Solving the mid-level dilemma: Call them what they really are

Solving the mid level dilemma: Call them what they really are

Dr. Michael Pappas hates it when a nurse practitioner is called a mid-level provider: “Stop calling nurse practitioners mid-level providers.” So do I, though my reasons are a bit different.  In order to understand them it will be necessary to revisit those dark ages, a time when such individuals were few and the roles played in the drama we know as health care were more clear.

Back then there were doctors and nurses.  Sure, there were medical assistants and technologists but at the risk of hurting some feelings I will posit that for the purposes of this discussion they don’t count.  Most people understood the difference between the doctor and the nurse, and most held both in high esteem.  “The doctor will see you” was unambiguous.  “The nurse will be there momentarily …” to handle any one of the myriad problems you might have, each one important, but none rising to a level requiring the doctor’s intervention.  It almost seems quaint now.

But as the demands for health care rose the supply of physicians, doctors, to meet those demands failed to keep pace.  We were faced with a doctor shortage.  A number of possible solutions were suggested, among them, “let’s train more doctors.”  This wasn’t a bad idea but it did have some problems.

Getting accepted to an American medical school was, and still is, one of the hallmark achievements of my life. At that time, those of us who succeeded represented the top one-half of one percent of graduating seniors in terms of GPAs and test scores.  And we were graduating from top-notch universities.  An elite bunch, as it should be. Medicine is a complicated discipline with profound consequences.  Patients have the right to expect that their doctor is smart and willing to work hard.

Though it’s true that some qualified individuals were overlooked — that the bar to admission was set a little too high — I believe that was preferable to the alternative.  There was also the somewhat cynical fear that more doctors at work would lead to fewer dollars per doctor.   (It is ironic that we have arrived at a point in the evolution of health care where we have somehow managed to realize both of these outcomes simultaneously; insufficient numbers of physicians earning significantly less money than in years past.)

So the next logical solution was to create a new type of practitioner to fill the expanding void.  Enter the physician assistant (PA). The PA generally has an undergraduate degree and somewhere in the neighborhood of 18 months of PA school.  Once so educated, the PA is then able to work alongside a physician, and under the physician’s license.  PAs can be found throughout the health care delivery system; in private offices, public clinics, hospital ORs and ERs, and are in general a welcome addition to the team.  They are not, however, doctors.

Nurse practitioners (NPs) are unique in that they are not doctors but can practice within their specialty independently.  They have college degrees, nursing degrees, and additional training to achieve NP status.  Their expertise is focused and they tend to be good at what they do.  Again, though, they have less time invested in training than a doctor.

The term “mid-level” derives from the amount of training each of these clinicians has received, and is not a slur or some sort of slang developed to demean or minimize a health professional.  Still, I’m fine with avoiding this label.  In fact, let’s take it a step further and get rid of the term “provider” while we’re at it.  When I hear one of us referred to as a provider the image conjured is of a shady character standing in the shadows across the street from your local high school selling pot.

So let’s call it like it is.  “The doctor will see you” should remain unambiguous. Or, the nurse practitioner will see you, or the physician assistant will see you.  Though we all as humans were created equal, we have by virtue of the choices and sacrifices we’ve made distinguished ourselves in different ways.  Our patients deserve the truth, and each of us deserves the respect we’ve earned.

Jim Pagano is an emergency physician and chief medical officer, Precision Scribes.

Image credit: Shutterstock.com

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  • QQQ

    “Dr. Michael Pappas hates it when a nurse practitioner is called a mid-level provider: “Stop calling nurse practitioners mid-level providers.” So do I”

    I also hate that the media is doing doctor bashing! But you know that’s going to continue as well!

    • Suzi Q 38

      I hate the doctor bashing too, but some doctors are so crazy that they make the news, both on TV and the internet.
      We have to keep in mind that these doctors are in the minority.

  • familydoc

    We need to stop using the title “Doctor” when we mean “physician”. Then DNPs will be all over soon and (rightly) claiming the general title “Doctor” as well.

    “The physician will see you now”

    • JR DNR

      Patient’s don’t understand who is who anyways.

      Man who is being caring to me, giving me contrast to drink, and walking me down the hall to get the xray? “Nurse”. Man who is running the x-ray machine who is a complete jerk, leading to game of good cop bad cop by the two employees? “Doctor”.

      People who came and talked to my mother and asked her the same questions over and over (while ignoring my presence in the room) at the University Center – must be Doctors.

      Person taking your history in the ER who didn’t introduce himself? Must be a Doctor, he’s taking your case history. But why do the discharge papers list my “doctor” as being someone I never met?

      Resident? Physician’s Assistant? Lab Tech? Are those doctors or nurses?

      If your patient knows who any of those people are, they either work in medicine or are someone you should feel sympathy for.

    • Suzi Q 38

      I always called my doctor “Doctor.” I have never confused him with my professors from college, a psychologist, or the DNP. I am smart enough to know the difference, thank you.

      • JR DNR

        I actually get irritated at people who insist on being called “doctor” because it’s something they earned. To me it’s like being demanded to be called “knight” or “duke”. I don’t think any amount of education should change your name. “That’s DOCTOR X” just comes across as someone full of their own self importance.

        I actually like physician. I use “medical provider” or “medical personnel” to specific that I’m not singling out physicians or doctors but including medical students, residents, nurses, lab techs, and others.

        • Suzi Q 38

          Interesting.

          “…..I actually like physician….”

          I am glad that you do. Everyone is allowed to use whatever words they like.

          • JR DNR

            It’s good to know if there are words that hurt others so you can avoid them.

            It’s a bit harder when we talk about about professional titles, especially since everyone has such wide preferences.

    • Patient Kit

      I think a lot of patients who like their docs are emotionally attached to the word “doctor” and will have a hard time switching to saying the more clinical-sounding “my physician”. Most non-physicians don’t use the word “physician”. It just doesn’t have the warm, fuzzy history and connotation of “doctor”. In switching words, doctors might actually lose something of value. But then, I might believe in the power of words a little more than the average bear. I think it would also be a mistake to start calling chocolate something else too.

    • Reese

      I completely agree.

  • goonerdoc

    Ah, the latest battle of syntax. Will it (or can it) be productive, or will it degenerate into name calling and mudslinging as usual? Can’t wait to find out. I’ll be checking in often.

  • Suzi Q 38

    I have never called my doctor a “provider.”

