What Doctors Really Think About the Rise of NPs and PAs

As a practicing emergency physician, I’ve spent countless hours rigorously training. Endless night shifts, high-pressure decisions, and challenging cases during residency were all essential to building the skills necessary to deliver the highest level of care to my patients. As grueling as medical training can be, there remains no substitute for the thousands of hours of hands-on experience that prepare physicians for the enormous responsibility of safeguarding patient lives.

This level of preparation reflects the profound trust our patients place in us and the high standards we hold for healthcare in the United States. It is for this reason that many physicians are deeply concerned about a growing trend: non-physician practitioners (NPPs), including nurse practitioners (NPs) and physician assistants (PAs), are increasingly being placed in roles beyond their training.

Let me be clear upfront: this is not an attack on NPs and PAs. These professionals play important roles in medicine—particularly in expanding access to care, especially in underserved communities, and as valued members of clinical teams. (There’s plenty of work to go around in healthcare!) However, patient safety must come first, and that requires ensuring that every practitioner operates within their scope of training to avoid compromising care quality and risking poor outcomes

For context, over the past few decades, while the physician workforce has remained flat – due in part to Congressional capping of residency spots despite population growth – there’s been a significant increase in the number of NPs and PAs entering the workforce. According to the American Association of Nurse Practitioners, there are over 325,000 licensed NPs in the U.S. as of 2021, a sharp rise from just 120,000 in 2007. Similarly, the number of certified PAs has grown by 76% in just the past decade.

The Training Gap and Its Impact on Patient Care

The difference in training between physicians and NPPs is stark. Physicians undergo a minimum of 11 years of post-secondary education and training, including residency and sometimes fellowship, amounting to 15,000–20,000 hours of clinical experience. In contrast:

• NPs typically complete 5–7 years of education and 500–1,000 hours of clinical training.
• PAs undergo 6–8 years of education with approximately 2,000 hours of clinical training.

The importance of these hours cannot be overstated. Clinical competence is built through sheer volume of experience—seeing enough cases to recognize atypical disease presentations, anticipate complications, and navigate high-risk, complex medical decisions.

Moreover, specialization matters. NPPs are often trained to work across multiple fields, providing broad but shallow expertise. An NP, for instance, could move from primary care to urology to orthopedics without the same depth of specialized training that would be required of a physician to practice in these areas. (And while many — but not all — are provided some degree of on-the-job training at the beginning, it’s nowhere sufficient and is often provided by the physician who is already seeing a full load of patients.) If a physician wanted to change specialties, they would be required to complete 3–8 years of residency again before being allowed to practice independently. (While certifications are available for NPPs, they are often not required.)

In high-acuity settings like the emergency department, hospital wards, or intensive care units, the difference in training becomes particularly consequential. Complex cases require not just knowledge but critical decision-making skills honed through years of hands-on practice. Inappropriate placement of NPPs into these roles—often due to employer cost-cutting—can compromise patient safety, increase complications, and leave physicians to manage the fallout.

NPPs Lack Specialized Training But Are Thrown Into Speciality Contexts

Whereas physicians undergo a minimum of 11 years of post-secondary education and training – with typically between 15,000-20,000 hours of clinical training, NPs typically have 5-7 years of education and 500-1,000 hours of clinical training while PAs receive approximately 2,000 hours, or 6-8 years of education and clinical training. It is extremely difficult — maybe impossible — to substitute for hours of clinical experience. One needs to see enough cases to understand various presentations of disease, complications, outcomes, and develop the necessary critical thinking skills.

Team Dynamics and Workforce Tensions

Hospitals face economic pressures, and replacing physicians with NPPs can reduce costs—NPs and PAs typically earn less than half of what physicians do. However, this approach risks short-term financial gain at the expense of long-term safety and care quality. Investigative reporting has highlighted concerning trends where cost-cutting measures result in higher profits but more medical mismanagement.

From a workforce perspective, poorly defined roles create tension. Physicians may feel their expertise is being undervalued, while NPPs may feel overburdened or placed in situations beyond their training. Open communication and well-defined collaborative practice models are essential for maintaining team morale and ensuring safe, high-quality patient care.

The Broader Impact: Physician Jobs and Care Access

The increasing reliance on NPPs raises valid concerns about job security for physicians: 27 states have granted full practice authority to NPs — allowing them to practice independently without physician oversight. The reliance on NPPs threatens to displace physicians in primary care and certain specialties. Even back in 2018, the New England Journal of Medicine reported that the growth rate of NPPs is outpacing that of physicians, potentially leading to a saturated job market for new doctors. This not only affects physicians but could also dilute the quality of care available to patients.

Meanwhile, the physician workforce remains capped due to Congressional limits on residency positions, despite growing demand for medical care. Addressing these systemic issues—not cutting corners on care—will better serve patients and protect healthcare quality.

The Path Forward: Collaboration, Training, and Investment

The solution is not to diminish the role of NPPs but to build a balanced, collaborative system that prioritizes patient safety. Here’s what we need:

• Clear Team Structures: Physicians and NPPs should work together within their respective scopes of practice. Physicians, as the most highly trained medical professionals, must remain central in leading patient care—particularly in complex and high-acuity settings.
• Rigorous NPP Training: NPPs should be supported through additional education and standardized training programs to ensure they are fully prepared for their roles.
• Support for Physicians: Investing in physicians means ensuring they can practice at the top of their license—whether through compensation transparency, addressing workforce burnout, or expanding residency opportunities. At Offcall, we’re working hard to support physicians through initiatives like salary transparency and tools that advocate for the profession

Ultimately, our collective goal must be to deliver high-quality, safe, and effective care to every patient. This requires a healthcare system that values training, expertise, and collaboration, while ensuring that all providers—physicians, NPs, and PAs alike—are placed in roles that match their abilities.

By investing in a balanced system, we can ensure that the dedication and skill of all healthcare providers serve patients’ best interests while upholding the trust and safety that are the cornerstones of modern medicine.