When I was a cocky young reporter fresh out of journalism school, I complained to my father that my editor at the Toronto Star was an idiot. My father, the senior partner of an accounting firm, wasn’t interested in having me elaborate.

“How long has your editor worked at the Toronto Star?” my father asked.

“He’s been there about 10 years,” I said.

“How long have you been a reporter at the Star?” my father asked.

“Six months, but,” I stammered.

“No buts,” my father interrupted. “Your editor has been at the Star 10 years and you’ve been there for six months. Your editor may be an idiot, but he still knows a lot more than you. There is no substitute for experience.”

That conversation with my father played in my head the entire time I read, “Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.” Though my own experiences with physician assistants had already enlightened me to avoid them, “Patients at Risk” made me angry as it drove home just how deceitful and corrupt U.S. healthcare has become.

Niran Al-Agba Twitter photo.

The deceit are the studies purportedly showing that NP and PA patient outcomes are statistically the same as medical doctors. According to Niran Al-Agba and Rebekah Bernard, the MD authors of “Patients at Risk,” all of the studies involved NPs and PAs who worked under the supervision of doctors. The authors insist there are no credible studies evaluating patient outcomes involving NPs and PAs working without medical supervision, which they are doing with increasing frequency.

The corruption is that hospitals and other healthcare facilities are increasingly foisting NPs and PAs on patients without patients knowing it. The trend in healthcare today is to refer to everyone who interacts with patients as “healthcare providers” and they all wear white coats. At some hospitals, even the orderlies and housekeeping staff wear white coats, so it’s impossible to distinguish the real doctors among the white coat brigades.

Nurse practitioners and physician assistants aren’t real doctors. They can’t, don’t, and never will provide comparable medical care. They’re MD Lites – Less training. Less knowledge. Less skills.

Common sense dictates that NPs and PAs cannot perform at the same levels as doctors. It takes 10 to 14 years to become a licensed physician in the U.S. Doctors aren’t allowed to diagnose, treat, or prescribe independently until they have racked up 15,000 to 16,000 hours of clinical training. Even with all this prior training, studies show that it takes an additional 10 years of experience for cardiologists, endocrinologists, and internists until they are statistically more likely to make the correct diagnosis than their counterpart specialists with less experience.

NP and PA training education programs aren’t uniform across the country, so patients don’t even know how many years of training their NP or PA provider has, but it’s a fraction of what licensed physicians have. NPs and PAs undergo less than 1,500 hours of clinical training, some getting licensed with as little as 500 hours. There are NP schools offering 100 percent of training online and they guarantee acceptance of all applicants. Medical schools have about a 40 percent acceptance rate. Call me a snob, but when it comes to my healthcare, I want a doctor who had the elite smarts to get into medical school, preferably one in the top tier.

Rebekah Bernard

Hospitals and other healthcare businesses love NPs and PAs because they can pay them less, but bill insurance companies at nearly the same rates as doctors. Another benefit is NPs and PAs order more tests and prescribe more drugs than physicians, so — Ka-Ching! — they deliver ancillary profits. U.S. hospitals increasingly are being run by ethically challenged MBAs and accountants who regard patients as ATM machines, not humans deserving of quality medical care.

Al-Agba and Bernard dedicate their book to a 19-year-old elite athlete and straight-A student named Alexus Jamel Ochoa-Dockins, who likely would be alive today if she hadn’t been misdiagnosed by a nurse practitioner at Mercy El-Reno Hospital in Oklahoma.

The authors walk you through the misdiagnoses and treatments Ochoa-Dockins received after she arrived in an ambulance complaining of chest pain. They explain why the NP so widely missed the mark, and the legal case that ensued. The authors educate readers about the thought process doctors employ when making their diagnoses and how it differs from NPs and PAs. I found it quite fascinating. I also found it fascinating that NPs and PAs aren’t held to the same legal standards when their misdiagnoses result in injuries or death. Juries are instructed that the standards of care expected of physicians don’t apply to NPs and PAs. Funny how the faux physician industry isn’t demanding equality when it comes to malpractice claims.

My first experience with a physician assistant was at Stanford Health in Palo Alto. My appointment was to see an accomplished specialist who trained in the US and UK and had seen me previously. The hospital bait-and-switched me, but as I perceived Stanford as only offering first-class care, I didn’t object.

The PA cavalierly prescribed me a drug without addressing my concerns about possible side effects. I was alarmed that she didn’t check with the specialist before prescribing the drug. I went online and found that while the drug was most commonly used to treat my condition, in a very small population the drug was known to trigger a virulent cancer. My Stanford primary care doctor spent considerable time explaining to me the pros and cons of the drug, and I opted not to take it.

Worse Pills, Best Pills, a watchdog publication following the prescription drug industry, several months ago prominently listed the drug on its “Do Not Use” list. As an aside, I saw another specialist who put me on an alternative drug that hasn’t caused any side effects since I began taking it years ago.

As an example of the benefits of seeing an experienced doctor, about a year ago I went to see a physician at One Medical about a foot problem. The doctor, with decades of experience, observed something else about me that gave her concern and chose to focus on that. At One Medical, doctors are required to rigidly adhere to a schedule and my allotted time was 15 minutes. The doctor made a decision that proved to be correct – she treated the medical condition needing the higher priority. My foot problem curiously went away.

One Medical relies heavily on NPs and PAs, and I’m doubtful that had I seen one they’d have the experience to sway from the medical issue I came in for. In fact, I’m doubtful that doctors in the early stages of their careers could make such bold medical decisions. One Medical has grown aggressively since I joined the company years ago and the ratio of doctors to NPs and PAs seems to have widened since then, which worries me. That said, One Medical still attracts some top-flight doctors who did their residencies at top-tier hospitals. (More on my experiences with One Medical can be found here.)

