In recent years, healthcare systems in both Canada and the United States have been strained by an acute shortage of primary care providers. Despite Canada’s single-payer model and the United States’ mixed public-private approach, the two countries share a common struggle: ensuring patients can readily see a clinician for routine checkups, chronic disease management, and urgent but non-emergency needs. This shortfall has left millions without timely access to basic healthcare services—an issue intensified by aging populations, rising healthcare costs, and the lingering effects of the COVID-19 pandemic.
The Challenge of Physician Supply
Part of the access problem stems from our long-standing reliance on physicians as the principal gatekeepers to primary care. In Canada, fewer physicians per capita than the OECD average has left around 4.6 million citizens without a regular primary care provider (College of Family Physicians of Canada, 2022). Rural regions bear the brunt of this shortfall, forcing residents to travel significant distances or rely on overcrowded emergency rooms for routine needs. South of the border, the United States has more doctors per capita overall, yet over seven thousand Health Professional Shortage Areas remain underserved. According to the Health Resources and Services Administration (HRSA), these shortage areas affect tens of millions of Americans who struggle to secure timely medical appointments.
Although it is tempting to say, “Just train more doctors,” the reality is that producing new physicians is neither quick nor inexpensive. In Canada, a medical student typically completes a four-year undergraduate degree, four years of medical school, and at least two years of residency before practicing independently. In the United States, the path is similarly long—at least four years of medical school plus three years of residency for family medicine. Estimates in both countries suggest the price tag of educating one physician can run into hundreds of thousands, even close to a million dollars, once institutional costs and government subsidies are factored in (Association of American Medical Colleges, 2021; Canadian Medical Association, 2021).
Unfortunately, we don’t have decades—or the budget—to wait. The population is aging, chronic conditions are more prevalent than ever, and healthcare systems are under increasing strain. If we are going to bridge the gap in primary care capacity, we must look beyond the traditional solution of adding more physicians.
A More Flexible, Cost-Effective Approach
In the midst of this dilemma, a viable option stands ready: physician extenders. In many clinics, hospitals, and community health centers, nurse practitioners (NPs), physician assistants (PAs), and other trained healthcare professionals have already proven their ability to deliver safe, high-quality care in a fraction of the time—and at a lower overall cost—than adding new physicians to the system.
Nurse practitioners, for instance, typically begin their career as registered nurses (RNs) and then complete a master’s program in advanced nursing practice. In Canada, NP programs have expanded in provinces such as Ontario, Manitoba, and British Columbia, often supported by bridging curricula for experienced nurses. In the United States, more than 355,000 licensed NPs currently practice in primary, specialty, and subspecialty care settings (American Association of Nurse Practitioners, 2022). Physician assistants, a profession with roots in U.S. military medicine, typically undergo two to three years of postgraduate training focused on general medicine, physical exam skills, and clinical procedures. Their adaptability and shorter training timeline make them indispensable in addressing primary care bottlenecks.
This is not merely a theoretical proposition. A seminal study published in JAMA in 2000 by Mary Mundinger and colleagues found that patients with common primary care conditions experienced similar outcomes, satisfaction levels, and service utilization whether treated by an NP or a physician. Subsequent research has reinforced these findings, noting that PAs also achieve comparable or better results in chronic disease management, particularly when working collaboratively in multidisciplinary teams. The implication is profound: expanding the use of NPs and PAs can free physicians to focus on more complex cases, decrease wait times, and maintain high standards of patient care.
Addressing Concerns Over Competition
Despite the wealth of evidence supporting nurse practitioners and physician assistants, some physicians harbor reservations. A fear of competition or lost income is not uncommon, and there are legitimate questions around malpractice liability and scope of practice. Yet in practice, clear collaborative agreements, well-defined protocols, and team-based models often alleviate these worries. The Canadian Medical Protective Association (CMPA) and the American Medical Association (AMA), along with state and provincial medical boards, have issued guidelines that detail supervision arrangements and liability considerations in shared-practice environments.
In fact, many physicians who have worked alongside advanced practice providers come to see the partnership as an asset. When routine tasks—such as follow-ups, preventive screenings, and patient education—are handled by NPs or PAs, physicians have more time for patients with complex medical needs, research, or healthcare leadership activities. In many clinics, overall patient volume grows, revenue increases, and burnout rates decline.
Ineffective Quick Fixes
In the face of mounting evidence of shortages, governments often resort to blunt policy measures to push doctors to see more patients. In Canada, some provinces stipulate minimum patient enrollment quotas or require physicians to provide after-hours care; in the United States, Federally Qualified Health Centers must meet benchmarks to maintain federal funding. Although such mandates may lead to minor gains, they often intensify the stress on an already overburdened workforce, potentially worsening turnover and burnout. Moreover, these policies do not solve the fundamental supply-and-demand mismatch.
