Abstract
Introduction: In response to the national primary care physician shortage, states are increasingly turning to legislation that expands the scope of practice for advanced practice providers (APPs), such as nurse practitioners (NPs) and physician assistants (PAs) to practice independently without physician oversight. While the effects of these laws will be multi-faceted, little is known regarding how these laws will affect states’ future abilities to attract and recruit physicians to practice within their state. This study explores medical students' (MSs) attitudes toward APP independence legislation, focusing on their perceptions of equivalency of care, the potential impact of these laws on their future practice choices, and their views on professional collaboration.
Methods: An anonymous survey was administered to MSs across all 4 years of schooling at a Midwestern medical school.
Results: This survey had a 21% (109/518) response rate. 86% of MSs expressed disagreement that APP care is comparable to physician care. In addition, 59% of respondents reported they would be less likely to practice in states allowing APP independence, a figure rising to 71% among those interested in pursuing primary care.
Discussion: The majority of MSs do not view APP-driven care as equivalent to care delivered by a physician. Further, states that enact APP independence laws may struggle to attract future physicians as the majority of MSs in this study consider the legislative landscape of the state they practice in.
Conclusion: States considering APP independence laws should consider the results of these studies when attempting to address their physician shortage.
- Advanced Practice Nursing
- Health Policy
- Medical Education
- Medical Legislation
- Medically Underserved Area
- Nurse Practitioners
- Physician Assistants
- Scope of Practice
- Surveys and Questionnaires
- Workforce
Introduction
The landscape of primary care delivery in the United States is experiencing substantial transformations, primarily driven by an increasing physician shortage and rising demand for health care services.1 In response to these issues, many states have turned to legislation that permits advanced practice providers (APPs), such as nurse practitioners (NPs) and physician assistants (PAs), the ability to practice independently without physician oversight.2,3 In 27 states and the District of Columbia, NPs have been granted full practice authority.4 Moreover, 5 states have recently implemented laws that allow for PA independent practice to provide primary care services (PCS). These legislative measures are designed with the intent to enhance access to care, particularly in underserved and rural areas where physician shortages are most pronounced.5
The expansion of APP independence has sparked considerable debate within the medical community.6–8 Proponents point to studies that demonstrate APPs provide high-quality, cost-effective care through measurements such as hospital length of stay, smoking cessation counseling, and health education services thereby helping to address issues associated with the primary care physician shortage.9,10 Critics, however, express concerns about patient safety and the potential emergence of a two-tiered health care system particularly impacting vulnerable populations as there are significant training discrepancies between the professions.11–13 To become a practicing physician in the United States, an individual must complete 4 years of medical school followed by at least 1 year of an Accreditation Council for Graduate Medical Education (ACGME)-certified residency. PAs, alternatively, only require 2 years of graduate level schooling, and NP training varies widely, with some programs offering online didactic curricula with limited clinical exposure.14,15 For example, the average family medicine physician exits residency with around 20,000 hours of clinical care compared with only 2,000 hours for a recently graduated PA.12
While much of the discourse surrounding APP independence focuses on workforce distribution and provider training, an equally important consideration is the role of APPs in improving racial and ethnic representation within the health care workforce. Compared with medical school admissions, which have long struggled with diversity, the NP and PA professions have successfully attracted and retained individuals from historically underrepresented groups at higher rates than medical schools.16 This is particularly relevant given that provider-patient racial concordance has been linked to improved patient satisfaction, communication, and health outcomes. By broadening access not only to care but also to providers who reflect the diverse communities they serve, APPs may be addressing disparities in ways that extend beyond simply increasing provider numbers.17,18
The relationship between physicians and APPs has been described as both collaborative and, at times, contentious.19,20 While many practicing physicians and APPs report positive working relationships and complementary views on patient care, disagreements exist regarding APPs’ scope of practice and their professional roles. These tensions are evident in the positions of various professional organizations as many medical student and physician associations such as the American Medical Association and American College of Physicians oppose expanded APP independence while organizations representing APPs such as the American Academy of Physician Associates advocate for it.8,21,22
Despite the ongoing debate among professional organizations and policy makers, there is limited research on how these legislative changes are perceived by resident and attending physicians as well as medical students (MSs). As future health care providers, MSs’ attitudes toward APP independence may significantly influence the future practice patterns of physicians. As these students progress through their training, they are not only developing their professional identities but also forming opinions about their future roles within a dynamic health care landscape. Understanding their perspectives on APP independence is crucial, as it may impact their career choices, including decisions about specialization and practice location.