    Once, one of my specialists told me to “Go back to your PCP.” I was not sure who he was talking about. I thought PCP was “Primary Care Physician.”

  • James O’Brien, M.D.

    I’m looking forward to another 350 post thread where we can all vent our spleens about being offended by technical jargon instead of focusing on real problems in medicine.

  • QQQ

    Hold on, let me get some popcorn and RC cola for this one! The drama is getting good!

  • Markus

    It is common in German (Doctor, Arzt), French ( docteur, medicin), and Spanish ( doctor, medico) to distinguish someone with an advanced academic degree from a physician.
    Of course, it usually takes about 15 seconds for the patient to discern if you are worthy of being a healer no matter what you call yourself (I will grant that they can be fooled.) When I was a junior in medical school I was being observed by a great senior staff physician. At the end of the exam, I thanked the patient. My mentor said that soon patients would thank me at the end of the exam. This turned out to be true. Credentials are important, but take notice of the thank you at the end of the exam.

  • Health is Wealth

    Introducing yourself as “Doctor” in any clinical setting implies to unsuspecting audiences that you are a physician. If you are not a physician, and still introduce yourself as “Dr. So and So” you are intentionally, or unintentionally, misleading clinic audiences.

    • Kaya5255

      You are absolutely correct!
      Visible name tags with the providers name and title would be a step in the right direction…but only if unobscured by lab coats, stickers, etc!!

      • Reese

        In my state, it is the law that hospital employees wear badges that clearly display one’s title; where I worked an NP would have a badge with an attachment that in large letters says, “NP.” It wouldn’t matter if s/he was an NP or DNP, the tag would still be “NP.”

        Patients hear “Doctor” and sort of tune wout whatever comes after that.

  • Jim Pagano, MD

    That may be true in Michigan but it is not so where I practice, in California. Here PA’s do practice under the license of a supervising physician, though the degree of supervision varies depending on the practice type and environment. PA’s can write their own prescriptions here.

    I agree that everyone should introduce themselves as what they are, and I have no problem with the word, ‘physician’. However, in a healthcare setting I think the majority of patients would assume the ‘doctor’ was in fact a physician. I also agree with @patientkit:disqus that the term ‘doctor’ has a certain time-honored warmth and fuzziness with which patients have become comfortable.

    • patricia kelly

      Having practiced as a PA in both California and Michigan, the PA roles are the same, and both are licensed by their respective states. The supervision that an experienced PA needs (and gets) is akin to the supervision a fourth or fifth year resident gets from the attending. A very experienced PA is usually treated as a colleague and consulted from time to time by their physician partner. The supervision a beginning PA gets is like the supervision a first or second year resident gets from the attending. I did a PA residency in emergency medicine at LAC/USC and was treated exactly like the MD interns when in the hospital and on call. The supervision a PA student gets is exactly like the supervision of a third or fourth year medical student. Both the PA, and senior resident, and the attending, have their own licenses and are liable for their own errors. There is cross liability in many situations because “interdependent” and team practice is now the norm.

      • Jim Pagano, MD

        As noted by @Brian Smith above, despite your experience at LAC/USC your training is not equivalent to that of your MD associates. I have worked with graduates of that program. They are well-trained PA’s, and after a few years in practice they can function well. As PA’s. Not as physicians. With a few exceptions they lack the critical assessment skills a physician has developed as a result of longer and more rigorous training.

        Still, PA’s have a place in the healthcare workplace and when properly utilized can provide a distinct benefit.

        • patricia kelly

          Never said that I was as well trained as my MD colleagues, because they went on for two more years of residency. To be clear, my residency was after PA school and two years of practice, and my rotation schedule was interchangeable with an intern on most of the services (we got more ED time). But of course, that additional two years makes a huge difference. Never wanted to be compared with an MD, just wanted to be a good, competent PA. I am retired now from clinical practice but I have seen huge contributions from PAs over my career.

  • Jim Pagano, MD

    I’m all for fighting that battle. Outlining a strategy to do so would make for an interesting discussion. I think @Brad_Majors:disqus would agree.

    • James O’Brien, M.D.

      No, I think what will happen is that we will adopt the Native American strategy circa 1850 and fight each other instead of the common enemy. Which is why we shouldn’t worry about words.

  • kidmodel

    A bit off topic, but interesting corollary: Thomas Jefferson’s University (The Esteemed University of Virginia) has a policy that ALL faculty are called Mr. and or Mrs/Ms. PhD notwithstanding. The ONLY faculty called “Doctor’ are Medical Doctors. Interesting fact
    Mr. JeffersonOut of respect for the founder of the University who did not have a Ph.D., University faculty are referred to as Mr. or Mrs. instead of Doctor, even if they have a Ph.D. Students and faculty historically addressed each other in this manner. Medical doctors are the exception to the rule and they should be referred to as Doctor.

    • CLJ Murphy

      In England and Australia, surgeons and specialist consultants are Mr., not Dr. They would find it demeaning to be mistaken for a mere “doctor”.

  • Patient

    Years ago, I would say Dr, but now I call my Dr by his first name. I feel more comfortable and he doesn’t mind it at all. I’ve also called him a few others names at times too … lol BUT I do have a problem when medical assistants call themselves nurses when they are not nurses.

    • Brian Smith

      Yes but medical assistants can do the same job as nurses do with half the training! They can obtain vitals, place IVs, administer medications, perform assessments. They are also willing to work longer hours and in rural areas.

      I support that medical assistants be allowed to call themselves nurses. After all, they do the same job as nurses but with half the pay. There is also years of research that shows MAs can obtain vitals, follow physician protocols, just as well, if not better, than nurses.

      The American Association of Medical Assistants (AAMA) have established scope of practice of MAs:

      Taking medical histories
      Explaining treatment procedures to patients
      Preparing patients for examination
      Assisting the physician during exams
      Collecting and preparing laboratory specimens
      Performing basic laboratory tests
      Instructing patients about medication and special diets
      Preparing and administering medications as directed by a physician
      Authorizing prescription refills as directed
      Drawing blood
      Taking electrocardiograms
      Removing sutures and changing dressings

      Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of medical assistants to practice to the full extent of their education, training, and competence. Medical assistants of today, future nurses of tomorrow.

      The nursing association has, for years, hindered our scope of practice for no other reason than turf protection.

