Stop calling nurse practitioners mid-level providers

Stop calling nurse practitioners mid level providers

I really hate it when a nurse practitioner is called a mid-level provider.

“Mid-level provider” isn’t even a legal or academic term. It is slang developed to demean or minimize a health professional, who is not an MD.

The term “mid-level provider” is primarily aimed at nurse practitioners (NPs) as well as physician assistants (PAs) and mid-wives. It is insulting to health professionals as well as to the patients that they serve.

Let’s be logical and think about this. “Mid-level” implies that he or she provides middle of the road or average care, not high-level care. Who then delivers high-level care? It must be the MD, of course. So, who delivers the lowest level of care? Nurses?

Nurses are the foundation of medical care. They tell us (MDs) when they recognize a problem or a need for an intervention. Then, we act. They are not low-level providers. Therefore, if nurses are not low-level care providers, then nurse practitioners cannot be mid-level providers.

What do the patients and families think when they hear this? “Don’t worry Mom and Dad, a low-level and mid-level will take care of your sick child, until the high level arrives.” That just sounds stupid.

It is also insulting to anyone who has decided to pursue higher education and improve oneself that he or she has finally achieved mid-level competence.

Maybe the term “mid-level provider” got started based on the number of years in training. I understand that physicians have more years of school than practitioners. I get that. But, most of us know that we define ourselves after we begin working on our own, and are responsible for our own decisions. The first 3 to 5 years after graduation is when we grow and decide what kind of clinician we will be.

Children and their parents want to receive excellent medical care delivered to them by a kind and gentle clinician. MDs don’t have a market on that one. If, as a clinician, you can provide excellent medical care with humility, then you provide the highest level of care available. I don’t care if the initials after your name are MD, NP, PA, or DOA. Children definitely don’t care. They just want to get better.

So let’s move out of the dark ages, and join the age of enlightenment. Let’s not insult our patients by telling them that we will provide mid-level care to them, and let’s not insult our co-workers by calling them less than what they are.

Instead of “a mid-level will be seeing your child,” how about, “Our clinician will be right with you, and he or she will take excellent care of your child?”

Michael D. Pappas is a pediatrician and can be reached at Children’s Intensive Caring.

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  • Anne-Marie

    For the love of all that’s transparent, let’s please not promote the habit of referring to everyone as a clinician. The scope of practice is not the same and patients deserve to know the credentials of who is going to be caring for them.

    Unless, of course, you think it’s OK for CNAs and medical assistants to be called clinicians too? After all, they’re part of the team, are they not?

    The word “mid-level” is not meant as a slur on the nurse practitioner’s clinical skills. It’s about the scope of what the professionals in the health care ecosystem are trained and licensed to do.

    I wanna know when I’m talking to the doctor and when I’m talking to the nurse practitioner. I wanna know when I’m talking to the nurse and when I’m talking to the medical assistant. What I don’t need or want is obfuscation that feeds someone’s professional ego while being dishonest with patients.

    • James O’Brien, M.D.

      It’s not a slur, it’s an administrative designation. No one is implying mediocre.

      Should mid-level managers in business be offended too? How about mid-level ranks in the military? How about midfielders in soccer? Basketball players who sign under the mid-level exemption to the salary cap?

      As a general rule everyone should stop scouring the earth looking for reasons to be offended.

      • Patient Kit

        Do you want to be called doctor or provider? Words do mean something.

        • James O’Brien, M.D.

          I could care less.

          • Mengles

            Well, I do care.

          • James O’Brien, M.D.

            If you signed up as a PPO (“preferred provider organization”) member, the term provider didn’t bother you enough not to take the money. To insurance companies, we are providers. (Although I personally don’t take insurance for treatment anymore.) Big deal.

            Of all the things wrong with medicine right now, I would put being called a provider about 7,645th on the list.

          • Dr. Cap

            This entire discussion is fantastic! “I’m a doctor.”
            “No, I’M a doctor!”
            “You’re both wrong. I’m a DOCTOR!!”

            Where I come from “mid levels” are PGY 2s or 3s. I still can’t shake it and nobody knows what I’m talking about where I am now…

          • Suzi Q 38

            “No!” Only specialists are true doctors!
            When does the hubris end.

          • querywoman

            I think a midlevel or a physician extender would be like an extension in a table: chop the doctor in half at the waist and insert a 3 inch extension.
            These are stupid terms!

        • HeisenbergHattie

          Accuracy is important. That’s why words matter.

        • Suzi Q 38

          How about “midlevel providers”, since GP’s and FP’s are not a specialists?

      • Lisa

        It may be an administrative designation, but I think the term is meaningless when trying to communicate with patients. As a patient, I want to know what someone’s title is. The title means something. An administrative designation doesn’t.

        • Kristy Sokoloski

          There was a patient that had gone in to the clinic one of the days I had to see my Primary Care Physician and she was looking for the MA that worked for one of the NPs. She told the girl at the front desk that she needed to speak to her doctor’s nurse. The girl at the desk asked who her doctor was. The girl’s like I don’t know the last name but I know it’s doctor so and so (giving the first name). The girl did not correct the person asking for the particular MA but she had an idea who this person was looking for. This person thought that the NP was an actual doctor. And that’s instead of the title of her job which was a “Nurse Practitioner”. So yes, it does have meaning to the patient when it comes to what term is used to describe the different providers of care. Because otherwise patients are going to continue to think as this one that I just mentioned: that of thinking that her provider was an actual doctor when they were not.

          • Mike Pappas

            We all should introduce ourselves and state our title/job description, when interacting with a patient.

          • Mengles

            Tell that to NPs who wish to be called “Doctor”. Patients know doctors to be physicians. Period.

          • Lisa

            I have never had a Nurse Practioner introduce themselves to me as a doctor or heard a Nurse Practioner call themselves “Doctor.”

          • Patient Kit

            I’ve never had a NP or PA introduce themselves as a doctor either. And I was unaware that NPs and PAs, in general, want to be called doctor.

            From a patient’s perspective, I think it needs to be made very clear who we are talking to or being treated by, be it nurse, NP, PA, doctor or anyone else. Patients should never be allowed to think they are talking to a doctor when they aren’t. And when a NP or PA is spending time with us and giving us good care, patients need to know who that care is coming from as well. Transparency for patients about who is who is non-negotiable. Then individual patients can decide who they are comfortable being treated by. For example, my elderly mom recently told me that she likes her current NP better than any doctor she’s had for the last 25 years. The point being that Mom knows she’s being treated by an NP and she’s happy with her treatment.

          • Anne-Marie

            I’ve dealt more than once with PAs who were referred to as “the doctor” or “Dr. So-and-So.”

            To be clear, they didn’t introduce themselves this way… but that’s what the staff called them. Ditto with medical assistants who repeatedly seem to be referred to as “the nurse.”

            My guess is it’s a form of verbal shorthand that everyone on the staff understands. But don’t assume what’s clear to you is clear to your patients.

          • Patient Kit

            In fact, assume the opposite — that it’s NOT clear to patients at all. I did not realize that this is going on. Shorthand or not, as a patient, it is unacceptable to me for a medical office to be run like this — calling everyone who works there by a title above their education level. Why do that? By the same logic, if I need a lawyer, I don’t want the paralegal to call herself a lawyer and the legal secretary to call himself a paralegal and the janitor to call herself the legal secretary. Why do this? Where are the actual doctors? Is it that complicated to call ourselves and each other by our actual titles?

            I can see NPs and PAs objection to being called mid-levels. But they shouldn’t be called doctors either. And I completely agree that everyone being called the same thing like provider or clinician is neither fair or clear. Which may be the powers that he’s ultimate goal — to confuse us all.

          • ninguem

            Of course not all do it, in fact most don’t, but indeed yes, many nurse practitioners go to great lengths to mislead the public into thinking they’re physicians. I see it all the time.

            They get a PhD in something, then go around calling themselves “doctor”.

            I see it all the time. They up the ante, and put the name of a medical specialty on their business cards, stationery, and signage.

            “cardiology” or “rheumatology” or “psychiatry” or “pediatrics”

            The patient comes back to me, claiming to have seen a pediatrician or a psychiatrist or a cardiologist, and I waste time on a wild goose chase.

            “Are you SURE you didn’t see a nurse practitioner?”

            “No, I saw a PSYCHIATRIST, name was Dr. Mary Smith.”

            Then patient pulls out a business card, and sure enough, the card reads “Dr. Mary Smith, Psychiatry”, all in big print, and in microprint “ARNP”. Note the word “psychiatry”, not “PsychiaTRIST”.

            The public often confuses notary publics, thinking the notary is an attorney. The Bar associations often require certain signage.

            http://www.nationalnotary.org/not-an-attorney-ca

          • Suzi Q 38

            My daughter is and NP and doesn’t have her patients call her “doctor.”
            I think that some physicians are making too big of a deal about all of this.
            If I am on Medicare, need a physician and no one will accept my medicare payments, I will gladly see an NP.
            Heck, I see NP’s and PA’s now on occasion, both in the clinic and the teaching hospital. I have done so for years.
            The ACA will make NP’s and PA’s “first line providers.”
            I made that name up, BTW.

