For many patients, seeing a nurse practitioner (NP) has become a routine part of primary care, in which these NPs often perform the same tasks that patients have relied on doctors for.
But NPs in specialty care? That's not routine, at least not yet. Increasingly, though, NPs and physician assistants, also known as physician associates (PAs), are joining cardiology, dermatology, and other specialty practices, broadening their skills and increasing their income.
This development worries some people who track the health workforce, because current trends suggest primary care, which has counted on NPs to backstop physician shortages, soon might not be able to rely on them to the same extent.
"They're succumbing to the same challenges that we have with physicians," said Atul Grover, MD, PhD, executive director of the Research and Action Institute at the Association of American Medical Colleges (AAMC). The rates NPs can command in a specialty practice "are quite a bit higher" than practice salaries in primary care, he said.
When NP programs began to proliferate in the 1970s, "at first it looked great, producing all these nurse practitioners that go to work with primary care physicians," said Yalda Jabbarpour, MD, director of the American Academy of Family Physicians' Robert Graham Center for Policy Studies. "But now only 30% are going into primary care."
Jabbarpour was referring to the 2024 primary care scorecard by the Milbank Memorial Fund, which found that from 2016 to 2021 the proportion of NPs who worked in primary care practices hovered between 32% and 34%, even though their numbers . The proportion of PAs in primary care ranged from 27% to 30%, the study found.
Both NPs and PAs are advanced practice clinicians who, in addition to graduate degrees, must complete distinct education, training, and certification steps. NPs can practice without a doctor's supervision in more than two dozen states, while PAs have similar independence in only a handful of states.
About 88% of NPs are certified in an area of primary care, according to the (AANP). But it is difficult to track exactly how many work in primary care or in specialty practices. Unlike physicians, they're generally not required to be endorsed by a national standard-setting body to practice in specialties like oncology or cardiology, for example. The AANP declined to answer questions about its annual workforce survey or the extent to which primary care NPs are moving toward specialties.
Though data tracking the change is sparse, specialty practices are adding these advanced practice clinicians at almost the same rate as primary care practices, according to frequently cited research .
The clearest evidence of the shift: From 2008 to 2016, there was a 22% increase in the number of specialty practices that employed NPs and PAs, according to that study. The increase in the number of primary care practices that employed these professionals was 24%.
Once more, the by the AAMC predict a dearth of at least 20,200 primary care physicians by 2036. There will also be a shortfall of non-primary care specialists, including a deficiency of at least 10,100 surgical physicians and up to 25,000 physicians in other specialties.
When it comes to the actual work performed, the lines between primary and specialty care are often blurred, said Candice Chen, MD, MPH, associate professor of health policy and management at George Washington University.
"You might be a nurse practitioner working in a gastroenterology clinic or cardiology clinic, but the scope of what you do is starting to overlap with primary care," she said.
NPs' salaries vary widely by location, type of facility, and experience. Still, according to data from healthcare recruiter , formerly known as Merritt Hawkins, the total annual average starting compensation, including signing bonus, for NPs and PAs in specialty practice was $172,544 in the year that ended March 31, slightly higher than the $166,544 for those in primary care.
According to forecasts from the federal , NP jobs will increase faster than jobs in almost any other occupation in the decade leading up to 2032, growing by 123,600 jobs or 45%. (Wind turbine service technician is the only other occupation projected to grow as fast.) The growth rate for PAs is also much faster than average, at 27%. There are more than twice as many NPs as PAs, however: 323,900 versus 148,000, in 2022.
To Grover, of the AAMC, numbers like this signal that there will probably be enough NPs, PAs, and physicians to meet primary care needs. At the same time, "expect more NPs and PAs to also flow out into other specialties," he said.
When Pamela Ograbisz, DNP, FNP-BC, started working as a registered nurse 27 years ago, she worked in a cardiothoracic intensive care unit. After she became a family NP a few years later, she found a job with a similar specialty practice, which trained her to take on a bigger role, first running their outpatient clinic, then working on the floor, and later in the intensive care unit.
If NPs want to specialize, often "the doctors mentor them just like they would with a physician residency," said Ograbisz, now vice president of clinical operations at temporary placement recruiter .
If PAs want to specialize, they also can do so through mentoring, or they can receive "certificates of added qualifications" in 10 specialties to demonstrate their expertise. Most employers don't "encourage or require" these certificates, however, said Jennifer Orozco, DMSc, PA-C, chief medical officer at the American Academy of Physician Associates.
There are a number of training programs for family NPs who want to develop skills in other areas.
Raina Hoebelheinrich, 40, a family NP at a regional medical center in Yankton, South Dakota, recently enrolled in a three-semester post-master's endocrinology training program at . She lives on a farm in nearby northeastern Nebraska with her husband and five sons.
Hoebelheinrich's new skills could be helpful in her current hospital job, in which she sees a lot of patients with acute diabetes, or in a clinic setting like the one in Sioux Falls, South Dakota, where she is doing her clinical endocrinology training.
Lack of access to endocrinology care in rural areas is a real problem, and many people may travel hundreds of miles to see a specialist.
"There aren't a lot of options," she said.
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