Ep. 69 MD vs NP: Patient Protection or Turf War?

Rebekah Bernard, MD

A massive push to increase the number of nurse practitioners and physician assistants and to extend their scope of practice is under way.  The stated goal is to address a real or perceived shortage of primary care physicians. This effort worries many doctors who are concerned that patients are getting short-changed in the process.  But is this concern justified or is it simply motivated by protectionist interests?

Our guest is Dr. Rebekah Bernard, a successful family physician from Fort Myers, Florida.  She is board member of Physicians for Patient Protection, an organization calling for more transparency regarding the difference in training between physicians and non-physician providers, and advocating for legislative action to avoid misrepresentation of the capabilities and knowledge-base of nurse practitioners.


Rebekah Bernard, MD: Twitter and practice website


What’s ruining medicine for physicians: replacing primary care physicians with NPs/PAsMedical Economics Staff Editorial, December 4, 2018

Can I see a nurse practitioner instead of a doctor?”  Cedars-Sinai Blog January 28, 2019

IOM Report. The Future of Nursing: Leading Change, Advancing Health.  Institute of Medicine (National Academies of Science, Engineering and Medicine) Report.

Rebekah Bernard. How to Be a Rock Star Doctor: The Complete Guide to Taking Back Control of Your Life and Your Profession 

Rebekah Bernard. Physician Wellness: The Rock Star Doctor’s Guide


Ep. 3 Should Doctors Protect Their Turf?


  1. Lysander Spooner on 03/15/2019 at 8:26 AM

    I, for one, am 100% on Dr Accad’s side here.

    The people in government cannot know what is best for all the people looking for healthcare.

    If I need blood drawn or a minor wound treated then I would prefer a practised nurse & absolutely NOT a harried doctor with far less practical experience of hands on minor care. Especially if I was paying the bill myself.

    Dr Koka’s story does not prove the NPs are dangerous: it shows that patient choice is vital. His friend knew she wanted a doctor & in a true free market system she would have got one immediately. It is the various constraints imposed – by force – by the “wise” overlords calling themselves the government that created a system in which Dr Koka’s friend was obliged to deal with an NP.

    I’m sure Drs Koka and Barnard mean well, but it does seem arrogant and patronising to assert that patients should be forced to deal with “licensed” practitioners only. It is my body, my life and my money. You don’t know me or my circumstances. How can you possibly know what is best for me?

  2. Lysander Spooner on 03/15/2019 at 8:31 AM

    Every time I hear the ‘but people will die’ argument put forward by Dr Barnard, I watch the classic Remy clip : https://m.youtube.com/watch?v=eXWhbUUE4ko

  3. Ricky Cochran on 03/15/2019 at 6:14 PM

    Dr. Bernard mentions that her next step for her growing DPC practice was to get a physician partner, and definitely not a nurse practitioner. She implicitly calls for a system where nurse practitioners, if the are to become increasingly independent, would receive more training. But the simplest solution, to me, evades her: hire and train the nurse practitioners herself.

    • Mary on 04/20/2019 at 1:44 AM

      Ricky, I think you’re seriously underestimating what it requires to adequately train someone in medicine. It’s not something you can just do on the side in a clinic while continuing to see a normal amount of patients. And even if someone could pull that off, a single clinic would still lack the variety of cases someone really should see before working without pretty close supervision.

  4. Anthony Perry, MD on 03/17/2019 at 3:25 AM

    I can’t even finish listening to this whole interesting discussion without jumping up to comment.

    The entire rationale and existence of the medical system is to address the health interests and concerns of consumers; let’s not even call them patients. Intrusion of government with it’s licensing and advocation for third party involvement has developed a grossly paternalistic system wherein the seekers of medical evaluation and treatment are treated like the “patients” we call them. I think the introduction of independent nurse practitioners in this regard is a helpful development and is at bottom being forced by consumers who want more convenient access, more personal attention and a lower price. Otherwise independent NP’s would not exist.

