One thing that bothers me is the term "physician". I hear nurse practitioners referred to as non-physician providers or mid-level providers. Granted NPs don't have the level of education as an MD/DO but the care they have been trained to provide legally is just as high quality. Mid level sounds inferior to who would be considered a high level provider... If an NP was providing medical treatment outside of his/her scope illegally then yes I would consider that mid-level because they aren't trained to provide that care.
First I don't think anyone should ever try to hide their credentials (NP, PA, MD, DO, etc). Patients have the right to always know the level of education of the provider that is treating them. With that said, it bothers me to read " non-physician" providers. The actual definition of the word physician is an individual that practices medicine. In WA State as an NP I can legally practice medicine under my own license without supervision... Many other states are the same. And in states requiring supervision it should be considered supervision by a medical doctor, etc, not supervision by a physician... The term physician does not belong to MDs or DOs exclusively. Don't get me wrong EVERY patient should not be miss led about your credentials but if I see a patient and state "I'm a nurse practitioner and will be the physician treating you", etc that should be acceptable... The argument about who can be called doctor, and physician I feel is ridiculous. The only importance I see is the fact that every provider clearly states his credentials to every patient. After that if I have a DNP I should be free to be called doctor or physician and as an MSN-NP, called a physician. The term physician and doctor were around well before the creation of medical school so to think they have the only right to that term is preposterous... I do understand the goal of not miss leading patients but if credentials are offered to every patient, beyond that I feel the term doctor to those educated appropriately or physician to anyone who practices medicine and healing is free game to all no matter your credentials.
Am I off on my thinking of this? Would love to hear your thoughts on this. Any MDs or DOs want to offer their personal feelings on this? Not trying to start an argument but would love to hear how others feel on this topic of who has the right to the term doctor or physician.
(I know there are other threads on the term "doctor" but didn't find anything on the term physician.)
I get that the title of doctor is ambiguous. Like, I know a psychiatrist who trained in Australia and has a MBBS. He doesn't have a doctoral degree of any type. In a lot of the world you may still become a physician or surgeon with a bachelor's degree. In Australia, the MD, for example, is more akin to a PhD in medicine after one earns a MBBS, MChD, or BMed, et al. But when they come here and pass the licensing exams they are physicians and are automatically referred to as DOCTOR when they don't hold a doctorate. I've always wondered why attorneys aren't referred to as "doctor" since the American lawyer has a J.D. or Juris Doctorate.
That said, I don't care if we're called nurse practitioners, midlevels, physician extenders, or whatever. It doesn't bother me, and I don't think the education or training is comparable or "just as good." A DNP does not make you anything more of a nurse practitioner. They aren't clinical degrees particularly if they're earned post-masters. They're hocus pocus. If you want healthcare admin then do a MSHA, or if you want a real research degree get a PhD. I think if you earn a clinical degree, get licensed to be a clinician and can pass all three parts of the USMLE or even COMLEX then you could conceivably call yourself a physician, but the medical board will never go for it so it's pie in the sky.
I'm also of the opinion that I wouldn't want my patients getting me confused with a physician. Of course, if the patient calls me "doc" after I finish a DNP program, that's a very different discussion. "Provider" would be fine by me.
I was browsing this forum to get more information for my sister who is interested in nursing, with the goal of potentially becoming a family practice NP. I was here to educate myself on how one pursues this track, and I happened to come across this thread, and myself being a physician wanted to know what it had to do with.
Just a little bit of my background, I am a PGY1 Internal Medicine Resident Physician, with the end goal of becoming a Cardiologist. I graduated from an Osteopathic Medical School, and I took the COMLEX and the USMLE exams, and matched into an ACGME accredited Internal Medicine residency.
I wanted to give you my perspective on this. Let me first start off by saying, my main exposure to mid-level providers (that is what we call them at my hospital, no offense intended) are medicine PAs and NPs, and they work on the observation units and non-teaching services under the direction of an Attending Physician.
