How Can They do That?

How can nurse practitioners, nurse anesthetists, anesthesiology assistants, midwives, physician's assistants, chiropractors, doctors of pastoral science and medicine, naprapaths and naturopaths be allowed to attempt to practice medicine and potentially cause patient safety issues? There are a few factors at play:
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  • Lobbying

    We have seen many instances in which lobbying has been allowed to supersede merit. And make no mistake, midlevel organizations spend millions of dollars annually attempting to buy the right to practice as doctors when they are not.  When buying the right to practice above one's training level doesn't work, midlevels have run for public office and introduced legislation attempting to promote their peers, thus serving more as political operatives then representatives of their constituents.  Many industries have submitted to allowing economy to dictate morality. In other words, the prevailing belief is that if something is profitable, it must be “right” or “ethical” or “socially acceptable.” We know this is not the case as many things can be legal and profitable but be unethical or socially unacceptable or not in the best interest of society. Doctors refuse to submit to the aforementioned trains of thought because so many lives of patients hang in the balance if they are unknowingly steered, coerced or forced into seeing a midlevel for patient care rather than a doctor. Midlevels have already gained the ability to attempt to practice medicine without a medical degree and now many self-identify as “doctors” because they may hold a doctorate but not a medical degree. No amount of lobbying, campaign contributions (or guarantee of votes) will make midlevels qualified to provide medical care like a doctor. If midlevels do successfully lobby politicians to have full, unsupervised practicing rights and/or to be recognized as “doctors” despite not having a medical degree, patients and citizens of our country will be deceived because many of these midlevels will not be specifying they are a midlevel.  It is only through sacrifice and dedication that one can provide medical care of the highest quality. Simply put, it is only doctors who have dedicated themselves to provide this quality of care to their patients.

    “Midlevels have already gained the ability to attempt to practice medicine without
    a medical degree and now many self-identify as “doctors”
    because they may hold a doctorate but not a medical degree.”

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  • Midlevel Educational Institutions

    Midlevel educational institutions are profiting handsomely from the mass-production of midlevels while facing no consequences for adverse patient outcomes as a result of their curriculum and/or the very nature of the job of being a midlevel.  In fact, the existence of diploma mills appears to be so widespread that the Accreditation Commission for Education in Nursing (A.C.E.N.) has acknowledged this issue and has displayed the following message on their website:

    "About Degree Mills and Accreditation Mills...
    Recently, several issues have been cited regarding "degree mills," which refers to unaccredited institutions who offer degrees of questionable merit.  Additionally, concerns have also been raised regarding institutions who claim to hold accreditation from dubious accreditors which are referred to as 'accreditation mills.'"

    The industry of mass-producing midlevels is a hundred million dollar industry with what appears to be little oversight.  Just how mass-produced are individuals of these jobs? Based on our research, the number of doctors graduating from osteopathic and allopathic medical schools between 2009 and 2017 increased by 23.5 percent from 20,466 to 25,297.  These numbers appear to be tightly controlled and overseen by the government and other regulating bodies.  The number of midlevels graduating from programs of nurse practitionry and physician’s assistance alone have increased (based on projections from what information is available) by 138.6 percent from 15,089 to approximately 36,000 during the aforementioned timeframe.  Unless these educational institutions have solved the age old conundrum of increasing quantity while simultaneously increasing quality (of the education of a midlevel compared to that of a doctor), for every one doctor who is educated and trained (11 years minimum), on average three nurse practitioners can be educated and trained (4 years) or two nurse anesthetists can be educated and trained (6 years) or two physician’s assistants can be educated and trained (6 years).  Based on the explosion of midlevel graduates, many wonder why there is such a discrepancy between the increase in the number of medical graduates versus midlevel graduates.

    Many midlevel educational institutions now offer degrees online and via “distance learning.” While online courses can be an excellent way for students to learn and achieve degrees in other fields, in healthcare (which requires direct patient contact, and large amounts of it) no learning module or simulated virtual patient can or will take the place of live interactions with patients.  Furthermore, the benefits of a full education in the healthcare field (i.e. learning in class) allows individuals to collaborate, identify new ideas and use teamwork to solve problems.  No email exchange can take the place of learning from industry leading doctors as medical students do during their medical education.

    In acts that appear to validate the concerns of doctors, nurses, pharmacists and patients, midlevel "residency" and "fellowship" programs have begun to sprout across the country.  This appears to be acknowledgement of the fact that many midlevels are unprepared to care for patients when they complete their cursory training.  These are not medical residency or medical fellowship programs and the rigorousness of this training is incomparable to that which doctors undergo.  Even with this attempt at preparing midlevels, we have concerns that this may be yet another step in giving them a false sense of confidence.  As surely as one would not use a Band-Aid (manufactured by Johnson & Johnson) for a hemorrhage, extra training on a flawed foundation does not address the underlying issue; it simply attempts to mask it.  Even with additional training, many feel (and observe) midlevels still won’t (and don't) have the training and education required of doctors.

