Primary Care for the 21st Century: Education & Training

Physicians and nurse practitioners complete their education and training with different types and levels of knowledge, skills, and abilities that are not equivalent but are complementary. Primary care physicians receive far more education, clinical training, and continuing medical education to ensure they are well-equipped to diagnose and manage patient care. Many family physician practices have embraced nurse practitioners and physician assistants as physician extenders in their offices.

Most nurse practitioners—also known as APRNs and advanced registered nurse practitioners—typically receive their education through a one-and-a-half to three-year degree program that confers a Master of Science in Nursing (MSN), depending on the prior education of the student. Approximately 77 percent of nurse practitioners hold an MSN degree. Many of the remainder used alternate pathways available in their states to achieve nurse practitioner licensure without an advanced degree.³² Typically, for entry into master’s level nursing programs, students are required to at least have passed the National Council Licensure Examination for Registered Nurses and to have satisfactorily completed the Graduate Record Examination.³³ Eleven states and the District of Columbia do not require that nurse practitioners hold a master’s degree.

The training and certification nurse practitioners receive is appropriate for dealing with patients who need basic preventive care or treatment of straightforward acute illnesses and previously diagnosed, uncomplicated chronic conditions. But patients with complex problems, multiple diagnoses, or difficult management challenges require the expertise of primary care physicians working with a team of health care professionals.

Family physicians typically receive their education through a four-year graduate degree program at one of the 130 accredited medical schools in the United States and an additional three-year program of clinical residency. Students must pass the Medical College Admissions Test for entrance into medical school. Medical students spend nearly 9,000 hours in lectures, clinical study, laboratories, and direct patient care. The overall training process begins with medical school and continues through residency. During their time in medical school, students take two “step” examinations, called the United States Medical Licensing Examination, and must take core clerkships, or periods of clinical instruction. Passing both examinations and the clerkships grants students the Medical Doctor (MD) degree, which entitles them to start full clinical training in a residency program.³⁴ Physicians can also earn a doctor of osteopathic medicine (DO) degree through colleges of osteopathic medicine.³⁵ The residency program, as defined by the American Medical Association, “is three to seven years or more of professional training under the supervision of senior physician educators. The length of residency training varies depending on the medical specialty chosen: family practice [medicine], internal medicine, and pediatrics, for example, require three years of training.”

When it comes to costs associated with replacing physicians with nurse practitioners or nonphysicians in health care practices, a recent study titled The Impact of Nonphysician Clinicians. Do They Improve the Quality and Cost-Effectiveness of Health Care Services? found that “the evidence that role revision increases health care efficiency or lowers costs is weak and contradictory. Health care planners need to be alert to the possibility that, while nonphysicians cost less to employ than physicians, savings on salaries may be offset by lower productivity and less efficient use of non-staff resources.”³⁷ Utilizing all health professionals in a team approach will work for the patient and the practice. It is important to recognize that “involving nurse practitioners in a practice team and exerting their full capabilities is a promising way to expand primary care workforce.”³⁸

Next: The Future of Care