Advocates for independent practice frequently argue that physician shortages justify allowing non-physician providers to practice without physician oversight in rural and medically underserved areas. At first glance, this may appear to be a practical solution to a pressing access problem. However, the ethical implications deserve careful examination.
Physicians complete four years of medical school followed by three to seven years of residency training, accumulating between 12,000 and 16,000 hours of supervised clinical experience before practicing independently. Physician assistants typically complete two to three years of graduate education with approximately 1,600 to 2,000 clinical hours. These pathways are fundamentally different in both depth and breadth of training.
If policymakers acknowledge that physicians possess substantially more training and expertise, then an uncomfortable ethical question emerges: Is it appropriate to direct patients in underserved communities toward healthcare models that rely on less extensively trained practitioners functioning independently when wealthier or urban communities continue to receive physician-led care?
Additionally, such a policy risks creating a two-tiered healthcare system. One tier would offer physician-led care for communities with abundant healthcare resources, while another would rely on independent non-physician practices for communities already facing social, economic, and healthcare disadvantages. From an ethical standpoint, this raises serious concerns.
The principle of justice in medical ethics requires that patients be treated fairly and that access to quality healthcare not depend upon geography, income, or social status. Underserved populations should not be expected to accept a lower level of clinical expertise simply because they have fewer healthcare options. A shortage of physicians may explain the problem, but it does not necessarily justify lowering the standard of care.
There is also the ethical principle of nonmaleficence, the obligation to “do no harm.” Independent practice models are often promoted as solutions to access challenges, yet if patients receive care from clinicians with significantly less training in diagnosis, complex disease management, and medical decision-making, there is a risk that the quality of care may be compromised. Even if such harm is unintended, policymakers must consider whether expanding independent practice exposes vulnerable populations to increased risk.
Equally important is the issue of patient autonomy. True autonomy requires informed consent. Patients have the right to understand who is providing their care, the extent of that individual’s training, and how that training compares to that of a physician. If patients are unaware of these differences, they cannot make fully informed decisions about their healthcare.
The ethical solution is not to diminish the important contributions of physician assistants or other non-physician providers. Rather, it is to strengthen physician-led team-based care, expand physician recruitment and retention efforts, improve residency opportunities, and develop innovative models that bring physician expertise to underserved communities. Non-physician providers are invaluable members of these teams, but their value is maximized when they practice collaboratively within a structure that ensures patients have access to the highest level of medical expertise.
Ultimately, the question for our legislators is not whether underserved communities deserve healthcare access. They unquestionably do. The question is whether underserved communities deserve the same standard of care as everyone else. Ethically, the answer must be yes. Healthcare policy should strive to eliminate disparities, not institutionalize them. A system that reserves physician-led care for some populations while offering a lesser standard to others risks violating the very principles upon which medical ethics are founded: autonomy, beneficence, non-maleficence, and justice.
All the best,
Mark J. Adams, MD, MBA, FACR
MSSNY President
