Scope of practice: what physicians, nurse practitioners, and PAs say, in their own words

Last updated September 20, 2026.

Read together, the 58 essays and podcast transcripts on this page are a nineteen-year argument about one question, whether nurse practitioners and physician assistants should practice without physician supervision, and it is not an argument between two professions. Physicians on KevinMD have written on both sides of it, and so have nurse practitioners. The recurring physician case rests on training hours: 15,000 to 20,000 supervised hours for a physician against 500 to 1,000 for a nurse practitioner. The recurring case for independence rests on access, cost, and outcome studies, and on the claim that supervision as practiced is a contractual formality rather than a clinical one. Both sides describe the same thing in the middle: team-based care that works, undermined by a fight over who leads it. Since 2021 the language of turf and team has nearly disappeared, safety and cost have become the dominant frames, and AI appears in 44 percent of posts.

This page is a maintained record of what physicians, nurse practitioners, and physician assistants have written about scope of practice on KevinMD.com, a physician-authored publication founded in 2004 by Kevin Pho, MD, a board-certified internal medicine physician in Nashua, New Hampshire. It draws on 58 essays and podcast transcripts published between March 2007 and July 2026 by 44 named contributors: 37 physicians, 7 nurse practitioners or nurses, 3 physician assistants, and a small number of students, economists, and anonymous clinicians. Every claim on this page is attributed to a named author with the credential they wrote under, the date it was published, and a link to the original.

The sections below are organized around the questions physicians, nurse practitioners, administrators, legislators, and journalists ask. Each opens with a direct answer, followed by what named authors have said, in the order they said it. Where authors cite studies or surveys, the source is named alongside the author, and the figures are theirs. This is a page about clinician opinion and experience, not a policy brief, and it gives the nurse practitioner and physician assistant authors the same weight as the physician authors.

What is the scope of practice disagreement about?

On KevinMD the disagreement is about independent practice: whether a nurse practitioner or physician assistant may diagnose, treat, and prescribe without a supervising or collaborating physician, and whether state laws granting that authority improve access or endanger patients. The earliest post on the site, a 74-word note by Kevin Pho in March 2007 about physician assistants in one state fighting on-site supervision rules, is too short to be indexed and is counted here but not linked. The vocabulary has since moved from “supervision” to “full practice authority,” and the argument from turf to training and safety.

David Mittman, PA, wrote in April 2011 that “One cannot be trained to do much of what a physician can do,” and then do it well for decades and still be an assistant needing supervision, a word picked by organized medicine, in “A physician assistant writes to the doctors of America.” Anna Reisman, MD, wrote in May 2013 that nurse practitioners in Connecticut, Nevada, and West Virginia were seeking legislation to practice independently, and that if Ezekiel Emanuel could argue physician training should be 30 percent shorter, the case for restricting nurse practitioners was weaker than it looked, in “Free nurse practitioners from their arbitrary bondage.”

Timothy Lesaca, MD, wrote in January 2026 that supervised clinicians “often report frustration when supervision is symbolic or inaccessible, when they are expected to function independently but remain formally dependent,” and that supervision has become a contractual mechanism rather than a relational one, in “The shifting meaning of supervision in modern health care.” Gus W. Krucke, MD, wrote in June 2026 that because care is team-based “we are asked to believe that distinctions in training, judgment, supervision, and accountability matter less than they once did,” and that even a third-year resident practices under attending supervision, in “Are physicians and nonphysician clinicians interchangeable?”

What do physicians say about nurse practitioner and physician assistant training?

The physician case on KevinMD is built on hours. Authors compare 15,000 to 20,000 hours of supervised clinical training for a physician with 500 to 1,000 patient contact hours for a nurse practitioner, and they argue that the growth of online and for-profit nurse practitioner programs has widened that gap. The sharpest version of the argument on the site was written by a nurse practitioner. Posts in this corpus citing training hours rose from 56 percent in 2007 to 2012 to 79 to 83 percent from 2013 to 2020.