          • SteveCaley

            I have. A family friend asked me to visit their teenage son’s psychiatrist to let her know what our friend’s adolescent child was going through, from the perspective of a family friend. (The boy was later hospitalized in a psychiatric facility.) She was treating him with psychiatric medication.
            My friend spoke of this caregiver as “Doctor” and at the visit introduced the caregiver as “Doctor.” I spoke with her and called her “Doctor” several times. She knew I was an MD physician throughout the discussion. No comment was made.

            I took her business card on the way out. She was a P-MH NP. (psychiatry/mental health nurse practitioner.) Not a psychiatrist.
            Their practiced dumped John, the suffering adolescent, when he became sicker and more complicated.
            I no longer will identify myself as a “doctor” in any situation outside of practice – any social situation. I am a little ashamed of the healthcare field, actually. I prefer “Mister.”
            [PS: As to the PhD moniker, I use "Doctor" socially with colleagues who have a PhD, but not if it becomes professionally ambiguous. Germany even banned the public use of "Doktor" for PhD's, reserving it for "Arzt" (MD's.) I also have a PhD in Biochemistry and Cell Biology, from before medical school. In the US, a nurse with a EdD gets called "Doctor" in the university but not in the clinic. That's the proper etiquette for the handle 'doctor.']

          • Charlie Buscemi

            with all do respect, I have a PhD and do introduce myself as Doctor. “Hello, I am Dr. Buscemi, your Nurse Practitioner”…this isn’t a state of mind or a “wish” to be called doctor. My PhD gives me the right to do so.

          • Lisa

            I think your introduction is clear, but I grew up with a father who was an optometrist and had a PhD. I used to have explain to friends why he was called ‘Dr.’ when he was not a doctor.

          • Patient Kit

            Well, that would be confusing to a lot of patients. While you certainly have the right to “Doctor” because you have earned your PhD, I think it is essential, in a medical setting, to make it crystal clear to patients that you are not a medical doctor. Can I ask what you have your PhD in?

          • Charlie Buscemi

            I have never had a pt be “confused”. They actually appreciate having a doctorally prepared NP. My PhD is in Nursing

          • EmilyAnon

            The patient may not show confusion because in most cases they probably innocently accept that “doctor” means physician, unless you qualify beforehand.

          • Charlie Buscemi

            i ALWAYS clarify that I am a doctorally prepared NP. thank you for your comments.

          • Mengles

            Most patients are not professionals themselves. They don’t know what “doctorally prepared” means, as many of them don’t have a bachelor’s. What you term as clarification is actually obfuscation. If you wanted to inform them, you would say you were a Nurse Practitioner, end of story to avoid any confusion.

          • Charlie Buscemi

            well, when you’re an NP with a PhD YOU can do it that way…I on the other hand will stick with “Hi, Im Dr. Buscemi, your nurse practitioner”

          • Ava Marie Wensko George

            I totally agree with you Dr. Buscemi

          • Patient Kit

            Thank you for clarifying. An NP with a PhD in Nursing introducing themselves as “Doctor” is new to me. How do you know it’s not confusing to patients? How do you know that when patients are sick, stressed and in a medical setting, the only thing they hear is “Doctor”? That said, I don’t know what the solution is. But I stand corrected on NPs introducing themselves as “Doctor”. I really didn’t realize that is happening. How common is it for NPs to have a PhD?

          • SteveCaley

            And I never insist on being called “Doctor Doctor” as I have an MD and a PhD both. But these squabbles are just fistfights on the boxcar transport – all the healthcare professions are traveling to their own demise.
            In my state, acupuncturists wear white coats and legally call themselves Doctors. Herbalists can call themselves Doctors. They wear white coats and sell nutraceuticals ‘effective in diabetes.’ Good onya, mate.
            I don’t care if PA’s call themselves doctors – in fact, who cares if we go back to the old days and let anyone with a matchbook degree call themselves doctors and prescribe whatever they want. If it no longer matter, it no longer matters. I no longer even believe in “prescriptions” for most medicines – let people take them over-the-counter if they wish to. Let’s be responsive to the customer’s wishes, let’s.

          • Ava Marie Wensko George

            Absolutely!

          • Jenny Jackman

            The new NP grads are required to have a Doctorate degree in nursing, so they would appropriately be addressed as “Doctor X”, as would any other professional with a doctorate.

          • Lisa

            I think Charlie Buscemi’s introduction would work in under those circumstances, with a further explanation if necessary.

          • Patient Kit

            So then, we’re headed toward all MDs, DOs and NPs being called “Doctor”? I really had no idea this was happening. I guess all “doctors” can expect to start being asked by patients on a regular basis: “What kind of doctor?” and “What kind of degree?”. Because this is all pretty cloudy and patients have a right to know. I’m glad this thread made me newly aware of this. But I hate to have to start wondering from now on whether a doctor is really a medical doctor. And asking.

          • EmilyAnon

            There will soon be another ‘doctor’ in the mix. The Assistant Physician.

            “Missouri is going to allow medical school graduates who did not match into residency programs to practice as “assistant physicians” in rural, underserved areas, a plan that does not sit well with physician organizations.”

            http://www.healthleadersmedia.com/page-1/QUA-306297/ACGME-Chief-Sees-Huge-Risk-of-Error-in-Proposed-Assistant-Physician-Licensure

            (Kit, did you get the PM I sent via OCNA?)

          • Patient Kit

            Just got your PM at OCNA and responded, Emily! Thanks! If I’m considered so nasty, bigoted, hostile, intensely emotionally needy, the queen of sensitivity (and every other name I’ve been called here at KMD in the last 24 hours), maybe it’s time once again for me to step away from this blog. Life is stressful enough. I really don’t need this kind of abuse from a doctor.

          • Suzi Q 38

            Good!
            They need care too.
            If physicians do not want to live and work there, and PA’s and NP’s are willing, so be it.

          • Suzi Q 38

            Your future ACA (Obamacare) at work.
            This is the governments solution to the GP and Fp shortage.

          • popstand

            Yes, that is the solution, based on the studies which indicate equivalent outcomes in a primary care setting.

          • Ellen Ozdych

            If I might clarify a misconception, DOs ARE physicians (surgeons, pediatricians, psychiatrists, internists, ophthalmologists, etc.) trained IN medicine with even more training in holistic practices. Their title of Doctor had been rightfully earned. They go through four years of medical school, internship, and several years of residency, and many, many board certifications. I am a little disappointed with kevinmd for the mistype at the end of the article.

          • Suzi Q 38

            My daughter is a new NP grad.
            She will be working for a physician in a large geriatric clinic. She is not required nor does she have a doctorate degree in nursing.
            If she did, she has the right to be called doctor, if the state or license agency gives her that right.

          • jazzywest

            Nurse Practitioners who have earned a Doctorate Degree deserve to be called “Doctor” as does any other professional who has achieved that level of education. NPs are not shy about explaining who they are and what they can do.

        • Mike Pappas

          Well put

      • Mike Pappas

        “Have the humility to learn from those around you.”

        John C. Maxwell

    • Mike Pappas

      I agree with transparency. This is not about blurring our credentials. It’s about using a “label” that has no legal or medical distinction. We all should introduce ourselves and state our title/job description, when interacting with a patient.

    • Nicholas

      @Anne-Marie: I don’t think NPs and PAs are asking you to be dishonest with patients. They’re asking for a more appropriate term for their role.

      Mid-Level Provider itself is confusing and obfuscating to patients, so it’s probably best to identify them as the “nurse practitioner” or the “physician assistant”. Then, allow the NP or PA to further inform the patient on their role and scope if necessary.

      • Anne-Marie

        I was the first person to comment on this post yesterday and I was responding to the original author’s suggestion in his final paragraph to use the term “clinician” to avoid negative connotations.

        While it’s more sensitive to the professionals involved, it comes at the expense of blurring their credentials for the patient – and that’s not being straightforward with patients, although not intentionally so. Hence my statement about using titles to be more transparent.

        In the 16 hours or so since I posted my comment, the conversation has gotten rather lively and some of the context has shifted.

        In regard to your point… understood.

  • NPPCP

    It’s really all very simple and I know everyone can understand: The AANP has issued a statement rejecting the phrase “mid-level”. Very few NPs I know like the title. It is a profession-wide dislike of the term. So, if a profession doesn’t like it, then you respect them and call them by what they wish to be called – Nurse Practitioners!!! And patients DO deserve to know who they are being “seen by.” Anne-Marie summed it up quite nicely. Don’t call us “clinicians” – call each of us what we are. MA, CNA, receptionist, PA, physician, NP. To call a PA or NP a “mid-level” when you KNOW it is widely known that they do not like the term is to INTENTIONALLY defame and degrade. I call physicians “physicians”. They prefer this and it is deserved respect for another profession. In the rare instance I am called a “mid-level” (I never tolerate that term), I immediately let the physician know they are a “provider.” Their dislike for that term is probably stronger than mine for “mid-level.” I never call physicians providers except in this instance. I let them set the rules – “physician and NP” or provider and mid-level.” Not much else to this argument. Either you respect and call us what we prefer, or you don’t. Same for us.

    • doc99

      I’ll stop using ” mid level” when folks stop calling me “provider.”

      • James O’Brien, M.D.

        I didn’t get the memo from the AANP in my inbox. How negligent of me not to keep up on such minutiae.

        Is this really where society is going. To be constantly outraged by perceived slights?

        Call me a provider. I don’t care. You can call me anything you want including a quack if you get rid of MOC which is far more insulting.