      • Brian Smith

        The education of MAs is merely few credit hours shorter than that of an RN. Our local university has the curriculum of medical assistants with a total of 61 credit hours. RNs, at the same university, have to enroll in 70 credit hours of coursework. Furthermore, the NCLEX, the board certification exam that graduating RNs have to pass, requires minimum of 75 questions to pass. On average, In 2009, the average number of items (questions) administered per candidate was around 121 on the NCLEX-RN and 115 on the NCLEX-PN examinations.

        On the other hand, the CMA (AAMA) Exam is a rigorous exam that requires a thorough, broad, and current understanding of health care delivery.

        The exam consists of 200 multiple-choice questions administered in four 40-minute segments (almost twice as long as the NCLEX). The National Board of Medical Examiners, which is responsible for many national examinations for physicians, including the United States Medical Licensing Examination (USMLE), serves as test consultant for the CMA (AAMA) Certification Exam. As a result, the reliability and validity of the CMA (AAMA) credential are of the highest order.

        Despite comparable training and possibly more rigorous board examinations, MAs are not respected as a profession. In fact, MAs, spend more time with patients than RNs. RNs on the other hand come in to the patient’s room to administer physician ordered medications at scheduled times and then run off to the computer to document their notes. MAs, for years, have taken abuse from nurses, when at times, it is the MAs that have alerted the nurses when the patient is deteriorating, prevented nurses from overdosing insulin causing life threatening hypoglycemia. We do all of this in the face of insults to our profession, because above all, we care for the patient.

        It is the narrow minded, turf protection thought process, engendered by the nursing association that is limiting scope of practice for medical assistants. Medical assistants are not proposing to be nurses – we respect what nurses do, and we are not trained to handle ICU level patient care/NP level care, but we can and have been, for years, providing safe and efficient, assistance in outpatient healthcare. There is clearly a nursing shortage now that experienced RNs have advanced their education to practice under the supervision of physicians. According to the “United States Registered Nurse Workforce Report Card and Shortage Forecast” published in the January 2012 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country between 2009 and 2030. We strongly believe this can be alleviated, at least partially, by medical assistants.

        Please – lets not quiver over credentials, but rather, together, as a team, provide safe and efficient assistance in caring for the most important person, our patient.

        • Reese

          Can’t you write something that reflects your won thinking? This is a canned response that reads like talking points from some MA association

          • Brian Smith

            Sarcasm

          • Reese

            No, it’s the truth.

      • Patient

        I refuse to have an Medical Assistant touch me in anyway while at the doctors office. I do not even allow them to call me with results, etc. Too many mistakes have been made that I have personally witnessed for years. Years ago, I did not even realize who I thought were nurses were actually medical assistants and their scope of practice. It’s illegal for Medical Assistants to pass themselves off as nurses. You indicate medical assistants are shy a few credit hours compared to nurses. I don’t know what state you live in, but I have seen programs for Medical Assistants that are only 6 weeks in length. Some 6 months. Some 9 months. The majority of the ads that run for medical assistants indicate a certificate or they will train. GED or High School graduate. Several years ago, a medical assistant almost gave my daughter the wrong shot. I’m glad my daughter knew better and told her to stop. The medical assistant already wiped her arm and had the cap off of the syringe when she asked my daughter “you are here for your birth control shot”. My daughter said “no, for my second gardacil shot”. The medical assistant said “oh, I will be right back”. When I questioned the medical assistant her reply was “we always ask what the patient is here for”. I said “yes, I understand that, but you question it before you bring in the medication, wipe the arm and remove the cap from the syringe”. Medical Assistants are worthless. Yes, they are paid very little, but it takes multiple medical assistants to run an office where a doctor could have just one RN who would take care of everything and not complain. I can go on and on, but I’m sure I’ve already hit a nerve with many. So I will stop. We all have our own opinions on this topic.

      • crnp2001

        Obviously, you are insane. Your commentary shows as much. There is NO comparison between MA and RN personnel. Look up any state board of nursing licensure requirements. I think you’re a troll. You certainly couldn’t have been a NURSE in a past life…prior to your “doctor” credential. Starting to wonder if you are even a physician.

      • crnp2001

        You are truly off your rocker, if you state that MAs and RNs function equally. Did you EVER practice as an RN? Surely, if you had, you would realize the difference in training and PROFESSIONAL LICENSURE. Someone who feels that these roles are the same and equal really needs his head examined.

        After all of your posts, I realize that you are not only a troll, but have serious issues with your own abilities. Good luck to your patients.

      • Patient

        The majority of the states will not allow a medical assistant begin an IV and the states need to regulate having them call in prescriptions. In the last two years, 7 of my prescriptions were called in incorrectly by the medical assistant.
        The need to stop the classes for medical assistants in these allied health schools.

    • Guest

      The education of MAs is merely few credit hours shorter than that of an RN. Our local university has the rigorous curriculum of medical assistants with a total of 61 credit hours. RNs, at the same university, have to enroll in 70 credit hours of coursework. Furthermore, the NCLEX, the board certification exam that graduating RNs have to pass, requires minimum of 75 questions to pass. On average, In 2009, the average number of items (questions) administered per candidate was around 121 on the NCLEX-RN and 115 on the NCLEX-PN examinations.

      On the other hand, the CMA (AAMA) Exam is a rigorous exam that requires a thorough, broad, and current understanding of health care delivery.

      The exam consists of 200 multiple-choice questions administered in four 40-minute segments (almost twice as long as the NCLEX). The National Board of Medical Examiners, which is responsible for many national examinations for physicians, including the United States Medical Licensing Examination (USMLE), serves as test consultant for the CMA (AAMA) Certification Exam. As a result, the reliability and validity of the CMA (AAMA) credential are of the highest order.

      Despite comparable training and possibly more rigorous board examinations, MAs are not respected as a profession. In fact, MAs, spend more time with patients than RNs. RNs on the other hand come in to the patient’s room to administer physician ordered medications at scheduled times and then run off to the computer to document their notes. MAs, for years, have taken abuse from nurses, when at times, it is the MAs that have alerted the nurses when the patient is deteriorating, prevented nurses from overdosing insulin causing life threatening hypoglycemia. We do all of this in the face of insults to our profession, because above all, we care for the patient.

