Our findings suggest that a substantial number of primary care physicians are unlikely to embrace policy recommendations aimed at further expansion of the roles and supply of nurse practitioners. In particular, physicians' concerns about the likely effect of an expanded workforce of nurse practitioners on several aspects of health care quality need to be addressed in discussions of strategy for the development of the U.S. health care workforce. Among respondents to our survey, more than 70% of physicians and 90% of nurse practitioners agreed that nurse practitioners should practice to the “full extent of their education and training,” and a clear majority of nurse practitioners (75%) reported that they are in fact doing so. However, majority support of this broad principle broke down in a more detailed analysis of the perceptions and experiences of the two groups. Notably, physicians and nurse practitioners disagreed about whether nurse practitioners should lead medical homes or receive equal pay for providing the same services that physicians provide. Although physicians overwhelmingly rejected the statement that nurse practitioners provide the same quality of care that physicians provide, nurse practitioners clearly supported the statement.

As we consider these polarized views, it is important to acknowledge that nurse practitioners and physicians come from very different cultures of professional education, are guided by different theoretical perspectives, and often develop their clinical skills in different practice environments. The training of the two groups varies in scope and duration, along with the respective processes of licensure and credentialing. It is not surprising (and indeed may even be expected) that physicians and nurse practitioners emerge without a common vision of their roles in the provision of primary care. Our survey results support calls for increased innovation in interprofessional education of the primary care workforce, encompassing curriculum content, training, and demonstration of competence.12

Respondents in the two groups were far apart in their views on equal pay for providing the same services. Physicians' opposition to equal pay is consistent with their perception, expressed in these data, that for any given service, they provide a higher quality of care than do nurse practitioners. Nurse practitioners' support for equal pay is consistent with their majority view that physicians do not provide a higher quality of care for any given service. These survey data cannot provide evidence of the relative value of the training and expertise of these professionals. Nevertheless, the data suggest that physicians do not think that increasing the supply of nurse practitioners would have a positive effect on either the cost or the effectiveness of care, whereas more than 80% of nurse practitioners believe that increasing their numbers would improve the cost savings and quality of health care. From a societal perspective, we might consider whether expanding the supply of nurse practitioners and paying them equally for the same services that physicians provide would negate current savings from the disproportionately lower payments nurse practitioners now receive. More information is needed on the economic implications of the division of work between physicians and nurse practitioners before policymakers can definitively answer the question of whether employing a greater number of nurse practitioners and expanding their role would result in overall cost savings.

Our study has several limitations. First, we did not measure experience with, or attitudes about, physician assistants or other health care professionals who provide primary care. Second, our sample source for nurse practitioners, as compared with that for physicians, had a higher rate of inaccurate contact information and did not contain data on activities associated with direct patient care. However, our results are consistent with the findings of the 2009 National Ambulatory Medical Care Survey, which documented the proportion of office-based physicians who employed nurse practitioners.13 The Department of Health and Human Services recently conducted a national survey of nurse practitioners, and the results are expected to expand the national database on primary care and specialist nurse practitioners in the United States.14 Third, in samples of this size, it is difficult to control for all personal and clinical-practice characteristics that differ between the two professional groups. The lack of diversity with respect to sex and racial or ethnic group in these samples limits our analysis. However, differences between the two groups were highly significant on virtually every outcome, even with samples of this size.

As we consider these findings, we cannot help but reflect on the effect of these attitudes and practices on patients and patient care in the U.S. health care system. As changes are proposed in the size and configuration of the health care workforce and in the education and preparation of physicians and nurse practitioners, can the public be assured that the quality of health care will be maintained or improved? Furthermore, from a practical perspective, patients may need objective guidance in selecting health care professionals who are the most appropriate for them. Currently, the confidence that 82% of nurse practitioners have expressed in their ability to practice independently as leaders of patient-centered medical homes is not reflected in the attitudes of the majority of physicians we surveyed. Reasoned discussion about the education and roles of both physicians and nurse practitioners is needed to ensure that patients are receiving appropriate health care services.

Our data provide evidence to inform ongoing public debates among physicians and nurse practitioners about their roles, responsibilities, and scope of practice. Both physicians and nurse practitioners will be needed to address the many challenges of developing a workforce that is adequate to meet the need for primary care services. It is our hope that the stark contrasts in attitudes that this survey reveals will not further inflame the rhetoric that has been offered by some leaders of the two professions but rather will contribute to thoughtful solutions for health care workforce planning and policy.