M.J. Dewan is interim president and SUNY Distinguished Service Professor, Upstate Medical University, Syracuse, New York. J.J. Norcini is president and CEO, Foundation for the Advancement of International Medical Education and Research, Philadelphia, Pennsylvania.
Acad Med. 2019 Jul;94(7):950-954. doi: 10.1097/ACM.0000000000002764.
Patients can be treated by a physician, a nurse practitioner (NP), or a physician assistant (PA) despite marked differences in the education and training for these three professions. This natural experiment allows examination of a critical question: What is the minimum education and training required to practice primary care? In other words, how tall is the shortest giant? State licensing requirements, not educational bodies, legislate minimum training. The current minimum is 6 years, which includes 27.5 weeks of supervised clinical experience (SCE), for NPs. In comparison, PAs train for 6 years with 45 weeks of SCE, and physicians for at least 8 years with 110 weeks of SCE. Initial, flawed studies show equivalent patient outcomes among the professions. If rigorous follow-up studies confirm equivalence, the content and length of medical education for primary care physicians should be reconsidered. Unmatched medical school graduates, with 7 years of training and 65 weeks of SCE, more than the required minimum for NPs, deserve to practice independently. So do PAs. If equivalence is not confirmed, the minimum requirements for NPs and/or PAs should be raised, including considering a required residency (currently optional). Alternatively, the scope of practice for the three professions could be defined to reflect differences in training. There is an urgent need to set aside preconceived notions and turf battles, conduct rigorous independent studies, and generate meaningful data on practice patterns and patient outcomes. This should inform optimal training, scope of practice, and workforce development for each invaluable primary care clinical practitioner.
尽管医生、护士从业者 (NP) 和医师助理 (PA) 之间在教育和培训方面存在显著差异，但患者可以由这三种专业人员中的任何一种进行治疗。这种自然实验允许我们检验一个关键问题：从事初级保健工作所需的最低教育和培训是什么？换句话说，最矮的巨人有多高？州许可要求，而不是教育机构，规定了最低培训要求。目前的最低要求是 6 年，其中包括 27.5 周的监督临床经验 (SCE)，这是针对 NPs 的。相比之下，PA 培训时间为 6 年，有 45 周的 SCE，而医生至少培训 8 年，有 110 周的 SCE。最初的有缺陷的研究表明，这三个专业的患者结果相当。如果严格的后续研究证实了等效性，那么应该重新考虑初级保健医生的医学教育内容和长度。未经匹配的医学院毕业生，经过 7 年的培训和 65 周的 SCE，超过了 NPs 的最低要求，应该能够独立行医。PA 也是如此。如果没有确认等效性，那么应该提高 NPs 和/或 PA 的最低要求，包括考虑强制性住院医师培训（目前是可选的）。或者，可以根据培训差异来定义这三种专业的执业范围。迫切需要抛开先入为主的观念和地盘之争，进行严格的独立研究，并生成关于实践模式和患者结果的有意义的数据。这应该为每个宝贵的初级保健临床医生提供最佳培训、执业范围和劳动力发展方面的信息。