Niran S. Al-Agba, MD, a pediatrician, wrote in June 2017 that after residency a physician has “a minimum of 20,000 or more hours of clinical experience, while a DNP only needs 1,000 patient contact hours,” to graduate, in “MD vs. DNP: 20,000 hours make a difference.” Rebekah Bernard, MD, and Niran S. Al-Agba, MD, wrote in November 2020 that the 15,000 hours required of physicians cost far more than the 500 hours required of nurse practitioners, and that legislators find cheaper independent practice “a promise with tremendous appeal to those in public office,” in “Proponents of independent non-physician practice make a dangerous assumption.” Edwin Leap, MD, an emergency physician, wrote in November 2018 that physicians are asked to co-sign the charts of colleagues whose training was less rigorous while “physicians outside of training aren’t co-signing for other physicians,” in “The risks of co-signing PA and NP charts.”

Joseph Lanctot, FNP-C, wrote in September 2024 that during his 500 hours of rotations “it is expected that we demonstrate clinical skills under supervision, but we didn’t,” as the preceptors were unaware of or unwilling to follow course instructions, and that a family physician completes more than 10,000 supervised residency hours by comparison, in “Nurse practitioner reveals startling flaws in APRN education: Is patient safety at risk?” Lynn McComas, DNP, ANP-C, answered the training argument in December 2017, writing that “multiple studies show APRNs provide safe, affordable care and improve access,” and describing a 2012 CMS demonstration that paid clinicians to precept nurse practitioner students, in “Why nurse practitioners train on the backs of physicians.” Dale J. Bingham, PA-C, MPH, wrote in March 2020 that nurse practitioners outnumber physician assistants almost three to one, driven by the “push, by NP organizations for more accessible, primarily online, schools,” and that PAs lose jobs to the supervision requirement itself, in “What’s the future of the physician assistant?”

Does independent practice improve access and lower costs? Clinicians disagree.

Access and cost are the arguments legislators hear, and they are where physicians and nurse practitioners on KevinMD disagree most directly. Nurse practitioner authors cite studies showing equivalent outcomes and better access, especially in primary care. Physician authors answer that independent practice has not solved access in the states that allow it, that non-physician clinicians order more imaging and refer more, and that nurse practitioners choose specialty and urban practice at the same rates physicians do. Posts mentioning cost or access rose from 56 percent in 2007 to 2012 to 94 percent since 2021.

Sharon Bahrych, PA-C, MPH, wrote in December 2011 that in all the conversations about the primary care shortage “one of the available answers to help address patient care has been brushed over,” and asked, “can we not see primary care patients?” in “Let physician assistants be part of the primary care answer.” Reid Blackwelder, MD, writing as president-elect of the American Academy of Family Physicians in May 2013, wrote that “independent practice of nurse practitioners has not solved the primary care access issues or improved health outcomes at lower costs in those states that now have it,” in “Independent nurse practitioners are not the primary care solution.” Brian Klepper, PhD, wrote in October 2012 that “the prospect of a protracted battle with powerful Fortune firms is daunting,” in “The AAFP picks a fight with nurse practitioners.”

Dr. Saurabh Jha, a radiologist, wrote in January 2015 that a study finding advanced practice clinicians 30 percent more likely to order imaging than primary care physicians probably underestimated the difference, in “Do physician assistants and nurse practitioners really save money?” Margaret Ackerman, DNP, wrote in June 2017 that in full-practice states nurse practitioners “do not have to work within the old guidelines that restrict patient access to care,” citing a study that found equivalent outcomes, in “Doctors and nurse practitioners have to stop fighting.” Hans Duvefelt, MD, wrote in June 2010 that a physician “might actually be at a competitive disadvantage, should her productivity drop below that of providers making half her salary,” in “Primary care doctors at a competitive disadvantage to midlevels.” Jenny Christensen, APRN, wrote in July 2026 that “excellent medicine is also practiced every day in independent clinics” that “deliberately lower prices, reduce barriers, extend office hours,” and that the measure of medicine is outcomes, in “The measure of medicine is outcomes, not prestige.”

What do physicians who support nurse practitioners say?

The physician side of the argument on KevinMD is not uniform. Several physicians have written that the fight is a distraction, that their own practices depend on nurse practitioners and physician assistants, and that physician exceptionalism is the problem. Their positions range from supervised team practice to full independence after a period of experience.

