Introduction of Terminology
In the United States, the terms “doctor” and “physician” are used interchangeably. For the sake of this Patient Safety Guide, and for the sake of simplicity, the term “doctor” will be used to encompass both. Traditionally, in the medical field (in a clinical setting, with very few exceptions) a doctor is one who is a(n):
For the purpose of this Guide, we will focus on D.O.s and M.D.s when referring to doctors.
In the medical community, one who has a doctorate degree other than a D.O. or M.D. is not considered a doctor. There are individuals who will make assertions to the contrary. However, if we were to indulge their assertions, a doctorate who holds a Ph.D. in philosophy in a hospital setting would be able to dress like a doctor, address himself or herself as a doctor and not be viewed as misrepresenting himself or herself. Technically speaking, attorneys hold the degree of doctor of jurisprudence (J.D.) however, no one ever hears an attorney refer to himself or herself as a doctor. Many states now allow individuals who are not medical doctors to address themselves as “doctors” in a clinical setting because they may hold a “doctorate” degree (which is not a medical degree), but they are usually required to indicate (with a modifier) what they hold a doctorate in.
In order to avoid confusion and to maintain accuracy, midlevels (as described below) who may have doctorate degrees will collectively be referred to as midlevels and will not be referred to as doctors, although some may be identified as having “doctorates” which is not an equivalent degree to a medical degree in this Patient Safety Guide.
Who Would You Call?
If you were approached by a law enforcement officer, how comfortable would you feel asking him or her if he or she was really a law enforcement officer? Most wouldn't think to ask because they would think they shouldn't have to. One would safely assume that an individual dressed as a law enforcement officer is a law enforcement officer.
If you noticed a fire in your home, would you call the plumber or the irrigation specialist? After all, they do know about the properties of conducting water. But you, of course, know there is much more to putting out a fire and saving lives than requiring this type of knowledge alone.
If you noticed someone burglarizing your home, would you call the mall security guard? Or, if one of your family members suddenly collapsed, have you ever heard anyone exclaim, "call a nurse practitioner!"? Or have you ever heard anyone say, "We need to get him to the emergency department to see a physician's assistant right now!"? The answer, of course, to all of the above is no.
For each need in your life, you have a good idea of the type of individual you need to assist you. You likely demand the best-trained and most highly-educated individual in that field to fulfill your needs. Furthermore, you would think and expect the individual you hired was truly a member of the profession you need (society's commonly held notion rather than one individual's or a certain group's (re)definition of a word, meaning and/or profession).
The Hospitalist’s Union admires and encourages those who seek an education no matter what their profession or line of work may be. However, when individuals and an entire industry employ the guise of education to attempt to transform their line of work into another's profession (as demonstrated in this Patient Safety Guide), we have serious concerns.
Creative Medical Marketing
No doctors we are aware of in the medical community recognize nurse practitioners, nurse anesthetists, anesthesiology assistants, midwives, physician's assistants, chiropractors, doctors of pastoral science and medicine, naprapaths or naturopaths as doctors. Furthermore, no doctor, pharmacist or patient with which we have spoken feels that any individual of the aforementioned jobs can provide patient care of the same quality of a doctor. This fact remains unchanged despite any:
-Accreditations they may claim to have.
-Certifications they may claim to have.
-Degrees they may claim to have.
-Experience they may claim to have.
-Training (no matter who it may have occurred with, under or where) they may claim to have.
In the medical community, nurse practitioners, nurse anesthetists, anesthesiology assistants, midwives and physician's assistants are collectively referred to as “midlevels” or “midlevel providers” (sometimes abbreviated as M.L.P.s). (Sometimes also referred to as midlevel practitioners) (Spelling variants for "midlevel" also include "mid-level" and "mid level"). Certain health insurance companies appropriately classify midlevels. In a recent bulletin, Anthem Blue Cross and Blue Shield Medicaid referred to midlevel practitioners as "including but not limited to advanced practice registered nurses [another name for nurse anesthetists and nurse practitioners], physician's assistants and nurse midwives." The Drug Enforcement Administration's (D.E.A.) classification of a midlevel "means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice." One of the many questions this Patient Safety Guide will attempt to answer is, "Why does the D.E.A. have a recognized and separate classification for midlevels which also includes ambulance services, animal shelters, chiropractors, euthanasia technicians, homeopaths, naturopaths, doctors of oriental medicine, nursing homes, and optometrists?"
“In the medical community, nurse practitioners, nurse anesthetists,
anesthesiology assistants, midwives and physician's assistants are collectively referred
to as “midlevels” or “midlevel providers” (sometimes abbreviated as M.L.P.s).”