    This additional training is optional.

    “Many doctors and informed patients view these midlevel educational institutions
    as nothing more than diploma mills based on the clinical decisions they
    have seen midlevels make and as a result of the necessity to provide
    additional medical care as a result of medical errors caused by midlevels.”

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  • Hospitals and Healthcare Systems

    In an effort to further boost their profits, many hospitals and healthcare systems are laying off doctors and hiring more midlevels. Just as troubling is the fact that (if they do not layoff a doctor) they give the doctor no choice but to risk his or her medical license by requiring them to supervise a midlevel and assume the risk (as their supervising doctor) of being drawn into a lawsuit due to a missed diagnosis or mistreatment by a midlevel. Hospitals and healthcare systems are ruthless businesses that gamble on the potential harm to patients, the likelihood of patients discovering harm and the likelihood lawsuits would be filed by the patients if they should discover harm (risk assessment). Hospitals and healthcare systems like to play the game of “white coat bait and switch” since most patients assume that every individual wearing a white coat is a doctor. This unfortunately is not the case, as many midlevels will either claim to be a doctor, not correct the patient when he or she assumes the midlevel is a doctor (or refers to them as one) or fault the patient for assuming they are a doctor (since they usually dress like one) but for not looking at their identification badge with small print (which (if accurate) should identify the midlevel as not being a doctor).  In fact, many midlevels will aggressively blame patients and family members for these "misunderstandings."  To many midlevels, these are passive measures and justifiable defenses for confusion that has been caused and enabled (either covertly, overtly or through neglect) by hospital administrators.  One should not be deceived by the rosy marketing of patient care and community involvement touted by hospitals and healthcare systems. These institutions are usually ruled with an iron fist by M.B.A.s, M.H.A.s and/or administrators who have little experience in (or concern of) direct patient care. Their primary concern, by a large margin, is profits.  There are instances where patient safety concerns raised by doctors regarding care provided by midlevels do not conform to their business model.  In many of these instances, they will accuse doctors of being "disrespectful."  There have even been instances of retaliation against doctors for raising these concerns.  This is the hidden philosophy of many administrators:  Profits before patients.  By imposing midlevels upon the medical profession, hospital administrators have contributed to the lowest morale and highest level of burnout of doctors in history.

    If hospitals and healthcare systems are as concerned about providing patient care of the highest quality as they aggressively advertise themselves to be, why are they not using they're lobbying power to have the government investigate why the education and training of doctors is not keeping up with patient demand (while we are already in the midst of a shortage)? We are unaware of any steps such as this taken by any hospital or healthcare system, and we are unaware of any intentions they may have to do so.  What we are aware of, however, is hospitals and healthcare systems now attempting to surreptitiously introduce midlevels through their marketing campaigns in an effort to normalize their use for patient care in place of doctors.

    “Hospitals and healthcare systems are ruthless businesses that gamble on the potential
    harm to patients, the likelihood of a patient discovering harm and the likelihood a
    lawsuit would be filed by the patient if they should discover harm (risk assessment).”

    “Hospitals and healthcare systems like to play the game of “white coat bait and switch”
    since most patients assume that every individual wearing a white coat is a doctor.”

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    *****Side Note:  How Hospitals and Healthcare Systems are Driving Up the Cost of Healthcare for Patients

    Ironically, by laying off doctors, hospitals and healthcare systems are only improving profits by pennies on the dollar (in the short-term).  According to an article dated October 25, 2017 from The American Council on Science and Health, “Physician salaries account for only eight percent of overall healthcare expenditure in the U.S.”  The high cost of healthcare is actually due to administrative costs (including the inflated salaries of hospital administrators and paying for incomes for excessive numbers of administrators), facility fees and due to markups on prices of services and equipment for the simple fact that they (hospital administrators) know that patients have no choice or alternatives, especially in an emergency (a Time Magazine article titled "Bitter Pill:  Why Medical Bills are Killing Us" from March 4, 2013 perfectly outlines many of the points mentioned above).  According to an article from Athenahealth.com from November 7, 2017, “The number of physicians in the United States grew 150 percent between 1975 and 2010, roughly keeping with population growth, while the number of healthcare administrators increased 3,200 percent for the same time period.”  According to the results of a study published in Clinical Orthopaedics and Related Research from October, 2018, “From 2005 to 2015, the mean major nonprofit medical center CEO compensation increased from USD 1.6 +/- 0.9 million to USD 3.1 +/- 1.7 million, or a 93% increase…”  In other words, as of 2015 CEO salaries at nonprofit hospitals were up 93% since 2005 (in ten years, their salaries almost doubled).