        You see I am insulted by actions, not words. But how quaint of me.

        Maybe I should get with the Zeigeist and stay up all night and think of different words that can offend me. Or I could get a good night’s sleep.

        • Patient Kit

          Seriously, are you really a psychiatrist? If so, I’ve never known a professional who practices in the field of mental health who has such distain for emotions. Between this post and the retirement thread in which you express disdain for compassionate doctors as “touchy feely nonsense”, I’m genuinely baffled by your approach to and discounting of emotion.

          I think you’re also in a real minority of doctors if you really like being called a provider as much as you like being called doctor. Most doctors like to be called doctor. So that’s what I call them — doctor or doc — as a show of respect unless they ask me to call them something else. As for NPs and PAs, why is it so hard to understand and accept that they feel — yes, feel — demeaned and insulted by “mid-level”? Knowing how they feel, what’s so hard about calling them NP and PA?

          • James O’Brien, M.D.

            Since this board does not have an ignore feature please do not respond to my posts.

          • guest

            I agree with you. I had no earthly idea this was considered a derogatory term.

          • Nicholas

            Those agencies use “Non-Physician Provider (NPP)” or “Non-Physician Medical Provider (NMP)” as well I believe.

        • Nicholas

          @James: Even if the term came about with no ill intent, there’s a clear and obvious call to use something MORE accurate and appropriate–why are you so married to not changing/adapting? If that is something that makes your colleagues and provider associates in the medical profession feel better, why are you so resistant to supporting that request?

          I think if I went around the hospital and started calling my physician colleagues “mid-levels”, they’d have an issue with that. I imagine most would be offended.

    • Patient Kit

      I agree with you. It’s really pretty simple — just call everybody what they are — doctor, NP, PA, nurse, etc. That provides transparency for patients about who is treating us and respect for the individuals who are providing that care. The quest for one word to describe everybody in healthcare, be it clinician or provider, has to go. It is both demeaning and intentionally vague. And even worse than “mid-level” is “extender”. “Extender” makes me think of adding breadcrumbs to limited meat to stretch that meat. Or doctors standing on NP or PA “Extender” stilts. Words do matter. They have hurtful connotations.

  • Dave Mittman, PA, DFAAPA

    As a PA who has close NP and physician colleagues, I would like to thank Dr. Pappas for saying what needs to be said.
    There is nothing middle of the road about my care, or the level that it is given. If you want to tell someone that a member of the team-someone who is in effect your partner- is “middle of the road”, that is your problem. Just do not include me. And who is lower level? The RN that holds the hand of someone who is dying. I think that is the highest level of care. I guess that’s why I am a PA.
    Over 50 % of family physicians work with PAs and NPs. I bet the number of surgeons is even higher.
    I will never understand the mentality where people need to put others down. Sadly, some people need to feel superior in any way they can.
    Dave Mittman, PA, DFAAPA

    • Mike Pappas

      Thank you for the positive comments.

    • Chiked

      It seems like most NPs and PAs on this blog have serious insecurity issues. There are many assistant coaches, many co-pilots, many vice-presidents. Not once have I heard any of them think of their job title as derogatory even though they are all fit to handle the primary job on their own.

      If you guys or gals want more respect, here is an idea….form a standalone training school and residency. While you are at it, start a respected journal with novel research and ground breaking innovation. Till then, you all sound like BIG babies at time when our healthcare is in a crisis.

      • NPPCP

        Here I go – such a simple concept being repeated again. I have a feeling you already understand but just prefer to antagonize. I went to school for a Family Nurse Practitioner degree. My representing organization rejects the term “mid-level”. They speak for all NPs in the country on an organizational level. NPs prefer to be called “NP.” So when you address us please use NP. It has nothing to do with insecurity at all. That statement was pulled out of nowhere (well, somewhere), again, to denigrate. So – now you know. You will either respect us and use NP or you won’t give a flying flip and call us something else. It’s all up to you and your conscience. There is no other way to look at it. Do it or don’t. But you know. Concerning being a big baby – sounds similar to the AAFPs feelings about the “medical home” and “captain of the ship”. Wanting to be “captain of the ship” sounds a little babyish to me as well. We all have our examples. Do what you will and I will do the same. I will start and respect you as “physician” if you decide not to return the favor, it will go downhill from there. Very very simple.

  • guest

    These days, most of us get called things that we don’t particularly care for: most physicians do not really like being called “providers.”

    I see all of these terms more as administrative shorthand, rather than having an actual clinical implications.

  • buzzkillerjsmith

    I agree with several commenters here that the term mid-level should not be used. Provider also should not be used.

    Call us doctors or physicians or docs or hey-you or healers with almost God-like powers and call those currently demeaned by the m-word nurse practitioners and physician assistants.

    Calling professionals by the titles they prefer is the way to go. I would actually prefer to be called Your Excellency but I think that might be pushing it.

    • Kristy Sokoloski

      Dr. Buzz,

      I agree with you about you being called doctors, physicians, or doc. And the reasons for why I agree with that are numerous but one of the biggest reasons I agree with you on that is because of the fact that you put so much work (on multiple levels) in to getting that degree. So respect should be shown for that. As for your last comment, you made me laugh. Thanks for that.

      And yes, when I address my doctors I address them as “Dr. So and so”.

    • Mike Pappas

      Well said, Your Excellency…

    • Mengles

      Except NPs who now are getting their DNPs want to be called doctors too.

      • Lisa

        Ah, now I see what prompted the comment above.

      • Suzi Q 38

        Psychologists are called “doctor” because they earned their degree. Same with DNP’s.
        Totally legal.

    • Lisa

      My husband calls doctors “Medical Deities.”

  • QQQ

    Hold on, let me get some popcorn and soda pop! The drama is going to begin!

  • Thomas D Guastavino

    Im curious. If you use then “clinician” would the patient not assume they are seeing the doctor.? Does the patient have a choice here? Would they potentially get angry and claim fraud later?
    Its probably better to use the earned title. “Our (doctor, nurse, PA, nurse practitioner) will see you now”. Better still, introduce yourself with your earned title.

    • Kristy Sokoloski

      Very well said. This goes to my point that I made to one of the other posters about the patient that she was getting care from an actual doctor and not the NP. You also make a good point about not only the patient as to whether or not they have a choice but the thought that when they find out that they didn’t see an actual doctor that it could cause some even bigger problems.

    • Mike Pappas

      Agreed. We all should still introduce ourselves and state our title/job description, when interacting with a patient.

  • SteveCaley

    American Indians can probably smell this argument coming a mile away. What is the correct term for the Washington Redskins? What does it mean to be offensive?
    It is very simple – to be authentic in dealing with other human beings, or inauthentic? That is all there is. If one is authentic, and one follows the biblical “Golden Rule,” that is all there needs to be. [Matthew 7:12]
    I have patients and neighbors who do not look White to me. I never know whether they prefer “American Indian” or “Native American.” I consider those terms equally rude. I do not ask. In the few times I hear a self-reference, it’s usually “American Indian.” That’s nice. That’s not my business. If they say “Ukranian,” I do not correct them.
    Indians seem to become uncomfortable when someone asks – “How would you like me to name the box that I put you in?” They appear not to really care. They seem much more interested in what you intend to do after you put them in the box. That worries them.
    Martin Buber and Thurgood Marshall brought together two different strands of this thought. Once I encircle your existence and identity and put it in a box, it then becomes all about MEYOU are simply another thing in my world, an object like a telephone or a microwave. I claim lordship over you.
    The argument then becomes mere amusement for the lords and ladies of Versailles, then. Should light-skinned Negroes wear contact lenses to change their eye color and appear more White? Such a discussion is not only pointless, it is wicked.
    It’s like the semiotics of the White Coat – what does it Mean? It is now a meaningless symbol, like wearing scrubs. Now, the clothes are dalliances, amusements, like wearing a tricornered hat. Go ahead! Do so!
    Are MD’s or CNFP’s or CNA’s clinicians? We pretend it has meaning; it does not. Like the scrubs, it is a vain term, an argument over nothing. I suppose that the Native North American Indigenous People would agree with you. Call us what you wish, they seem to say. Just stop shooting at us.

  • Mike Pappas

    I appreciate your comments!

  • Mike Pappas

    You stated “my ego couldn’t handle things like this”…

    “There is no respect for others without humility in one’s self.”
    Henri Frederic Amiel

    • James O’Brien, M.D.

      Honestly, I think your beef is with the Federal government, which is where these terms originate. It’s actually not slang, it’s a federal designation.

      • Mike Pappas

        First, I would like to say I enjoy jousting with an intelligent colleague. Sometimes, we don’t appreciate we have that freedom in this country.
        Secondly, I like the church lady, but I didn’t know it was called the “Superior dance”.
        Lastly, your point is well taken. That’s why I wrote the article, and now people can not “accidentally and innocently” call a nurse practitioner or PA “mid-level”.

        • NPPCP

          Excellent summary. It’s not by accident.

      • Carlo Coello

        I, personally, don’t care if the individual seen me is a M.D., a DO, a NO or a PA. What I really care is how compassionate, sincere, smart, approachable and human that professional is. You could have graduated from Harvard, but to me, it means nothing if your demeaning is cold, insensitive and God-like.

        • James O’Brien, M.D.

          Thank you Captain Obvious. Because I thought my ideal doctor should be crass, phony, stupid and unapproachable. Not to mention carrying 10 communicable diseases.

