Where's the data showing at unsupervised NPs/PAs are safe and effective?

There are often statements that "five decades" of research shows the safety and efficacy of nurse practitioners and physician assistants. However, they rarely point out one important fact: That every single study on care provided by nurse practitioners and physician assistants was performed under the supervision of physicians, with access to physicians for questions or concerns, or following physician-created protocols.

While studies DO show that NPs and PAs can provide high-quality care when working together with a supervising physician, there are no quality studies showing the safety and efficacy of non-physicians when practicing without physician supervision, following physician-created protocols, or without physician availability to answer questions and provide needed assistance.

The best meta-analysis of nurse practitioner care, a Cochrane review, found only 18 studies of adequate quality to analyze. Of these, only 3 were performed in the United States, and every single study in the Cochrane review involved nurses working under physician supervision or following physician-created protocols. Yes, even supposedly independent NPs in Mary Mundinger's famous 2000 study were practicing under a collaborating physician, as required by New York statute at the time. In addition, NPs in the study were assigned a physician mentor and received an additional 9 months of training with medical residents.

VIDEO: Reviewing 50 years of research from the Cochrane database

VIDEO:  Rebutting Mary Mundinger's claim that her study involved 'independent' NPs

Studies showing concerns about care provided by non-physicians

Regarding the emphasis for physicians to “choose wisely,” research raises concerns about overuse of health care resources by nonphysician practitioners. Studies show that nonphysician practitioners:


  • order more labs than physicians

  • order more radiographic tests than physicians,

  • prescribe more medications including opioids and antipsychotics

  • prescribe more unnecessary antibiotics than physicians,

  • place lower quality referrals than physicians

  • perform significantly more biopsies than physicians to diagnose malignant neoplasms in patients < 65 years.

Flynn, BC. The effectiveness of nurse clinicians' service delivery. AJPH. 1974;64:604-611.

Hughes DR, Jiang M, Duszak R. A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits. JAMA Intern Med. 2015;175:101–107. doi:10.1001/jamainternmed.2014.6349

Muench, U , Perloff J, Thomas C, et al. Prescribing practices by nurse practitioners and primary care physicians: a descriptive analysis of Medicare beneficiaries. Journal of Nursing Regulation. 2017;8:21-30. doi:https://doi.org/10.1016/S2155-8256(17)30071-6

Sanchez GV, Hersh AL, Shapiro DJ, Cawley JF, Hicks LA. Outpatient Antibiotic Prescribing Among United States Nurse Practitioners and Physician Assistants. Open Forum Infect Dis. 2016 Aug 10;3(3):ofw168. doi: 10.1093/ofid/ofw168. PMID: 27704022; PMCID: PMC5047413.

Lohr RH, West CP, Beliveau M, et al. Comparison of the quality of patient referrals from physicians, physician assistants, and nurse practitioners. Mayo Clin Proc. 2013;88:1266‐1271. doi:10.1016/j.mayocp.2013.08.013

Nault A, Zhang C, Kim KM, et al. (2015). Biopsy use in skin cancer diagnosis: comparing dermatology physicians and advanced practice professionals. JAMA dermatology, 151, 899-901. doi:10.1001/jamadermatol.2015.0173.