Here's a Better Solution to the MD vs. NPP Debate

In an op-ed from earlier this year, Dr. Graham Walker argued that too many NPPs (non-physician practitioners such as physician assistants and nurse practitioners) are given responsibilities beyond their training. I agree wholeheartedly with the concerns he raised. But I believe the debate over NPPs speaks to a broader, more fundamental issue in healthcare: competence.

It’s true that NPPs fresh out of school don’t have the depth of training that physicians do. But an NPP with 20 years of rigorous clinical care might have more competence than a brand-new resident physician. That doesn’t mean an NPP can do a physician’s job — but it does mean that experience and competence should be given more weight in our credentialing system. Our current approach fails to recognize or adapt to this reality.

Our professional requirements, for both physicians and NPPs, are rigid relics of an era when healthcare looked vastly different. This rigidity hinders our ability to harness and reward competence wherever it exists, to the detriment of patients, providers, and the healthcare system as a whole.

Credentialism is the false idol of healthcare

An outstanding NP or PA with 20 years of largely independent clinical practice in family practice has vast knowledge, exceptional procedural skills, and high patient satisfaction. If they wanted to become a board-certified family physician, they’d have to start medical school from the beginning and complete a three-year residency. That’s absurd.

A competence-based system could shorten that pathway to one or two years of combined education and training, focusing on gaps in knowledge and skills (probably inpatient, ER, and ICU) rather than rehashing what the provider has already mastered. Not only would this save hundreds of thousands of dollars in educational costs, but it would also allow clinicians to contribute sooner as fully certified physicians. The same could be said of an experienced NPP in most specialties.

Competence-based models for workforce growth, lowering medical debt, and combating burnout

The benefits of a competence-based system go beyond individual career paths. For starters, this type of system would help address the looming physician shortage without sacrificing quality. By reducing the time and cost required to achieve certain certifications, we could attract more people to the profession and allow seasoned healthcare workers to advance more efficiently. This would have downstream effects on the economics of healthcare: Many physicians would spend less time in training and accumulate less debt. As a result, they’d be able to achieve financial stability on lower salaries.

Another significant advantage is flexibility. Imagine a scenario where a mid-career emergency medicine physician wants to transition to neurology, or even just try it out for a few years. Traditionally, they’d need to complete a three- to four-year neurology residency. But what if that path isn’t feasible for the emergency physician, because of family obligations or financial constraints?

In our current system, the emergency physician would probably be stuck. But a competence-based system might offer an alternative option for switching specialties. For example, the physician could perhaps first complete a focused year-long education and training program to become an NPP in neurology. Then, with some combination of NPP neurology experience, testing, and additional residency-like training, they could become a board-certified neurologist. This path lets the emergency physician:

• gain experience in neurology while maintaining a steady income
• transition to board-certified neurology over time without having to repeat basic medical training they don’t need
• change careers again if their interest in neurology doesn’t live up to their expectations

Overall, alternative pathways like this one would help seasoned clinicians change specialties without starting over entirely, making career shifts an option for more clinicians and lowering barriers to workforce adaptability. There could even be implications for increasing workforce efficiency for certain subspecialties.

While the data is limited, more flexible career trajectories within medicine could also result in less burnout and lower rates of attrition to other industries. After all, some data shows that mid-career physicians have the highest rate of burn-out.

The metric that matters

A shift from credentials to competence would also promote improved patient outcomes and public safety. This means developing a system that rigorously and objectively measures the actual experience, skills, and abilities of healthcare workers. Competence isn’t primarily about where you trained, and it places less importance on how many years you’ve practiced. Instead, it prioritizes what you can do, reliably and consistently, under real-world conditions.

How might this look in practice?

A competence-based system would incorporate more varied tools. While we’d still use tests to determine our knowledge base, certified logs with types of patients cared for and procedures performed would also be required. So would real-time, scenario-based assessments designed to mimic the challenges of clinical practice. For emergency physicians, this could mean simulations of high-pressure situations like managing a crashing trauma patient or rapidly diagnosing an elusive cause of sepsis. For other specialties, assessments could be tailored to their specific job demands, from complex surgical techniques to nuanced diagnostic reasoning.

But real-time assessments and simulations wouldn’t be the only measures. Others would be incorporated too, including knowledge-based exams, letters of recommendation, case logs documenting patient care and procedures performed, and specialty-specific requirements backed by evidence. Residency training would also become more personalized and adaptable. For example, a seasoned PA in the emergency department who’s looking to become a physician might need only a focused, one-year residency that emphasizes intensive care and leadership, after demonstrating knowledge proficiency through exams. This approach ensures rigorous training while eliminating redundant education, making the path to physician certification more efficient and tailored.

Addressing critics of a competence-based system

To those who question whether competence-based models work, we need only to look at the evolution of healthcare professions over time. Respiratory therapists, certified nurse midwives, physician assistants, and other advanced practitioners have all seen their roles expand based on competence rather than tradition. Yet our embrace of competence has been timid, hampered by entrenched systems that prioritize legacy structures over patient-centered progress.

History supplies another example: When medical specialization was first introduced in the late 1800s as scientific knowledge and surgical techniques advanced (along with other factors), it was met with significant resistance. Later on, in the early 20th century, structured residencies became the norm to ensure competence in specific fields. Today, residencies are accepted as the gold standard for physician training — yet they, too, could evolve to become more flexible and competence-driven.

Outside of medicine, the tech industry provides a compelling parallel. Employers care less about degrees and more about demonstrated skills — whether through coding projects, certifications, or problem-solving assessments. There are certainly differences between the two industries that might be relevant to credentialing. Software engineers, for instance, don’t fight disease and death on a daily basis. But these differences don’t mean the industries can’t learn from each other.

A call to action

Reforming our credentialing and training systems will not be easy. It will require buy-in from policymakers, professional organizations, and educational institutions. But most of all, it will require a cultural shift within healthcare — a willingness to let go of the status symbols we’ve clung to for too long and embrace a model that prioritizes outcomes over egos.

As physicians, we understand the value of competence better than anyone. It is time for us to demand a system that reflects that understanding. Let’s lead the way in building a healthcare workforce that is not just qualified on paper but truly prepared to meet the challenges of modern medicine. Because, at the end of the day, our patients don’t care about our titles. They care about whether we can help them. And so should we.