          Does this thread really merit 180 posts when other more important topics have less than ten?

  • Steve

    I’m not in total agreement with your points but while we are on the topic of titles, its worth pointing out that no where in your piece did you mention DOs who make up about 10-15% of the physician workforce. There was a reference to “DOA” when mentioning other degrees. I am not sure if this was a typo for “DO” or whether you meant Dead on Arrival. Just a reminder that anytime you refer to the physician workforce as a whole it should be “MD/DO”, not MDs. It makes your argument on titles much weaker when you exclude colleagues on equal footing who have a different degree than your own. I know you didn’t mean any disrespect by this- just an observation.

    • Mike Pappas

      I stand corrected. It’s my MD arrogance showing. I just proved my own point.

      • NPPCP

        Steve made your exact point. DOs do not like being left out and like being called DOs. Dr. O’Brien would not like being called something else than what he is either. It’s all okay because he is not affected. As far as the innocent usage of the term “mid-level”, those folks are not even on the radar in this conversation and are a red herring. The folks who use the this term with full knowledge of what they are doing are the physicians and administrators. Anyone engaging in this conversation or reading this article will either call us NPs because they respect us or call us something else to degrade or irritate us. Everyone here is fully aware now.

        • RuralEMdoc

          Actually, DO’s don’t really care all that much, because every time I go work everybody calls me Doctor. I also try not to get caught up in semantics too much.

          • NPPCP

            NPs do care about the term and that’s okay too. Every time I go to work at my private practice, everyone calls me by my first name. Basically we have the same job and different titles! Titles are important!

          • Steve

            I don’t care either on a day to day basis- a doctor (read: physician) is a doctor no matter what the degree. For some reason I cringe a little when the term “MDs” is used to describe the entire physician workforce. Granted we are a minority but we are there. The funny thing is that I don’t buy into any of the OMT or osteopathic principles- for me its just where I happened to go to medical school so I don’t get militant about it like some do.

        • Suzi Q 38

          Aren’t D.O.’s physicians?

      • Steve

        No worries! Like I said below- I’m not sure why I cringe when this happens and I more often make it into a joke (“DO aware” instead of “MD aware”). I like being the scrappy one who is in the minority (there’s a long story in regards towards my own journey into medicine). One of my professors said it best “The MDs are like Hertz- they’re number 1. DOs are like Avis- we try harder”

  • Mike Pappas

    Thank you.

  • James O’Brien, M.D.

    You didn’t just compare “mid-level” to the N-word, did you?

    That statement is far more offensive than calling someone a mid-level provider.

    • querywoman

      What’s in a word, a name, a label? Shakespeare penned, “A rose by any name would smell as sweet.” Maybe that’s not an exact quote.
      Sticks and stones may break my bones, but words will never hurt me!
      What a lie!

      Words hurt!

  • NPPCP

    Sorry – in my book and in the book of insurance companies you are a “provider”. To your MD colleagues you are an MD. To the rest of us and society you are a provider and “you are just going to have to deal with it.” In the book of providers your “extra 8 years of training and ‘hundreds of thousands of dollars’ to ear the title” mean very little when you have no respect for the rest of us. Unchecked egos can cause us to do lots of things we shouldn’t my fellow provider.

    • RuralEMdoc

      Interesting that your “book” and the insurance companies “book” are the same………….

      But since we are talking about this, you are actually 85% provider according to CMS.

      • NPPCP

        Yes, and your point is my friend? We are both able to do the same things under CMS rules with very minor exceptions. So to continue the kerfuffle, I am a more “cost effective provider” than you. Why do you do this? Why aren’t you willing to call “an NP an NP”? Why are you piling on with Sean instead of being willing to call us who we are according to our degree? The answer is obvious – it’s either no respect, not really caring, or outright disdain. No one would treat a friend or colleague they like with such disrespect. So you stand where you stand and the wheel goes ’round.

        • RuralEMdoc

          My point is that you agreeing with anything an insurance company puts out is bad form.

          To illustrate that point I demonstrated what the ultimate insurance company, CMS, thinks of NP’s. Don’t worry, they don’t think much more of any other “provider’s” either.

          I have never actually used the term mid-level. If you don’t like it, then I will never use it in the future. So in that sense, this article has served it’s purpose.

          I admit that I took a swing below the belt, but my point was that we are actually all in this fight together, and it is stupid to fight over an increasingly smaller piece of the pie while administrators and CEOs take money out of the system.

          That is what the term “provider” means. It means “an expendable resource that is easily replaced” to CorpMed. NP, PA, MD, DO. None of us should use the term. Ever.

          • NPPCP

            I am on your side. I really really am.

    • Mengles

      And yet patients (the ones that actually count in this debate) know the difference and want to keep their doctors.

      • NPPCP

        Yes, my friend, they do. Or their NP, or whatever person has been caring for them competently. You are so right. Just give them the choice. They will go where they want and find who they want to care for them. Thank you.

      • Lisa

        Quite frankly, as a patient who has been seen and treated by NPs and who has a primary doctor I like, I would be quite willing to seeing a NP for primary care.

  • NPPCP

    I didn’t go to “mid-level” school – I went to NP school. What is wrong with being called an NP? What is wrong with a physician being called a provider?

    • RuralEMdoc

      There is nothing wrong with wanting to be called what you are.

      The term “provider”, however, is not about education or anything like it. It is a CorpMed/ Insurance company term creatd to distinguish providers from “consumers”, you know those pesky people who keep showing up at our door because they are sick or something.

  • RuralEMdoc

    It is important to note that the “only thing separating them is a residency” is a pretty massive “only”

    It is silly to argue about the education aspect. NP’s do not have anything close to the education as physicians.

    You could argue you don’t need that much education to deal with most medical problems (and you might even have a point), but to attempt to say that your education really is equivalent in total years to some (certainly not all) foreign trained physicians, minus one teeny tiny little residency thing, is just plan ridiculous.

    • Nicholas

      @RuralEMdoc: Excellent point. NP or PA attempts to diminish the level and time of training in medical residencies is egregious.

      The shorter length of training and lack of residency requirement for NPs and PAs is somewhat of an advantage as it provides a quicker entry into practice. However, post-graduate residencies/fellowships are growing in number for these roles and they still require additional training, notably in sub-specialties as new graduates.

  • Tim Tufuga

    As an Australian this is the first time I’ve heard of the term. The first impression I got was that within a medical administrative, and procedural pecking order perspective, the positioning of a nurse as a mid-level provider, is suggestively accurate. I would consider the entire medical procedure would have a process that would view a nurse as a conduit provider under instruction from a medical specialist who is superior to the nurse in terms of patient diagnosis and subsequent prognosis from the presumably subordinate clerical staff and orderly. In which case it may be clearly identifiable for any layman patient in understanding the medical process when entering a medical surgery or hospital.

  • guest

    I am sure you do great work and are a caring and competent practitioner.

    A US residency is an arduous and intense process that involves thousands of hours of post graduate education and supervised clinical activity. Ask any medical student if they felt ready to care and be responsible for patients straight out of school. I will bet 99% of the time the answer will be NO. Yet the NP believes just this with just a fraction of the education an MD or DO receives.

    I find it concerning a bit that NPs think they are anywhere near as educated as a physician!

    • Mike Pappas

      On training, you are correct. But, please remember that most of us become the people we are AFTER our training, not just from our training. If we read, learn, and educate ourselves to become better, those many years of “practice” can make us excellent, regardless of our designation.

    • ErnieG

      In addition, medical school admission is much much much more competitive than RN/NP/PA school admission. The best students don’t aspire to RN/NP/PA schools. The intellectual capacity of medical students is much greater than RN/NP/PA students.

      • Lisa

        The barriers to becoming a doctor is greater than the barriers to becoming a RN/NP/ PA, but I I think you are on thin ice comparing the intellectual capacity of medical students versus RN/NP/PA students. What you should be discussing is the ability to perform academically, take tests and the willingness to dedicate years of life to training.

      • guest

        Yes, it is much more competitive but I wouldn’t assume that there aren’t RN/NP/PAs who could not have gone to medical school if they chose to do so.

        I was at the top of my class. I started out pre-med, and I made better grades in chemistry & other pre med classes than classmates who are now physicians. Ultimately, I decided I didn’t want to spend all of that time going to med school, I didn’t want the debt, and I didn’t want all the responsibility. I worked in the business field for years, before going back to school for a BSN-RN. Did I aspire to be a nurse? No, I can’t say I did. But, we aren’t all in these jobs because we were incapable of doing more.

  • HeisenbergHattie

    When I began my RNP career, it was part of my job to explain what “Nurse Practitioner” was to my patients. I explained the differences and the similarities between my RNP training/experience and MD training/experience. It was time-consuming, but worth it. Patients began asking to see “my nurse practitioner” when calling for an appointment. Relationships and trust were built using that (accurate) title. Depending on the sophistication of the patient, they might call me “Doctor” regardless of my explanation. Particularly my Hispanic patients. I would correct them once, then I would drop it. Never once did any patient refer to me as a “mid-level”. I think the reason for that is because it is meaningless. I hold no degree that announces my completion of “mid-level” training. I think accuracy is important clinically. I also think accuracy is important when describing what a person’s title is. Especially if there is a graduate degree that clears things up. Thanks for reading.