“Patients at Risk” opened my eyes to some other issues.

I’ve always perceived the Robert Wood Johnson Foundation, the largest health-focused philanthropy in the country, as a pristine organization. Robert Wood Johnson was the founder of Johnson & Johnson.

Turns out, RWJF is a big proponent of nurse practitioners. In 2009, the RWJF gave $4.2 million to the Institute of Medicine to develop policy recommendations on the future of nursing. Eleven of the 18 “Future of Nursing” committee members had close relationships with the RWJF, and several committee members had close ties to the American Association of Retired Persons, which receives funding from the RWJF.

If the RWJF is giving the AARP funding, that gives me serious concern. The AARP isn’t the do-good organization for seniors the public perceives, but rather an aggressive purveyor of dubious financial and other products. As Al-Agba and Bernard note, nurse practitioners write more prescriptions than physicians, which is good for J&J’s drug business. It’s not a giant reach when you consider that J&J is a major producer of opioid pain medications and was ordered to pay $572 million for its role in the opioid crisis.

Physicians need to wake up and staunch the ever-increasing diminishment of their training and expertise by greedy healthcare CEOs driving down healthcare costs and quality so they can pocket obscene sums of money for running supposed “nonprofits.” A good starting point might be taking a page from Intel, whose “Intel Inside” logo on PCs years ago created an awareness and public perception the company’s chips were superior. I propose developing an arresting white coat logo that says, “Real Doctor Underneath.”

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Dr. T

Thank you so much for speaking truth! It is often very difficult for physicians to do so as they become labeled as “disruptive physicians “ for stating obvious facts that go against the grimy corporate agenda. For the sake of patients and our futures as patients, thank you.

Dave Mittman, PA

Are you still in Toronto? They still don’t have enabling legislation for PAs there. Not like the USA. Not sure you know much about the profession, if you did you would know PA outcomes as measured by many studies are comparable to those of physicians. Many of those studies were not done by PAs but by physicians or nursing professionals. We learn medicine as generalists, going through all subjects and specialize later after graduation. We require close to 2,000 hours of classroom training and 2,000 hours of clinical rotations (internship). Few other professions require that. We treat all Naval Seal teams and the US President. We are not an experiment. Been around over 50 years and everyone who works with us says we are excellent. Just what are you against?


This article has some serious flaws. The first is conflating PAs and NPs. The PA profession was designed by a physician and modelled after medical school. By definition, PAs don’t work without physicians. Nurse practitioners on the other hand don’t practice medicine, they practice some form of nursing. They argue for independent practice and doctoral degrees. Surely you see a difference here?

The fatal logic problem with your article is noting that experience is king. That’s fine, but what about a PA with substantial experience? Do you want to see the family practice doc one year out of residency or the PA who has been in family medicine for 25 years? You also fail to note the effect of residency hour restrictions on physician training. Docs now finish residency training seeing 30-50% fewer patients than they did decades ago.

And for what it is worth, it sounds like the PA you saw was following the standard of care by your own admission.


Is it scientific to base your conclusions of about an entire profession based on an anecdote?

If you use the rationale that experience matters, then the patient really should be seeing the provider with the most, and many times that isn’t the person with MD after their name.

When one person, or in this case professional group, feels insecure, it’s almost instinctual to lash out at the person or group that you fell “better than”. Hence, the rhetoric of the PPP.

I actually think patients are smart and many are savvy consumers. Their priority is having access to the care they need when they need it. PAs and NPs fill that need. They are held to the same standard of care as physicians and data shows similar outcomes and less cost. It’s win win for everyone except a small number of vocal physicians whose egos just won’t let them work as part of a team.


I am shocked this is now considered journalism. You discredit your argument within the first paragraph says “there is no substitute for experience” and this is certainly true for all professions, including physicians. You are correct that PAs and NPs are not physicians, but much of medicine does not require 10 years of post graduate training. Many studies have indicated that approximately 80% of medicine can be adequately performed by non physician providers. If we are going to assert that more training is always better, why stop at 15-20,000 hours? As medicine has become more complex, training has become longer and this is overall a good thing. But as physician training becomes longer and more complex, there are great access issues due to the shortage of physician supply and lack of physicians in primary care and other internal medicine concentrations. I am sorry to hear you have had negative experiences, but the book and your personal experiences readily discount multiple studies while holding up anecdotal experiences and stories as representative. Should I discredit all psychiatrists because of “The Shrink Next Door” or all surgeons because of “Dr Death?” We have a healthcare access issue and simply advocating for more barriers to reduce patient access doesn’t solve that problem.

Mark Komorowski

Thank you for peeling the onion. Thirty years of watching poor outcomes from mid levels is hardly anecdotal; including episodes of care that could have cost my wife her life. When a mid level seeks legislation to be an equal than something is awry.

Marion Mass M.D. vs Healthcare Suits

[…] Mass, 53, is one of five founders of Practicing Physicians of America, a grassroots organization that seeks to empower physicians to fight against the corporatization of healthcare and put patient care and safety ahead of profits. PPA’s founders are among the rare doctors who dare to speak out against the U.S. healthcare establishment, which is dominated by deep-pocketed private equity firms, hospital executives more focused on their personal enrichment, and a host of corporate middlemen who are driving up costs while adding little or no value. Another PPA founder is Niran Al-Agba, whose book “Patients at Risk” I’ve previously written about. […]

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