I’m writing this piece because I’m finally at the point that I am truly angry. I am angry at how physicians have become devalued in modern health care. I’m angry at how systems of care have participated in this by replacing physicians with lesser trained mid-level practitioners. I’m angry at how our title “doctor” has been hijacked to allow patients to be misled or, in many cases, deceived.
It wasn’t that long ago that when someone introduced them to you as “doctor” in the clinical setting that you most certainly knew you were seeing a physician. I have a different perspective than many physicians because I was one of these mid-levels. I was a 27-year-old physician assistant working in family medicine back in the late ’90s. But over the next few years, I began to realize that I was lacking in fundamental medical knowledge that made me unsure of myself at times. More frightening though was that I didn’t know what I didn’t know. This meant that I often didn’t seek out the expertise of my supervising physicians because I didn’t know I needed to.
Now before I go any further, I’d like to address the term, mid-level provider. Somehow it has developed into what mid-levels would say is now a negative connotation. I specifically remember when it was a victory for the PA profession to be called a mid-level provider because it helped define our knowledge level more appropriately than the word “assistant.” Now, it’s no longer a title the PAs and NPs want, and so they have decided to call themselves advanced practice providers. At the same time, physicians have been demoted to simply “providers,” further confusing the general public and disrupting the true hierarchy. Now — God forbid — I use the word “hierarchy” because we all know it’s going to result in the cliché response about how physicians just need to be team players. We embrace hierarchy in the airlines because we all know it saves lives. Co-pilots don’t fly solo, and mechanics don’t fly as co-pilots simply because they have a working knowledge of the aircraft. It’s a no-brainer; lives would be at risk. In medicine though, we have decided that patient lives are less valuable than air travelers.
Because I was so frustrated with the many gaps in my knowledge, I decided to go to medical school after four years of full-time work as a PA. It was certainly a wake-up call to realize how in depth the material was compared to what I had learned as a PA. There were countless standardized national exams and board exams in addition to coursework that had to be passed in order to advance and ultimately graduate. There were literally thousands of lightbulb moments where I came to finally learn what it was that I didn’t know as a PA. I can safely say that any med school graduate is vastly more prepared to practice medicine on that day than a physician assistant or nurse practitioner who graduates the same day. But the irony is that we turn these mid-levels loose to start practicing basically independently when the medical school graduate must complete another three to seven years on average before being allowed to independently practice in their specialty. Now in 2018, we find a decreasing amount of funding for residency positions for physicians. So there are literally thousands of physicians who find themselves unable to work due to a shortage of training positions. Several states are addressing this problem by creating a new category of licensed physicians who, by virtue of graduating from medical school, will be able to work as graduate physicians supervised by a board certified peer. However, just this last week a bill was introduced for this purpose in Oklahoma that was opposed by the state PA association.
The association claimed that it made no sense to create a new “untested profession” when there were already PAs meant to fill this role. So even from the profession we birthed, we find an attempt to devalue us. This still falls short of the ultimate misleading and dangerous practice by NPs of obtaining online doctorate degrees and introducing themselves as “doctor” in a health care setting.
In a strangely ironic twist, the very systems that love to brag that they hire only board-certified specialty physicians are the same ones that will throw a new mid-level to the wolves and allow them to practice nearly independently. In many cases, patients never realize they aren’t seeing an actual physician. This is a pure game of deception and goes to the root of why we need legislation that requires that patients be given a choice and know exactly who is caring for them. I wish I had a dollar for every time I have heard a PA explain to someone that they learned the same information as physicians, just over a shorter period of time. I wish I had a dollar for every meme I’ve seen on Facebook defining an NP as having the “brain of a doctor and heart of a nurse.” These statements are more than just inaccurate; they are misleading and offensive.
Nowadays, the physician-mid-level relationship is often one that is forced upon both parties due to corporate greed. It’s simply cheaper to hire a PA or an NP and require the physician to “supervise” them and take all liability. It is essentially an unfunded mandate passed down to the physicians in order to keep their jobs. Rarely is time given to properly train or supervise and even less often is compensation involved.
So yes, I am angry. But I am secretly optimistic. I have seen the grassroots movements begin to grow from other angry physicians who feel devalued. The reality is that the administrators that participated in the hijacking of medicine really don’t have any way to earn a living if the physicians of the country decide to unit and stand up for themselves. I’ve even heard the call to unionize. Luckily, there are still systems that value the physician. In the end, these will be the systems that will survive when physicians find their voice.
The author is an anonymous physician.
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