With Alberta allowing nurse practitioners to open their own clinics starting in 2024, the province has plunged itself headfirst into a debate that has been argued in medical communities across countries such as Canada, the U.S. and the U.K.
In physician and medical student circles, there is a term for it. We call it “scope creep.” This is the phrase physicians use when professions such as nurse practitioners (NPs), begin increasing their scope of practice and take on a larger number of responsibilities.
A major reason physicians are worried about scope creep is because of the difference in education. Physicians often have to finish a bachelor’s before doing three to four years of medical school, and another two to eight years of residency. NPs on the other hand often do a bachelor’s before doing either a two to three-year master’s or three to five years’ doctor of nursing, with most completing a master of science in nursing.
In addition to the differences in length of education, there’s also a difference in the focus. In medical school and residency, students are taught to view the human condition from all aspects, from the biological to the social. Medical education for physicians also has a heavy focus on diagnostic reasoning. This ensures doctors can make the right decisions in clinical settings.
NPs learn many of the same things. They often have a holistic education as well, with a good amount of time spent on management and prevention, but comparatively less time on diagnostic reasoning than doctors.
Although there is much overlap, the differences between the two in terms of education are what gives each profession its strengths.
Primary care physicians have stronger diagnostic reasoning capabilities, with less need for followups and specialist consultations on specific concerns, and fewer orders of diagnostic imaging when compared to primary care NPs. For patients needing support with new problems, family doctors are often the way to go.
Meanwhile, primary care NPs are excellent at disease management and prevention. Patients under NP care have lower emergency and hospital in-patient use compared to patients under the care of physicians only. In studies done in the U.S., NPs also cost less compared to physicians in primary care. This could be due to many different reasons, such as different payment models, incentive structures and practise styles.
By working together, primary care physicians and NPs complement each other, and this is reflected in the data. Patients with chronic diseases in primary care practices with both professions are more likely to complete recommended care management plans, and they also often have lower systolic blood pressure and cholesterol levels. NP-physician teams have better adherence to best practices, and there’s a decreased risk of preventable hospitalizations.
Thus, the priority should be to strengthen medical practices and improve care integration. Many practices are struggling with overhead and administration, and making sure these practices are supported and able to build strong teams with different care providers is by far the best step forward.
Yet, NP-led practices can play an important role. As long as they stay within their scope and focus on their strengths in prevention and care management, they could make health-care systems more robust.
If the Alberta government is truly worried about physician shortages, there’s an easy solution — people who graduated from non-Canadian medical schools, known as International Medical Graduates. Although hundreds apply, there are only 40 spots for IMGs. They actually have to get through two interview cycles and have multiple barriers to apply, such as completing an English examination even if their mother tongue is English.
Alberta’s move toward NP clinics could be helpful, but it shouldn’t be the focus of its strategy. Supporting medical practices, creating care teams and greatly increasing IMG residency spots should be the priority, and this is what will allow the creation of a robust primary care network.
Kerry Yang (he/him) is a first-year medical student at the University of Calgary.