    To help rein in healthcare costs, perhaps it’s time for governmental programs including (but not limited to) Medicare, Medicaid and Tricare to limit reimbursement and/or funding to facilities, hospitals and healthcare systems that exceed a certain proportion of payment to overhead including (but not limited to) facility fees and administrator salaries / benefits to payments to individuals involved in direct patient care including doctors, nurses, pharmacists, occupational therapists, physical therapists, speech pathologists, etc. Furthermore, it may be time for governmental programs to withhold or sharply decrease payments to facilities, hospitals and healthcare systems that pay administrator incomes and provide benefits that exceed a set monetary limit which would be applicable from the time of initiation of the policy to the lifespan of that individual without the opportunity of transference to (a) designee(s).

    Paying hospital C.E.O.s and administrators higher incomes has never been proven to improve levels of patient care, thus there is no value.  An October 16, 2013 article from The Atlantic titled "Why Are Hospital CEOs Paid So Well?" confirms this whereby they describe a study performed by investigators at the Harvard School of Public Health.  Some of the key findings from this study and quotes from The Atlantic article include:

    • "There is little correlation between CEO income and hospital quality--but there is between salary and excessive marketing."

    • "The study found no link between nonprofit CEO pay and a number of important hospital quality indicators, including mortality rates, readmissions rates, and the amount of charity care such institutions provide.  Such findings are especially ironic at a time when hospital executives say that improving quality is their organization's top priority."

    • "And quality indices are not the only hospital performance metrics to show no correlation with CEO compensation.  Even the financial performance of hospitals shows no such link.  Other recent studies have also showed no correlation between pay and community benefit."

A May 17, 2014 New York Times article titled "Medicine's Top Earners Are Not the M.D.s" appears to corroborate the facts above and further demonstrates how overpaid and bloated hospital administrative staffs are with the following points:

    • "The proliferation of high earners in the medical business and administration ranks adds to the United States' $2.7 trillion health care bill and stands in stark contrast with other developed countries, where top-ranked hospitals have only skeleton administrative staffs and where health care workers are generally paid less.  And many experts say it's bad value for health care dollars."

    • "And studies suggest that administrative costs make up to 20 to 30 percent of the United States health care bill, far higher than any other country.  American insurers, meanwhile, spent $606 per person on administrative costs, more than twice as much as in any other developed country and more than three times as much as many, according to a study by the Commonwealth Fund."

    • "Among doctors, there is growing frustration over the army of businesspeople around them and the impact of administrative costs, which are reflected in inflated charges for medical services."

Regarding marketing, it may not only occur for the hospital and/or healthcare system at the direction of a hospital's C.E.O. and/or administrators.  It appears as though it may occur on behalf of the C.E.O. and/or administrators as well.  According to its website, Becker's Hospital Review "features up-to-date business and legal news and analysis relating to hospitals and health systems.  Content is geared towards high-level hospital leaders (CEOs, CFOs, COOs, CMOs, CIOs, etc.), and we work to provide valuable content, including hospital and health system news, best practices and legal guidance specifically for these decision makers..."  In an email (for which we did not receive a response) to Becker's Health Care on August 31, 2017, (in response to their article "60 Critical Access Hospital CEOs to Know in 2017") we included in our message the following:

"I was wondering if you could let me know how one is selected to your list.  Specifically, what criteria your company uses or if any of the individuals are contracted with the sponsor, Athena Health."

Again, we did not receive a response, but our inquiry was in response to one of their publications which appeared to be serendipitously timed to include a hospital's C.E.O. after one of our members raised concerns about that hospital C.E.O.'s management and made the community aware through publications sent to the town's citizens (please see the paragraph titled The Media below).  A voicemail left with this organization on January 9, 2019 regarding inquiry into what criteria is used for one to be listed on their "hospital CEOs to Know" has not yet been returned.  It is this organization's right to list anyone whom they may choose for any reason.  It is our right to let the public know there may not be a meritorious and/or extraordinary reason as to why any of the hospital administrators have been placed on their list.

Given the facts above, and given the facts presented in a Forbes article dated February 26, 2017 it seems that hospitals would be best served by having doctors serve in administrative and leadership roles.  In the article titled "Study Shows That Doctors Make Better Hospital Leaders" the following key points are made:

  • "So, who's better at running a hospital:  a doctor or someone who has never really taken care of patients?  Take a wild guess at the answer provided by a Harvard Business Review article entitled "Why The Best Hospitals are Managed by Doctors."  In the article, James K. Stoller, Amanda Goodall and Agnes Baker mention that physician-run hospitals topped the U.S. News and World Report rankings and earned ~25% higher quality scores than non-physician-run hospitals, according to a study published in Social Science & Medicine."

