Tracy Cardin, ACNP | Physician | July 25, 2018

So out in the varied land of hospital medicine, I have noticed something that I have no clear explanation for. It turns out there is often a gap in productivity between that of NP/PA providers and physicians. The range of the gap varies wildly – I just got off the phone with a group leader who has observed a 50 percent difference to a smaller gap of perhaps 10 percent. In my very rough and unscientific analysis, I routinely see a 15 to 20 percent gap.

But I simply don’t understand why this gap exists. The physical time to see and examine a patient, coordinate care with consultants and case managers, discuss the plan of care with family, write a note and bill is the same regardless of experience or credentials behind a name.

Or is it?

Does the more robust education and training of physicians force them to be more efficient? Do we focus so much on “safety” of NP/PA providers that we fail to train them to be efficient? Is there a lack of experience at the outset of their careers compared with that of a physician? Is there a double standard?

When I ask about the source or impacts on the gap, I receive a variety of replies: NP/PAs can’t “handle the volume”. NP/PAs are “early career” and don’t have the experience.

There is often a perception as well to “protect” the NP/PAs. They “spend more time” with patients and families. They “take longer to document”.

Whatever the root cause, this gap has an important impact on two main areas.

First, any economic advantages of deploying NP/PA providers can easily melt away without similar levels of patient volume, though the acuity of patients need not be similar. Optimization simply requires similar productivity.

And secondly, the lack of parity can create cultural conflicts breeding what I call “the secret ingredient” – resentment. If physician providers routinely see more patients than NP/PAs, yet NP/PAs want to have similar input into the practice, this can create a disparity. And disparities create friction. And friction creates instability. And instability means providers leave for other practices. Which leads to hiring less experienced people. Which may expand the gap.

So how do we address this and prevent existing gaps from expanding? I have a few takeaway points:


  • NP/PA providers should be onboarded and trained in three discrete arenas: hospital-specific processes, independent medical judgement in the patient population they are caring for and efficiency.
  • Don’t just accept a gap. Research why it exists and ways it can be addressed.
  • Analysis of the financial costs of this gap should be analyzed and factored in to decisions about NP/PA optimization.

How do you “mind the gap?”

Tracy Cardin is a nurse practitioner. This article originally appeared in the Hospital Leader.