In 2021, Nicole Barbosa, a media relations specialist in Austin, Texas, moved back to the US after more than a decade abroad. Getting medical care established stateside was a priority for her — but when she tried to make an appointment with a primary care doctor at a local health care system she trusted, she was surprised to find herself at the end of a months-long wait list.
Meanwhile, a physician assistant in the same practice was available within days. At first, Barbosa wasn’t sure how physician assistants were different from doctors. Still, she booked the appointment, and when she saw the provider the following week, she was delighted by the unhurried pace. “She answered all my questions without me feeling like she was rushed or needed to quickly move on to her next appointment or task,” she says.
The care was so good that when her provider left the practice, Barbosa signed up to see another physician assistant. During visits, “I just always feel valued and seen,” she says.
Americans seeking health care are increasingly likely to get it from people who aren’t doctors. The reasons are partly related to supply and demand: A nationwide physician shortage has been mounting for decades. And while the pipeline for producing more doctors hasn’t widened — something that would literally require an act of Congress — schools that train nurse practitioners (NPs) and physician assistants (PAs) have proliferated. As a result, nurse practitioner numbers have tripled since 2010, and there are nearly twice as many physician assistants now as then. In primary care clinics, emergency departments, operating rooms, and medical specialty offices, these medical professionals are now doing a lot of the same tasks doctors do.
These changes may be imperceptible to many people, but if you’ve noticed them and you’re wondering how to think about it, you’re not alone. Maybe you, like Barbosa, are trying to choose a primary care provider and want to know more about the professions. Or maybe your health system has assigned you to see a nurse practitioner or a physician assistant and you’re wondering what that means.
Whatever your situation, it’s worth understanding the strengths each profession brings to the work of patient care, and what makes for a good fit between providers and people; just keep in mind that within each role, there’s a lot of variation in practice style based on personality differences and variability between practices.
Questions for yourself
What do I want from a visit with my provider?
The differences in the training that doctors, NPs, and PAs get before entering practice has a lot to do with how they approach patient care — and those differences can have a big impact on what happens during your visits.
Doctors and physician assistants are trained in the medical model, explains Joanne Spetz, a health economist at the University of California San Francisco who studies the nursing workforce. “A lot of medicine is around understanding body systems, understanding diseases — basically understanding how body systems get screwed up,” she says. People trained in these models focus largely on how to diagnose and treat illness and injury, and also to some degree on how to prevent illness.
The nursing model is more holistic, says Spetz. The nursing paradigm, which guides nurse practitioners’ training, considers not only the physical needs and ailments of the patient, but also other factors like the patient’s personal goals and situation. For example, she says, if a patient has pain, a nurse would seek to identify the physical causes but also understand how the pain is impacting the patient’s social and emotional function — whether they can eat, whether the pain makes them withdraw from family, whether other stressors make it difficult to manage the pain.
Another important distinction is in the cost to employ members of each profession: While physician assistants and nurse practitioners earn around $125,000 annually, physicians earn about $230,000. Because doctors’ time costs their employers more than other providers’ time, many health care systems allot less of it to the patients they see.
Together, these factors mean that NPs and PAs may be scheduled for longer visits than doctors are with the patients they see in primary care settings, which means more time to answer questions and provide patient education.
It’s not clear if these visits are actually longer, says Tamara Ritsema, a physician assistant and professor at George Washington University’s PA program. Due to a quirk in documenting PA and NP visits within the US health care system, it’s hard to gather data on differences in visit length between provider types. It’s possible patients just feel like some visits are longer because of variations in providers’ styles.
“We hear this all the time from people: ‘My PA or my NP spends more time with me,’” says Ritsema. “We do not know if that is true or if they are leveraging better communication strategies, such as sitting down while they talk to the patient, or using more patient-friendly language.”
Because they’re trained in the nursing model, NPs in particular are primed to do patient-centered coaching. This includes helping patients near the end of life prioritize quality of life as they see it, says Spetz — to “elicit what your personal bucket list is before we start recommending all of these treatments.” Nurse practitioners’ holistic approach is a specific asset in addiction medicine, according to some of Spetz’s research. Other studies have shown patients are more likely to get health education and counseling services, including advice on quitting smoking, from NPs and PAs than physicians.
How medically complicated am I?
The road to becoming a doctor is substantially longer than the paths to other medical professions. Before they can practice independently, doctors spend four years in medical school and three to seven years in an on-the-job training program called residency; meanwhile, typical physician assistant and nurse practitioner training programs take two to three years to complete. (All of these programs require undergraduate degrees for admission; NP programs require an undergraduate nursing degree.)
During medical school, doctors take a range of courses on the invisible mechanisms that keep the body working — and that underpin disease — in coursework that includes biochemistry, pharmacology, genetics, microbiology, and other hard sciences. Once they start taking care of patients, a lot of their education is aimed at connecting the dots between those complex mechanisms and the diseases they’re seeing in clinics and on hospital wards. By the time the least experienced doctor enters the workforce, they’ve had at least 10,000 hours of clinical experience.
Physician assistants take an abbreviated version of this educational path, and like medical school graduates, finish their programs prepared to work in any medical setting. Also like medical school graduates, they need more on-the-job training before they’re considered competent in their field, says Ritsema. But while that training is formalized for doctors as a residency program with clear requirements, it’s less formally prescribed for PAs, she says. A PA fresh out of school has a minimum of 2,000 clinical experience hours under their belts. Because many PA programs require prior health care work as a prerequisite, many of these professionals hit the workforce with substantially more clinical experience.