  • Nicholas

    Advanced Practice Provider (APP) is that modern term you’re looking for.

  • Charlie Buscemi

    the error in calling NPs mid-level is that it suggests that we are “half-way” there in terms of medicine. Which might be correct for PAs but NOT NPs. NPs are educated (Master’s and Doctorates) in colleges of nursing, take advanced practice nursing board certifications and are licensed by boards of nursing. We practice advanced practice nursing NOT medicine. In 18 states (and more soon to come) we are fully independent clinicians. so yes, STOP calling us mid levels.

  • HeisenbergHattie

    The 2009 film “Hangover” … Stu tells ER MD “I’m a Doctor”. Everyone else says “You’re a dentist.” Cracks me up.The actor playing Mr Chow is an MD in real life. I used to work with him at Kaiser. (just lightening the mood)

    • Mike Pappas

      Can’t beat a “doctor” with a sense of humor. Appreciate the comic relief.

  • Chiked

    Just as long as you have the decency when you walk into my room and make it clear that you are a DNP and not an MD. Many patients want to be seen by an MD and it is wrong to suggest to them otherwise.

    • NPPCP

      Agree 100%. Absolutely. Many states have laws with serious fines to prevent this. I agree Chiked.

  • Chiked

    “Let’s be logical and think about this. “Mid-level” implies that he or she provides middle of the road or average care, not high-level care. Who then delivers high-level care? It must be the MD, of course. So, who delivers the lowest level of care? Nurses?”

    You are showing complete ignorance of what nurses do. Unlike PAs or NPs, they actually have a separate training pathway which is why no one ever refers to them as lower. The same for pharmacists or dentists. Midlevels or whatever you want to call them train differently….dare I say under supervision of doctors. If they want the same level of respect, establish a separate standalone pathway or shut up.

    • NPPCP

      Well dang. Again, who asked for the same level of respect? When and where? We ask only to be called who we are – NP. Please don’t use the term mid-level. Why is this so difficult? You MD, me NP. That’s all. That’s it. Any use of the term “mid-level” is out of sheer disrespect and disdain. I can’t think of anything anyone else could say about this.

    • Mike Pappas

      You can’t use the expression “mid level” without an upper and lower level? So, who is the lower level?

      • Chiked

        If you want a hard definition, medical students and interns.

        • Mike Pappas

          If medical students and interns are “lower level”, then 2nd and 3rd year residents must be “mid-level”. Is that your point?

          • Chiked

            No. My point is that once you have an official license to practice medicine, as a 2nd or 3rd year resident should, you are legally held to the same standards as any other doctor. You are not a “mid-level”.

  • Anne-Marie

    This is all totally fascinating but I hope we don’t lose perspective. At the end of the day, a title is just that – a title.

    To patients (yes, patients! Remember them?), your title certainly does tell us that you’re licensed and credentialed in your chosen discipline, that you’ve completed all the required training and presumably have an acceptable level of competence.

    It doesn’t tell us whether you graduated first in your class or at rock-bottom. It doesn’t tell us if you’re kind, a good listener, nonjudgmental and good at problem-solving. Do you keep an open mind about the patient’s diagnosis? Are you able to think outside the box? Do you recognize the limits of your knowledge and abilities? Will I feel OK confiding in you? Can I trust that we’ll be on the same side? Will you accept responsibility when the care falls short?

    Odds are that if you made it through your training, you can probably answer “yes” to all of these. But a string of initials after your name is not a proxy for having all the right stuff. You also need thinking skills and people skills, and don’t kid yourself that patients won’t know the difference… because we do.

  • ErnieG

    This whole discussion is weird. I really don’t think the
    term “mid-level provider” was intended to “put down” NP or PA. I see it more as an administrative title used by hospital suits, and by the DEA, rather than a strange way to make NP or PA feels inferior. If that was the intention, there are much more subtle, indirect, and probable unintentional ways put down an NP or PA that actually
    mean something. It is akin to calling physicians providers—I personally don’t give a hoot. When patients see me, they see an MD after my name, have certain expectations that I either meet or don’t meet. I don’t call other physicians provider, such as “you will see another provider if I am not here” or use “mid-level” such as “this is mid-level so and so”. This dislike of the term seems to be self-image problem, but if NP and PA don’t like to be called “mid-levels,” then I’ll do just like I did with my cousin Cesar, who didn’t like to be called “Ceasar salad,” I just called him Cesar to keep him from crying. Now calling NP or PA “advanced practice providers”—that is something even weirder. I think physicians should be called “super advanced practice providers,” or SAPPS, because that is likely all we’ll end up being. In the end, this “respect” demanded by anyone is over-rated anyway.

    As an aside, the most subtle, indirect way I once unintentionally put down an “advanced practice provider” was to ask the cardiology NP
    who equated SOB with heart failure whom they proudly “diuresed” but did not improve was what the estimated JVD was, if they actually had hepatojugular reflex, and how much weight was lost overnight. There was not much of an answer. Seems like those “wet” crackles really were the patients ILD he had all along, and the x-ray really did not have vascular congestion. And all this from a rheumatologist who was
    consulted because the guy developed a gout attack from the furosemide. It was not that I enjoyed it, just that the patient really did not benefit. The NP did not like it because I was “mean to her,” or said the cardiologist SAPP.

  • Patient Kit

    I like Sage-Femme.

  • guest

    I agree with you. I also think people who are not physicians should stop wearing white coats. I was required as a research nurse to wear a white coat with the dept name on it any time I met with patients. Even though I always introduced myself as a nurse, there were times when patients either didn’t hear what I said or forgot. I was mistaken for a doctor on more than one occasion and quickly corrected the misunderstanding. Patients may be stressed or have hearing difficulties, and they may not hear half of what is said. The positions need to be very clear. I am a nurse not a physician. I asked if I could opt out of wearing the white coat and was told it was mandatory. I felt like a fraud, playing dress up in a doctor’s clothes. Luckily I’m not in that position anymore. I don’t miss the white coat.

    • Suzi Q 38

      Who cares.
      I know who my doctors are.

      • guest

        I cared because it was deceptive to patients and visitors. I worked with very sick patients who had multiple physicians in white coats coming in and out their hospital rooms. The last thing they needed was a nurse coming in wearing a white coat to further confuse the situation, and confuse them it did. Nurses don’t need to wear white coats.

        • Suzi Q 38

          I never understood the white coat thing anyway.
          Make all of the coats, including doctors, different.
          Doctors should have dark colored coats, to conceal the stains.

  • Charlie Buscemi

    Actually it does give me the right. In Florida, legislation preventing NPs from using the Dr title was struck down.

    • Ava Marie Wensko George

      Wow~ In Florida? Congratulations to common sense :)

  • Charlie Buscemi

    Lucky for us your objections mean nothing

    • Ava Marie Wensko George

      Bravo! :)

  • Mike Pappas

    No. DOA stands for “dead on arrival”, and is dry humor. It has nothing to do with DOs. DO = MD or maybe even DO > MD or vice versa; it depends on the doc.

    • JW

      I laughed. :)

  • Mike Pappas

    Point taken. Thank you.

  • Mike Pappas

    Thoughtful response. Thank you.

  • Suzi Q 38

    In reality Sean,
    You are still a “little fish” in a huge ocean of other fishes.
    With your superior attitude, I am sure the world will be at your feet in no time.
    And what is your specialty? You mean G.P. or F.P.?
    Ask Buzzkillersmith about that. He will tell you how hailed you will be when you get out to the real world.

    Every degree, career or job deserves some level of respect.
    If you don’t offer respect to others, you won’t be getting it in return.

  • Lisa

    I certainly understand what an OD degree is.

    I’d tell a friend my dad was an optometrist and they say “oh he is an eye doctor” (meaning ophthalmologist). Well, no . . . My dad suggested that I use the explanation above in response to my friends who thought he was a medical doctor. He thought his PhD (and the fact that he was a professor of optometry) was what entitled him to be called doctor.

  • Lisa

    I don’t think it at all unethical for someone who has a doctorate degree to to introduce themselves as Charlie Buscemi described above: “Hello, I am Dr. Buscemi, your nurnse practioner.” Actually, I like that solution because it gives me a lot of information. It tells me someting about the persons education in addition to telling me about their professional role.

  • Lisa

    Um, my dad got his graduated from optometry school and got his PhD over 60 years ago. One of my sisters is an OD. I really think I understand how the education of optometrists has has changed, especially over the last 25 years.

    I was just trying to indicate my understanding of the introduction that Charlie Buscemi uses.

  • querywoman

    American English speakers currently love to call a place or person something other than its proper names. On a different thread, look at the practicing of doubling celebrity names: Brangelina, Kimye, etc.
    Give me a nurse practitioner or a physician’s assistant. I do not want a midlevel or a physician extender. Physican extender – does that imply a yardstick attached to an arm?

  • QQQ

    Oh boy, the drama on this topic turning into a classic soap opera now! Let me get a box of tissues to wipe the tears away! 8…^(

    *sniff* This is better than The Young and the Restless” *sniff*

    https://www.youtube.com/watch?v=AUFQ4Fmy8FI

    • Mike Pappas

      Most of us here aren’t “young”, just restless.

  • Patient Kit

    I wonder, if we quizzed the public, how many think Dr Phil is a medical doctor. Psychologist, psychiatrist. Both are routinely called doctor.