      It is the narrow minded, turf protection thought process, engendered by the nursing association that is limiting scope of practice for medical assistants. Medical assistants are not proposing to be nurses – we respect what nurses do, and we are not trained to handle ICU level patient care/NP level care, but we can and have been, for years, providing safe and efficient, assistance in outpatient healthcare. There is clearly a nursing shortage now that experienced RNs have advanced their education to practice under the supervision of physicians. According to the “United States Registered Nurse Workforce Report Card and Shortage Forecast” published in the January 2012 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country between 2009 and 2030. We strongly believe this can be alleviated, at least partially, by medical assistants.

      Please – lets not quiver over credentials, but rather, together, as a team, provide safe and efficient assistance in caring for the most important person, our patient.

      • Reese

        This would be laughable, if it weren’t so scary. No, sorry, MAs do not get an education that is nearly on par with an RN. Comparing an MAs curriculum to a nurse’s curriculum is comparing apples to oranges. You are failing to note that more nurses are pursuing a bachelor’s degree for entry into nursing, and more facilities are requiring a BSN for entry level. A BSN is 120-130 credit hours. It would be interesting to do a side by side comparison of the courses required for an MA and those for an RN.

        Your board examinations are not more rigorous than a nurse’s. It’s possible to pass NCLEX with 75 questions, but that is because it’s a computer adaptive test, meaning the questions get progressively difficult each time you answer correctly. That’s far different from the exam MAs take. FWIW, I took NCLEX-RN years ago when it was a two day exam, given over 8h each day and ~800-1000 questions. (I don’t remember the exact number anymore; it was a while ago.)

        MAs do not have a license that stands on its own merit. You are allowed to do patient care under the physician’s delegation. If he allows you to do a particular task and you harm the patient, he is the one who is ultimately held liable. If I do something that harms a patient, it’s my license that’s on the line.

        As a nurse, I have caught mistakes physicians have made, but that doesn’t mean I am equal to them. We all make mistakes from time to time, and part of being a health care team means having each other’s back to help prevent harm to the patient. You seem to suggest that only MAs care for their patients. That’s just wrong.

        There is a role for MAs, and a good MA can be helpful. MAs are not the answer to the “nursing shortage,” which, if you did any real research, doesn’t even exist. We should care about credentials; credentialing is one way that we can insure the patient is getting appropriate care from the appropriate provider.

        There is more to being an RN than just tasks. People who don’t understand this are those who feel they could do the same things a nurse could do. It’s that lack of understanding which makes it imperative to make sure people don’t step outside their scope.

        • Patient

          AMEN! Thank you!!!! There is NO comparison with an MA and RN … What I don’t understand is why doctor’s don’t get it! They continually call their medical assistants nurses. The doctors out there need to WAKE UP and really look at who they have hired.

          • JBS

            This is how physicians feel about the arguments with NP & MD’s……..just saying.

          • Patient

            I understand and I’m glad physicians feel the same way with NP & MD’s. When I go to the doctor, I do NOT want to see a NP or PA. I actually had an appt for my well woman exam about 10 years ago with my doctor and a lady walked in and said “hi, I’m Judy and I’m helping out Dr Smith today, I will be doing your exam”. I replied “I don’t think so”. She replied with the same line of helping out Dr Smith. I again replied “I don’t think so”. Finally, after going back and forth a few times, she said “so you don’t want me to do your exam’. I replied “If you don’t have an MD behind your name, then NO”. She left the room. I have several stories about NP incorrectly diagnosing my son and ordering labs for my daughter “just because she never had them before”. There was no reason for labs at all. I left that practice after that. When I called and complained, I was told what she did was inappropriate, but nothing else was done.

  • logicaldoc

    “So let’s call it like it is.” Exactly “Doctor” Pagano. Regardless of what the defensive needs of others are and what they say, I’d go one step further. “The Medical School Graduate who spent 4 years in College earning the credentials to be admitted to Medical School, who spent the last two years of Medical School doing 36 hour shifts with 18 hours in between, back to back, in a real hospital clinical setting, who then went on to a real Accredited Residency Program for at least another 3 years, continuing on with 36 hour shifts each year, admitting 10-20 real sick hospital Patients during each one of those 36 hour shifts, in the most intensive hospital and apprentice program that can be thought up, who then went on to pass the highest distinction in his/her field by becoming Board-Certified, who gave up at least 11 years of his/her life after High School to achieve this level of education, training, and experience, will see you now”.

  • CLJ Murphy

    When most patients hear “Doctor” in a medical setting, they assume “medical doctor”, not “nurse with a PhD.”

    My older, retired brother fills some of his hours as a volunteer at his local community hospital. He has a PhD in History. He does not refer to himself as “Doctor Murphy” when patients come to him with questions, as that would obviously be misleading — no matter how technically “true” it would be.

  • Dave Mittman, PA, DFAAPA

    Dr. Pagano: With all due respect, you know little about the PA profession. Sorry but not sure what you are describing. PAs have 27 months of post-graduate training in programs that are by hours spent training-eight weeks shorter than physician level medical school. We serve as autonomous providers and lead medical teams when we have the appropriate experience. I just want to be factual.
    Also-PAs can have doctorates as can NPs. Whether we tell it to patients is a different matter, but to say we do not have doctorates is also unfair. All pharmacy, PT, OT, psych, audiology, etc. schools are at the doctorate level and they call themselves doctors. Why does that not bother you? Why would you not want the people seeing patients with you practicing with the highest level of education they can get? Sorry, if we are really a team, I don’t understand.
    Lastly, we are licensed in most states with our own licenses.
    We are not here to be physicians nor do we proport to be. Stop thinking the world revolves around everyone wanting to be a physician.
    Dave

  • kidmodel

    Let’s just all call each other ‘Chef’! There – problem solved!
    Seriously, once, about 15 years ago, I was part of a hospital big=honcho meeting about turf battles about who was going to be ‘in charge’ when one of the uppermost echeleon admin types said this: “….just get them (the doctors/nurses/other clinicians) arguing about their ‘titles’, then we can sneak in the back door and get our jobs done!” I swear to you a true story. Did that bean counter have our number? I suspect the answer was a resounding YES. Let’s NOT go the way of the Native Americans and allow infighting to defeat us…….if that happens (and it IS HAPPENING RIGHT NOW) we have ourselves to blame for the pandemonium which ensues.