Many hospitals, healthcare systems and individuals in the healthcare field who are not doctors use vague and misleading terms that can confuse patients. Some of the most commonly used terms are below. One may encounter any number of combinations of the titles and descriptors listed. Please note, the following individuals may use upper case or lower case letters for the abbreviations provided. The use of upper case letters does not demonstrate a higher degree or more training.
What’s even worse is that individuals of medical pseudo-professions sometimes rebrand what it is they practice by inventing new terms such as:
Precise Terms Matter
In the fields of marketing and advertising, if one is proud of the individuals, goods and/or services he or she provides then he or she refers to that individual, good or service by one or two names for the sake of reinforcing that brand. On the other hand, when one is less than proud of what he or she is representing, than he or she may resort to renaming, remarketing and/or rebranding. When renaming, remarketing and/or rebranding fail, these individuals may resort to simply changing the conversation, taking advantage of commonly held assumptions and/or mimicry (imitation). With all of this mentioned, why is it that doctors (D.O.s and M.D.s) are only referred to as "doctors" or "physicians" whereas the individuals (mentioned above) who are not doctors, have over forty different terms (and titles) to describe themselves?
The Exploitation of Imprecise Terms and the Incongruence Between the Formal Definitions of Words and the Natural Language Definitions of Words
Midlevels benefit from the "association game" and "word drift" whereby they self-deduce (and attempt to convince others) they are doctors or legitimate providers of healthcare services because the education and/or training they have undergone are on the fringe of that which doctors receive. People know better than to engage these individuals.
It is worthwhile to explore one of the many justifications midlevels employ to mislead patients and society into believing they are doctors (or the equivalent of one). According to many dictionaries, a doctor is defined as "a qualified practitioner of medicine; a physician." Midlevels are not physicians. Many dictionaries, however, offer a secondary definition of a doctor as being "a person who holds a doctorate" for which a doctorate is defined as "the highest degree awarded by a graduate school or other approved educational organization." As mentioned below, holding a doctorate degree (other than a D.O. or M.D. degree) is a false summit in the healthcare field with regards to having the knowledge to provide patient care as compared to being a doctor. Furthermore, midlevels may not only exploit the subterms of the formal definition(s) of being a doctor but they may also exploit the differences between the formal definition of a doctor and its natural language usage. For the majority of doctors, nurses, pharmacists, nonmidlevel professionals in the healthcare field and patients with which we have spoken, they indicated their first thought when hearing the word "doctor" was "doctor." They felt this needed no further explanation and none of them cited one who holds a doctorate degree (Ph.D.) as their first response. However, when asked to define a doctor, they all indicated an individual who is either an M.D. or a D.O. They all assumed a doctor was a medical doctor until there was notification to the contrary. When asked if others could be doctors as well, most indicated that they knew individuals who held Ph.D.s (doctorate degrees) could be referred to as doctors, but that none of them did so.
For a better understanding, an antithesis to the points made above about precision (and its potential resultant exploitation) in language can be applied to the term "meat."
Five different dictionaries provide five different definitions of meat which may depend on whether it is the flesh / tissue from a mammal, whether the animal can fly, and/or whether it is domesticated. Despite the definitions provided for the word "meat," one's concept of it may vary according to how he or she was raised (his or her family's concept of it), his or her culture's / ethnicity's / religion's definition of it and even depending on which part of the country in which he or she was raised.
When one refers to meat, many concepts and definitions can apply. When one refers to a doctor, there is little ambiguity except in cases where midlevels are seeking opportunity and attempting to arbitrarily change the understanding of what one is. While some midlevels may hold doctorate degrees, their attempts at integrating into the healthcare system as doctors are insincere and misleading as the degree they hold is neither a medical degree nor equivalent to one.
Midlevels self-identifying as doctors have as much commonality to doctors (D.O.s and M.D.s) as rowboats have to aircraft carriers. The lowest common denominator is that they are both watercraft. From there, the similarities virtually end. Please reference the profound differences in standards, quality and quantity of education and training required in the tab titled "You Be the Judge of the Care You Have Received / Will be Receiving."
One observed case of hypocrisy was an instance where a midlevel who self-identified as a doctor reprimanded a registered nurse (an R.N.) because she referred to herself as a doctor. The nurse (as part of her previous career) had a Ph.D. in education. Although both were incorrect and misleading to their patients for identifying themselves as doctors in a clinical setting (without having a D.O. or an M.D. degree), it was ironic to observe a midlevel reprimanding a nurse for employing the same misleading principle he (the midlevel) employed to mislead patients himself.