    • NPPCP

      Nice! So true!

    • PrimaryCareDoc

      Dr. Laura, too. Her PhD is in physiology!!

      • Patient Kit

        Not to mention Dr Joyce Brothers. It was my psychotherapist sister (MSW, not Dr Sister) who pointed out to me — when I mentioned this discussion to her last night — that psychologists, who have a PhD but no MD, have long used “Doctor” professionally.

        • ninguem

          In Washington State, if that nurse practitioner with an interest in mental health were to use the term “psychiatry”, or “psychiatric” in signage or stationary, with the clear intent to mislead the patient into thinking same nurse is a psychiatrist, that’s OK.

          If that same nurse used the term “psychologist”, “psychological”, “psychology” in advertising or signage, that same nurse would be in violation of RCW 18.83.020, unlicensed practice of psychology.

          http://apps.leg.wa.gov/rcw/default.aspx?cite=18.83&full=true#18.83.020

      • Suzi Q 38

        And she makes a lot more money talking and listening…..

  • Charlie Buscemi

    what exactly is not ethical in saying “Hi, I’m Dr. Buscemi, your Nurse Practitioner”? I am clearly stating that I am a nurse practitioner. IF they need further clarification I am more than glad to do so. The public needs to be informed that many NPs, CRNAs, CNMs have DNPs and PhDs.

    • Mengles

      The patient doesn’t have the time or patience to hear a rigamarole about the different positions in the hospital. Saying Dr. at the beginning when patients think they’re getting a doctor, and thus tune out the later part about being an NP is unethical.

    • RuralEMdoc

      The public doesn’t care if people in those professions have a research doctorate.

      Most American’s don’t need research, they just need a rectal…….

  • Charlie Buscemi

    my patients have NEVER been confused. I always follow up my introduction with an explanation. They are proud that their NP has a doctorate.

    • RuralEMdoc

      Never??? Ever??? Not once. Absolute clarity and understanding is achieved by every patient?????

      What is to there be confused about. You wear a white coat, and call your self Dr. Buscemi, but you are not a physician. Super Clear. No opportunity for confusion.

      Most of my patients can’t even name a single medication they take (except for Norco, they always remember that one).

      On another note, they really do not care if you have a doctorate, as long as you can refill said aforementioned prescription.

      • roy123

        But as health care professional you should care, We are supposed to protect our patients and that means being critical of the people taking care of them and how they are trained

  • Lisa

    UCB started offering an OD degree in the later 60′s, after changing the program from 5 years of study post high school to one requiring six years of pre-optometry and optometry curriculum. So I am not even certain my dad has an OD degree. I’ll have to check on that one.

  • Charlie Buscemi

    His objection to NPs getting PhDs has nothing to do with his care. He has the option to seek his care elsewhere

  • Charlie Buscemi

    I agree, deliberately trying to represent a physician (or any other provider) is fraud. However, as I have posted here, I clearly state that I am a Nurse Practitioner.

    • roy123

      Not according the case in PA. A jury agreed with the patient that the NP was internationally misleading by using “Dr.” Now all badges have in red “Nurse” “physician” so not confuse. It is YOUR job to not mislead.

  • NPPCP

    Mengles and Charlie (I know mengles posts well) – PLEASE STOP. Mengles, stop chasing him around and flea biting! Charlie – you introduce yourself as Dr. Buscemi, the Nurse Practitioner and it is legal in your state. Johanne has commanded you to stop. Mengles is going to tag you with every post. Neither likes the fact that you do this and feel it is unethical. We are ALL CLEAR on this. You all fail to agree. So we are all good and life goes on and nothing changes. Please, you are filling the comments up with nothingness.

  • NPPCP

    And you have hit the nail on the head. The comments could be closed with this being the last one. It “has always been this way” so it should “always be this way.” One thing is certain, things never stay the same. And somehow, miraculously, they always work out in the end. Other healthcare professions will continue using the doctor title and things will all be alright. NPs see 1 out of every 5 patients in this country and that doesn’t include those patients seen by the NP but billed under the physician who never sees them (now that is unethical). AND, things will all be okay. I am amazed at all of this. :)

  • Chiked

    Yes, there are many types of doctors but they all work in separate settings. Big difference.

  • Lisa

    I said I have never heard an NP refer to themselves as a doctor and I do pay attention. Don’t assume because I am a patient that I am stupid, ignorant, or oblivious.

    To me, the fact that a person has a doctorate is important. It indicates their level of training. If I were to see a NP who had a doctorate on a regular basis, I would want to know where they got their degree and what their field of study was.

    • PrimaryCareDoc

      The problem is that most NP doctorates are not clinical, but research or public health based. They can be earned through online programs.

  • ninguem

    You can beg to differ all you want, I don’t care. I see it all the time.

    No, physicians don’t own the title of doctor.

    If doctors changed their title to “ballerina”, the programs would start producing “nurse-ballerinas”. What they’re trying to do is obvious and deliberate.

    When the word “doctor” is in 24-point type on the business card, and the word “nurse practitioner” is in 8 point type, it’s pretty clear what they’re trying to accomplish.

    • DeceasedMD

      what i can’t figure out is in Europe the specialists are called “Mr.” instead of Dr. In fact i think they might be insulted if you call them doctor. Go figure.

  • buzzkillerjsmith

    People too? Foibles?

    Maybe. Sure, I put my pants on one leg at a time, but once my pants are on, I perform medical miracles. Whilst listening to BOC.

    https://screen.yahoo.com/more-cowbell-174128899.html

  • Nicholas Baker

    Because in clinical practice it is disingenuous and confusing to patients. In an academic setting it is perfectly legitimate.

  • Mike Pappas

    I agree with you. That’s what the article is about. Being aware and respectful of all of our colleagues. Nothing more and nothing less.

  • Mike Pappas

    It’s just that simple.

  • Mike Pappas

    Agreed. That’s why “mid-level” is an unnecessary label. NP, PA, MD, DO, RN work just fine.

  • Mike Pappas

    Yes, that is true. The doctor is ultimately responsible for the patient. That is not what this article is about. It is not about PAs or NPs being better than MDs or DOs. It is about using a term has no medical or legal foundation. That’s all.

    • NPPCP

      Dr. Pappas, concerning NPs – especially in independent states – the ultimate responsibility rests with the NP. There is no tie to a physician. The physician holding the final liability no longer applies in our current medical system. Thank you.

      • Mike Pappas

        Thank you. Can you please tell us which states are independent??

  • Mike Pappas

    If you stop referring to NPs as “mid-levels”, I’ll bet they’ll back up your request to not refer to EMS pros as “ambulance drivers”. It can work both ways. It’s about respect.

    • NPPCP

      You got that right!!!

    • Chiked

      Yeah, but then the MAs (medical assistants) wouldn’t want to be called that either because of who knows what. Then the security guards would want to be known as “hospital defense officials”. I mean this could go on.

      If you really think this is about the mid-level moniker, you are naive. This is about blending dare I say merging of all providers so that one day they can all be paid the same thing regardless of the pathway of training. The only loser would be the patient.

      • Mike Pappas

        This article is about being respectful to one another. That is all. I know because I wrote it.

  • Mike Pappas

    Agreed. That is very clear and honest.

  • Ava Marie Wensko George

    I totally agree. When I receive my PhD, I will be Dr. George….Period. Not a physician who also has a doctorate, but a doctorate in my field of practice. When I earn it, I’m keeping it.

  • Ava Marie Wensko George

    Why should a PhD have to qualify their credential? It is not more accurate….You are asking this PhD to completely discount their education. We need to educate the public rather than discourage someone who has worked hard for their doctorate to just gloss over it because our patients are not used to NPs with PhDs….

  • Ava Marie Wensko George

    Did Dr. Buscemi earn a doctorate? If he did, then it is not about ethics at all.

  • Peter Schwimer

    The Chair of my hospital dept. used to refer to all non-MD’s as physician extenders. It would be best I suspect if we stopped worrying about our presumed hierarchical status and just referred to ourselves by name and profession.

  • Joe

    Am I off-base for thinking that there are way bigger things to worry about?

    • T H

      You would think so, but people prefer to argue over trivia because it is safer and easier than arguing over the bigger things.

  • Patient

    One reason could be when we sign up for insurance, we need to make sure our doctor is part of that insurance. Or choose a doctor who accepts our insurance. We are not looking at “which NP” is on the insurance. It’s deceiving to a patient to be treated by a NP, PA, etc. when they expect they are going to see an actual MD.

    • NPPCP

      I’m listed as a general practice NP on ALL major insurance plans I accept. You are able to choose me if you wish. If not, that’s fine too. Makes no difference. Plenty of patients to go around.

  • Rebecca

    This discussion has illuminated to me several things. First of all, not all nurse practitioners have a doctoral degree, but those who do should definitely be called doctor. They have a doctor of nursing practice degree, which means they have 4 years of undergraduate education (resulting in a Bachelor’s of Science in Nursing) and 4 years (8 years total) of graduate education and thousands of hours of clinical. They have a scope of practice that allows them to practice in specialty areas such as pediatrics, adult, older adult; primary care and acute care, etc. They should introduce themselves as Dr. XXX, your nurse practitioner, and their name tag should have the DNP degree noted on it. The public should be aware of the person who is caring for them – and the person’s credentials; meaning that the DNP has a very high level of education. They are not a medical doctor; (MD), but a DNP. MD’s and DNPs have a different scope of practice which each must practice within. They have similar years of education, but different scopes of practice. I do not think for a second that people are too simple minded to not be able to understand that kind of introduction. I have a Phd in nursing, and when I have clinical students in the hospital I introduce myself as Dr. XXX, Nursing Faculty at my university. Even confused people know that I am not a physician, and I have never once had someone say, “Call yourself Suzie nurse” instead of my professional title. Let’s give our public the correct information about us rather than treating them like they are stupid. Why are we still having this debate? Silly and pointless to be sure.