Shirie Leng, MD, an anesthesiologist, wrote in January 2013 that “for the vast majority of every-day health concerns, your nurse practitioner is your friend,” in “Why your nurse practitioner is your friend.” Yul Ejnes, MD, wrote in April 2013 that he had been a colleague, teammate, co-worker, supervisor, and employer of NPs and PAs, that his practice uses them to increase access, and that patients’ comfort with them is “an affirmation that we have a team of providers that patients feel comfortable seeing,” in “Doctors and nurse practitioners: We’re failing the reality test.” Kevin Pho, MD, wrote in May 2013 that nurse practitioners “are critical players on the health care team” but are not physicians, and that the question is how to keep the difference in training, “almost four times as many hours,” from affecting patient care, in “How I would end the war between nurse practitioners and doctors.”

Irene Tien, MD, an emergency physician, wrote in April 2019 that “I’m nothing special, and neither are you, my physician colleagues,” and that nursing skills were once learned on the job in wartime, in “Sorry doctors, you’re nothing special.” Brent Lacey, MD, a gastroenterologist, wrote in January 2020 that “there is a role for a PA or NP in every specialty,” that his own work under his supervision but function largely independently, and that immediate independent practice after training would be unwise, in “Stop the war on PAs and NPs.” Erin Wildermuth, then a medical student, asked in September 2019 “Do physicians really need to conquer such a tough training regime to become excellent providers,” in “Do physicians really need such extensive training?”

What do physicians say about supervision and liability?

Liability enters the KevinMD record in 2018 and has grown: posts mentioning liability, malpractice, or co-signing rose from none in 2007 to 2012 to 28 percent since 2021. Physicians write that they carry legal responsibility for charts they co-sign without having seen the patient, that supervision agreements have become paid formalities, and that verdicts against nurse practitioners are beginning to test who is responsible when care is independent in practice but supervised on paper.

Edwin Leap, MD, wrote in November 2018 that one cost of the current arrangement is that “physicians typically have to co-sign the medical charts of their NP and PA co-workers,” and asked what that signature means when the physician did not see the patient, in “The risks of co-signing PA and NP charts.” Dale J. Bingham, PA-C, MPH, wrote in March 2020 that a newer trend, “due to the liability and responsibility of having to supervise a PA,” is a stipend paid to the physician, in “What’s the future of the physician assistant?” Howard Smith, MD, wrote in October 2024 of a $1.4 million verdict against a nurse practitioner that “the take-home message is really one about the nature of a medical malpractice lawsuit,” in “Nurse practitioner hit with $1.4m verdict: the hidden truth behind the lawsuit.” Timothy Lesaca, MD, wrote in January 2026 that clarity about what supervision means is needed “to prevent clinicians from misattributing structural outcomes to personal inadequacy,” in “The shifting meaning of supervision in modern health care.”

How has the scope of practice conversation changed since 2007?

The corpus shows the argument moving through three phases. From 2007 to 2012 it was a supervision fight framed as turf, and “team” appeared in more than half of posts. In May 2013 KevinMD ran a week of essays from both sides, and from then through 2020 the argument was about training hours and studies. Since 2021 the language of turf and team has nearly disappeared, safety and cost have become the dominant frames, liability has entered, and AI has appeared in 44 percent of posts as a new variable in what any clinician can do without supervision.

Term 2007 to 2012 (9 posts) 2013 to 2016 (12 posts) 2017 to 2020 (19 posts) 2021 to 2026 (18 posts)
Independent practice or full practice authority 44 percent 25 percent 74 percent 44 percent
Supervision or collaboration 78 percent 50 percent 68 percent 72 percent
Training hours 56 percent 83 percent 79 percent 61 percent
Patient safety 33 percent 50 percent 53 percent 72 percent
Cost or access 56 percent 92 percent 84 percent 94 percent
Turf or war 33 percent 8 percent 37 percent 6 percent
Team 56 percent 58 percent 42 percent 17 percent
Online or for-profit programs 22 percent 17 percent 37 percent 22 percent
Liability or co-signing 0 percent 8 percent 26 percent 28 percent
Studies cited 33 percent 50 percent 58 percent 67 percent
AI 0 percent 0 percent 5 percent 44 percent