Nurse practitioner trainees also take a variety of didactic courses that overlap to some degree with PAs’ classes. However, they choose which population they want to work with while they’re still in school — whether that’s all comers or newborns, children, women, older adults, people with mental illness — and their clinical training prepares them to work with that population in particular. By the time they graduate from NP school, these professionals have completed at least 1,000 clinical experience hours — a figure that may be higher depending on what state they’re in.
These differences in training mean that if you “have super-complex medical conditions and all your drugs are interacting with each other,” a doctor caring for you has an advantage over other providers, says Spetz. After all that practice caring for complicated patients, physicians are used to puzzling out how dysfunction at the microscopic level can cause disease, and choosing diagnostic strategies to untangle a web of confusing symptoms or laboratory results.
Not everyone’s a medical mystery. Plenty of research studies have shown that for less complex patients — people without multiple chronic conditions who aren’t taking tons of medications — the care NPs and PAs provide is just as safe and cost-effective as the care doctors provide.
NPs and PAs who work as part of collaborative and supportive teams are most likely to have good outcomes, says Candice Chen, a pediatric doctor and researcher who studies primary care workforce issues at George Washington University. An environment that enables them — and doctors — to ask for and receive help when they need it is a key ingredient of quality care.
There’s currently a lot of behind-the-scenes tussling among professional societies and state medical boards over how much care NPs and PAs should be able to provide without a physician collaborator. But these professions are not interchangeable with doctors, says Candice Chen. Although NP and PA care is in many cases equivalent or even better than doctors’ care, a recent study suggests NPs caring for more complex patients at Veterans Health Administration emergency departments had worse outcomes than doctors.
On teams where providers can easily ask for help, patients who need providers with certain skills are more likely to get seen by those providers. “The question becomes, how do you put those teams together so that everybody knows where their limits are, and knows where to get help?” says Candice Chen. More experienced professionals are also more likely to deliver high-quality care, even to complex patients, says Spetz. Research backs her up: In the VA study, “performance differences between the two professions become smaller as provider experience increases,” says Yiqun Chen, a University of Illinois Chicago health economist who coauthored the report.
Regardless of who’s providing your care, it’s not just education and experience that determine whether that care is good, says Ritsema. The best NPs, PAs, and doctors all know when they’re in over their heads, and need to call for help. “The people that make me feel secure are the ones that put my care above their ego,” she says.
That means being open to asking questions of the other members of their teams — and to being asked questions by you.
Questions to ask a provider to see if they’re a good fit
What’s your training and background?
In general, Americans can be fairly confident that their provider has been trained to a high standard, says Ritsema. But because PAs’ and NPs’ on-the-job training is less formalized than that of physicians, it may be harder to determine the level of experience these providers have just by looking them up on a website.
It’s okay to ask your provider what their training and experience is, says Ritsema: “To be honest, if your provider, whoever that is — doctor, PA, NP — is unwilling to answer that in an uncomplicated way, that might raise a red flag to me,” she says.
Where would you go if you needed help with my care?
Good providers know what they don’t know, are unafraid to ask for help when they need it, and have resources they can draw on in those situations — regardless of their degree, says Candice Chen. But as a patient, it can be hard to determine whether your provider and the practice setting they’re in meet that description.
If the practice has a website, you can look in advance to see what the mix of providers looks like, as their colleagues will probably be their first stop for support. You can also ask a new provider what happens if something serious comes up, or if you need a referral.
It’s harder to determine whether a practice truly has a collegial and supportive environment where providers are encouraged to seek help. Here’s where it’s useful to talk to any people in your social network who work in health care, says Ritsema. “Health professionals recognize those characteristics of humility in other health professionals, and they know who the cowboys are” — that is, which ones to avoid, she says.
Watching how providers interact when you’re at the practice can also be incredibly informative, says Spetz. “The medical assistants are like your canaries in the coal mine,” she says: If the providers are brusque and condescending toward these and other support staff in the office, it can be a sign of a dysfunctional hierarchy — not the kind of functional team that encourages requesting support and insight from others.
Are you the right person to answer this question?
Medicine is not a field that any single health care provider can know everything about: Increasing specialization and rapid changes in technology means even the best providers will have substantial knowledge gaps about conditions they don’t see on a regular basis.
So while it’s reasonable to expect a certain level of knowledge from your health care provider, expecting them to answer questions that aren’t in their purview can set you up for disappointment, and lead you to misjudge a good provider as incompetent. If you ask a primary care provider about the intricacies of a vascular surgery, “the PA or NP in primary care — and, frankly, the doc in primary care — is not going to have the answer to that,” says Ritsema.
It’s okay if you don’t know who to ask about what subject — and it’s okay to ask who to ask! Just be aware that hearing “I don’t know” from a provider doesn’t always indicate a knowledge deficiency that would be fixed if you switched providers. Sometimes, they’re not the right person to answer that question in the first place.
You can change providers
If your provider isn’t able to get answers to your questions within their specialty, or their repeated efforts to diagnose or treat a medical condition don’t seem to be going anywhere, it’s okay to ask for a second opinion from a different provider, either in the same practice or in a different one. “One of the things we probably need to do is to empower people to not let politeness be the enemy of advocating for themselves,” says Candice Chen.
Ritsema agrees. “If you don’t have confidence in your medical provider for whatever reason,” she says, “schedule an appointment with somebody else who you think will make you feel more confident.”
