The training and education given to nurse practitioners does not adequately prepare them for independent practice, according to two physicians—one who used to be a nurse practitioner (NP) and another who was a certified registered nurse anesthetist (CRNA).
“The difference was really phenomenal,” said Jennifer Allen, MD, a family physician in Washington, Missouri, during a panel discussion on scope of practice at the 2025 AMA State Advocacy Summit held last month in Carlsbad, California.
She completed her graduate education to be an NP between 1997 and 1999, before going on to medical school.
“I considered myself an expert nurse practitioner and I had been in practice for a long time,” Dr. Allen said. “And when I came into my medical education, I thought: Oh, I got this.
“But I was blown away by what I didn't know and the depth and breadth of what we are taught in medical school,” she added. “There's no comparison.”
Kathy M. Perryman, MD, an AMA member and past president of the Missouri Society of Anesthesiologists, agreed.
Dr. Perryman first worked as an intensive-care unit nurse before training between 1977 and 1979 to become a CRNA and then going to medical school.
While CRNA training, medical school and residency training have certainly changed since that time, she said that there is still the same knowledge and skill-set gap.
“The clinical science courses and the educational materials that I learned when I was in CRNA school were basic; they were not all-encompassing,” said Dr. Perryman, a former pediatric anesthesiologist in Kansas City, Missouri who retired in 2021. “In medical school, it's a much deeper, larger field of knowledge that you gain on the same subjects, and you learn them in such depth, that there's just an amazing difference between the two.”
She thinks unsupervised practice is something being promoted by the leadership of national organizations, and that it’s not something CRNAs are pushing for themselves.
“I learned that they're valuable members of our team,” Dr. Perryman said. “But I also learned that they needed to be supervised by a physician who evaluated the patients so that they could make sure that they were appropriate for their anesthetic that day and make sure that the anesthetic plan was appropriate as well and then supervise the whole thing and the post-op care.”
Nurse practitioner programs generally last two to four years, though some nurse practitioners can get their degree in as little as 18 months after becoming an RN. Online-only programs are not only allowed, but very common. Physicians, by contrast, must complete four years of medical school to earn a degree as an MD (a doctor of medicine) or a DO (doctor of osteopathic medicine). There are no online medical schools. Nurse practitioners will tally just 500–750 patient-care hours in training. By comparison, physicians get between 12,000 and 16,000 hours of patient-care experience by the time they finish residency.
Nurse anesthetist programs, meanwhile, run two to three years and typically require completion of one year as a critical care nurse prior to admission. Nurse anesthetists complete around 2,500 hours of clinical training and aren’t required to complete a residency. By contrast, after completing medical school anesthesiologists complete at least four years of residency, racking up 12,000–16,000 patient-care hours.
The AMA is fighting scope creep, defending the practice of medicine against scope of practice expansions that threaten patient safety and undermine physician-led, team-based care.
More oversight needed
Florida family physician Rebekah Bernard, MD, co-author of the book Patients at Risk: The Rise of Nurse Practitioners and Physician Assistants in Healthcare, moderated the panel discussion. And she recalled that, on her first day on her first job out of residency at a federally qualified health center, she was introduced to a nurse practitioner and physician assistant and was told “you'll be responsible for signing off on their charts.”
“I was a little bit taken aback,” Dr. Bernard said. “For one, that was never discussed during the interview process, but for two, no one ever talked to me or trained me on how to supervise nonphysician practitioners.”
Although Dr. Bernard originally felt that she wasn’t ready to provide supervision, that feeling didn’t last long, which she realized doing chart review.
“My training did prepare me,” she said. “And, as I was reviewing charts, I caught so many different errors of omission or mistakes that were being made just simply because of lack of training.”
According to a new AMA survey of state medical associations and national specialty societies, 87% of respondents reported that scope of practice was their top advocacy priority. Nearly all the state medical association representatives surveyed (94%) said scope of practice was their top legislative priority, compared with 67% of respondents from national specialty societies.
Call for more clinical training
Also on the panel was John Canion, an emergency medicine nurse practitioner in Texas. He advocates for more rigorous and standardized nurse-practitioner education and training.
In December he launched a Facebook page called “Clinical NPs For Change,” which is intended “to provide a voice for nurse practitioners that will promote, stabilize and standardize nurse practitioner education for improvement of clinical practice promoting improved patient outcomes.”
Last year, he wrote a report, published on his Substack page, that documents the explosive growth in the number of nurse practitioners while also lamenting the lack of clinical training and education standards.
Around 171,000 NPs were practicing in the U.S. in 2013, and this grew to 385,000 in 2023, according to the American Association of Nurse Practitioners.
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See how the AMA defends against scope of practice expansions that threaten patient safety.
“However, since 2010, nursing and NP leadership have provided no direction regarding the profession’s future,” Canion’s report says. “The downside to this expansion is the reduction in admission standards and the push from all sides of academia to increase the number of NPs in the country at all costs.”
Canion has been pushing to boost nurse practitioners’ clinical training to between 2,000 and 6,000 hours.
“Over the past decade, the quality of education has decreased significantly,” Canion said at the AMA State Advocacy Summit.
He also expressed concern about how much of the nurse practitioner training happens online. While Canion said he didn’t see much difference between hearing a lecture online or hearing it in a classroom, he argued that many aspects of education and training need to be hands on and in person.
“You can't teach somebody how to manipulate a shoulder, how to examine a knee or how much pressure to put on through a video,” Canion said.
Canion also pointed out the lack of standardization in the nurse practitioner clinical training.
“We have no control over how their 500 hours of training is spent,” he added. “We can't say whether they sat in an office, sat in a broom closet and counted matchsticks for that time, or even showed up.”
Dr. Allen noted that she serves a preceptor for nurse practitioners in training, but receives little guidance on how to do that well.
“I happen to precept nurse practitioners frequently because they call and ask, and I figure somebody has to do it,” she said.
“You're not given any kind of a rubric,” Dr. Allen added. “I feel like I have to teach the first two years of medical school in four weeks.”