  • kidmodel

    doctor nurse

  • Kaya5255

    Let the turf wars begin!!!
    Healthcare consumers have an absolute right to know the name and title of the person who is offering care. We are not stupid or uninformed people. We all know the difference between MD, DO, OD, NP, PA, RN, LPN, etc. NP’s and PA’s with doctoral degrees are not DOCTORS OF MEDICINE. I pay the MD big bucks for their training and experienc, as they ultimately, have the responsibility for care.
    I make no apology that I hold NP’s and PA’s as mid-level providers, Technicians and Technologists as ancillary support staff and Aides and Assistants low-level support staff. They all have a function to perform and it should be under the supervision of the physician.
    I, too, hold a doctoral degree…not in medicine.

  • Brian Smith

    The education of MAs is merely few credit hours shorter than that of an RN. Our local university has the curriculum of medical assistants with a total of 61 credit hours. RNs, at the same university, have to enroll in 70 credit hours of coursework. Furthermore, the NCLEX, the board certification exam that graduating RNs have to pass, requires minimum of 75 questions to pass. On average, In 2009, the average number of items (questions) administered per candidate was around 121 on the NCLEX-RN and 115 on the NCLEX-PN examinations.

    On the other hand, the CMA (AAMA) Exam is a rigorous exam that requires a thorough, broad, and current understanding of health care delivery.

    The exam consists of 200 multiple-choice questions administered in four 40-minute segments (almost twice as long as the NCLEX). The National Board of Medical Examiners, which is responsible for many national examinations for physicians, including the United States Medical Licensing Examination (USMLE), serves as test consultant for the CMA (AAMA) Certification Exam. As a result, the reliability and validity of the CMA (AAMA) credential are of the highest order.

    Despite comparable training and possibly more rigorous board examinations, MAs are not respected as a profession. In fact, MAs, spend more time with patients than RNs. RNs on the other hand come in to the patient’s room to administer physician ordered medications at scheduled times and then run off to the computer to document their notes. MAs, for years, have taken abuse from nurses, when at times, it is the MAs that have alerted the nurses when the patient is deteriorating, prevented nurses from overdosing insulin causing life threatening hypoglycemia. We do all of this in the face of insults to our profession, because above all, we care for the patient.

    It is the narrow minded, turf protection thought process, engendered by the nursing association that is limiting scope of practice for medical assistants. Medical assistants are not proposing to be nurses – we respect what nurses do, and we are not trained to handle ICU level patient care/NP level care, but we can and have been, for years, providing safe and efficient, assistance in outpatient healthcare. There is clearly a nursing shortage now that experienced RNs have advanced their education to practice under the supervision of physicians. According to the “United States Registered Nurse Workforce Report Card and Shortage Forecast” published in the January 2012 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country between 2009 and 2030. We strongly believe this can be alleviated, at least partially, by medical assistants.

    Please – lets not quiver over credentials, but rather, together, as a team, provide safe and efficient assistance in caring for the most important person, our patient.

    • Dr. Cap

      And… no.
      The fact that you compare the number of test questions tells me that you have zero idea the magnitude of difference (from a physician perspective) working with RNs and MAs, both in acuity, accuracy and work ethic. So through this logic, should BSNs have even higher status because they, like, went to college?

      Actually, this is fantastic. Yes! Why not divert the quarrel to nurse-esque professions? Maybe enlist housekeeping to increase THEIR scope of practice too!

      Keep up the good fight!
      [Mwahahahaha....]

      • Patient

        Love your reply to B Smith. Thank you. Very true, a house keeper can be a medical assistant. A restaurant manager can be a medical assistant. So very true, he has no idea the magnitude with the difference between an Medical Assistant and Nurse. My daughter will be graduating with her BSN and no way will she be on the same level as a medical assistant. She has worked too hard and long to graduate and will further her education.

      • Brian Smith

        /Sarcasm

        • Patient

          They don’t deserve to be defended.

        • Dr. Cap

          Thanks Brian!
          BWAHAHA!!!

      • JBS

        LOL…I was thinking the same thing…..they seem a feisty bunch…divert….lol

  • Reese

    I call him/her by first name, just like I did with most doctors I worked with.

    FTW!

  • crnp2001

    Really? Your lack of knowledge of the NP (or DNP) role is astounding…get rid of the “mid-level” moniker, BTW. I (and my NP colleagues) do NOT practice “mid-level” care whatsoever. We are held to the highest standards as our physician peers are. Who, pray tell, is a “low-level” provider?

    I daresay, you haven’t worked with ANY of us, by your commentary. My EIGHT physician peers recognize what I do as valuable, and I have found issues that even THEY missed. I am regularly asked for my opinion on THEIR patients. We don’t HAVE to be equal in education. Multiple studies show that we achieve equal or BETTER outcomes in similar patient populations. I have my own patient panel of patients…why? I provide excellent care, and many of my patients prefer to see ME, the NP, over any of the physicians.

    We are here to stay. There are more than enough patients to go around. And I am not “relegated” to the “easy” patients. Mine are equally challenging in Internal Medicine. So…get your facts straight, and perhaps, just perhaps, spend some time working with us. I am pretty sure that you will see that we are NOT “mid-level” anything.

    • Brian Smith

      1. “Really? Your lack of knowledge of the NP (or DNP) role is astounding…get rid of the mid-level moniker, BTW”

      I’m an NP who went to medical school and residency. Instead of arguing to equivalence and change in legislation, the NP movement needs to change their education. NP school is terrible compared to MD school. I went to the best (top 5) in the country and learned stuff about ethics, social health policy, but zero knowledge about pathophysiology and disease management. In fact, I worked full time while going to nursing school part-time for 2 years. I graduated top 10% of my NP class with near perfect GPA (I was the only male NP in my class). Most of my NP practice I was following protocols and treating symptoms, until I went to medical school. This is where I learnt science and medicine. I couldn’t work while in med school because there was so much to learn and I had high academic expectations.

      NPs lack of basic science and medical knowledge will never be overcome regardless of # of years they have practiced.

      I urge NPs to go to medical school and residency in order to EARN the right to practice independently. The other possible solution is to drastically change NP curriculum to mimic MD curriculum with rigorous entrance requirements and an equivalent residency training.

      The FTC claim that NPs go into primary care and rural area is far from the truth. As a practicing NP and most of my NP colleagues (YES A MAJORITY) wanted to practice in derm, cardiology, subspecialty and in an urban city. The few ~ 50% want to practice PCP and far less 180 mmHg, Recent surgery 6 months, window period > 4.5 hours. age 80. The drug only works in that particular setting. No good clinician would ever extrapolate that data and use it on a 85 y/0 who comes in with an ischemic stroke with a recent whipple procedure 2 weeks ago has SBP > 200 mHg. Because the drug hasn’t been studied in that setting and giving it to that patient would be unscientific and dangerous.