I wanted to clarify what you meant by 'An NP is qualified to do what a GP does', since my primary residency training will qualify me to become an Internist, aka a GP.
By the time I am a board certified Internist, I will have completed all 3 levels of the COMLEX examination (each exam is 8 hours long, done in two 4 hour sessions, with a 50 minute lunch break, of which the intensity I never want to re-live, let alone countless hours stressing over/studying for), in addition to the USMLE exam (which I personally chose to take, but not all osteopathic physicians do, my reason being I wanted to matriculate into an ACGME program near my hometown), done 3 years of formal residency training, which on average is 70-80 hours a week while rotating through the hospital wards and units (MICU and CCU), as well as more regular hours, from approximately 8 pm to 5 pm when rotating through the outpatient clinics (which include general medicine and every single subspecialty in medicine. In addition to this, we take part in simulation labs (where we walk into room with robots programmed to act as crashing (and sometimes subacute scenarios as well) patients, with other physicians acting as providers (RNs, family members, consulting physicians, etc) to simulate a real life scenario). In Simulation Labs, we also practice procedures such as CVLs, intubation, BLS/ACLS where we are code leaders, and numerous other things. We also participate in evidence-based didactic/journal club sessions, electives and research on a regular basis. In addition to this, while on floor wards, we have formal lectures given by an attending or a senior resident at least once a day. On most days, there are 2 lectures given, in addition to M&M every Wednesday, in addition to Grand Rounds offered not only in Medicine, but our Medicine subspecialties as well.
Every rotation and didactic driven course I described to has a unique flavor and twist, and I could go on for hours as to how they are structured and run, but then I would digress too much, but the common denominator is that, at every single step of the way there is dedicated faculty (board certified internist and subspecialist) teaching us medicine every single day. Oh, and we take a 4 hour inservice exam (of which we receive a detailed score report and breakdown with our strengths/weaknesses) every year (in addition to our Steps and Boards), and we are evaluated by all our Attendings after every rotation (ACGME requires this).
In total, we average approximately 15,000 hours of dedicated clinical training over 3 years, before ever becoming the sole decision maker aka Attending Physician aka 'The Buck Stops With Me'. Not only this, but a majority of us are published in peer-reviewed journals. I myself am currently working on multiple case-reports and abstracts to submit at local and national seminars and the ACC (American College of Cardiology). I will eventually start working on retrospective and prospective studies once my abstracts are accepted (crossing my fingers that they are!).
My point is, this is what I go through to become an Internist, or GP as known by the public. To be honest, I haven't even skimmed the surface of what we had to do to even get accepted into a residency. This is why I have earned the title of 'Physician', and this is why it is a legally protected title in many hospital systems and states. So this is why I advise caution when you decide to make a very general blanket statement such as 'An NP is qualified to do what a GP does'. If I have misconstrued your question, or come off as offensive, I had no intention of doing so, I am simply just trying to help you understand things from my point of view. Like I said, I work harmoniously with many NPs in my hospital, so please do not take this the wrong way. I hope I answered the OPs question.
I have been an ICU nurse for almost 7 years and thinking about going back to school to become an NP. I am considering getting my DNP but I will never refer myself as a "doctor" in a practice setting. I will introduce myself to my patients as "Hi, I am Jane Doe and I am your nurse practitioner". Once patients hear the word "doctor", they will assume that the person went to medical school and completed his/her residency. My husband will have his PharmD in June and he will not refer to himself as "doctor" to his patients either. I also believe that the term "physician" should only be used by a person who graduated from medical school and completed his/her residency. Anybody who does not have an MD or DO after his/her name and refers to him/herself as a "physician" need to be disciplined for fraud. If I ever become a nurse practitioner, I do not want to be referred to as a mid level practitioner or a physician extender because I am a nurse practitioner.
