Should Nurse Practitioners Complete Medical Residencies?

About three months ago, something awful happened. The oncology nurse practitioner (NP) whom I trained for the past two years in my subspecialty decided to seek employment elsewhere in order to have a more flexible work schedule.

My team and I lamented we had a going-away dinner to say thank you for her work. And for the next three months, I trudged through my days in a busy oncology clinic, seeing patients as efficiently as I could on my own.

My inbox was getting backlogged with patient calls, my patients were starting to notice that I needed an extra day to call back with results, and my nurse was on the brink of exhaustion from helping to pitch in more than usual with patient communications.

After several months, my practice was able to hire a new NP who had extensive nursing experience in a high-acuity unit, but who had just become certified as a nurse practitioner.

On our first day in clinic, seeing how little he knew about medicine, I realized we had a long way to go to train him to manage oncology patients. But I knew that within the next year under my supervision, he would become more adept, and my patients would come to appreciate and trust him.

A recent editorial from the Boston Globe suggested that removing the barrier of physician supervision of NPs in Massachusetts would afford patients more access to primary care, cut costs and allow NPs who receive “extensive training” to achieve their degree to practice independently. They point to a lack of data to say that outcomes are worse and that one foundation analysis showed a reduction in preventable hospitalizations. NPs, the editors said, offer a cost-effective solution to the shortage of primary care physicians. The editors portrayed physicians who are against NPs practicing independently as greedy, even sexist, and outright wrong.

The argument against NPs practicing without supervision is not a misogynistic or patriarchal position framed as an “us versus them” scenario, as the editorial suggests.

I want to live in harmony with an inter-professional team of nurses, advanced practice clinicians, physical therapists, and social workers, among many other unsung heroes that work behind the scenes to take care of cancer patients. But is it remiss of me as a physician to raise the alarm when I feel patient safety is potentially at risk because NPs do not have to attain the same standards that assure I am fit for independent practice?

Should we not be concerned when NPs or any other clinician wants to practice independently without the same training or certification as physicians?

Would you board a plane flown by an advanced flight attendant who took extra training in flying but did not go through the same rigors as a traditional airline pilot, especially if the reason was that the airline needed to address a pilot shortage, or that it cost more to hire a formally trained pilot?

To show that outcomes of patients managed by NPs are not worse than physicians is speculative, since the acuity, years of experience among NPs and practice settings may vary widely.

Of course, there are strong arguments on both sides why either side is misguided — the physician who is said to be rude and spend less time with patients than the NP, or the NP who knows very little and makes mistakes.

Social media is wrought with these anecdotes that mostly serve to pit members of the health care system against one another when really we should be working as team that is focused on safe and evidence-based patient care.

But shouldn’t all independent practitioners have similar certifications?

Is it offensive to ask my NP to go through residency or at least gain more experience fresh out of NP school before seeing patients on his own without supervision? Even though the rigors of medical school and nursing school are different, I have nothing against NPs practicing independently, provided they undergo the same post-graduate training, board certification, annual continuing medical education, and costly board re-certification as physicians. Then, by all means, help us to fill the primary care void and advance medicine through independent practice.

The author is an anonymous physician.

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