA training will make more important the need for collaboration between our health professions as residents from different traditions of education learn together.
Redesign preclinical education to foster desired outcomes, including teamwork skills, with the ultimate goals of medical education in mind
Second, analysis of PA and NP training programs could help us to identify what early content and courses are most useful in preparation for clinical practice. We should attempt to look carefully at what the three training approaches can learn from each other about premedical and preclinical education and be open to change. Current premedical curricula prepare students for the high-stakes MCAT but may not address the competencies we desire for our graduates at the end of residency training, which include professionalism, communications, systems-based care, and knowledge and skills related to solving patient problems with teams.
The history of the development of PA training programs demonstrates how the emphasis on using the experience and skills of returning military medics, who were accustomed to working as members of a team with physicians, helped to forge trust and collaboration with physicians in the early PA programs.15 Even though there are issues of power relations, teamwork is more important than ever in the current health system. If at the end of training we want our residency graduates to understand how to work as a team, we may want to emphasize teamwork in our selection criteria for health professions education and to develop courses along the health professions educational continuum that build toward that outcome, starting in the preprofessional years. We can redesign our preprofessional and professional education with that end in mind and provide a continuum of education based on our desired outcomes, which may lead to shortening the duration of training as our curricula build on each other.
Embrace change but strive to base reform on best evidence and collaboration
Finally, if there is soon a physician workforce shortage, as is currently projected, and if costs of health care continue to rise due to an aging population with increased health needs, there will likely be market forces that will support disruptive innovations such as increased roles for the growing cadre of PAs and NPs to fill the unmet needs created by the physician workforce deficits. Development of a PA and NP workforce whose members have the education to work effectively as members of a health professions team will benefit not only the PAs and NPs but also the physicians who will collaborate with PAs and NPs and those who will be cared for by them.
Discussions about how to integrate NP and PA training with physician training must not become caught up in the historical discourses about power that have created resistance to previous efforts at collaboration. Reform of our educational programs will require cooperation between various stakeholders such as accreditors, licensing boards, and educators, but, ultimately, market and political forces may dictate change. I hope our community can embrace the process of change but work hard to see that reform is based on best evidence and include broad stakeholder involvement to achieve safe, high-quality care for the public.
David P. Sklar, MD
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