  • "Is this really any surprise?  Imagine trying to coach a team or come up with new plays when you never actually played the sport.  Or conducting an orchestra if you can't read or play any music."

  • "By the time a physician has finished medical training, he or she has had at least three years of intense experience caring for a wide variety of patients, at least five years of navigating through hospital systems and working directly with personnel throughout the hospital, and at least seven years learning about the body, medicine and medical technology."  We feel it is important to contrast this with the education and training of many hospital administrators which is comprised of a four year undergraduate degree and a master's in business administration (M.B.A.) or a master's in health administration (M.H.A.) which can be achieved online in one year (for a total of 5 years of education following graduation from high school).  Some hospital C.E.O.s and administrators have no education beyond a baccalaureate degree (a 4 year degree).  This is in contrast to the minimum of 11 years of education and training doctors undergo after high school graduation.


Please note, many hospitals and healthcare systems may market themselves as organizations that are faith-based, secular, family-oriented, charitable, nonprofit and/or community based.  All of these descriptions are marketing terms and/or tax classifications.  They have little bearing on the advertised benevolence of the organization and thus are unlikely to change how much the patient is being charged.

Hospitals and healthcare systems rake in money from the government, health insurance companies and individuals who pay out of pocket (in addition to other likely sources).  Like any other business, they should be willing and able to operate within the constraints of a budget.  Despite their budgets, they appeal to companies and individuals to donate to them or their affiliated foundations.  Unfortunately, many well-intentioned companies and individuals unknowingly donate to hospitals which may subsidize bad behavior and/or poor choices like continuing to engage in wasteful / unnecessary spending and financial irresponsibility. Hospitals may use these donations to blur the line between necessity and luxury.  Hospitals do not need new marble floors, fountains, gardens, paintings / plaques / statues (honoring past and present administrators) or anything of this nature.  There is no reason why citizens should be complaining about the high cost of healthcare while some hospitals appear as luxurious as five star hotels.  Unfortunately, because of administrators ignoring, neglecting and/or misrepresenting those that engage in direct patient care, there is often a disconnect between hospital administrations and healthcare workers.  In many respects, many view these two as separate entities.

Donating to hospitals and healthcare systems appears to encourage wasteful spending.
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  • Health Insurance Companies / Medicare / Medicaid

    Insurance companies’ profits are currently through the roof (according to a CNBC article dated August 5, 2017, "Combined, the nation's top six health insurers reported $6 billion in adjusted profits for the second quarter" (of 2017).  That's up more about 29 percent from the same quarter a year ago..."). But this is not good enough for them. They attempt to steer patients to see midlevels since the reimbursement for them is lower compared to doctors. It is also important to not forget the decades' worth of taxes taken from your paycheck to pay into the Medicare system.  Insurance companies (and the government) are protected by a firewall since they can’t be held liable for the medical errors caused by midlevels. Rather, that burden is placed on the shoulders of the medical malpractice insurance companies, the company (the hospital or healthcare system) by which the midlevel is employed and/or the supervising doctor of the midlevel. You pay enough as it is for health insurance. You deserve to receive the best medical care and to get your money’s worth paid for by your hard labor and sacrifice.  Always insist on receiving medical care from a doctor and a doctor alone.

    If health insurance companies are as concerned about providing patient care of the highest quality as they aggressively advertise themselves to be, why are they not using they're lobbying power to have the government investigate why the education and training of doctors is not keeping up with patient demand (while we are already in the midst of a shortage)? We are unaware of any steps such as this taken by any health insurance company, and we are unaware of any intentions they may have to do so.

    “Insurance companies are protected by a firewall since they can’t
    be held liable for the medical errors caused by midlevels.”

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  • Certain Doctors

    In many states, midlevels are prohibited from practicing what it is that they do without the oversight of a doctor. This scenario is truly one of being stuck between a rock and a hard place. While midlevels do not possess the education, training and skills to practice medicine they have been enabled to attempt to do so (through the reasons listed above) but few doctors want to risk their licenses by supervising a midlevel. The risk to a doctor’s license is through adverse patient outcomes due to care rendered by midlevels. While supervising doctors are supposed to review each patient case with the midlevel working under them, there can be instances when midlevels have undiagnosed a patient or misdiagnosed a patient and/or have not conveyed information to their supervising doctor and thus potentially pulling a doctor into a medical malpractice lawsuit. While doctors are better trained and educated than midlevels, they do not know everything. They are well aware of their knowledge set and they “know what they don’t know” and who to consult or where to research when they don’t. Midlevels on the other hand, by virtue of the quality and quantity of the education they undergo may not “know what they don’t know.” And this has had chilling results. Many patients, doctors, nurses, pharmacists and other individuals have expressed concern that many midlevels are unknowing victims of the Dunning-Kruger effect.  Some also posit that midlevels may also be subjects of the Big Fish Little Pond Effect (B.F.L.P.E.) however we have no opinion regarding this at this time.  Some feel midlevels shouldn't be blamed for potential patient care errors (since they are pursuing paths that have been forced open to them, yet they may not be qualified for), however this is little solace to those who have been affected by the care they attempt to provide.  Many doctors in the medical community feel that a quote by the great Stephen Hawking sums up their interactions with midlevels: “The greatest enemy of knowledge is not ignorance, it is the illusion of knowledge.”