Thanks for your input from the perspective of an MD. I see how my comment between an NP and GP is possible disrespectful but I want to add one point and see what you think. Hopefully you see this and respond. The training you have gone through is obviosly way more extensive then any NP program. If NPs in some states are trained and given the authority to basically fill the "clinical practice" role of a GP then that should leave two answers, NPs are not qualified to be filling this role independently or MDs/DOs are over qualified... What do you think? Again no hard feelings I'm not trying to offend anyone at all and I appreciate your response to the thread!
My belief is that MDs/DOs are over qualified GPs which is why you have the training that allows you to go a little further and become a cardiologist or surgeon, etc. Don't get me wrong the education you go through is impressive and I don't want to offend, belittle or be disrespectful. If my take im this is wrong then on the other side of the coin I would assume NPs then should not be filling the GPs clinical practice role "independently"...
Again thanks for your input. I don't call myself a physician, doctor, doc, etc to any patients I have treated but just wanted to see what people thought mainly on the term physician since the medical dictionary's definition of that word covers what NPs do... I agree with many of the above comments about confusion to patients and I also believe that all patients should know exactly what credentials are held especially when there is that large educational difference because patients should never be misled regarding your qualifications. Thanks!
First off, welcome. I wish there were more physicians here engaging in this discussion, as I think it's an important one, and one that needs to be had as the fields of medicine and nursing continue to evolve. I do want to address a few things that you discussed, and also provide you with some information about us.
Just a little bit of my background, I am a PGY1 Internal Medicine Resident Physician.
I am a practicing dual-boarded NP, with a masters degree and a doctorate, working with complex medical patients in both the clinic and the community hospital.
You mention being a PGY1, and being that it's not quite May yet, I assume you are just finishing your clerkship?
I wanted to clarify what you meant by 'An NP is qualified to do what a GP does', since my primary residency training will qualify me to become an Internist, aka a GP.
One of the most important parts of practice, at least for me and most of my colleagues (NP/PA/DO/MDs), is being conscious of what you know and what you don't know. I think most experienced providers in practice understand this, either because they were taught it or because they engage in reflective practice and realize they have made mistakes. It has been my professional experience that novice NPs and PAs tend to be more aware of this than novice physicians, although physicians have direct oversight for their first few years of practice (residency). That being said, after a year (or less) of your residency, do you feel that you fully understand what it takes to be an internist? I think most would agree that it takes many years of practice to really sort out that it means (and what it takes) to do this job, regardless of degree. And I can tell you from my practice, it is a humbling job at times, a job that demands confidence but becomes dangerous with overconfidence.
By the time I am a board certified Internist, I will have completed all 3 levels of the COMLEX examination (each exam is 8 hours long, done in two 4 hour sessions, with a 50 minute lunch break, of which the intensity I never want to re-live, let alone countless hours stressing over/studying for), in addition to the USMLE exam (which I personally chose to take, but not all osteopathic physicians do, my reason being I wanted to matriculate into an ACGME program near my hometown), done 3 years of formal residency training, which on average is 70-80 hours a week while rotating through the hospital wards and units (MICU and CCU), as well as more regular hours, from approximately 8 pm to 5 pm when rotating through the outpatient clinics (which include general medicine and every single subspecialty in medicine.
I think everyone would agree about the rigor of medical education and training. Even medicine is talking shortening both the education and the training: there are now 3-year medical schools and this new concept of "associate physician" without any residency. Medicine has three rigorous and standardized competency exams.
In comparison, NPs have taken two national certifying exams prior to practice, have rotated through medical-surgical, OB, psych, pediatrics, community in addition to their specialty. Many have been RNs with years of experience in patient care.
The models are different, but what does the published data on the topic demonstrate about outcomes? For me, that's what is important, not how a provider gets to where they are but rather the care that they deliver.
In addition to this, we take part in simulation labs (where we walk into room with robots programmed to act as crashing (and sometimes subacute scenarios as well) patients, with other physicians acting as providers (RNs, family members, consulting physicians, etc) to simulate a real life scenario). In Simulation Labs, we also practice procedures such as CVLs, intubation, BLS/ACLS where we are code leaders, and numerous other things.