A Doctor? Or A Case of Renaming, Remarketing and/or Rebranding?
Food manufacturers rebrand high fructose corn syrup in an attempt to mislead consumers by using other names such as:
As you can see above, one can provide many glorious names to something, but the names don’t change the nature of the substance. In a similar vein, midlevels are aggressively attempting to use glamorous new titles to project things they are not or more than they are. This may not only be occurring on an individual level, but also on an organizational level as well. According to one source, "The American Academy of Nurse Practitioners (AANP) released a position statement in 2009, updated in 2010, 2013 and 2015 denouncing the use of several relegating terminology. Terms such as "mid-level provider," "physician extender," "limited license provider," "non-physician provider," and "allied health provider" when referring to nurse practitioners are considered derogatory by the AANP. The American Academy of Nurse Practitioners prefers that nurse practitioners are referred to as "Nurse Practitioners," "independently licensed providers," "primary-care providers," "health-care professionals," and "clinicians." in reference to the legal and professional paradigm that nursing practice is considered separate and independent of other licensed professionals."
These individuals in the healthcare field are attempting the practice of medicine (and even performing surgical procedures) without having undergone a medical education through an accredited medical school (ones that educate D.O.s or M.D.s). Furthermore, they have not undergone medical residency training or medical fellowship training (despite some individuals claiming to have a medical “specialty” which is described in section #5 of the tab titled "Tools Midlevels Employ which May Mislead Patients"). If these individuals claim (which many do) the training they have undergone is different and equivalent to that of a doctor, it is not. Please refer to the tab titled "You Be the Judge of the Care You Have Received / Will Be Receiving." Furthermore, they attempt to describe what it is that they practice as being a different branch of the medical field. Again, it is not. It is the attempted practice of medicine with a nursing degree or a degree in physician’s assistance, not a medical degree. There is only one path to the top of the mountain of knowledge required to have the responsibility and duty of medical decision-making. Midlevels have not climbed it. Rather, they have climbed halfway to the summit and planted a flag of achievement and claimed a title tantamount to “doctorate of half mountain.” Because they have achieved the title of “doctorate of half mountain,” they feel entitled to refer to themselves as “doctors.” When they return to base camp, they mingle with doctors and attempt to assimilate by claiming “we are all doctors here.” Attaining a D.O. or M.D. degree marks the pinnacle of education and training in the medical field to become a doctor. In any other field, obtaining a doctorate does the same however obtaining a doctorate in the healthcare industry (as some midlevels have) does not.
“If these individuals claim (which many do) the training they have undergone is different
and equivalent to that of a doctor, it is not. Furthermore, they attempt to describe
what it is that they practice as being a different branch of the medical field. Again,
it is not. It is the attempted practice of medicine with a nursing degree or a degree in physician's assistance, not a medical degree.”
While this is a serious matter, unfortunately only a movie reference best captures the analogy of “doctorate of half mountain.” In a well known movie, a character makes the statement, “60% of the time, it works every time.” One cannot undergo only a fraction of the training and education of a doctor (“60% of the time” as referenced above) then claim to be a “doctor” (“it works every time” as referenced above). In other words, one cannot claim to be 60% of an expert, and still claim to be an expert. Similarly, one cannot claim to be a “doctor” by obtaining a “doctorate” degree about the practice of medicine (or any remotely related field) without actually being a doctor (as evidenced by obtaining a D.O. or M.D. degree).
Becoming a doctor and practicing medicine are quantized: Either one fully commits to becoming one, or one does not. There are no gradations to being a doctor. Either one learns the full breadth of knowledge required for safe medical-decision making for his or her patients, or he or she does not. One cannot “convert” being a midlevel into being a doctor. This is best demonstrated by the example below:
An attorney is one who graduates from law school.
A paralegal did not graduate from law school and, therefore, is not an attorney.
A paralegal who has worked for an extended amount of time is not an attorney.
A paralegal who has worked under a world-renowned attorney is not an attorney.
A paralegal who has taken a few weekend courses is not an attorney.
An attorney is one who earns a law degree by graduating from law school.
A paralegal should not invent -or shouldn't lobby legislators to have the right to invent- an alternative school of purported equivalence and claim to be an attorney.
Attorneys hold the degree of juris doctorate (J.D.). Can you imagine a paralegal inventing the degree of “paralegal doctorate” (P.D.) and addressing himself or herself as an attorney? This absurdity is what is currently occurring in the medical field.