For most of us, the word “doctor” in the health care setting tends to conjure up a person who completed college, innumerable pre-med requirements, medical school, internship, residency and possibly specialty fellowship (sometimes more than one). It implies a long road that ranges more than a decade, inclusive of countless board examinations with continued recertification, annual mandatory continuing medical education credits and accounts for exposure to the most clinical hours of other staff personnel in breadth, depth and scope.
It is this description that we think of when the individual responsible for our care in the hospital or an emergency room or outpatient facility interacts with us. They are no better than any other caregiver albeit a nurse, respiratory therapist or you-name-it. Doctors are just replete with a certain skill set intended for comprehensive oversight of patient management and the highest complexities of care that are distinct from other forms of training. They obtain the most unrestricted licenses commensurate with the rigorous extent of their studies and are permitted to perform procedures and prescribe medications per their discretion for the issue at hand.
Roles were once more clearly defined and understood especially by the general public. Nurses were nurses. Doctors were doctors. Phlebotomists were phlebotomists. All functioned as a team and overlaps were the glue with which they worked. Nurses taught doctors things and vice versa. All were motivated to care for the patient. Tasks particularly assigned to each with room to pick up the slack and be of help no matter the team member. The harmony is often a beautiful thing.
For a host of reasons, some well-intended and others misguided, a push to blur the lines of expertise and responsibility was forged. The spectrum of why is vast from hospital cost-cutting and utilizing less experienced staff at the top of their ticket stretching them beyond the scope of their training to an increasing desire of some of these health professionals to obtain greater and greater autonomy with less and less requisite learning and experience.
First came titles like “clinician,” “advanced practitioner,” or “provider.” This umbrella term was used to throw all levels of training into one pot and dilute the term "doctor." It routinely confuses patients who believe they are seeing a “doctor” which from an ethical standpoint is in opposition to the basic tenets of the profession like doing no harm. Hospital and other administrators endeavored to back this trend given their propensity to do more and more with less and less, a classic first step in staffing shortages.
Non-doctor health professionals, backed by powerful lobbies, are also playing a role as they are increasingly interested in the easing of certain practice restrictions. These ambiguous, often nebulous titles mask a stark reality - people will be able to practice medicine without ever having to attend medical school, perform rigorous residencies or be comprehensively and extensively trained as physicians.
And, it's happening.
There are serious consequences to poor staffing assignments. I have discussed this repeatedly. For example, in To Survive the Hospital, Make Sure Your Heart Stops on a Weekday where a new study echoed previous global data that hospital survival is reduced for those admitted on weekends and at night. Substantially worse outcomes occurred which were attributed to organizational and care differences. The skeleton crew of less experienced providers resulted in a lower survival rate of patients with in-hospital cardiac arrest when they take place in the evening or weekend.
Then, there is the entire ethical morass of claiming to have more training than you actually do. In my article The Worst 'Healthcare': 'Stem Cell' Clinics Wrought With Red Flags, Insincerity And Blindness, I discuss three patients resultant blindness or near blindness as a disastrous consequence of having “stem cells” injected into their eyes. In it, I referenced that the attorney for one of the patients filed a public complaint that “the injections were performed by a nurse practitioner who was introduced as a physician.” This is not an isolated event. The State of Maine (bold mine) is considering Bill LD 538 (HP 382) which is an “Act To Allow Advanced Practice Registered Nurses Who Have Attained Certain Degrees To Use the Title of Doctor.” Confusing patients as to who is treating violates basic standards of the caregiving professions.
NPs, physician assistants, nurses and doctors alike are invaluable to the caregiving team but they all have distinct roles with unique training and wide disparities of experience to support them. What is at stake with this relentless erosion and blurring of lines is making sure patients get the best care. The coordinated effort to diminish the term “doctor” is not aligned with patient well-being and patient-centered care, as wonderfully described in this JAMA article: Eliminating the Term Primary Care “Provider."
In Will More Nursing And Optometrists Lead To Erosion Of Patient-Centered Medicine?, I further address new legislation efforts in Alaska by optometrists to lift surgical restrictions that already exist to permit them to inject into the globe of the eye as well as extend their prescribing to include higher scheduled narcotics. Optometrists are not medical doctors and don't acquire years of post-graduate surgical training. Ophthalmologists do. In a letter on behalf of the American Academy of Ophthalmology and Alaska Eye Physicians and Surgeons, the authors clearly affirm “there is now data that proves optometrists who are performing laser surgery are causing harm to patients in Oklahoma.”
Part of the shift comes from the health policy trends of working away from a lead attending care model to a team-centered approach. I would argue this is mostly financially driven given the current reality of devaluing training by diminished reimbursements as well as unfettered cost-cutting. It is also a branding or marketing effort since teams are and have always been part of the treatment of patients. Additionally, due to physician shortages particularly in remote locations, a drive to figure out innovative ways to get personnel there-- no matter the extent of training-- is aggressively underway at present.
There are efforts to have to reduce the need for physician oversight, especially in remote locations. Which certainly makes some sense if no care is available, some knowledge can help when there is none. These include a range from having nurse practitioners not have to be supervised under a physician license to encouraging medical students who recently graduated and have one year of internship training to go to remote areas.
While the argument can be made for creative solutions in dire remote locales, the slippery slope of this trend of diminishing training and rigorous comprehensive learning with greater and greater responsibility in the mainstream is a dangerous one. The tangible harms are well-documented when it comes to patient care and outcomes.
But, this doesn't stop the train that has clearly left the station. For example, a new degree was just launched by Lincoln Memorial University-DeBusk College of Osteopathic Medicine (LMU-DCOM) called "Doctor of Medical Science Degree" or DMS. Per their website, they boast two years of online didactic training and a desire to expand clinical competencies. It is unclear what other education is offered that involves actual patient care and clinical exposure-- all I could find was a so-called "clinical residency" of 12 credit hours. They express their goal is to bridge the gap between physician and physician assistant. Physician training far exceeds that number of hours of clinical exposure. Those receiving a Doctor of Nurse Practice (DNP) degree might also refer to themselves as "doctor." The Guardian just reported on the National Health Service's (NHS) latest career path of a "surgical care practitioner" which currently consists of a small group of nurses who will be allowed to perform a narrow scope of surgical procedures in the absence of a surgeon.
With the ever-changing landscape, it is important for patients to be informed that not every member of their care team has interchangeable training when it comes to invoking the term "doctor." To many, this is inconceivable-- a word so aptly repeated in the iconic film "The Princess Bride" whose hilarious clip of that scene is atop this article. For some this concept is baffling and genuinely "inconceivable" given the idea a person can start practicing with a much shorter and less in-depth period of schooling when a physician can't until they complete their seven or so thorough, extensive years and pass all requisite examinations.
