Book Review on Patients At Risk: The Rise of Nurse Practitioners and Physician Assistants in Healthcare by Niran Al-Agba and Rebekah Bernard

  • Agarwal, Rita, MD, FAAP, FASA
| Dec 10, 2020

Agarwal-RitaI want to start by saying that I work regularly with outstanding nurse practitioners (NPs). We work collaboratively, and we trust them implicitly. We round on patients together, discuss cases, ask questions, and critically evaluate complex problems. On the days that our NPs are off or unavailable, we really feel their absence. On a busy inpatient pain service, their contributions to care are immeasurable and genuinely improve patient care and outcomes. But in my practice, ultimately the physicians are responsible.

This book focuses on the rise of independent practice and issues around “scope ofPatients at Risk practice.” It is a book that should be read by physicians, patients, lawmakers, and hospital administrators to get context and perspective regarding the issues of independent practice. The authors try hard to be objective, pulling data and examining primary sources whenever possible. 

Alexus Ochoa Dockins was a healthy and vibrant 19-year-old student who had a tragic encounter in an emergency department that was only staffed by one nurse practitioner (NP). The nurse practitioner was certified in family practice, and did  not have the additional acute care training , as recommended by the nursing boards.

The authors of this book start with a summary of Alexus’ history and weave the harrowing details of her treatment throughout this book. The book is aimed at both patients and physicians and traces the history and evolution of independent practice by advanced practice nurses and physician assistants. Interestingly, both models were started in Denver, Colorado, by pediatrician Dr. Henry Silver. In 1965, Dr. Silver created the first NP training program to try and address a predicted physician shortage. The program at the University of Colorado was created to focus on well child exams, immunizations, health education, and preventive health strategies. The first physician assistant training program was started in 1969 with the stated goals of limiting PA practice to hospitals, clinics, and doctors’ offices under physician supervision. Programs rapidly grew and spread throughout the country, with over 400 NP programs in the US today.

The authors describe the differences in the various types of programs, from the traditional models that require prior nursing experience, to Direct Entry, accelerated, and online programs. Some of these programs advertise 100% acceptance rates, and some are fully online; many have hefty tuitions but can allow even people without any experience or education in nursing to become nurse practitioners in 2-3 years. To qualify for the nurse practitioner certifying exam, students need at least 500 clinical hours. Many of the current programs do not provide these clinical hours, instead mandating that students find their own preceptors, who can be either NPs or willing physicians. The experience can be highly variable, and often quite limited. For example, the NP who cared for Alexus spent her clinical hours at a county hospital providing prenatal care to healthy pregnant women. That was the entirety of her clinical experience prior to being hired to work as the only provider on duty in the Emergency Department when Alexus was rushed to the hospital. Unlike the hiring of physicians, the employment of NPs may have minimal requirements for type, variety, range, structure, stringency, or depth of relevant experience.

The different types of nurse practitioners are supposed to inform practice parameters. Alexus’ NP was a Family Nurse Practitioner who lacked the additional training required for acute care. More and more NPs are pursuing “doctorate” degrees that are typically non-clinical, designed to create leaders and administrators in healthcare.

Physician Assistants have more standardized training affiliated with medical schools and a requirement for 1500 clinical hours. They typically get a master’s-level degree and are licensed by state medical boards. However, just as with NPs, PAs are now increasingly pursuing doctorate-type programs.

There are excellent training programs for both NPs and PAs, but the lack of regulation and consistency in training, particularly for NPs, is disconcerting. While NPs must pass their certifying exam, the remainder of their training can be minimal and haphazard.

The authors spend a great deal of time exploring the reasons why NP and PA independent practice has increased so dramatically in medicine. They do a critical analysis of the available literature (scant as it is), debunking the myth that non-physician providers save money and improve access to care. They review the studies that are frequently quoted by nursing leadership to support these claims, and find the studies to have been misquoted and misinterpreted. Unfortunately, many politicians and hospital administrators still believe that NPs and PAs with lesser training, lower salary, and increased willingness to follow protocols and guidelines will save costs. Study after study shows that non-physician providers order significantly more unnecessary tests and obtain many more consults.

The authors also spend time describing the consequences of using non-physicians who have neither the right education nor the experience in positions that can impact peoples’ lives. They have collected hundreds of stories, and have scoured the literature for evidence both in favor of NP/PA independent practice and against. They have interviews with patients, NP students, practicing NPs and PAs, residents, nurses, and physicians. The authors make a compelling case against independent practice for non-physicians. They make a plea to nursing organizations and boards to better regulate the quality of education provided to the dedicated people seeking additional qualifications. 

This is a deep dive into a troubling trend in US healthcare and a must-read for anyone with an interest in healthcare policy and patient advocacy. I 100% support NP and PA practice in the right circumstances, and I believe that it truly improves patient care in many situations, but I found the stories and information in this book quite distressing.

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