      Similarly, NPs, at best, have been studied (with questionable data) for the management of chronic, stable, medical conditions. To say that they are equivalent to physicians whose medical education, clinical experience, is an order of magnitude better than that of NPs, is frivolous. Just because 2 studies showed (methodologically flawed as proved above and published by nursing associations) that nurses can handle 3 chronic conditions does not mean they are ready to handle cases with diastolic heart failure exacerbation, CKD, patients that present as a diagnostic challenge, critically ill ICU patients.

      Lastly, to even consider such a trial would be unethical. Imagine asking your grandmother who comes into the ER with a NSTEMI – “Mrs. Smith, I know you’re having a heart attack right now, but we are going to a flip a coin and assign your care to a physician or a NP depending on whether its heads or tails. Mind you, the education and clinical experience of a NP is 1/10th than that of a physicians’, but we are going to flip this coin anyway because the nursing associations believe that nurses are equal to doctors. If you agree, please sign here.” Good luck enrolling patients on that trial.

      This might come as a shock to nurses, but Evidenced based practice means more than reading the conclusion paragraph and agreeing with the authors. This entails appropriate critique of the study methods, statistical power, and ability to reject the null hypothesis. This is the fundamental difference between a physician and a nurse. You’ve proved it by making a statement that says “multiple studies..”, when in fact you haven’t read and critically appraised any of the literature yourself but are on the other hand parroting back the authors conclusions/nursing propaganda. Physicians are critical thinkers and problem solvers that can independently analyze and interpret data instead of just reading the conclusion statements.

      However, what NPs are trying to do is claim the expertise and prestige of a physician without actually putting in the hard work (both in terms of quality and quantity). And no, your 10 years as a RN passing out physician ordered medications doesn’t count as “clinical experience”.

      2. “We don’t HAVE to be equal in education”

      Midlevels are a classic example of “I want my cake and eat it too – ” They aren’t willing to put in the hard work of medical school, residency, and/or fellowship and yet they want to claim equivalence to physicians. Instead of trying to convince the public, politicians, and patients that your online DNP degree and 500 hours of clinical experience is equivalent to that of a MD, you had the choice of attending medical school – but you didn’t. If you want to practice medicine independently, then do it the right way, you owe it to your patients.

      NPs with 2 year of online programs, 600 clinical hours is equivalent to a medical student. I wouldn’t let an intern or even a 4th year resident practice independently, then why should NPs/PAs (midlevels) who have far less clinical experience, no rigorous basic science training, and easier board certification exams (I’ve taken NCLEX, GRE, FNP, MCAT, USMLE Steps, ABIM/ABP and I assure you the FNP exam is a joke compared to the MD exams) be allowed to practice solo? In fact, my 3rd year family medicine clerkship exam was more challenging the final board certification exam for FNP.

      I know most states are allowing NPs to practice solo, but just because politicians (who have more interest in money than patient care) agree with you doesn’t mean that its the right thing to do.

      Practicing independently is a right that is earned after years of training. Circumventing this with inferior training and claiming equivalence with poor data reeks of inferiority complex.

      As much as this is about turf protection, there are enough patients for both MDs and NPs. But to practice independently and have the same rights as an MD, you should go through similar training. Point in fact, the DO movement. The AMA was initially opposed for DOs practicing medicine. But the DO medical schools revamped their programs and added clinical residencies. And now they are almost equivalent to MDs.

      I promise you that most 3rd year medical students can pass the FNP board exam, but I doubt any of the practicing NPs (despite years of experience) would be able to pass the USMLE. They made Columbia NPs (top 10 NP school in the country) take a watered down version of USMLE Step 3 and 50% failed. Most of my colleagues took that test post-call (36 hour ICU call) and passed. Ergo, their knowledge base is not equivalent.

      If given a choice between a pilot who has 600 hours of flight experience, versus a pilot who has had 6000 hours of flight experience, who would you choose?

      The ludicrous argument that NPs are practicing “nursing” and should go through separate nursing board exams is frivolous in and of itself. NPs are and have been practicing medicine for years – so they should be subject to the same board exams. While creating simpler, watered down board exams/curriculum and then turning around and asking for the same privileges/respect/salary of someone who has undergone far rigorous training is wrong, don’t you think?

      I’ve worked with dozens of NPs – apart from URI/Strep pharyngitis/UTI or titrating anti-hypertensives, I wouldn’t trust them with anything else.

      We want good clinicians – I encourage all future nurses who want to independently provide care – to go to medical school and residency. You’ll learn pathophysiology, biochemistry, pharmaceutical mechanisms of actions, and REAL SCIENCE. You will learn how to take care of patients. Sure, it’ll be tough, but you owe it to your patients. I’ve been to the other side and I assure you there is a vast difference in my knowledge and clinical skill than my previous knowledge base despite years of NP practice and RN, BSN, FNP-C under my belt. Sure, I will openly concede there are exceptions to this rule. There are few NPs who are better than some MDs. But these are rare minority of NPs and even though I was never one of them, I still know some who are, and guess what, I was shocked to learn that they aren’t clamoring to practice independently.

    • JBS

      It is midlevel care…it is above an RN but not an MD….It think you may be confused what “midlevel” means….at any rate, the most educated comments I have heard come from my 5 friends, 3 NP’s and 2 PA’s who have later gone to med school….there is a former NP post on here too….there is a huge difference in training and knowledge and only ignorance can argue otherwise. I think there is a great need for midlevel practitioners and the good ones are great….but the ones who do not know their limits….are ego driven and scary…no MD is feeding their ego to ask to be called a title they have earned….it isn’t about ego but about conveying to the patient who you are….an MD…an individual who has spent an extraordinary amount of time in school and post graduate training in order to learn an endless amount of information & gain a large amount of clinical experience in order to help the patient. I used to shy away from calling myself an MD bc I didn’t want anyone to think I had an ego…but a patient once told me, “doc, I don’t care about your ego, I care about my confidence…I want to know that the blonde girl who looks 12 has gained the title to be giving me these answers.” Fair enough I thought…..and so from that point on, to my patients, I am an MD. To my family and friends, I’m the same blonde girl they grew up with, no ego here. With all that said, I do think if mid-levels want to practice the same scope as MD’s with 1/10 the training they should consider taking the same board exams….have fun with steps 1, 2, and 3….they suck but when I studied for them, they reminded me why I have earned the title MD…bc mastering that level of knowledge builds confidence. So take them….they don’t measure you as a whole practitioner but they do test your fund of knowledge which you claim is on par.