  • Martin Herman

    I think the premise is faulty. Saying med level doesn’t imply anything about the care, rather the scope of practice of the individual. Most mid levels that I work with render excellent care, some even better than some physicians I know. However their scope is limited, they know it and I know it. Patients should too.
    On another note, if this nit picking attitude about mLP vs Clinician has any teeth, consider how offensive it is to refer to the highly advanced department of emergency medicine as an emergency room (ER). I have worked in a lot of EDs in my career, only once was it a single room. Most are full departments with numerous beds, critical care nurses, and other ancillary staff. It is really demeaning and insulting to refer to the department as a “room”, as if it was just a place to examine patients. Likewise it is even more offensive an insulting to the highly specialized specialist in emergency medicine as the “ER doc” . We are specialists, many of us are sub specialists, having spent 4-7 years in training. We are EDPs ( emergency department physicians), or emergentologists, but never just “ER docs”….
    Would you refer to a sugeon as the operating room doc? think about it. DOn’t the physicians staffing the hospitals “front door” deserve the respect afforded other specialists?

  • Mike Pappas

    It actually is…

  • http://cognovant.com/ W Joseph Ketcherside, MD

    Undergraduate degree with straight A’s, medical school at the University of Chicago, 6 years of residency, and board certification. Sorry, but nurse practitioner is not the same as a board certified neurosurgeon. It just isn’t. It is a mid-level position. Yes a clinician, but they are not the same and it’s not right to act like they are.

    • NPPCP

      No one would ever compare an NP to a neurosurgeon. It’s like comparing an engineer to an artist. They do not even do the same thing and have nothing in common. Your point is moot doctor. Now caring for patients with various simple/complex maladies on a day to day basis – that is different. I do it every day (20-30 a day) in my private practice NP clinic. Nope – wouldn’t set foot in your clinic and even try to do what you do. BTW, I do take care of the local neurosurgeon and his entire family. I am their PCP.

    • Suzi Q 38

      “……Sorry, but nurse practitioner is not the same as a board certified neurosurgeon. It just isn’t. It is a mid-level position. Yes a clinician, but they are not the same and it’s not right to act like they are.”

      No one said that the two examples you gave (Np and Neurosurgeon) were the same….LOL. Surely you jest.

      This analogy would be similar to saying that a GP was the same as a neurosurgeon….Such hubris.
      No one thinks that an NP is the same as a neurosurgeon, just as I doubt that anyone would confuse a GP with a neurosurgeon.

      Besides which, if I needed a neurosurgeon, I would call one, but if I had other problems, a neurosurgeon would be of very little use to me.

      Please don’t insult the intelligence of many by stating that most of us would confuse NP’s with neurosurgeons.

      Believe me, we know what the difference is.

  • Patient Kit

    As a patient, until very recently, I was completely unaware of the epic turf battle going on between physicians and NPs. This entire thread highlights how big that battle is. I hope you all can somehow resolve your issues with each other soon so you can work together effectively against your common enemies. If not, they’ve got you exactly where they want you — divided and conquered. And, looking at the big picture, that is not good for physicians, not good for NPs and not good for patients.

  • NPPCP

    Two things – After all of this – you still used “mid-level.” Next – reality is NPs completely take the place of physicians already. It has been going on for years. I own a private practice NP clinic without “family physician involvement.” So the “never take the place of a physician” is a faulty statement. The “should be responsible” is an opinion. I understand where you are coming from – we just disagree and that’s okay. Kaya, are you an independent provider like me?

    • Chiked

      The argument I hear so much is that NPs or PAs are already doing the jobs of MDs and so therefore calling them mid-levels is inappropriate.

      Forgive me for this example but I want to make sure I am clear. Walmart and Amazon completely vaporized independent stores and bookstores across the country. Not because they were better or even close to equal but the market forces tilted the playing field.

      These market forces today would be malpractice, reimbursement, salary etc etc. The fact is that the best medical students are running away from primary care and those who are remotely interested, do not go to the rural areas.

      This fact does not mean NPs or PAs give equal or better care. It is just market forces at play again. Proof that NPs or PAs provide equivalent care is when you can take fresh graduates from each program and compare them. I highly doubt it will be a contest.

  • NPPCP

    Your comment continues to expose the circus-like atmosphere here. just call us what we are. Love all this!! We are only missing appetizers and drinks!

  • NPPCP

    Close to the truth but you are on to it! It’s okay if I am employed and see you and the physician owned clinic gets the payment. I am completely safe then as they will never see the chart or the outcome. But if the payment goes to my private clinic – WELL!! You know the rest of the story…..

  • NPPCP

    How about calling them the NP or the PA? Too much to ask? Too taxing? No, not really.

  • EmilyAnon

    caveat emptor

  • Dave Mittman, PA, DFAAPA

    It is unbelievable how we can not get out of each other’s way. “I am better than you” should be the medical care professional slogan, regardless of the profession.
    And regarding the doctorate, why would anyone NOT want the highest educated person in that profession seeing a patient? It’s insane to not want that, unless your motives are something else than looking out for the patient.
    Dave

  • Anne-Marie

    “I have patients who don’t care if you’re the janitor.”

    Good grief. They *should* care. The whole point of training and credentialing is to help ensure patients are being cared for by people who know what they’re doing, whatever their scope of practice may be.

    • Suzi Q 38

      Maybe the NP or PA does know what h/she is doing.

  • EmilyAnon

    I absolutely agree on this. When a patient is in the exam room waiting to be seen, a million things whirling through their mind, Door opens, “Hi, I’m Doctor…………..”
    that’s the only word that registers.

    • HJ

      When I am a patient waiting in the exam room, I have already done a great deal of research about that person walking in the door.

    • Lisa

      That simply is not true. Before I make a medical appointment, I have know who I am going to see and a fair amount about their credentials. Part of my due dillegence.

      I am not so awed by the word doctor that I am not going to pay attention to the full sentence of introduction.

      • EmilyAnon

        “That simply is not true.”
        Are you saying my experience is not true, but your experience is? There are no absolutes with anecdotes. They’re just personal stories.

        • Lisa

          You said “a patient’, implying every patient has the same experience that you do. If you had said that was your experience, I would not have objected.

          • EmilyAnon

            then your blanket statement “that simply is not true” implies that it is never true. You should have qualified it with “in my experience”.
            We could go round and round with this, but I’m sure it’s boring everyone.

  • EmilyAnon

    “I have patients who don’t care if you’re the janitor.”

    Wow, what a low opinion you have of your patients. Some guy comes into the exam room with bucket and mop and patient immediately lays back on the exam table waiting to be examined. A silly metaphor.

  • logicaldoc

    Patients refer to PA’s and NP’s all the time as their “Doctors”. They don’t know better. Of course PA’s and NP’s can do just as good of a job for the common obvious ailments. I work with them all the time and the good ones know their limitations and actually engage me often. However, please tell me what grueling Residency program these “Providers” went through and please tell me why I then bothered to become an M.D.? It certainly wasn’t for the money; I could have made millions in 5-10 years coming right out of an Ivy League University straight on to Wall St. Also ask yourself who you want running the Code when you are the Patient in the bed with no heart beat.

  • Doug Capra

    Context is extremely important. No, physicians don’t own the title of “Doctor,” but within the context of a hospital or clinic, it’s logical to assume that the title “Doctor” means a medical doctor. Introducing someone as “Doctor,” in this context, followed by an explanation that the’re really a PA or NP, can be tricky. What medical professionals say and what patients hear can be different. I think that within a medical context (hospital, clinic, etc.) Physicians and Doctors are just that, and anyone else is what they actually are and that must be made clear to teh patient.

    • logicaldoc

      Exactly; should be “made clear”; and that means more than once the first time around.

  • Santa Diego MD

    I may be in the minority, but I agree entirely with the article. In my experience, the term “mid level” is used only in administrative circles. I don’t like the term because it is imprecise, and I view it as an insult to my friends who are PAs and NPs. I would never call a PA or an NP a mid level. I just refer to them by professional degree. As we all know, “mid level” is not a professional degree, nor is it a job description (e.g. physical therapists are referred to as “PTs” because it describes their job, even though it is not their degree). I agree that Mid Level is a slang term that should be eliminated. It implies status differences where true status differences do not exist. I do think it is a slur. If we keep the term, should we expand it to include: primary care MDs as “high level providers,” some specialists and general surgeons as “high level providers,” and subspecialists and specialty surgeons as “very high level providers?” It makes no sense to me.

    • Mike Pappas

      Thank you very much. No argument from me.

    • Suzi Q 38

      Agreed.
      Should the GP, FP, dermatologist or allergist be called a mid-level physician??? If physicians like to use this term, it will only be a matter of time when it becomes a viable term to describe some of them.

