MDs vs. NPs in Primary Care . . . The Conflict Continues

Feature |
June 5, 2013

MDs vs. NPs in Primary Care . . . The Conflict Continues

  1. Anne A. Moore, DNP, APRN, FAANPAU1964,
  2. Diane E. Judge, APN/CNPAU119 and
  3. Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BCAU1480

Societal needs should supersede the disparate self-perceptions of physicians and nurse practitioners.

  1. Anne A. Moore, DNP, APRN, FAANPAU1964,
  2. Diane E. Judge, APN/CNPAU119 and
  3. Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BCAU1480

Advanced-practice nurses (including nurse practitioners [NPs], clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives) have become commonplace within the U.S. healthcare delivery system since their inception in the 1960s. Now, the clinical workforce is estimated to include >180,000 NPs, approximately 35% of whom provide primary care. But how do NPs and physicians view their respective roles? Researchers analyzed responses to a survey (conducted from November 2011 to April 2012) of 505 primary care physicians and 467 NPs to evaluate their attitudes about healthcare delivery, compensation, and collaboration. Questions included topics such as scope of practice, hours worked, compensation, and attitudes toward NPs in a primary care role.

Three quarters of NPs believed that they were practicing to the full extent of their training and education. Fully 82% of NPs (vs. 17% of physicians) agreed with the statement that NPs should have the authority to lead medical homes. Two thirds (64%) of NPs (vs. 4% of physicians) believed that they should receive equal pay for the same services. Two thirds (66%) of physicians believed that they provided higher quality of care than NPs; 75% of NPs disagreed with this statement.

These results, taken together with an accompanying Health Policy Report, provide insight into the evolution of the NP's role in the face of economic and political influences. NP certification programs were initially developed — and continue — to fill a healthcare gap for a largely uninsured, underserved population. These “certificate-prepared” NPs work in large clinics serving both urban and rural populations. With the projected shortage of primary care physicians (an estimated 33,100 by 2015), NPs again occupy an ideal position to address a healthcare deficit.

Today's NP is a formally educated clinician: In addition to being a registered nurse, the NP graduate must now have — at minimum — a master's degree in nursing and should hold national certification in a practice domain. Doctor of Nursing Practice (DNP) programs are burgeoning. Many NPs are trained as primary care providers in family, adult, or pediatric care. The Institute of Medicine (IOM), in a 2010 report, supported the mission to eliminate barriers to advanced-practice nursing, stating that nurses should be free to “practice to the full extent of their education and training.”

With the assistance of the Federal Trade Commission (FTC), the IOM sought to promote advanced-practice nursing as a safe alternative to physician-delivered care. The American Medical Association (AMA) disapproved of this effort, accusing the FTC of “aggressive advocacy.” The Robert Wood Johnson Foundation drafted a document entitled “Common Ground: An Agreement between Nurse and Physician Leaders on Interprofessional Collaboration for the Future of Patient Care,” coauthored with representative leaders of national physician and nursing organizations. However, the AMA, upon learning of the document's existence, garnered support from the American Academy of Family Physicians, and American Osteopathic Association, and the American Academy of Pediatrics to withdraw support from the dialogue, essentially halting the document's progression.


  1. Anne A. Moore, DNP, APRN, FAANPAU1964,
  2. Diane E. Judge, APN/CNPAU119 and
  3. Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BCAU1480

An editorialist notes that the U.S. has fewer primary care physicians per capita (30 per 100,000) than any other industrialized nation, and that an adult in this country typically waits ≥6 days to see a primary care doctor. Given the multiple stakeholders, financial incentives and disincentives, and egocentrism, one wonders, “What happened to the patient?”

Many studies have shown that NPs achieve outcomes at least equivalent (and sometimes superior) to those of MDs for management of the most common chronic conditions (diabetes, hypertension, and asthma); in some studies, patients were more satisfied with NP-provided care than with MD-provided care (Cochrane Database Syst Rev 2005;2:CD001271). NPs are legally authorized to diagnose, treat, and prescribe without mandated relationships with MDs in at least 18 states and the District of Columbia (N Engl J Med 2011; 364:193). In a good example of collaboration, the American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives have issued a joint statement to foster practice relations.

Perhaps the real question is how best to train the broad spectrum of primary care providers our population needs, given the range and complexity of diseases and comorbidities patients may have. It's in patients' best interests for physicians and nurses to abandon the issue of “who does it better?” and instead move forward with “how can we get everyone the best healthcare possible?”