    Doctors who do choose to supervise midlevels usually have lucrative incomes. This can be an enticing scenario to retired doctors and ones who are on the brink of retirement since this can serve as a great source of revenue in their golden years. Their profits come through “skimming off the top” of their midlevel’s labor (many doctors who engage in this practice view this as a way of accumulating "passive income"). In fact, of the doctors who manage midlevels, many see few patients per day and may rubber-stamp their approval on their midlevel’s work without even fully reviewing what it is they have done. This is easy money for the supervising doctors and bad practice for their patients who deserve to see a doctor rather than a midlevel. In many states, supervising doctors do not even need to be physically present when their midlevels are seeing patients. In one state, “supervision” means being accessible by phone (with no geographical limit on distance). A question many have posed is how can a physician's assistant be allowed to provide care when there is no physician present to assist?  This is an oxymoron given the specific name of this type of midlevel.  It is a terrifying notion knowing that an overwhelmed midlevel (physician's assistant, nurse practitioner or midwife) may be receiving instruction over the phone as a patient deteriorates with potentially no doctor in sight. In the medical community, the supervision of midlevels is considered to be “medical subcontracting” and it is looked down upon by the overwhelming majority of doctors. There are many instances where doctors guide their patients to doctors alone by not referring them to doctors who employ / supervise midlevels. Other doctors instruct their patients to bypass midlevels when referring them to doctors who do employ / supervise midlevels.  When seeking medical care for themselves, most doctors we are aware of will not see anyone who is not a doctor and, more importantly, when their family members require medical attention, they will not allow family members (especially their children) to see anyone who is not a doctor.  You, as a patient, deserve nothing short of the best medical care available.

    Many doctors find the choices of the minority of doctors' (who advocate for midlevels) logic regarding their advocacy quizzical.  These advocating doctors will espouse increasing patient access to healthcare as one of their many justifications.  Of these advocates, the majority feel midlevels should be allowed to continue to attempt to practice medicine but only under the supervision of a doctor (i.e. not practice autonomously) which affords these supervising doctors the opportunity to profit off of the labor of their midlevel.  Of these doctors who do supervise midlevels (as mentioned above) many see few patients per day and may rubber-stamp their approval on their midlevel’s work.  Thus, if one follows the money trail of these advocating doctors, one could surmise these doctors support midlevel practice when they can directly profit from it (although their supervision may be lax or virtually absent and thus no different than a midlevel attempting to practice autonomously) and are opposed to it when they can't.  Their argument for "increasing patient access to healthcare" may hinge upon what may be financially beneficial to them.  Allowing financial decisions to guide decisions and staffing with regards to patient safety is unethical and unacceptable.

    If you seek medical services at a hospital, healthcare system / facility, urgent care clinic, surgical center, outpatient office, medical practice, medical group and/or emergency department, you have the right to see a doctor and you should always exercise that right. If you will be undergoing surgery or a procedure, inform all team members you want only doctors involved in the pre-operative process, the operation itself and your postoperative care. This means that you want only surgeons involved (as all surgeons are doctors) and only anesthesiologists involved (as all anesthesiologists are doctors). If a doctor attempts to dissuade you, stand your ground as it is your right to receive care from the most qualified and most highly trained individuals. Many doctors who supervise midlevels will attempt to assure you they are supervising everything (although they may not be directly involved in your care) or that you’re in good hands with the midlevel they supervise or attempt to use other means to involve a midlevel in your care. If they do not comply with your wishes as a patient, you should seek care with a doctor who will. If you are hospitalized at a facility that does not have doctors who will provide medical care to you during your stay, and you are informed you are stable enough to be transferred, ask to be transferred to a facility that does and be sure to stand your ground. Your health should come before the profits of a supervising doctor and before the paycheck of individuals who did not commit themselves to becoming a doctor as midlevels have not. It is your body and you should demand only the best.