  • ninguem

    Thanks for the laugh.

  • Chiked

    Very true….and in 10 years from the now, the “new” mid-level name will be attacked by some as not being appropriate.

  • Patient Kit

    Do you really think it doesn’t matter whether we patients know whether we’re being treated by a physician or by a NP? Seriously? It doesn’t matter whether we know?

  • EmilyAnon

    You mean the patient will be greeted in your ER with “Hi, I’m Joe Smith, I’ll be treating you today.” And providing your title takes too much of your time?

    At my hospital there is a list of patient’s rights in every waiting room. One of which is “Patient will know the names and professional relationships of physicians and non-physicians who will see him/her.” And the patient doesn’t have to prod to get that information.

  • Lisa

    I just realized this article has more comments that some of Dr. Wible’s most popular ones.

    • buzzkillerjsmith

      Really. We need to leverage this somehow, two weird tastes that taste even weirder together.

      Perhaps we can come up with an article in which doctors and NPs savage each other in the harshest possible terms over the question of who is better qualified to be almost comically inappropriately intimate with their patients by coming over to the patient’s houses, feeding them dinner in their adult high chairs and giving them rubdowns with baby oil and then changing their adult diapers, telling them we love them and then putting them to bed with a kiss goodnight.

      • Lisa

        Snort . . .

  • Deanna Tolman

    Kevin, thank you.
    And Anne-Marie — comparing a nurse practitioner’s 6-8 years of post-high school education, increasingly finishing with a doctoral degree, years of patient care experience, and board certification to a high school graduate CNA is just one more insult. You should be ashamed of yourself.
    My patients call me whatever they want, my 1500 patients in my independently-owned nurse practitioner family practice.
    Deanna Tolman, DNP, FNP-BC, DCC
    Head2Toe HealthCare, LLC, Aurora, CO

  • Suzi Q 38

    I agree with most of what you are saying, but NOT with your last paragraph.
    The term “midlevel” is disrespectful.
    How about we call GP’s and Fp’s, who did not stay in school to get their specialist degree only “midlevel physicians.”

    Nice.

  • Suzi Q 38

    With the ACA, (which is the reason why so many doctors voted for Obama), there will be a lot more PA’s and NP’s functioning in hospitals as hospitalists.

    Reality.

  • Suzi Q 38

    I know that they are not the same, and I am a patient.
    I also know that they can provide a good deal of patient care.
    I have seen one or two this year.

  • Suzi Q 38

    Why should he?
    “Hi, I am Doctor Smith,” I am your psychologist, which is not an MD.”

  • logicaldoc

    Well said Brian Smith; the truth and nothing but the “truth”.
    Some people who haven’t experience Medical “Residency” programs simply have no clue how intense and consuming it is (which ultimately is where you learn to be a “real” Clinician).

  • logicaldoc

    Funny with all the continued commenting how no one has been able to logically answer the question I posed (which ultimately proves the point): So please tell me again why I even went to Medical School?
    (implication of which obviously includes follow up by Medical “Residency”)

  • buzzkillerjsmith

    The thread that wouldn’t die!

  • rational2012

    A nurse practitioner is a nurse. That’s why the word nurse comes first and is the noun in the phrase. He or she has an extra qualification, but is still a nurse. Sort of an advanced nurse, if you will. Maybe a prescribing nurse. Why is there even a distinction between NP and PA? Because of diploma-inflation? Schools selling education? Or is it because nurses have an inflated view of themselves and seek something to justify and promote themselves? Patients, especially under-educated or overly-sick patients, cannot tell what these people are licensed to do. Why trust them at all? A physician has been called doctor for so long, imagine him or her having to be referred to as a nurse-superior or some other such thing that emphasizes his or her status vis-a-vis nurses. A nurse is a nurse is a nurse and I usually don’t like them much, for good reason. They need to stay in the box where they belong.

  • logicaldoc

    So please tell me again why I even went to Medical School followed by Residency? lol; no logical response yet.

    Brian Smith; you keep hitting the nail on the head:
    “The problem with DNPs is that they are diagnosing, analyzing test results, and prescribe medications – essentially the same thing as medicine.”

  • DeceasedMD

    Well that is quite interesting. I met a specilist once from the UK and I felt like I was insulting him calling him doctor. I had to keep reminding myself he was Mr. But Robby, why are specialists wanting to be called Mr. or Monsieur, which does not distinguish them from anyone else?

  • logicaldoc

    I wrote a book in 2009 doing just that (my attempt to educate the public): exposing what the difference is as part of my overall answer to how to reform healthcare. Right now I’m giving it away free on Amazon. Check out the initial Comment/Warning in the “Look Inside” feature. I wholeheartedly agree with every statement you make (ironically many of which are in my book). I predict once the Extinction of the Primary Care Physician (chapter in my book) comes to fruition, 10 years later, you will begin seeing the average age that people live to begin to come down again. BTW, you used a Cardiac example. I wonder if any would ever be able to recognize a case of Wegener’s granulomatosis or decline the clinical diagnosis of Rheumatoid arthritis because the blood test came back negative.

    http://www.amazon.com/Only-Prescription-Healthcare-Reform-Perspective-ebook/dp/B004QTOOAS/ref=sr_1_1_bnp_1_kin?ie=UTF8&qid=1406001305&sr=8-1&keywords=louis+lobalsamo

  • C2

    In a hospital, physician’s office, ED, clinic….ANYWHERE that PATIENTS only know that the word. “Doctor” means PHYSICIAN…. YES. THEY OWN IT ONLY THERE. I am not taking anything away from the PhD’s who have worked hard, but introducing your academic-only title when caring for a patient where the word doctor means only one thing, is weird and wrong. WHY DO IT knowing it means that in a clinical setting? Not one person has responded as to why? And I’m not talking about “my education has given me the right to do so”. I’m sorry, but when someone knows that word means physician in a clinical setting and they use it as their “right” to introduce themselves as Dr. I have to wonder why. It’s wrong, period.

  • kidmodel

    Medicine is full of these euphemistic descriptors and physician specialities are equally guilty of tacit slamming. Consider the phrase, “non-dermatologist physician” which I often read in the literature of my specialty…..OK, this means a physician, ostensibly an MD/DO who is NOT a dermatologist, right? To what end are we using such language? Certainly not to educate the patient who does not read these publications. Hence we have deteriorated to defining one another as what we are NOT. NPs, PAs, etc., are termed, “non-physician providers”. Is a woman a ‘non-man’, or a baby a ‘non-adult.’ Please, let’s all grow-up? If the issue is REALLY one of making certain that the patient knows who is ‘caring’ for them, then I suggest we need more time in the OV for the explanation of whose credentials mean what is almost an undergraduate course in itself! I get that we instinctively want to protect our turf and may even propogate the prejudical mind-sets of our respected ‘thought-leaders’/professors, but lets be mindful of the REAL issue which is (or should be) genuine patient safety. After all, we KNOW that quacks and snake oil salesman can be found in even the highest physician ranks. Recent government hearings involving the once-revered, bonafide cardiothoracic surgeon Mehmet Oz and his nefarious recommendations have illustrated all too well that competency and ethical behavior is not a matter of training or degree. Ethics cannot be legislated, but GREED seems to remain a most powerful motivator for despicable behavior.

    • querywoman

      As a chronic dermatology patient, I assure you that dermatology is the one specialty in which “non-this-specialty” labeling makes sense.
      I know that’s not your subject.
      But ignorance of skin is legion among the non-dermatologists.
      Personally, I would not want to use the media wh0re Ozball as my surgeon. I researched him recently and learned he is truly a highly skilled surgeon. I still don’t want him!

  • Lisa

    Reese, clearly the medical practice should state who the appointment is with and their role. In your scenario, the practice doesn’t do that.

    My dermatologist has a NP. If I call for a routine appointment (ie skin check), I am offered an appointment with my dermatologist in a month or so. On the other hand, I can see the NP sooner. But the practice makes it clear who the appointment is with and their professional role. Seems simple enough to me.

  • roy123

    That is exactly why only board certified er physicians should see people in the ER. Otherwise you are just watering down care. We need to ask ourselves, why don’t we have enough physicians.

  • Kaya5255

    NP’s and PA’s ARE mid-level practitioners. They are not physicians. They do not have the level of education that physicians have, nor do they receive the level of clinical experience physicians get via residency.
    Mid-levels DO provide appropriate care, but as a healthcare consumer, I want their activities supervised by a qualified physician.
    I don’t expect the MD to stand over them, but they do need supervision.

  • SteveCaley

    The difference between the ubiquitous epidemic of vanity in American culture and the Ebola virus is that there is some hope for cure of the Ebola virus.

  • TheresaWillett MDPhD

    But for regular, longitudinal relationships, the family may indeed care. I have definitely earned the trust of patients based on my ability to explain more whys than some of my colleagues could do or chose to do. Anyway, I would be “Dr Dr” under these rules, and that just makes me want to sing silly 80s songs. Within the setting of the US healthcare system, and in the setting of a patient seeking care, a Dr. = physician. Maybe we need to create more effective and glib shorthand for other levels of training. If I were in a science setting, I would think Dr.=PhD. It is all about context. Now back to Robert Palmer…

  • Ava Marie Wensko George

    Dr. Laura’s extreme right wing political leaning tanked her career, not her use of the credential. She still is Dr. Schlessinger because she earned it.

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