APNs have done simulations as well.
Every rotation and didactic driven course I described to has a unique flavor and twist, and I could go on for hours as to how they are structured and run, but then I would digress too much, but the common denominator is that, at every single step of the way there is dedicated faculty (board certified internist and subspecialist) teaching us medicine every single day. Oh, and we take a 4 hour inservice exam (of which we receive a detailed score report and breakdown with our strengths/weaknesses) every year (in addition to our Steps and Boards), and we are evaluated by all our Attendings after every rotation (ACGME requires this).
Nursing uses a semester-system while medicine uses a block-system; the same material is covered in both disciplines, it's just done so in a different way. Just like medicine if the lecture is about pediatric oncology there is a pediatric oncology expert giving the talk.
NP students are trained 1-on-1 for the entirety of their clinical experience and evaluated twice a semester by their preceptor.
In total, we average approximately 15,000 hours of dedicated clinical training over 3 years, before ever becoming the sole decision maker aka Attending Physician aka 'The Buck Stops With Me'.
During those 15,000 hours you are practicing, making decisions, with support from your attending physicians. After you have finished your residency you are allowed to make those decisions without support (though I am a firm believer that no provider should every practice without support). NPs don't enter a residency; they enter practice with a collaborating provider (at least in most states) where they amass the same hours making the same decisions with the same support. The difference is, at the end of their 15,000 hours or more, in most states, NPs are not allowed to move on to practice without that mandated support.
Not only this, but a majority of us are published in peer-reviewed journals. I myself am currently working on multiple case-reports and abstracts to submit at local and national seminars and the ACC (American College of Cardiology). I will eventually start working on retrospective and prospective studies once my abstracts are accepted (crossing my fingers that they are!).
Many APNs are involved in research as well; actually many nurses at all levels are, and in many cases, nurses are the day-to-day operators of clinical trials. For example, I have more than a dozen publications in peer-reviewed journals, first author on five of them, and I have presented at local and national meetings a number of times.
My point is, this is what I go through to become an Internist, or GP as known by the public. To be honest, I haven't even skimmed the surface of what we had to do to even get accepted into a residency. This is why I have earned the title of 'Physician', and this is why it is a legally protected title in many hospital systems and states. So this is why I advise caution when you decide to make a very general blanket statement such as 'An NP is qualified to do what a GP does'.
Yet you have earned the title of "physician" without doing the majority of what you have talked about. How many of the 15,0000 hours have you completed? This is why I advise caution in assuming that the title makes the provider; you have every reason to be proud of your title, but to assume that your title means you are more qualified to speak about what practice is, especially prior to having completed your residency, is overstepping. It goes back to my original point, the most important principle of practice is being aware of what you know and what you don't know.
I have been an ICU nurse for almost 7 years and thinking about going back to school to become an NP. I am considering getting my DNP but I will never refer myself as a "doctor" in a practice setting. I will introduce myself to my patients as "Hi, I am Jane Doe and I am your nurse practitioner". Once patients hear the word "doctor", they will assume that the person went to medical school and completed his/her residency. My husband will have his PharmD in June and he will not refer to himself as "doctor" to his patients either. I also believe that the term "physician" should only be used by a person who graduated from medical school and completed his/her residency. Anybody who does not have an MD or DO after his/her name and refers to him/herself as a "physician" need to be disciplined for fraud. If I ever become a nurse practitioner, I do not want to be referred to as a mid level practitioner or a physician extender because I am a nurse practitioner.
The term "doctor" in the clinical setting is a complex one.
I have always wanted to do a study on what the lay public means when they hear the term "doctor" because I would wager that most people think clinically that "doctor" means the person taking care of them.
This may mean a chiropractor (who use the term clinically), a podiatrist, a physician, a psychologist, a dentist, a veterinarian, a NP/PA, a PT/OT, an opthalmologist, etc.