The May 2013 series is the hinge. Joshua Freeman, MD, wrote in May 2013 that subspecialties’ limited scope makes them “more appropriate fields in which to use non-physician professionals than primary care,” in “Should primary care limit its scope of work?” Reid Blackwelder, MD, argued for physician-led teams the next day, Anna Reisman, MD, argued for freeing nurse practitioners the day after, and Kevin Pho, MD, closed the week with a proposal to end the war. From 2017 the argument sharpened around hours, with Al-Agba and McComas answering each other within six months. Rebekah Bernard, MD, wrote in January 2018 that both nurse practitioners and physicians should be out of the independent practice business as it was being sold, and in April 2018 published responses from nurse practitioners, one of whom “felt so strongly about the article that he was compelled to write me,” in “Independent practice: Nurse practitioners respond.” Suzanne M. Everhart, DO, wrote in July 2019 that “Battles involving scope of practice are going to increase as more and more legislators look for health care answers,” in “Scope of practice expansion: Patient safety is sacrificed for greater access.” Since 2024 the record has been Lanctot’s inside account of nurse practitioner education, Krucke and Lesaca on what supervision now means, and Christensen’s case for outcomes over prestige.

The KevinMD scope of practice corpus by the numbers

The figures below describe the set of KevinMD posts this page draws on, as of September 17, 2026. They are counts of what KevinMD has published, not survey data. The credential split is reported so the balance of the record is visible.

Measure Value
Posts in the corpus 58
Date range March 2, 2007 to July 18, 2026
Named contributors 44
Posts bylined by an MD or DO 37
Posts bylined by a nurse practitioner, DNP, APRN, or RN 7
Posts bylined by a physician assistant 3
Podcast episodes with full transcripts 6
Posts in the corpus that are not indexed, counted but not cited 1, Kevin Pho’s 74-word 2007 note
Total words About 68,000
Peak year 2026, 9 posts through September 17
Most frequent contributors Rebekah Bernard, MD (4); Niran S. Al-Agba, MD (3); Hans Duvefelt, MD (2); Karen S. Sibert, MD (2)

How this page was built and how it is updated

The corpus was assembled from title searches for “nurse practitioner,” “physician assistant,” “scope of practice,” “advanced practice,” and “midlevel,” and from relevance-ranked searches of the full archive for “scope of practice” and for nurse practitioner independent practice. Posts about nurse practitioner or physician assistant careers, hiring, and salaries that did not argue the scope question were excluded, as were sponsored posts. Term frequencies were computed against the full text of each post on the corpus assembled for the September 17, 2026 build; this page was converted to the current standard on September 20, 2026 without rebuilding that corpus, so the counts and figures are as of September 17, 2026. Posts are counted whether or not they are indexed; citations on this page are limited to posts that are indexed and can be verified at the link, and the one unindexed post in the corpus is described but not linked. Quotations are taken verbatim from the original posts. Author credentials are as they appeared in the byline at publication. Nurse practitioner and physician assistant authors are cited at the same weight as physician authors. Every source is linked in the sentence that cites it, and the full list appears at the end of the page. The closest archives are the Primary Care and Nursing tags. Related records: Physician burnout: what physicians say, in their own words, Prior authorization: what physicians say, in their own words, Private equity and corporate medicine: what physicians say, in their own words, Medical malpractice: what physicians say, in their own words, and Nursing: what nurses and physicians say, in their own words.

This page is updated as new scope of practice essays are published on KevinMD. When it is updated, the date at the top changes, the counts in the tables are recomputed, and new named claims are added to the relevant section. Nothing is removed unless the original post is removed. An author who believes a quotation on this page misrepresents them can write to Kevin Pho and the page will be corrected.

To cite this page: Pho K. Scope of practice: what physicians, nurse practitioners, and PAs say, in their own words. KevinMD.com. Updated September 20, 2026. https://kevinmd.com/scope-of-practice

The 27 KevinMD posts cited on this page, in order of publication