    “If you seek medical services at a hospital, healthcare system,
    urgent care clinic, surgical center, outpatient office, medical practice,
    medical group, emergency department, and/or healthcare system / facility,
    you have the right to see a doctor and you should always exercise that right.”

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  • Pharmaceutical Companies

    Can you imagine the media storm that would take place if Pfizer or Merck had a campaign for doctors? Or if they “advocated” on behalf of doctors? In what appears to be one of the greatest ethics violations of our generation, we see the pharmaceutical company Johnson & Johnson advocating for midlevels, under the guise of their “Campaign for Nursing” agenda.  For unknown reasons, the media continues to ignore this issue which appears to represent a conflict of interest.

    Why would Johnson & Johnson take an interest in individuals who, in many states, can prescribe their medications and medical equipment without a doctor’s oversight? Aside from the obvious reason of attempting to empower those to raise their bottom line, they are likely aware that, compared to doctors, midlevels overprescribe medications (including narcotics), over-order tests and usually take a “shotgun” approach to attempting to treat patients. The training of a doctor enables him or her to know which tests are appropriate to order and when. The training of midlevels however (due to its truncated and incomplete nature compared to the training of a doctor) makes many of them dependent on ordering an excessive number of tests rather than learning the skills it takes to efficiently treat patients. While many midlevels attempt to justify their “shotgun” approach as being thorough, in reality it is wasteful, expensive, potentially dangerous and drives up healthcare costs. Many patients have been stuck with medical bills not covered by their health insurance company due to a lack of medical necessity. Many midlevels over order tests with the belief they are “covering themselves” (from liability) without consideration of the possibility the patient might be stuck with a bill.  Not only are pharmaceutical companies (indirectly) profiting by "advocating" for midlevels, they are also profiting by virtually ensuring more prescriptions will be written for patients through their advertising campaigns as well.

    Johnson & Johnson manufactures many medications and products that can benefit patients when they are properly used and administered.  However, according to a Reuters article dated December 14, 2018, “Facing thousands of lawsuits alleging that its talc caused cancer, J&J insists on the safety and purity of its iconic product.  But internal documents examined by Reuters show that the company’s powder was sometimes tainted with carcinogenic asbestos and that J&J kept that information from regulators and the public.”  Based on this information and the information above, it appears Johnson & Johnson will employ any means (including using midlevels through attempting to empower them) to get their products on the market and increase revenue.

    The Hospitalist’s Union urges individuals to contact their local representative to elucidate why a multibillion dollar, multinational pharmaceutical company is advocating for midlevels. Inquire about the legal and ethical implications of doing so.

    “In what appears to be one of the greatest ethics violations of our generation,
    we see the pharmaceutical company Johnson & Johnson advocating for
    midlevels, under the guise of their “Campaign for Nursing” agenda.”

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  • Lax Oversight

    In contrast to state osteopathic medical boards and state medical boards, it appears that state nursing boards are more concerned about advocacy and promotion than they are about regulation and oversight when it comes to midlevels under their authority (individuals who practice nurse practitionry, nurse anesthetism and midwifery). Based on interactions of the Hospitalist’s Union and other doctors with state nursing boards, complaints filed regarding midlevels misidentifying themselves as doctors have been broadly dismissed despite the fact that these organizations state that midlevels who hold a “doctorate” must identify what they hold a “doctorate” in. In one interaction with the Texas Board of Nursing, when they were notified of the widespread practice of midlevels (under their authority) identifying themselves as doctors, they indicated this was not legal. When asked what the punishment was for this, they could not provide a response or even a guideline for disciplinary action because they indicated each case and scenario is different. Based on their responses, it appears that one may falsely identify himself or herself based on the circumstances in which they are entrenched. It’s astounding to attempt to believe that a question with a black and white answer was being diluted by shades of gray by a licensing board that is purported to uphold standards. In another question posed to this state board, they repeatedly referred to “scope of practice laws” when questioned about where the field of nurse practitionry ends. It appears they are allowed to attempt to practice medicine (without having a medical degree) but the question is where does the requirement for a medical degree begin?

    In a complaint filed to the South Carolina Department of Labor, Licensing and Regulation regarding a midlevel falsely identifying himself as a doctor, this organization appeared unconcerned as well. When doctors identified a midlevel on social media falsely identifying himself as a “doctor,” he quickly changed how he addressed himself online, only after outrage was expressed by the medical community. In response to a filed complaint, this organization indicated “However, the statement of your complaint indicates that the respondent’s representation as a medical physician was revised on the website. Therefore, no further action is necessary.” If we are to indulge this organization’s logic, one may falsely identify himself or herself to the public as a doctor, then recant when identified as not being one with impunity.

