ZDoggMD on NPs and PAs: The Scope of Practice Debate Physicians Need to Have Honestly

This article discusses ideas from ZDoggMD — Dr. Zubin Damania, MD , Stanford/UCSF-trained internist, founder of the Health 3.0 movement. Full archive: zdoggmd.com | YouTube @zdoggmd

The scope of practice debate — what nurse practitioners and physician assistants should be legally permitted to do independently — is one of the most politically charged in medicine. ZDoggMD has tried to have this conversation without the tribalism, and his position is worth engaging with carefully.

The ZDoggMD Position: Team-Based, Evidence-Based

ZDoggMD's Health 3.0 framework calls for everyone on the care team to work at the top of their license — meaning NPs and PAs should do everything they're genuinely trained to do, and physicians should focus on the work that specifically requires physician training. This is not an argument for unlimited NP/PA independent practice; it's an argument for rational division of labor based on actual competency.

His critique runs in two directions: some physicians are defensive about scope of practice in ways that are more about protecting market position than patient safety. And some NP/PA advocacy organizations push for independence in clinical situations that genuinely require physician-level training and experience. Both are doing patients a disservice.

The evidence on NP/PA independent practice shows they provide equivalent quality for routine, well-defined presentations in primary care settings. The evidence also shows that case complexity matters enormously — for complex multi-morbidity patients, atypical presentations, and high-acuity situations, physician involvement is associated with better outcomes.

The Access Problem Makes This Urgent

With a projected shortage of 48,000 primary care physicians over the next decade, the question of NP/PA scope isn't abstract. Rural communities with no physician access aren't served by arguments that NPs shouldn't practice independently — they're served by no one. The choice in many underserved areas is NP independent practice or no access to care.

ZDoggMD's view: the right answer is collaborative models where NPs and PAs have meaningful autonomy for the work they're genuinely prepared to do, with clear pathways to physician involvement for cases that exceed that scope. Not unlimited independence, not turf protection — collaborative care with appropriate role definition.

ZDoggMD on the healthcare workforce and team-based care:

Works for the Whole Team

NoPajamaTime handles documentation for physicians, NPs, and PAs alike. Whatever your role, midnight charting is time you shouldn't be losing.