This study aims to explore MSs' attitudes toward state legislation that allow for APP independence, their perceptions of the equivalency of care rendered by APPs, and the potential influence of these laws on future practice decisions. By examining these perspectives, insights can be gained into how the next generation of physicians will respond to these laws and expanded scope of practice for APPs. As health care continues to evolve, comprehending these opinions is essential for informing policy decisions, shaping medical education, and fostering effective interprofessional relationships.
Methods
During the fall semester of 2024, first-, second-, third-, and fourth- year MSs at a medium-sized private allopathic medical school located in the Midwestern United States participated in an online survey administered via a Qualtrics platform. The survey was distributed through the school e-mail listserv, and detailed instructions were provided at the beginning of the survey, assuring students of the anonymity and voluntary nature of the study. An institutional review board application (IRB-FY2025-43) submitted to the Oakland University IRB was granted exemption status as anonymous survey research.
The survey consisted of 13 close-ended questions primarily consisting of 4-point Likert scales and a fifth answer option denoting they had no opinion on the matter. For clarity, APPs were defined to participants as either “physician assistants” or “nurse practitioners” at the beginning of the survey. The questions were organized into 5 broad categories: general understanding/familiarity of APP independence laws (1 question), opinion on the equivalency of care provided by APPs (2 questions), attitudes regarding APP independence laws (4 questions), the influence of these laws on decisions regarding state practice locations (3 questions), and opinions on the effects these laws will have on professional collaboration and job security (2 questions). In addition, participants were asked to indicate their year of training to ensure responses reflected a balanced representation across classes. Descriptive statistics were then utilized to analyze and summarize the survey responses.
Results
The overall response rate from the 4 classes surveyed was 21% (109/518). The response rate between classes was similar (Table 1). Self-reported familiarity and awareness of APP state independence legislation varied as 40% reported being either somewhat or very unfamiliar with these laws (Table 2).
Demographics
Stance on Various APP Statements
Opinions also varied on whether APP independence legislation was a responsible way to increase access to primary care for vulnerable populations as 36% agreed whereas half of students disagreed to some extent (Table 2). When asked if the level of care provided by APPs was equivalent to that of a physician, MSs overwhelmingly felt it was not at similar levels for both provider types (86% for PA-care, 87% for NP-care). MSs also widely rejected the notion that APPs should be able to provide PCS without the oversight of a physician at similar levels for both (84% for PAs, 82% for NPs). 72% of MSs felt that APP independence legislation would compromise the quality of PCS delivered to patients.
APP independence legislation also seems to be an influential factor for MSs when determining which state to practice in. Over half of MSs agreed that the presence of APP independence legislation in a state will be a significant factor they consider when deciding on their practice location (51%). 59% of all MSs surveyed agreed that they would be less likely to practice in a state that allows for APP independence. Of the students that were interested in practicing primary care, the percent of students agreeing that they would be less likely to practice in states with this type of legislation rose to 71%.
When asked if APP independence will negatively affect interprofessional collaboration between physicians and APPs, 72% agreed with this statement. A further 80% believed APP independence legislation represents a threat to the job security of physicians. These opinions remained consistent throughout each class surveyed indicating the year of MS schooling was not associated with a difference in opinion when compared with other years.
Discussion
One of the most striking findings is the pronounced skepticism among MSs regarding the equivalency of care provided by APPs when compared with that of a physician. The vast majority of respondents disagreed that APP care is equivalent to physician care, and a similar proportion rejected the idea of APPs providing PCS without physician oversight (Table 2). This perception aligns with concerns raised by some physician groups about patient safety and quality of care.21,22 However, it is important to note that these views may not fully reflect the existing evidence on APP care equivalency, which has shown that in many cases, APPs can provide care comparable to physicians for specific conditions.9,23,24
The strong opposition to APP independence among MSs is further reflected in their attitudes toward legislation allowing such practice. A substantial majority believe that APP independence legislation would compromise the quality of PCS (Table 2). This perception could potentially influence future interprofessional relationships and collaboration in health care settings. Further, a majority of respondents agreed that APP independence would negatively affect professional collaboration between physicians and APPs. This finding suggests that efforts to promote effective teamwork and mutual respect between different health care professionals may face challenges in the future. It also indicates a potential need for interprofessional training initiatives for health care workers to mitigate any adverse effects on collaboration between these groups.
