Blog | Tuesday, October 4, 2011

QD: News Every Day--Who do you think you're calling 'doctor'?


In Louisiana, physician assistants are fighting proposed limits to their scope of practice, as the state medical board made official its intent to require direct physician supervision of for procedures such as closing after surgery, doing endoscopic evaluations or placing or removing peripheral arterial lines, central catheters, chest tubes or drains.

Physician assistants are fighting to keep what they've got in Louisiana. But sometimes, it's not who gets to act like a doctor, but who gets to be called one.

The New York Times analyzed the issue: "As demand for health care services has grown, physicians have stopped serving as the sole gatekeepers for their patients' entry into the system. So physicians must increasingly share their patients--not only with one another but also with other professions. Teamwork is the new mantra of medicine, and nurse practitioners and physician assistants (sometimes known as midlevels or physician extenders) have become increasingly important care providers, particularly in rural areas.

"But while all physician organizations support the idea of teamwork, not all physicians are willing to surrender the traditional understanding that they should be the ones to lead the team. Their training is so extensive, physicians argue, that they alone should diagnose illnesses. Nurses respond that they are perfectly capable of recognizing a vast majority of patient problems, and they have the studies to prove it. The battle over the title 'doctor' is in many ways a proxy for this larger struggle.

"For patients, the struggle has brought an increasing array of professionals trained to deal with their day-to-day health woes, but also at times confusion over who is responsible for their care and what sort of training they have.

"Six to eight years of collegiate and graduate education generally earn pharmacists, physical therapists and nurses the right to call themselves 'doctors,' compared with nearly twice that many years of training for most physicians. For decades, a bachelor's degree was all that was required to become a pharmacist. That changed in 2004 when a doctorate replaced the bachelor's degree as the minimum needed to practice. Physical therapists once needed only bachelor's degrees, too, but the profession will require doctorates of all students by 2015--the same year that nursing leaders intend to require doctorates of all those becoming nurse practitioners."


Physicians are sensitive to the issue, since they've worked longer and harder to achieve their status. One wag referred to it as "Midlevel Medical Anarchy" and called the practitioners "noctors."

For the record, ACP Internist is sensitive to the issue, too, since our readers have brought up over the years. We call our MDs "physicians" while PhDs are still called "doctor."

So, ACP Member Kevin Pho, MD, entered into the fray with a commonsense solution: Universal board certification. He writes: "Have all doctorate-level clinical providers take the same board certification exam. It should be as rigorous as the ones currently provided by the American Board of Internal Medicine or the American Academy of Family Physicians in primary care, for instance. Those that pass truly deserve to be called "doctor," no matter what their background.

"Another, admittedly more realistic, option is to educate the public about the different 'doctors' who may be treating them. Let them know that not all board certifications are alike. Physicians certified by the American Board of Internal Medicine have different training requirements from those board certified with a doctorate in nursing. It is up to physicians and our professional associations to emphasize and publicize that.

"Trying to monopolizing the doctorate degree is a losing public relations strategy. What differentiates physicians is their more extensive training, symbolized by board certification status. We need to proactively capitalize on the strength, instead of reacting to the current trend of doctorate creep."


It looks like Dr. Pho is calling out both sides on the issue. Let's see who responds.