Just make it simple.... "Type of speciality + Nurse Practitioner" and make the word Dr. optional for those with DNP or PhD. I do not want to be clumped and tied with physician assistants as a "non-physician provider" group. As nurse practitioners, they are assigned a specialty such as family, women health, acute care, emergency etc. and, in some states, we are even only allowed to practice in certain specialty area. We should be given credit for this. Physician assistant receives generalized education and does not have an assigned specialty and they follow the specialty of the supervising MD. The scope of practice and legal requirements are also sometimes different from states to states.
NPs don't want to be "physicians" and "practicing "medicine", we have our own title. That's how we can claim independent practice. We argue that we are not practicing "medicine", but "advanced practice nursing", which allows us to diagnose and treat certain conditions under our specialty
If they just want to refer to all of non-physician providers, they can just say "physician assistant and nurse practitioner." I do not like the term "mid-level" either.
This is exactly why I believe physicians are at the pinnacle of healthcare, and I literally want to hide my face any time some NP blathers away about his or her master's degree and 750 patient contact hours as having parity to board certified physicians. I tip my hat. You've earned your title and degree.
While I envy your education, I am pleased that I spent a decade of my life, after college, doing other things before entering healthcare, but I knew that for me to become clinician satisfied with both work and home life I would need to become a midlevel so as not to displace another decade of my life. I laud your professional and objective demeanor as many physicians would be much more condescending toward the suggestions of the OP. Congratulations on your achievements, and I wish you success in securing the fellowship of your choice.
Hi guys,
I was browsing this forum to get more information for my sister who is interested in nursing, with the goal of potentially becoming a family practice NP. I was here to educate myself on how one pursues this track, and I happened to come across this thread, and myself being a physician wanted to know what it had to do with.
Just a little bit of my background, I am a PGY1 Internal Medicine Resident Physician, with the end goal of becoming a Cardiologist. I graduated from an Osteopathic Medical School, and I took the COMLEX and the USMLE exams, and matched into an ACGME accredited Internal Medicine residency.
I wanted to give you my perspective on this. Let me first start off by saying, my main exposure to mid-level providers (that is what we call them at my hospital, no offense intended) are medicine PAs and NPs, and they work on the observation units and non-teaching services under the direction of an Attending Physician.
I wanted to clarify what you meant by 'An NP is qualified to do what a GP does', since my primary residency training will qualify me to become an Internist, aka a GP.
By the time I am a board certified Internist, I will have completed all 3 levels of the COMLEX examination (each exam is 8 hours long, done in two 4 hour sessions, with a 50 minute lunch break, of which the intensity I never want to re-live, let alone countless hours stressing over/studying for), in addition to the USMLE exam (which I personally chose to take, but not all osteopathic physicians do, my reason being I wanted to matriculate into an ACGME program near my hometown), done 3 years of formal residency training, which on average is 70-80 hours a week while rotating through the hospital wards and units (MICU and CCU), as well as more regular hours, from approximately 8 pm to 5 pm when rotating through the outpatient clinics (which include general medicine and every single subspecialty in medicine. In addition to this, we take part in simulation labs (where we walk into room with robots programmed to act as crashing (and sometimes subacute scenarios as well) patients, with other physicians acting as providers (RNs, family members, consulting physicians, etc) to simulate a real life scenario). In Simulation Labs, we also practice procedures such as CVLs, intubation, BLS/ACLS where we are code leaders, and numerous other things. We also participate in evidence-based didactic/journal club sessions, electives and research on a regular basis. In addition to this, while on floor wards, we have formal lectures given by an attending or a senior resident at least once a day. On most days, there are 2 lectures given, in addition to M&M every Wednesday, in addition to Grand Rounds offered not only in Medicine, but our Medicine subspecialties as well.
