The Disenfranchised Physician—The Invasion of the Patient Snatchers

By Bob Sweeney

We’ve been exploring and commenting on the forces that seem to be relentlessly disengaging practicing physicians from the career satisfaction they anticipated when they chose clinical careers.  Here is a ubiquitous force—the arrival of physician extenders into nearly every corner of physician practice.

Here are a few summary figures about the nurse practitioner field:

  • In 2016-2017, 26,000 NEW NPs completed their degrees and 97.8% of those had graduate diplomas.
  • About 85% of NPs accept Medicare and 83% accept Medicaid.
  • 50% hold hospital privileges.
  • 96% write prescriptions and NPs have prescriptive privileges, including controlled substances, in every state plus DC.
  • Their average age is 49, and on average they have 11 years of practice experience.  
  • The majority (61%) NPs see three or more patients per hour and their malpractice rates are very low—only 1.9% have even been named as primary defendant in a lawsuit.
  • Over 70% of NPS are in family practice. Other well penetrated specialties include gerontology, psychiatry and emergency medicine, with a growing role in anesthesiology.  

Let’s take a quick snapshot of the other extender profession, physician assistants:

  • In 2017, there were 123, 000 practicing PAs, up from four (!!) in 1967.
  • PAs are able to practice in every state and territory of the US, plus DC.
  • Nearly all receive a master’s degree upon graduation.  
  • 2/3 are women, 87.3% are Caucasian; their average age is 32, with an average of 7 years of practice experience.
  • The distribution of PAs is as follows:  family and general medicine—20.6%, emergency medicine or urgent care—15%, surgery and subspecialties—18.5%, internal medicine–9.2%, hospital medicine–4.4%, peds–2%, all else–30.3%
  • Most PAs work in urban areas.

There are many reasons, both economic and clinical, for the growth of these professions.   Most physicians recognize that there are many functions in medicine that can be well executed by less highly trained and less costly clinical personnel—such as NPs and PAs.  However, there are profound side effects from the growth of these professions that affect the physician’s sense of self-worth. For example, any primary care physician feels committed to continuity of care with respect to his/her patients.  When the physician loses control of part of the diagnosis and treatment environment, there can be a real sense of disenfranchisement. Even physicians in specialties aimed at more immediate and short-term interactions with patients—such as emergency medicine– can feel diminished if their control of the engagement is subject to invasion or infringement.    A secondary side effect is the threat to physician incomes from the loss of revenue from non-acute but well-insured patient encounters.

The impact of the extender in medicine requires that medical schools, residencies and specialty societies devote attention and resources to preparing physicians for a radically changed environment.    The United States has benefited for over a century from its distinctively high quality medical care delivery. How do training and membership institutions, as well as society at large, address the potential threat to those standards from physician disenfranchisement, whatever the cause?


Robert E. “Bob” Sweeney, DA, MS

Principal & Managing Director