Perhaps the most concerning finding is the potential impact of these attitudes on future physician distribution and access to care. Over half of the surveyed MSs (59%) indicated they would be less inclined to practice in states with APP independence legislation, with this percentage rising to 71% among those interested in primary care. This trend could paradoxically exacerbate the very issue that APP independence legislation aims to address – the shortage of primary care providers in underserved areas. If a significant number of future physicians avoid states with APP independence laws, it could lead to an even more pronounced physician shortage in these areas, potentially worsening disparities in health care access. Given that states with higher percentages of rural populations are turning to APP independence laws to address their provider shortages, the findings of this study suggest the potential emergence of a two-tiered health care system in which rural populations rely most heavily on APPs for PCS whereas states that block APP independence legislation may have a higher percentage of PCS delivered by physicians.2,3
The perceived threat to job security is another significant finding, with 80% of respondents believing that APP independence legislation poses a risk to physician job security (Table 2). This concern persists despite projections of continued physician shortages, particularly in primary care.1 This perception may be fueled in part by recent headlines highlighting the firing and replacement of physicians by APPs at large health care institutions.25,26 This perception could potentially influence career choices and contribute to a reluctance to enter primary care specialties, further exacerbating physician primary care workforce shortages.
These findings should be carefully considered by state policy makers contemplating APP independence legislation. While these laws aim to enhance access to care, particularly in underserved areas, they may have unintended consequences if they dissuade future physicians from practicing in these states. However, given that 40% of respondents in this study expressed some degree of unfamiliarity with APP laws, further research is needed to better understand MSs’ opinions once they have become more familiarized with this topic (Table 2). Moving forward, policy makers must develop strategies to address the concerns of MSs and physicians while simultaneously working to expand access to care.
Moreover, the variable degree of familiarity with APP independence laws among MSs (40% reporting being somewhat or very unfamiliar) suggest a need for medical educators to incorporate formal instruction on these policies into their curricula. These actions would be in line with recent updates made by the ACGME to family medicine residency training programs to ensure learning environments consists of interprofessional teams that include APPs.27 This should improve learners' understanding and familiarity of NPs and PAs scope of practice and that of other health professionals also seeking increased scope and independence through legislation.
It is important to acknowledge the limitations of this study. The survey was conducted at a single, medium-sized private medical school in the Midwest, which may limit the generalizability of the findings to other regions or types of medical schools. Further the institution in which this study was conducted is in a state that has relatively restrictive APP independence practice that requires a collaborative or practice agreement with a licensed physician.28,29 This legislative landscape where the survey was conducted could have influenced MS opinions on APP-led care. Similar future studies should be conducted in states that allow varying degrees of APP independence to fully understand how state laws may impact MS opinion. In addition, the response rate of 21%, while not uncommon for survey research, raises the possibility that the views of nonrespondents might differ from those who participated. Future research should be conducted at additional institutions to capture a more diverse range of MS perspectives, including those at osteopathic medical schools as their graduates choose to practice primary care at higher rates in underserved communities.30
Conclusion
This study highlights significant concerns among MSs regarding APP independence legislation and its potential impacts on professional collaboration and MSs’ future practice decisions. These findings suggest the need for further consideration of APP laws among policy makers as it is possible these laws may unintentionally deter future physicians from these states and fail to achieve their desired effect to increase providers in underserved communities. These findings are also relevant to medical educators as well as the ACGME who advocate for curricula that prepare medical students and residents to work cohesively with APPs as it will be crucial to cultivate positive interprofessional relationships between medical professions so that all providers can collaborate effectively to meet the health care needs of the population.
Notes
This article was externally peer reviewed.
Funding: None.
Conflict of interest: None.
- Received for publication January 19, 2025.
- Revision received March 3, 2025.
- Revision received March 10, 2025.
- Accepted for publication March 24, 2025.