    In Arizona, it is illegal for a midlevel who holds a “doctorate” to identify himself or herself without specifying what they have a “doctorate” in. When calling the Arizona State Board of Nursing regarding information on various matters, one encounters a long list of voice prompts to navigate their system. While listening to their directory, they identify a nurse practitioner who is a member of their organization as a “doctor” without specifying what she holds a “doctorate” in. Can you believe that the organization purported to uphold standards is neglecting their very own?  What's just as troubling is that two complaints we have filed with this organization have taken over a year to investigate.

    As previously mentioned, the job of being a midlevel is not a different branch of the medical field (as many midlevels assert). It is the attempted practice of medicine with a lesser (and incomplete) certification (as compared to a doctor's). Nursing boards appear to be unwilling, unprepared and unserious about enforcing standards, which includes placing limitations on their licensees for the sake of patient safety. It is time for state osteopathic medical boards and state medical boards to annex authority over midlevels then gradually nullify their right to practice what it is that they do practice as more doctors are educated and trained.

    “Nursing boards appear to be unwilling, unprepared and unserious
    about enforcing standards, which includes placing limitations
    on their licensees for the sake of patient safety.”

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  • The Media

    It is uncertain why or when the media (including medical journals) initiated its anti-doctor agenda, however they have effectively silenced and debased the majority of doctors and their roles in the medical field.  One can frequently read articles that give credence to hospital administrators, insurance executives and medical association presidents, but dismiss doctors unless they are being chased down for commentary on a medical malpractice lawsuit, or if they are being used to promote an agenda or for commentary on medical breakthroughs.  It is not only news reports that misrepresent doctors, but also the portrayal of them in entertainment that casts a false light on them as humans, the sacrifices they have made and the lifestyles they are purported to lead.  Frequently, when the media needs a medical opinion or if they are seeking recommendations on medical policy, they interview those few doctors who have a medical degree (but do not work in the medical field) or who work part-time or who are considered to be academics that don’t need to deal with two of the most important factors in the medical field: Time and money.  They do all of this while ignoring those that work “in the trenches.”  Because a large portion of the media’s focus is on ratings, they will frequently seek those rare doctors who will be overly dramatic or those who will water down their medical opinions (so as to not upset patients and viewers) so that they will be invited back for future interactions (a Time Magazine article speaks to this whereby they published the results of a study that demonstrated “only 46% of the recommendations on the Dr. Oz Show and 63% on The Doctors (show) were supported by evidence”).  Based on the above, consumers of media coverage may be led to believe that what is most entertaining is the most truthful or accurate.  What contributes even more to the misrepresentation of doctors is the firewall of patient confidentiality.  News organizations will often speak with patients over the course of weeks and months (in the case of a medical malpractice lawsuit) and provide details and perspectives of patients, but they are well aware that doctors may not speak about these things in public.  As a result, they peddle heart wrenching stories that are incomplete in detail and do not cover every perspective while usually ignoring context (including (but not limited to) the culture and practices of the medical field).  This is not to say that all patient concerns should not be taken seriously and addressed.  This is also not to say there aren’t doctors who deserve to be sued and have their licenses revoked.  Rather, if a media outlet cannot (or is unable to) report all sides of a story, they either should not report the story or wait until they can.

    The media is adept at controlling the conversation since, after all, it is their bully pulpit. They decide which conversations will be held (selectivity), when they will be held and will frequently (unilaterally) end conversations without allowing doctors to have a response or by negating their responses by usually having the last word (with the frequent implication that the last word is the final conclusion or the correct solution to an issue).  Please reference the paragraph above titled "Pharmaceutical Companies" as evidence of the media’s selectivity in terms of reporting.

    If one needs further evidence of the media’s selectivity with regard to reporting (or allowing access to others to have the ability to report), one does not need to look beyond one of our member’s interactions with various newspapers.  When our member observed mismanagement and acts that did not appear to be in the best interest of a hospital’s patients, our member contacted that small town’s newspaper.  That newspaper indicated they were not interested in reporting the story. When our member inquired about purchasing advertising space to make the town’s members aware of what was occurring at that hospital, the newspaper refused to sell ad space to our member citing the fact that they (the newspaper) did not want to lose money due to the presumption that if they ran our concerned member’s ad, the hospital would no longer conduct business with them.  Frustrated, but not giving up, our member contacted the newspaper in the nearest big city.  They agreed to sell advertising space to our member which would be published every one to two weeks for approximately sixteen weeks.  After the first ad was run, apparently the newspaper was contacted by the hospital’s attorney and the newspaper refused to run any more ads.  With regards to the hospital’s attorney, we surmise he or she may have made a threat about suing the newspaper for libel.  Our member found an alternative way to publish their concerns and distribute them to the town (and surrounding towns) in which the hospital is located.  The facts and opinions contained in the distributed material were accurate and our member was never (and could not be legitimately) sued by that hospital, thus demonstrating whatever concerns the newspaper at the nearest big city had were flimsy at best.  We surmise that they, too, may have had concerns about losing advertising revenue from that hospital.