      • crnp2001

        Call us by our CORRECT titles, which are NP and PA. Or “Advanced Practice Clinicians.” We don’t practice “mid-level” care. Who, then, is “lower level?”

        You are correct in that our education is different. The vast majority of NP and PA providers DO understand our limits and consult when necessary. Same as PHYSICIANS.

        And you are correct about “conveying to the patient who you are.” What kind of confidence would a patient have hearing “mid-level?”

        Simply put: WORDS MATTER.

  • Tim Mosher

    Brian,
    As an NP, and having been taking care of patients in one role or another over 33 years, I can’t say that I disagree with WHAT you are trying to say. But I sure feel that the underlying attitude of verbosity and “I have arrived, sorry you haven’t” sure seems to come through. It will be a one-man crusade for you to try and push back the headwaters of these changes in medicine. Ultimately, how you work as a team member (with members that tick you off from time to time) will determine what kind of physician you are. The Hierarchy will not provide you with the esteem you apparently seek.

    • Brian Smith

      I welcome change – change that is for the best. But to have midlevels handle complicated patients independently is inefficient, expensive, and possibly dangerous. This might be anecdotal, but midlevels refer twice to three times more as MDs. E.g. the midlevels I work with referred multiple patients to a nephrologist for a creatinine of 1.3 (Just because our EMR flagged the lab value as outside normal range). It was mindblowing to them when I explained to them (3 NPs) that serum creatinine was an inference of renal function and can be spuriously elevated by (drugs that prevent excretion of creatinine in the distal tubule, exogenous dietary intake, etc.). Simple physiologic concepts that we learned in medical school weren’t taught in NP school. I enjoy teaching and they were happy they learned something new. This goes both ways – when I have a question about nursing, I ask them, and they are more than happy to teach me. We had a patient the other day with a chest port and I did not remember the anti-septic protocol for maintaining a chest port and I had to call one of the midlevels to help me and the patient.

      Sorry to break it to you, but when it comes to practicing medicine, MD training is clearly superior to midlevel training. Why does that offend you? Can you acknowledge the difference in training between a LPN and DNP? Sure both are nurses, but are they equal? Absolutely not. Do LPNs get offended that their training is inferior to DNPs? Yet LPNs are not out to confuse patients into believing they are just as good, if not better, than DNPs. Like it or not, there is a hierarchy in the work place that is commensurate to one’s level of training – but that doesn’t mean I go around insulting midlevels, nurses, LPNs, janitors, etc.

      I’m surprised that you were offended by my verbiage – especially when there is a clear difference in MD versus NP training, both in terms of quality and quantity.

      On the other hand, how do you feel about the “verbosity” that is used by the nursing association and/or nurses that claim NPs training is just “different” than MD, and in fact, NPs are independent practitioners that are equal if not better than MDs? No physician or patient would ever like that – especially when in fact the vast difference in training is easily quantified (just politically incorrect/taboo to say it out loud in public).

      Nonetheless, I’m polite and respectful to all the midlevels that work with me. Just as I’m polite any other human being that works with me including the EKG tech, janitor, administrative assistant.

      I get enough “esteem” from my patients – especially from those patients with whom I spend time discussing their diagnosis, teaching them about the disease process, educating them regarding how the drugs help lower their BP, blood glucose, etc. In fact, I get more “esteem” than I deserve.

      The NPs/PAs that I know are not offended by the term midlevel and they recognize their limitations and know that they are not equal to or a replacement for physicians, despite the years of practice. Their years of practice is not a substitute for the theoretical and clinical concepts of medicine that are taught in medical school & residency.

      What I’m starting to see is that there is a big disconnect from the nursing association and the actual nurses that I’ve had the opportunity to work with. The militant attitude of DNPs > MDs that is published by nursing journals is never seen in the clinic (atleast not in my personal experience). I just wish the nursing association would change their educational requirements to match their claim of equivalence.

      • crnp2001

        I bet if you really ask your associates, they WOULD be offended by the “mid-level” term. No one, apparently, wants to challenge the great doctor.

  • crnp2001

    Brian, too bad your NP education was not as rigorous as mine…and you felt it was lacking. There are some programs which are not up-to-par, but most that I and my NP colleagues have gone to are.

    It amazes me that someone who actually practiced as an NP (and knows what barriers we face) would be as negative as you are in your posting and support of NP colleagues.

    Congratulations on going to medical school. It was not an option for me due to finances and other factors.

    Your opinion that NPs are good for the “easy” patients doesn’t wash in my practice. I manage those “so-called high risk patients” EVERY DAY in my Internal Medicine practice. They aren’t referred to my 8 physician colleagues. I manage their care, and my outcomes are equal to the physicians’ outcomes. Do I collaborate? Absolutely. Guess what? SO DO THE DOCS. None of us practice in a vacuum. I am asked regularly for my opinion about tough cases.

    I also precept medical residents in their first year out. Let me tell you, some of them are greener than any of my NP students, whether or not they passed the USMLE 1 and 2 exams.

    You are certainly entitled to your opinion, but thanks, I’ll continue to practice excellent quality care, and be held to the same standards as physicians are. I didn’t need to go $250,000 into debt to do it. My patients prefer to see ME.

    • Brian Smith

      Just make sure your patients are aware that your definition of “independent practitioner” involves online nursing school, clinical experience that is 500 hours as opposed to 3 years of residency (11,000 hours), a final nursing board certification exam (120 questions) that is easier than 3rd year medical student clerkship exams.

      Sorry but with that rigor of education, it is no wonder that your self-defined standard of “excellent quality care” is easily met.

      Its not so much that its my “opinion” that NPs scope of practice is for non-complicated patients, its more that its inherent to their level of training.That’s what restricts their scope of practice. Ones scope of practice is determined by one’s level of training. If you want unfettered scope of practice, then expand your education that is commensurate to that scope of practice. Because right now, NP and PA level of education and clinical experience is that of 3rd year medical students. In fact, when I was finishing my 3rd year of medical school, I had more theoretical knowledge and clinical hours than a current fresh grad DNP. Yet, I wasn’t allowed, rightfully so, to have unrestricted scope of practice.

