Live Long and Well with Dr. Bobby
Let's explore how you can Live Long and Well with six evidence based pillars: exercise, good sleep, proper nutrition, mind-body activities, exposure to heat/cold, and social relationships. I am a physician scientist, Ironman Triathlete, and have a passion for helping others achieve their best self.
Live Long and Well with Dr. Bobby
#61 The Doctor Won't See You Now
More of us are being seen by nurse practitioners (NPs) and physician associates/assistants (PAs); for routine care outcomes look similar to physician visits, but for complex, new, or worsening problems you should push to see the doctor and ask for clear oversight.
Key topics
- Why this is happening: Longer waits and rising demand meet a physician shortfall, so systems lean on NPs/PAs to expand access. New-patient waits average ~31 days, varying widely by city and specialty (AMN
). Fewer people have a usual source of care, pushing visits to urgent care/ER (Milbank Scorecard
). - The scope shift: NP involvement in Medicare outpatient visits rose from 14% in 2013 to ~26% in 2019 (Harvard/Tradeoffs summary). Projections show rapid growth in NP and PA roles through 2030 (ValuePenguin analysis
). - Training differences (at a glance): NPs typically complete a master’s/DNP with ~500–700 supervised clinical hours and, in many states, can practice independently; PAs complete a master’s with ~2,000 supervised hours and practice with physician collaboration; physicians complete medical school plus 3–5+ years of residency (~10,000+ hours) and broad rotations—critical for complex differential diagnosis (AJMC overview
). - Quality of care, by the evidence: For common, protocol-driven issues, outcomes are generally similar. A Cochrane-summarized evidence base finds comparable results for blood pressure control, mortality, and patient satisfaction, with longer counseling time in NP visits (AJMC summary of RCTs
). Patients often feel PAs spend more time with them (JAAPA survey
). Diabetes care quality appears similar across clinicians (PubMed
); NPs tend to deliver more smoking-cessation counseling (AANP brief
). - Where this works well: Routine follow-ups (blood pressure, cholesterol, diabetes), protocol-based care, minor acute concerns (UTI, simple URI), post-op checks when all is going well—especially with clear physician involvement.
- When to push for the doctor: New, unclear, or non-resolving problems (e.g., complex headaches, persistent back pain, ongoing fatigue or depression), multiple chronic conditions, many medications, or when a serious alternative diagnosis must be ruled out (e.g., “heartburn” vs. cardiac disease).
- Advocate for transparency: Ask in advance who you’ll see, whether your case will be reviewed with a physician, and how escalation works if you’re not improving.
Takeaways
- Access will keep driving NP/PA growth; use it to be seen sooner.
- For routine care, NPs/PAs are often a solid choice with similar outcomes and more counseling time.
- For complexity, insist on physician evaluation or documented oversight.
- You have the power to ask questions, confirm the plan, and request escalation when needed.
You finally get that appointment with your doctor. You take time off work, you drive across town, you sit in the waiting room, and then a stranger walks in. Hi, I'm Sarah, the nurse practitioner. I'll be seeing you today. Wait, where's the doctor? If this sounds familiar, you're not alone. Today we're asking, when did healthcare become a bait and switch? And is this a problem? What does the evidence tell us? Hi, I'm Dr. Bobby Du Bois, and welcome to Live Long and Well, a podcast where we will talk about what you can do to live as long as possible and with as much energy and figure that you wish. Together we will explore what practical and evidence-supported steps you can take. Come join me on this very important journey, and I hope that you feel empowered along the way. I'm a physician, Iron Man triathlete, and have published several hundred scientific studies. I'm honored to be your guide. Welcome, my dear listeners, to episode number 58. The doctor won't see you now. Should you worry? This scenario is increasingly common. I have many listeners and friends tell me this happens pretty often. They schedule an appointment with their doctor, but then they're seen by the nurse practitioner or the physician's assistant. Not just when it's an appointment to see the PCP. This increasingly happens even when they visit a specialist. Here are a few statistics. In a study looking at care from 2013 to 2019 for Medicare patients, the likelihood of seeing a nurse practitioner rose from 14% of visits in 2013 to 26% of visits in 2019. I suspect it's far more often now since that study was done six years ago. And the numbers can be much worse. Today, let's look at the evidence in the following areas. Part one, why is this happening? Part two, is this good news or bad? And part three, what might you do? If you haven't, please sign up for my free newsletter. Tell your friends about the podcast. Many podcasts have fun names for listeners. And I'm thinking about this, and please help me to figure this out. Here are a few to consider The N of One Nation or the Control Group or the Outcome Optimizers. Let me know what you think. Email me at Bobby at drbobbyevidence.com. Okay, back to our story. Part one. Why is this happening? Well, it's getting harder and harder to get any appointment. On average, a new appointment takes 31 days, almost 50% higher, more days since 2004. Now this varies by city with Boston, it's 65 days, Atlanta, 12 days. The wait for a GI doctor is about 40 days, a dermatologist 36 days, a cardiologist 32 days. The growing weight is due to rising demand and not enough supply. On the demand side, we have an