    Must medical consumers always have as their only option the ultimate in expertise and must we have government and medical academia regulate this outcome? Does the patient’s incomplete knowledge demand that we must countermand the principles of individual freedom and choice? Of course not. We purchase goods and services of all kinds every day about which we are not experts. We make choices of this type all the time. People make decisions based on reputation, advice from friends and family, published evaluations, advertisements, and so forth.

    And of course people do make decisions all the time regarding their medical issues, including whether to interact with the system in the first place. They get advice from all sorts of sources. They seek and use all sorts of treatment outside of traditional care. When they do use the traditional system, they decide how and when to comply with the medical advice they are given. Are we to stop them from doing this as well?

    Independent nurse practitioners must take care to give service that consumers want to purchase, to guard their reputations and to function within the confines of the tort system for injuries caused. Physicians must do the same and if their additional training does indeed translate into superior value, they have little to fear.

    Of course our present situation, wherein there is ubiquitous use of NP’s in both primary care and specialists offices is considerably motivated by third party involvement in both payment and the complexities of practice. Patients in this instance of course must be informed of the respective qualifications of their practitioners and must understand the difference and for the most part they do. They are not ignorant. The NP’s in this setting must be supervised. Most often they accept this option because of necessity or convenience but in some cases the NP is preferred.

    It is a little surprising that Dr Bernard, who has experienced the benefits of withdrawing from third party supervision and instead turning her attention to providing direct value to those seeking her care, has so little confidence in the ability of the guiding hand of freedom and the market to sort these problems out. It is very hard to escape the paternalistic ideas which have permeated medical care for so many years.

    • Mary on 04/20/2019 at 1:40 AM

      “Patients in this instance of course must be informed of the respective qualifications of their practitioners and must understand the difference and for the most part they do.”. That’s not true. So many patients think the nurse practitioner (actually anyone in a white coat) they see is a physician, even someone they see over many visits and even if the nurse practitioner does not specifically claim to be a doctor (though that happens regularly as well).
      There’s a huge lack in transparency and understanding. There’s also the issue of physicians being replaced by nurse practitioners for financial benefit to hospitals and private equity groups, making it increasingly difficult for people to actually see doctors.

      This would all be less of an issue if nurse practitioner training was rigorous and standardized, as any training where lives are at risk should be. And that’s all aside from the issues around cost to the health system which we will all bear (nurse practitioners have been found to order more unnecessary imaging and testing, send more unnecessary referrals, prescribe more medications, and miss the diagnosis more often, all of which can increase costs incredibly quickly, especially given the high cost of imaging and medications).

  5. Mary on 04/20/2019 at 1:48 AM

    Dr. Perry — Honestly, the market eventually will probably sort this out as insurance companies catch on to excess costs from unnecessary testing and prescribing etc and more outcomes information emerges, but how many will be harmed in the meantime?

  6. Kevin on 08/23/2019 at 2:01 AM

    Why would I want medical services to be driven by a free market? The free market doesn’t make any services better. It doesn’t even make services comparable. What it does is force people to argue that their own services are more valuable, which is extremely difficult to prove scientifically.

    Consider medical goods which can be scientifically tested to meet a specific quality standard. Medical goods are not the same thing as medical services. What is a value-driven medical service? How do you prove value? Can you rate that value on Amazon.com as if it is a product? Goods and services are different things. Stop using the free market as a justifiable excuse to undermine an effective training system.

    Medical services must be driven by some form of governance whereupon everyone can agree that standardized training benefits society, and thereby allowing fewer quacks and charlatans to sell their own services on the free market (often inside hospitals). Quality of medical service is not driven by science or free market but by social contract: medical professionals justify their services only by meeting certain standards of achievement. What is the standard of achievement of a PA or NP? How can I be trusting of quality? Maybe I’ll just read an Amazon review.

  7. Larry Wilson on 09/28/2019 at 12:57 AM

    I listened to this podcast online.

    Does this mean the quality of the information was substandard?

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