      I feel sorry for your patients that your supervising/collaborating physicians, do not provide you with a patient panel that is appropriate for your level of education and hence scope of practice. Who knows, maybe you practice in a state that has independent practice rights.

      Patients “prefer” to see you is because of the same reason why patient satisfaction scores for midlevels are higher than physicians. Have a URI? Here take Levofloxacin. Abdominal pain? Lets get a CAT scan. Patients “feel” that they are being taken care of when in fact they did not need the Z-pack for the viral URI and ionizing radiation for dyspepsia. Don’t get me wrong, there are bad MDs that do this too, but NPs do this far more because they have never seen the ruptured appendix or ascending aortic dissection, etc. And its not their fault. I did the same when I practiced as a NP.

      The medical residents I’ve worked with, even interns, all of them, have been far more thorough, diligent, and intelligent than any midlevel. It surprises me that they are able to keep up with ever changing medical knowledge. Maybe I’m biased because these residents are from a top academic institution.

      Its sad that you believe NPs are equal to physicians. From the first day of medical school that involved cutting open a cadaver and learning every single muscle, artery, vein and nerve in the body, to the final day of residency where I had to perform an urgent pericardiocentesis in the cardiac ICU to save a man’s life, these experiences, collectively, make me an excellent clinician. Hence, medical school followed by residency has been, and always will be, the gold standard for the highest level of medical education. I would do it all over again in a heartbeat even if it cost $500,000. Its not about the cost, its about the knowledge and experience that I’ve gained that is unparalleled. No NP school provides that level of education in terms of breadth and depth. Until they do, midlevels will never be equal to physicians.

      At the same time, having been a NP in the past where a collaborative physician meant someone signing my charts and not even seeing the patients – is wrong. My collaborative physician wasn’t even on premises 4 out of 5 days of my work week! I’m sympathetic to NPs in that plight and those laws need to change.

      Despite evidence that midlevel education is not equal to physicians, I believe that nurses who purport superiority or equivalence to physicians are suffering from the Dunning–Kruger Effect. Google it: “The Dunning–Kruger effect is a cognitive bias manifesting in unskilled individuals suffering from illusory superiority, mistakenly rating their ability much higher than is accurate. This bias is attributed to a metacognitive inability of the unskilled to recognize their ineptitude.” Essentially, you don’t know what you don’t know.

      Its ironic that PAs, who undergo an abbreviated version of medical school, and in my opinion, a more rigorous clinical education than nurses, are not on the same platform as nurses – i.e. they are not claiming superiority and equivalence. I wonder why. Or maybe just not as aggressively and/or in a mainstream way?

      • crnp2001

        Get over yourself. Your opinion is based on your own experience, NOT that of mine, or many, many NPs in practice today.

        I won’t toot my own horn, but I have found things that MANY physicians have missed. Including finding a stage 4 lung CA with metastasis that THREE physicians missed! Why? NO ONE ASKED THE PATIENT ABOUT SYMPTOMS. No one. I was the one who found mets on his abdominal U/S, then a CT scan…after seeing abnormal LFTs on labs. His own GI doc told him his symptoms were due to gastritis due to NSAID use. REALLY?!?!

        My collaborating physician tells me that I am better than most physicians he knows. I don’t claim to have the same education as physicians, but believe me, I am DAMN GOOD at what I do. The tired “you don’t know what you don’t know” is old news, friend.

        You can spout all the rhetoric that you want about physicians (or med students, heaven forbid) being better than NPs or PAs. It doesn’t hold up in the real world.

        I am DONE with you. You will be entitled to your own opinion, as am I. When it comes down to it, I provide fabulous, up-to-date, empirically-researched patient care. My patients deserve no less…and they get the best care possible.

        I feel sorry that you cannot accept the fact that we NP and PA providers are here to stay. Perhaps you felt you needed to prove yourself by getting that doctorate degree. Good luck to you…and your patients. With your almighty attitude, they will need it.

        • Suzi Q 38

          “……I feel sorry that you cannot accept the fact that we NP and PA providers are here to stay….”

  • ll

    Oh, no! I will never darken the doors of ANY health care professional that treats me with no respect, and I pointed my finger in his face and told him to never, ever slam his hands near my arm again. He is only 45 yrs old and he has a long way to go in his specialty. He did not approve of the treatment plan that my doctor, who has been in practice since the 60s, has been using to treat my symptoms. My dad goes to a doctor in the same field and same age who treats him the same way. I think it is coming from their training. That is so sad.

    • Suzi Q 38

      I sometimes look at these young doctors and think:

      Is it your age? Is it the way they are teaching you in medical school and residency now? Why are you so jaded and uncaring so early in your career?

      Thank goodness not all of my doctors were that way, only two out of the seven.

      The best thing I ever did was realize it (gosh, i was a positive person at the time, stupidly positive), fire the loser doctors (two specialists) and move on.

      I did not leave quietly…..

  • Patient

    I ONLY let my physician draw my labs and start an iv, etc. He only has medical assistants and they are incompetent. When I was in the hospital, he would personally draw my labs and he started the iv, etc. He’s the only one and with one stick and he was going in blind, as I’m a hard stick. I’ve been stuck 10 times and never again. I think nurses are great, but I’m to the point that I now will pick and choose who will be my health care provider.

  • Jim Pagano, MD

    Thanks for all that. I didn’t start this conversation out of any sense of animus toward NP’s or PA’s, but merely to suggest that we need some truth in advertising. The education they receive is not equivalent to that of an MD, and, as you pointed out, their ability to analyze clinical data is generally not as well-developed.

    Government, with the dubious assistance of some medical organizations, is working hard to standardize practice protocols and develop ‘best practices’. While some of this is helpful in a limited sense, the reality is that medicine is practiced one patient at a time. A physician’s ability to diagnose an individual patient’s problem by doing a history, physical, and lab evaluation against a background of solid scientific training and knowledge is the cornerstone of our profession.

    Best practices and core measures make it easier for non-physicians to practice medicine acceptable to government, but they don’t, in my opinion, provide a good substitute for a well-trained, experienced physician.

  • Suzi Q 38

    If she wants to be called “doctor,” I would do so.
    If my professor in college wants me to call him “doctor” because he has a PhD, I would do so.
    Ditto for the Pharm D, the dentist, and the psychologist.

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