Replacing Doctors With Advanced Nurses...How Far Will It Go?


Primary Care Physicians in America are fast being replaced by nurses with advanced training. This article raises the questions of how far the trend will go...and how this will influence the future of physicians in primary practice.

As a physician and businessman, I wish the future looked better for Primare Care Physicians (PCPs). But history suggests things will get still worse.

The history of business in the United States teaches us disruptive innovation always starts from below. The “untouchable” market leader is threatened by a less expensive version of its own product. The smug incumbent ignores the unprofitable downscale threat. Then the new competitor decides to go upscale, is forced to innovate as a result, and successfully obliterates the once invulnerable Goliath.

Thus in our country Macy’s yielded to Target, Best Buy to Amazon, Blockbuster to Netflix … and soon PCPs to Nurse Practitioners (NPs).

NPs have exactly followed the disruptive innovation paradigm. The specialty was started in the early 60s to handle primary care in the rural and low-income areas physicians found unprofitable. Organized medicine turned up its nose at these “physician extenders” but otherwise ignored a non-existent financial threat.

However, once they captured the market abandoned by physicians, NPs decided to move upscale. And they predictably began innovating. They created curriculums, credentialing, and licensure programs. They backed studies showing most NP care was (in the NEJM’s words) “equivalent or superior to that provided by physicians.” Politically their profession lobbied in our US Congress to increase both their scope of practice and reimbursement.

NPs were rushing toward a gaping hole in the marketplace. They saw that 50 to 80 percent of a PCP’s functions didn’t require seven or more years of U.S training. They groomed themselves to handle those functions for less.

Their timing couldn’t have been better. Medicine had since become a business. Insurers now felt absolved of any implied financial obligation for a physician’s training or sacrifice. Business was interested only in cutting the costs of business. In addition, a surge in high-deductible insurance plans had created more cost-conscious consumers.

The result is NPs are flooding the medical marketplace. And recently a tide has become a tsunami.  We read regular headlines like, “Clinic Visits To Drug and Department Stores [run by NPs] Double in the Last Five Years,” and “Veterans Administration Now Allows Advanced Practice Nurses to Function as Primary Care Providers.”

NPs love their newfound prominence and responsibilities. They can’t wait to largely replace a PCP’s role. In our country they perceive it as karma for past disrespect.

I know this personally. I recently criticized the NP’s slogan, “Brains of a doctor; heart of a nurse.” I wrote it suggested doctors lacked compassion.

However, defensive NPs instead thought I was offended at the suggestion they had “the brains of a doctor.” The result was a pent-up barrage of angry NPs recounting their abilities, crowing about replacing family doctors, and voicing an almost visceral disgust at condescending doctors like me.

So where will all this leave displaced PCPs? Once again disruptive innovation provides a guide. Disruption typically doesn’t kill corporate incumbents; they lose the mass market but keep the luxury segment of their industry. For instance, European brands BMW, Daimler, Jaguar, Land Rover and Porsche all survive as upscale sellers in our country despite the fact they now make up only 6 percent of all automobile sales.

The PCP’s version of luxury cars is "concierge" care which bypasses insurers and caters to the affluent. The problem is, as with cars, any luxury market is inherently self-limited. Concierge medicine can’t save an entire profession.

I often lament the unfairness of all this to a MD/MBA friend who transitioned into consulting. He, though, is merciless. “I’m tired of the whining of practicing doctors,” he says. “We all face disruption in our careers every day. What made them think they’d be any different?”

The tough love advice for physicians is to honestly ask themselves the same questions everyone else faces in their careers: “What makes me a unique source of value? And, “Can someone else do what I do for less?”

In my view PCP’s are unique; their seven years of training allows them to share knowledge and treat the very sick patients no else can. The problem is their current day roles don’t unlock these skills.

Perhaps that’s the silver lining. As disrupted PCPs lose the mass market of patient care, the hope is their new future role will focus on what makes them truly unique.

Article last time updated on 18.07.2017.

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I'm a nurse and I totally agree. Each profession has its niche and "doctoring" is not the training a nurse receives. We learn compassion and how to look at the whole picture. It's an important role to be conjoined with one who has a more narrow focus and much deeper training. I have been to NP's. Their training is limited when it comes to complications or the patient that doesn't fit the norm. It can become difficult to admit to a hospital. I find the public is confused being led to believe an NP is a MD. If a doctor wants to use an NP in his office, that is one thing, but seeing them as the sole practitioner practicing under an absentee license is something else. Nursing should stay nursing and if a nurse wants to be a doctor, let him/her go to medical school.
#2 at 18.07.2017 from Marsha Carter (Nurse / Hospital nurse)
Great article, Michael - very 'on point' and topical. (One small error: in paragraph 5, I 'think' you meant "...most NP care..." instead of "...most PCP care...")
#1 at 18.07.2017 from Dr. Niro Sivathasan (Physician)
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