Every rotation and didactic driven course I described to has a unique flavor and twist, and I could go on for hours as to how they are structured and run, but then I would digress too much, but the common denominator is that, at every single step of the way there is dedicated faculty (board certified internist and subspecialist) teaching us medicine every single day. Oh, and we take a 4 hour inservice exam (of which we receive a detailed score report and breakdown with our strengths/weaknesses) every year (in addition to our Steps and Boards), and we are evaluated by all our Attendings after every rotation (ACGME requires this).
In total, we average approximately 15,000 hours of dedicated clinical training over 3 years, before ever becoming the sole decision maker aka Attending Physician aka 'The Buck Stops With Me'. Not only this, but a majority of us are published in peer-reviewed journals. I myself am currently working on multiple case-reports and abstracts to submit at local and national seminars and the ACC (American College of Cardiology). I will eventually start working on retrospective and prospective studies once my abstracts are accepted (crossing my fingers that they are!).
My point is, this is what I go through to become an Internist, or GP as known by the public. To be honest, I haven't even skimmed the surface of what we had to do to even get accepted into a residency. This is why I have earned the title of 'Physician', and this is why it is a legally protected title in many hospital systems and states. So this is why I advise caution when you decide to make a very general blanket statement such as 'An NP is qualified to do what a GP does'. If I have misconstrued your question, or come off as offensive, I had no intention of doing so, I am simply just trying to help you understand things from my point of view. Like I said, I work harmoniously with many NPs in my hospital, so please do not take this the wrong way. I hope I answered the OPs question.
First off, welcome. I wish there were more physicians here engaging in this discussion, as I think it's an important one, and one that needs to be had as the fields of medicine and nursing continue to evolve. I do want to address a few things that you discussed, and also provide you with some information about us.
Of course when we do participate in the threads that explicitly involve us, we get comments made over the fact that we're participating.
You mention being a PGY1, and being that it's not quite May yet, I assume you are just finishing your clerkship?
Post Graduate Year (PGY) 1 is the first year of residency where as clerkships are done during medical school. Unlike other residency years, however, PGY1 means a completely different thing in terms of experience in April (almost a full year in) than, say, July (fresh faced from med school).
One of the most important parts of practice, at least for me and most of my colleagues (NP/PA/DO/MDs), is being conscious of what you know and what you don't know. I think most experienced providers in practice understand this, either because they were taught it or because they engage in reflective practice and realize they have made mistakes. It has been my professional experience that novice NPs and PAs tend to be more aware of this than novice physicians, although physicians have direct oversight for their first few years of practice (residency). That being said, after a year (or less) of your residency, do you feel that you fully understand what it takes to be an internist? I think most would agree that it takes many years of practice to really sort out that it means (and what it takes) to do this job, regardless of degree. And I can tell you from my practice, it is a humbling job at times, a job that demands confidence but becomes dangerous with overconfidence.
Dunning Kruger, and I think for most interns (PGY1), that trough is hit pretty early on into intern year. I also think that the OP on this thread hasn't quite hit the trough yet with regards to his own professional development.
I think everyone would agree about the rigor of medical education and training. Even medicine is talking shortening both the education and the training: there are now 3-year medical schools and this new concept of "associate physician" without any residency. Medicine has three rigorous and standardized competency exams.
The concept of "associate physician" is not one without major controversy and is meant to the solution of, mostly Caribbean graduates, medical school graduates with $300k in debt, but unable to find a residency. Pretty much everyone I've seen who knows about that concept and knows the gap between theory and practice that residency fixes has huge issues with that program.
NPs don't want to be "physicians" and "practicing "medicine", we have our own title. That's how we can claim independent practice. We argue that we are not practicing "medicine", but "advanced practice nursing", which allows us to diagnose and treat certain conditions under our specialty
Quick question. How common do you see the sentiments like those of the OP, who sincerely believes that both NPs should be considered physicians AND practice medicine (the first being the topic of the thread and the second being explicitly mentioned in the first post)?
motoluver
9 Posts
Well said. I like your take on this! Thanks for sharing.