aging population with more illnesses. Anticipated, there will be a tripling of folks 85 and above in the next decades. Also, the supply is not keeping up. We have too few physicians. It's estimated we will have a shortfall of 180,000 physicians in the next 10 years. Fewer young doctors are going into primary care. PCPs are paid less, they see more patients, and they have a lot more paperwork. Also, a huge number of physicians are retiring. And finally, younger physicians want work-life balance. So they'll likely work fewer hours. My take. Waiting time likely to get worse, not better. One approach to this problem is to have more nurse practitioners and physicians assistants. In 2010, 15 years ago, there were approximately 56,000 nurse practitioners and 30,000 physicians assistants. By 2022, that number increased 56% for nurse practitioners, and the number of physicians assistants increased by 28%. By 2030, nurse practitioners will grow over 50% with 30% more physicians assistants. My take? It's increasingly likely that you will see more nurse practitioners and physicians assistants. Okay, on to part two. Is this growth good news or bad? Let's look at training and quality of care. To become a nurse practitioner, first they get a college degree. Then typically they work as a nurse for two to three years. They get a master's in nursing. Now, this sounds good so far, but the master's degree I mentioned, 60% are either partly or fully online. Also, nurse practitioners only get 500 to 700 hours of supervised clinical care compared to physicians who get 10,000 hours or so. Nurse practitioners have no required formal residency or a standardized curriculum. 34 states give full practice authority, meaning no physician oversight. Let's turn to training for physicians' assistants. They go to college, then they do two years schooling, often at a medical school, then they have 2,000 hours of supervised practice. Unlike nurse practitioners who often work without a physician involvement, that's not the case for physicians' assistants. Let's contrast that training with what is needed to be a physician. Physicians go to four years of college, four years of medical school, then they have three to five years of residency, 80 hours per week, or about 10,000 hours of clinical care or more. Physicians rotate throughout the whole medical system: inpatient, outpatient, ICU, specialty clinics. Physicians spend a lot of time learning differential diagnosis, or what are the many potential causes of a patient's symptoms? This really is the crux of being a doctor. We are trained also to care for complex patients. Now, mathematically, it is faster and less costly to train nurse practitioners and physician's assistants. How about the care given by these providers? Is it as good? One study of patients who saw a physician's assistant, two-thirds felt that the physician's assistant had more time. In a summary of 18 randomized controlled trials by the Cochrane group, nurse practitioners provided similar care. They had similar patient outcomes for blood pressure control, mortality, and patient satisfaction. Another study looked at diabetics, showed similar quality of care. And studies have shown that nurse practitioners spend more time counseling patients about stopping smoking. So now part three. So what is my take on all of this? Nurse practitioners and physicians' assistants get far less clinical training. But the research shows in general, for routine care, the quality is about the same. Are there scenarios where seeing the nurse practitioner or the physician's assistant make sense? Sure. It may well be the fastest way to get care. And it would be fine if there was close interaction with the doctor after your visit. For routine follow-up care for blood pressure or diabetes, seeing a nurse or physician's assistant is probably fine. If the care pretty much follows a protocol, all good. If it's a minor acute illness, a UTI, a cold, also good. You also probably have more time with them than with your doctor. So when do I worry? If you have a new or not obvious problem, like a complex headache, unresolving back pain, or continuing fatigue or depression, or you're just not getting better. Now, I would want to see my doctor. Why? It is critical to have the right diagnosis. Is it heartburn or could it be cardiac disease? Is the fatigue just due to poor sleep or something more serious like cancer? Also, do you have multiple conditions? Heart, kidney, diabetes, prior stroke. Again, I would feel safer if you saw your doctor or if you take a bunch of drugs. Part three, let's wrap up. You will likely see more and more physicians' assistants and nurse practitioners moving forward. For routine care, likely fine. You get to see someone more quickly. Um, but keep in mind the training is really different. Physicians have extensive and broad training. They're trained to step back and consider many causes. In contrast, nurse practitioners and physicians' assistants have much more limited clinical training. I also want true transparency. Know up front who you will be seeing. Feel empowered to ask whether they will discuss your case with a physician. Push hard to see a doctor if you are uncertain or you're not getting better. Please send me ideas, feedback, or how this podcast helps you. May you live long and well and get the care that you need in a timely fashion. Thanks so much for listening to Live Long and Well with Dr. Bobby. If you like this episode, please provide a review on Apple or Spotify or wherever you listen. If you want to continue this journey or want to receive my newsletter on practical and scientific ways to improve your health and longevity, please visit me at Dr. Bobby Livelongandwell.com. That's doctor as a dr bobby live longandwell.com.