An article appeared today in the New York Times as a followup to a bill passed in New York granting nurse practitioners the right to provide primary care without the oversight of a physician. The authors of the bill state "mandatory collaboration with a physician no longer serves a clinical purpose and reduces much-needed access to primary care". The need for more primary care providers is due to the shortage of primary-care physicians, the aging boomer population, and the Affordable Care Act.
Although the president of the American Association of Nurse Practitioners feels that the current "hierarchical, physician-centric structure" is not necessary, many physicians disagree citing that the clinical importance of the physician's expertise is being underestimated and that the cost-effectiveness of nurse practitioners is being over-estimated.
Many physicians also feel that "nurse practitioners are worthy professionals and are absolutely essential to patient care. But they are not doctors."
What are your thoughts on this? Where do nurse practitioners fit into the healthcare hierarchy?
Regular physicians you probably work with every day. I work with dozens of phsyicans who do not hold a doctorate in anything. You probably do to. I many countries the Bachelor of Medicine, bachelor of Surgery is the professional degree for physicians. If you work with any doctors who trained in China, pakistan, the UK, India and dozens of other countries they may not have an MD or DO. Despite this, and to avoid confision most of the them will have white coats that say "Dr. John Smith MD", even though they do not have an MD.
In order for a doctor from a foreign country (whether it be a MBBS/Bachelors that you are referring to or another foreign medical degree) they must be licensed before they can be called doctor or have an MD on their name tag. So yes, technically someone from the UK could come here with just 7 years of college since they combine medical school and undergrad - but they still have to take all licensing exams and complete a residency. It doesn't matter if it's a foreign doctor that is fresh out of medical school or one that has been practicing for 40 years. It is standardized and the number of years of training required before they can be licensed is controlled by the state. FSMB | Licensure Examinations | USMLE Step 3 | Initial State-Specific Licensure Requirements
I hope that clears up the confusion. BTW I'm a resident and I figured I could contribute to the discussion since I find it really interesting and it seems the MD voice is missing in this dialogue
Independent practice doesn't make them an MD not does it mean they practice just like one. So their malpractice shouldn't always be equal. My malpractice costs change based on what I'm doing (I am a provider already...just not as an NP right now). My insurance is based on what I'm doing and how I'm "employed" (private practice versus employed by a group or hospital).
I'm not sure I understand this comment. If NPs want to practice independently, just like an MD does why would they not have the same malpractice. Do you not see the same patients? Do you not share the same liability? In the current model I would agree because many of the complex patients are turfed to the MD while the NP sees the routine patients, but if you are practicing independently aren't you seeing both of these patients? Independent NPs (like primary care physicians now) would function like gatekeepers, seeing all the patients no matter their complexity unless someone is telling the patient that unknowingly has a complex problem that they should be seen by the MD instead. Same patients, you will have the same malpractice... and some would argue the same licensing.
FYI: Doctor does not equal physician. A Doctorate is just a degree that many APNs, like myself, have already earned.
I would argue in the academic setting I 100% agree with you. Anyone who has a doctorate has earned the right to be called Dr So and so. However, in healthcare this can be confusing and it isn't appropriate. For the average patient, doctor = physician. When a close family friend was hospitalized he did not insist on being called Dr despite his PhD in economics. But this was his choice. For APNs, since they are healthcare workers, referring to yourself as doctor with patients and other healthcare workers is misleading. If APNs want a title to acknowledge their work and higher learning, I think it's completely justified but it should not be doctor in the clinical setting. Blame the patients and society.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
So I just want to make sure I understand what you're saying. You're saying that there are people practicing as MDs and who call themselves MDs who aren't actually MDs?
No! Certainly not! I do know PHYSICIANS who are fully licensed to practice medicine as PHYSICIANS who do not hold either an MD or DO degree. I don't know what it means to practice as "an MD" since MD is only an academic degree and lots of people who have MDs are not physicians and there are physicians who do not hold MD degrees. I can't recall ever hearing any of them specifically calling themselves an MD, though I have seen then have "MD" behind their name on their hospital ID and listed as "MD" on the hospital website. One time, many years ago, when I asked about this I was told that the "MD" was used as a courtesy.
And you know of several of them at your place of work?
Yes, and I have known many others all throughout my career in various hospitals and in different states.
How is that legal?
I have no idea why it would be illegal. What would illegal about it?
I've worked at two large teaching hospitals in a large city and I've never heard of this phenomenon.
Not a phenomenon, rather ordinary and common. Have you ever asked?
