Bradley Flansbaum
First posted 4/2/11 on The Hospitalist Leader
In New York State, the issue of scope of practice is at the fore. Mainly, what activities can non-physicians (NP’s) engage in, with or without physician supervision? It is a heated subject here where I reside, but not the one I will address below.
Today’s New York Times discusses a similar matter, although altogether more controversial. Many of you are aware nurses are obtaining doctorate degrees and advancing their training. The divisive issue is how those with newly minted degrees should present themselves to the community, and secondarily, their pay, delay of entry into the workforce and its effect on patient access, and the necessity of this added qualification.
“Hi. I’m Dr. Patti McCarver, and I’m your nurse,” she said. And with that, Dr. McCarver stuck a scope in Ms. Cassidy’s ear, noticed a buildup of fluid and prescribed an allergy medicine.
The public may label physicians as biased if we condemn this ascertainment; we are a guild, a monopoly, protective of our turf and salaries. All potentially correct.
I am accepting and very tolerant of midlevel collaboration, very much so in fact. Over the years, I am consistently impressed with the level of quality and commitment these folks demonstrate. They deserve accolades and remuneration for their endeavors, and I see a vital future for them. The health system needs them, and I want them beside me. I am a huge booster as those who I work with can attest.
Why then does this issue, and articles like this rankle me?
I contemplated, and the answer arose quickly. It is in the title Doctor, and its application to the nurses employing it.
Now psychiatrists, orthopods, and ophthalmologists might disagree, this is sensitive stuff, but I have no compunction in introducing psychologists, optometrists, and podiatrists as “Doctor.” Surveys might prove me wrong, but the environment in which they practice and the scope of their delineated tasks differentiates them in ways I reason the public comprehends, even if it takes a prompt.
Here however, there is no discrepancy. Two clinicians–physician and nurse doctor–employed at an examination table; and to a casual observer, a false impression emerges.
Is it the money or prestige? No. Is it clinical outcomes performing rudimentary activities? Doubtful.
For me, it is communicating to the world the work behind the training—the sacrifices and untold hours of reading and time in the hospital, that in this context is lost.
Equal work for equal pay is something I trust in, and there many of my colleagues might not take umbrage. I can live with that. However, if you call yourself doctor in the framework of care delivery in a hospital or office setting—writing prescriptions and referring to subspecialists—ensure patients get it. We are not the same. The public service message goes with the title you bear. I am proud of my accomplishments and muddling those efforts are unacceptable, to me at least.
Dr. McCarver’s greeting above gets it right. My fear is she is the exception, not the rule.
Bradley Flansbaum MD is Director, Hospitalist Services, at Lenox Hill Hospital in New York City. He writes at The Hospitalist Leader.
Care And Cost 
“Doctor” doesn’t mean what it used to mean. Welcome to the party. The knowledge posessed by “Doctors” (as you use the term) has become a burden on healthcare due to the entitlement it brings. Look no further than local practice variability to see how “Doctors” are affecting modern healthcare. “Doctors” think they are 90% of healthcare. But they shouldn’t be. Patients need all that high end training (and associated cost) about 5% of the time. The rest of the time they need someone to listen, coalte concrete data, and apply a working system to their problem. As soon as you “Doctors” realize this, healthcare can move along to better things.