    Not only may newspapers limit reporting important stories and curtailing access to advertising space, they may also selectively provide or prevent access to their own stories. One of our members was contacted by another newspaper in another small town regarding patient safety concerns they had.  The newspaper assured our member they would follow up with them, but they never did. Once information was distributed in that town by our member, the newspaper contacted our member soon before their publishing deadline but our member did not want to make rushed statements at that time so the newspaper assured our member they would follow up with them (our member).  The newspaper never did, but they did proceed to publish statements made by a member of the hospital's board that were either knowingly false or made in reckless disregard for the truth (about our member).  Once our member published information (using alternative means) to rebut and provide the truth about the board member’s false statements, the newspaper ran a puff piece about the board member.  To the best of our member’s knowledge, that newspaper requires a paid subscription for individuals to access their articles online.  However, this puff piece article was accessible to everyone (i.e. payment was not required to access it).  To our member, in this tight knit community of heavy small-town politics, this was not accidental.

    Refusing to report is the equivalent of silencing.  Refusing to sell advertising space is obstruction.  In our opinion, limiting or restricting the ability to purchase ad space based on financial decisions and intimidation is unethical.  Any of the above occurring demonstrates that a newspaper (or media outlet) may be complicit in enabling practices that are not in the best interests of patients or (at the very least) prevent enacting necessary changes.  Curiously enough, newspapers (and the media) appear to be quite keen on granting non doctors op-ed space in their publications.

    Healthcare spending accounts for 17.9 percent of our nation’s G.D.P.  Wouldn’t you think the opinions, experiences and perspectives of those who have dedicated the most resources (through student debt and years of education and training) to the medical field would occupy more time in the media?

    No person is perfect and the same holds true for doctors.  Doctors (as a group) provide excellent medical care however the media continues to focus on exceptions, not the rule.  Furthermore, the media has provided the public with false perceptions about doctors, their roles and the healthcare system as a whole.  Midlevels, on the other hand, are the media’s darlings because (according to most media sources) “newer is better.”  Midlevels, to many individuals, are relatively unknown (since most assume they are doctors) and “newer” (since they have not been around as long as doctors).  Because the media seldomly misses an opportunity to take potshots at doctors, they have led patients to falsely believe they should seek medical care from alternative sources (while failing to mention these alternative sources are less qualified or even unqualified).

    One of the media's favorite talking points is training more midlevels to meet patient needs due to the national shortage of doctors.  On top of this, they frequently propose their solution as a permanent one, rather than as a stopgap measure as they fail to mention what measures should be taken to solve this issue.  One would think the most logical solutions to explore would be why there is a shortage of doctors and how to educate and train more doctors rather than pursuing avenues of lower quality of care.  When the media chooses to be, it is excellent at investigating issues, yet this one appears to have been glossed over for years.  While active drivers of change for many other issues, the media passively accepts the shortage of doctors as an inevitability with a "that's just the way it is" attitude (while offering mediocre solutions).  The media's approach to this issue is tantamount to one complaining about a lack of energy generated via solar power and seeking ways to change the sun rather than pursuing the obvious solution of manufacturing more solar panels.  This specious reasoning is part of the media's agenda and it is not serving the best interests of patients.

    If the media has the courage to honestly and fairly cover facts and opinions presented in this Patient Safety Guide, they will introduce it to their audience in a neutral manner and allow them to make their own decisions about it.  Our concern is (because of their agenda) the media may prime their audience by (preemptively) introducing or casting this Guide as biased, angry, opinionated, elitist or with any other adjectives that may elicit negative emotions prior to the audience member reading it.  Our other concern is that they may cite certain passages (without providing context) or cite only portions of passages.  And yet another concern is that the media may engage in influencing the news or reporting it in an agenda based manner rather than simply reporting it (as they should) in a neutral fashion.  Doctors do not attempt to dictate standards in the media industry, perhaps the media should not attempt to dictate standards in the medical field as well.  It may be time for the media to realize that upholding standards (in industries other than their own) is more important than universal appeal.

    Taking into consideration all of the above, the media has implicitly and explicitly decreased the buoyancy of doctors while elevating the crashing tide of midlevels.  This agenda is a disservice to the public and misleading to patients.  Falsely denigrating doctors does not elevate the credentials or competence of midlevels.

    “Because the media seldomly misses an opportunity to take potshots at doctors, they
    have led patients to falsely believe they should seek medical care from alternative
    sources (while failing to mention these alternative sources are less qualified or even unqualified).”