Instead, they risk alienating the very professionals needed to build a more robust system. A better strategy is to create the right incentives and remove unnecessary barriers, allowing each provider—physician, nurse practitioner, physician assistant—to function at the top of their training.
Strategic Scope Expansion and Incentives
Beyond better integrating NPs and PAs, Canada and the United States could do more to empower skilled registered nurses (RNs) and specialized technicians. If RNs with the proper certification can inject Botox for cosmetic purposes, why shouldn’t they be allowed, with additional training and under physician or radiologist supervision, to administer joint injections for pain management? Some interventional radiology technicians already place PICC lines, but current regulations in many regions stop them from performing other ultrasound-guided procedures that would expedite patient care.
Allowing these modest scope expansions requires safeguards: thorough training, clear clinical protocols, and on-site physician or specialist oversight. Yet such changes could substantially increase capacity and shorten wait times for routine procedures, especially in rural areas where specialists are scarce.
The key to success lies in thoughtful incentives that make it worthwhile for clinicians and healthcare organizations to adopt these team-based approaches. Clinics that hire NPs or PAs could receive targeted grants or better reimbursement rates when they demonstrate improved access and care quality. Governments might consider tax incentives or subsidies for interdisciplinary practices, particularly in regions where residents struggle to find a family physician. Payment reforms—in both Canada’s single-payer systems and the U.S. Medicare/Medicaid programs—could shift from rigid fee-for-service models to blended or capitated payments that reward outcomes and collaboration.
When physicians are financially and professionally supported, they are far more likely to bring nurse practitioners, physician assistants, and trained nurses into their practice. For instance, “incident to” billing in the United States, when structured effectively, enables clinics to be reimbursed for care delivered by NPs or PAs under physician supervision. In Canada, provincial billing frameworks could similarly recognize and fund extended roles for nurse practitioners or paramedical professionals.
Piloting and Scaling
The road to widespread acceptance and lasting change typically begins with pilot programs. Governments, insurers, and health systems can fund controlled trials in diverse settings—urban clinics, remote outposts, and everything in between. By systematically measuring wait times, patient satisfaction, and cost-effectiveness, policymakers gain hard data to justify broader scaling and public support. Such efforts are already underway: Ontario’s Nurse Practitioner-Led Clinics have a decade of data showing reduced wait times and high patient satisfaction, while in Manitoba, physician assistants have helped cut emergency department backlog.
Meanwhile, in the United States, the Department of Veterans Affairs has long integrated NPs and PAs into primary care teams, demonstrating that team-based care can reduce hospital admissions, especially for older adults with chronic conditions. In private sector clinics—like those run by large retail or pharmacy chains—NPs routinely conduct screenings, chronic disease management, and health education. While critics once worried about “retail medicine,” many patients report high satisfaction with the quality and convenience of these services.
A Timely Imperative
Ultimately, the best healthcare systems combine access, quality, and cost-effectiveness. Neither Canada nor the United States can afford to wait for a dramatic expansion of physicians alone to fix the primary care crunch. The evidence from decades of research and real-world practice indicates that a team-based approach, anchored by physician extenders, is one of the most promising ways to deliver better care to more people, faster.
Instead of regulatory strictures that coerce doctors into seeing more patients, policymakers, health system leaders, and professional associations would be wise to eliminate barriers and create positive incentives for employing NPs, PAs, and other trained professionals. Empowering allied health workers and enabling their safe scope expansions can free physicians to do what they do best: tackle the complex cases that truly require their advanced level of expertise.
The potential to transform both Canadian and American healthcare systems lies in embracing this collaborative ethos. By acknowledging that every provider on the team—from the physician to the nurse practitioner to the specialized technician—has a critical role, we can build a more robust, accessible primary care sector. For millions of patients who currently struggle with wait times and inadequate care options, that future cannot come soon enough.
References (Selected)
- Mundinger MO, Kane RL, Lenz ER, et al. (2000). Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial. JAMA, 283(1): 59–68.
- American Association of Nurse Practitioners (AANP). (2022). NP Fact Sheet.
- College of Family Physicians of Canada. (2022). Family Medicine Professional Profile.
- Health Resources and Services Administration (HRSA). (2021). Shortage Areas.
- Canadian Medical Association (CMA). (2021). The Cost of Medical Education in Canada.
- Association of American Medical Colleges (AAMC). (2021). Physician Supply and Demand Projections.
By making physician extenders a central part of primary care and modernizing the regulations that govern scope of practice, we have a chance to create a healthcare system that is both equitable and efficient. Rather than a fallback or a temporary fix, this approach stands as a strategic, evidence-based solution to a crisis that affects millions of people—and ultimately, the economic and social well-being of our nations.