Misdiagnosis can come from anyone, doc or APN. Happens every single day. All the NNP's I work with are outstanding. We rely heavily on them as the residents we work with are clueless most of the time. I feel they give a better family centered care due to their nursing background and they are much more proficient in procedures.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
In order for a doctor from a foreign country (whether it be a MBBS/Bachelors that you are referring to or another foreign medical degree) they must be licensed before they can be called doctor or have an MD on their name tag. So yes, technically someone from the UK could come here with just 7 years of college since they combine medical school and undergrad - but they still have to take all licensing exams and complete a residency. It doesn't matter if it's a foreign doctor that is fresh out of medical school or one that has been practicing for 40 years.
Thanks but I don't think there was any confusion about what it takes to be a licensed physicians in the USA. The confusion was that some nurses apparently didn't understand that there were medical degrees other than the MD or DO.
Nobody is claiming that physicians who hold medical bachelors degrees from overseas medical schools don't need to complete a US residency to become licensed.
FWIW I know a number of physicians licensed and working as physicians in the USA who attended a total of 5 years of college / medical school after completing secondary school (high school). One of our ortho surgeons I work with regularly went to medical school in Bulgaria and when t0 university for a total of 5 years, graduated when he was 22 and came home to the USA and entered a residency program. I have known others in the past.
One of the medical schools in my state has started a three year medical school. They have an early acceptance and a few people can be accepted to med school concurrent with their acceptance to an undergrad program and actually start med school without graduating with an undergrad degree. So some of the med school grads will graduate med school after a total of 5 or 6 years of university right here in the USA.
Specializes in Oncology; medical specialty website.
There's a term in Latin from the law, which I regret I cannot quote verbatim, but it means, "Everything you say is true; so what?"
The vast majority of routine primary care doesn't require all that vaunted "rigor," as evidenced by the fact that many studies show better outcomes (and more cost-effectiveness, better patient teaching, and higher patient satisfaction) from care by NPs for the chronic conditions that fill most of the appointment slots at PCP offices: minor illnesses, DM, COPD, CHF, well-woman care, well-child care ... I think it safe to say that an NP can recognize the need for referral to physician care prn. We can do that in hospitals, too. :)
Specializes in Pediatrics, High-Risk L&D, Antepartum, L.
If a pt. wants care from an NP, that's fine, but we shouldn't put patients in the position of having to be cared for by an NP/PA if they don't want to.
And I am going to drop out of this conversation. I have my feelings on the subject, which aren't likely to change. While my experiences with care from NP/PA have been bad, I realize that's anecdotal. Still, they were my experiences, which shaped my opinions on midlevel care.
I missed where a patient lost their ability to make a choice. Nobody said a patient has to see an NP...that certainly won't happen with independent practice. Don't want to see an NP? See your MD/DO...won't hurt my feelings. I've been burned more times with an MD, DO and PA than with an APRN (NP or CNM). In fact...I have NEVER been burned by an APRN.
You can make your choice...but that doesn't get to dictate regulations and laws because of your bad experience. If it worked that way...there wouldn't be anyone left to see...
I would argue in the academic setting I 100% agree with you. Anyone who has a doctorate has earned the right to be called Dr So and so. However, in healthcare this can be confusing and it isn't appropriate. For the average patient, doctor = physician. When a close family friend was hospitalized he did not insist on being called Dr despite his PhD in economics. But this was his choice. For APNs, since they are healthcare workers, referring to yourself as doctor with patients and other healthcare workers is misleading. If APNs want a title to acknowledge their work and higher learning, I think it's completely justified but it should not be doctor in the clinical setting. Blame the patients and society.
Okay....Then what do you call a Podiatrist, a Dentist, and a Psychologist (with a doctorate in Psychology) in the hospital? That would be Doctor and not a one of them are physicians.
When you introduce yourself to a patient do you always tell the patient that you are a resident in your x year of training? Do most residents ever tell their patients that their residents/interns?
Physicians have been confusing patients for decades longer than any other health profession, and continue to do so on a daily basis.
There is nothing wrong with a nurse who has earned their Doctorate to introduce himself or herself as Doctorate X your nurse. It often opens the door up to doing some explaining, but when has patient education been a bad thing.
Healthcare is always changing. Patients and society views are going to be forced to change with the changes in healthcare even if that means bruising a few physician egos along the way.
MD2B
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In order for a doctor from a foreign country (whether it be a MBBS/Bachelors that you are referring to or another foreign medical degree) they must be licensed before they can be called doctor or have an MD on their name tag. So yes, technically someone from the UK could come here with just 7 years of college since they combine medical school and undergrad - but they still have to take all licensing exams and complete a residency. It doesn't matter if it's a foreign doctor that is fresh out of medical school or one that has been practicing for 40 years. It is standardized and the number of years of training required before they can be licensed is controlled by the state. FSMB | Licensure Examinations | USMLE Step 3 | Initial State-Specific Licensure Requirements
I hope that clears up the confusion. BTW I'm a resident and I figured I could contribute to the discussion since I find it really interesting and it seems the MD voice is missing in this dialogue