Why are we teaching NPs and PAs to practice direct care?  

One thing that stands out about direct primary care conferences is the number of smiling faces and happy doctors. That is why I was so surprised to encounter some downright angry physicians at this year’s DPC Summit.

“Why are nurse practitioners and physician assistants attending this conference?” several asked. “Why are we teaching our competition?”

There has been a palpable change in physicians’ attitudes toward nonphysician practitioners in direct care—and there is good reason for it.

The number of nurse practitioners is growing rapidly, especially relative to the number of physicians. There are even states where NPs now outnumber physicians. Further, NPs can now practice without physician supervision in more than half the country, and a growing number of states have eliminated or weakened supervision requirements for PAs. The DPC Frontier practice mapper shows a large number direct care practices owned and operated by nonphysicians—sometimes charging patients as much as, or more than, nearby physician practices.

Some leaders in direct care have welcomed this growth, arguing that a rising tide lifts all boats. The more clinicians who leave insurance-based medicine, they contend, the more patients will understand and embrace direct care.

I disagree.

Direct primary care was built by physicians seeking to restore the physician-patient relationship. If DPC organizations train NPs and PAs to establish unsupervised practices, we are not simply welcoming more people into the movement. We are helping to create practices that compete directly with physicians while offering patients a fundamentally different level of training.

The question is not whether NPs and PAs can provide valuable care. It is whether substantially different levels of education and supervised clinical training should be treated as interchangeable.

Physicians entering primary care complete medical school followed by residency, accumulating 12-15,000 hours of structured, supervised clinical education. Meanwhile, NP educational pathways vary considerably. Sixty percent of family nurse practitioner students complete most or all of their coursework online, and 22% attend direct-entry programs for students without a nursing degree or any nursing experience. Certification as an NP requires just 500 supervised clinical hours before graduation, and students often struggle to find qualified preceptors.

That difference matters when someone plans to hang a shingle and assume responsibility for patients whose seemingly routine complaints may conceal complex or dangerous conditions—especially without physician backup.

It is also impossible to ignore physicians’ economic frustration. Doctors sacrifice years of earning potential and often take on hundreds of thousands of dollars in educational debt to complete medical school and residency. They then watch someone open a competing “DPC” practice after a two-year master’s program with a fraction of their clinical training.

No wonder doctors are angry.

But physicians must accept some responsibility for creating this problem. Too many have agreed to “supervise” NPs and PAs without providing meaningful oversight. Signing charts after the fact—or making oneself theoretically available by telephone—is not supervision. When physicians lend their licenses to practices they do not actively oversee, they legitimize the argument that physician involvement is unnecessary.

The alternative is not to exclude NPs and PAs from patient care. It is to work together within a genuine physician-led team. Consider the example of Hattiesburg Clinic in Mississippi. The clinic examined data from approximately 20,000 Medicare accountable care organization patients whose primary care was attributed either to physicians or to NPs and PAs managing their own patient panels. Patients attributed to the nonphysician practitioners cost the system more while delivering lower quality measures. 

The authors concluded that allowing NPs and PAs to manage independent patient panels—even with a physician technically designated as a supervisor—had failed to provide patients with equivalent quality. This led to a restructuring of care around truly physician-led teams.

A meaningful team model begins with the physician evaluating the patient, establishing the diagnosis, and developing the treatment plan. NPs and PAs can perform routine follow-up, reinforce education, monitor stable conditions, and help improve access. But the physician should reevaluate the patient when symptoms change, a new problem develops, or the treatment plan is not working—and should personally see the patient at least annually.

That is physician supervision. It recognizes the contributions of NPs and PAs without pretending their training is equivalent to that of physicians. Most importantly, it ensures that every patient has access to a physician.

This distinction should also guide conference attendance. I do not believe physician organizations should teach NPs and PAs how to establish unsupervised practices. However, NPs and PAs who work within—and are committed to—a physician-led DPC practice could appropriately benefit from education about direct care operations, patient communication, and team-based care.

The mechanics are not impossible. Conferences could create a registration category for NPs and PAs employed by physician-led practices and require the registrant to identify the supervising physician or practice. The registration language could state plainly that the organization supports physician-led care and that its educational programming is not intended to facilitate unsupervised nonphysician practice.

I have watched attitudes toward this issue change. In the past, I was reprimanded on direct care forums and warned to ‘be respectful’ simply for pointing out differences in education and training. At this year’s Summit, physicians were approaching me to demand that those differences be recognized.

In fact, when several attendees asked me, as a board member of the DPC Alliance, why NPs and PAs were being allowed to attend, I was a bit taken aback. “Don’t you know who I am?” I asked. “I literally wrote the book warning about unsupervised nonphysician practice.”

But their questions are valid.

Physicians don’t get shortcuts—we worked hard for the privilege of independent practice. And most importantly, all patients deserve physician-led care. 

If direct primary care is truly about restoring the physician-patient relationship, we should not be afraid to say so.