  • Disclosures for Anne A. Moore, DNP, APRN, FAANP at time of publication Consultant / Advisory board Watson

  • Disclosures for Diane E. Judge, APN/CNP at time of publication Nothing to disclose

  • Disclosures for Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC at time of publication Editorial boards Journal of Perinatal and Neonatal Nursing


Reader Comments (9)

Diana Crowe, MN, ARNP, BC Other Healthcare Professional, Internal Medicine, Community Health Outreach

The comments on this issue are valid. I have work at an indigent primary care clinic for over 20 years & have had the privilege of working with interns, residents, MDs, DOs, NPs ,PAs, & student NPs. We are all different in training, experience & abilities. But I deeply believe we are all needed. Income can be based on the type, level or complexity of work done as well as outcome. Physicians are extremely important in their roles as most highly & extensively educated & therefore responsible in leading high quality & compassionate health care. But they cannot succeed solo. Please let's find common ground in caring for those who need care - really good care for all!


Perhaps they should also take the certification boards in Family practice to demonstrate equal knowledge and recertify every 6-7 years

Carla Evans MSN, FNP-BC Other Healthcare Professional, Cardiology, Private practice

I'd be happy to sit for the exam.

Cooper,RN,MS, NP-C Other Healthcare Professional, Family Medicine/General Practice

I would gladly sit for this exam if it would change the way the AMA perceived our profession. if it helped our reimbursement parity. However, you and I know it won't.

Robin J Bohanan

I am a family nurse practitioner and have been privileged to work in an indigent health care center with physician partners. Partnering together for quality care for patients has been our goal. There is mutual respect of the experience and knowledge that each provider brings to patient care. I agree with the author - putting the patient at that center of this debate brings perspective on the real issue: providing quality healthcare for everyone.

Competing interests: None declared

margaret V diamond

I have been treated a few times by NP's and was very satisfied. I believe there is less ego involved.

Competing interests: None declared

Anonymous Doctor

The role of NPs in our healthcare system is always a hot topic. However, there is a reason that increasing independence of NPs makes doctors somewhat apprehensive. This article compares education and training between physicians and NPs: UPDATED.pdf

Competing interests: None declared

Steven D White, MD

Sirs: Two problems with NPs. At our office we train medical students, NP students and PA students. The medical and PA students have a much more thorough science background. As medicine progresses, without a significant science background, how are the NPs expected to stay truly proficient? Secondly, the original concept was to take trained, experienced RNs and make them providers. Now, the new RN can go into a NP program without experience. I have worked closely with some of these previously non-experienced NPs and found their knowledge base to be seriously lacking. Our office is presently looking for a "old-style" NP and having trouble finding one.

Competing interests: None declared

K.Collins MSN/FNP Other Healthcare Professional, Family Medicine/General Practice, Collaborative Family Practice office

You are 100% correct. I am a practicing FNP
of 33 years and a previous FNP state university clinical educator who quit teaching because many students came straight into the program having little experience as a practicing RN. Most DNP programs
are fully online courses with an emphasis on health
Policy yet provide a clinical title of Doctor of Nurse Practice upon completion.
All of the students I taught kept their Full time jobs so their FNP clinical course work was always secondary to their 12 hour shift demands. The Clinical training FNP preceptorships used to REQUIRE an MD, but due to the inability to find MD's willing to train FNP students it is now acceptable by the university for FNP students to be clinically trained by other FNP's or PA's Their education is fragmented and weak & by no means could these students pass the physician Family Practice certification Exam, which in my opinion, all independent Nurse Practitioners should be required to do as well as recertify as often as MD's.
Autonomy was NEVER the intention of the role creation for NP's nor PA's, rather collaboration in managing the complexity of the patients care. If a young FNP student wants autonomy and to be called a Doctor then he/she should complete medical school. Our Patients do not understand the alphabet soup of initials behind a NP's title nor should they have to. The Affordable Care Act should NOT become a platform to push Autonomy of NP's & PA's however It has because it sees NP's & PA's as a more Affordable option hence it will NOT pay an independent FNP medical home the same as a physician led Mefical home, these lower NP reimbursement rates are already established in
Working as a TEAM is what we should be

Your Comment

(will not be published)

Filtered HTML

  • Allowed HTML tags: <a> <em> <strong> <cite> <blockquote> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Do you have any conflict of interest to disclose?
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
Enter the characters shown in the image.

Vertical Tabs

* Required

Reader comments are intended to encourage lively discussion of clinical topics with your peers in the medical community. We ask that you keep your remarks to a reasonable length, and we reserve the right to withhold publication of remarks that do not meet this standard.

PRIVACY: We will not use your email address, submitted for a comment, for any other purpose nor sell, rent, or share your e-mail address with any third parties. Please see our Privacy Policy.