Viewpoint: Honesty in Healthcare Part 4: Who Is Doing What, and What Are Their Qualifications?
Patients and customers deserve full honesty and clarity.
IT’S CONTROVERSIAL: There is no shortage of controversy in healthcare. One major area of controversy pertains to evolving roles of various medical professionals. Here are some examples: Should physicians be allowed to dispense medications from their offices? Should pharmacists be allowed to prescribe some medications directly to patients? Should nurse practitioners and physician assistants be allowed to practice independently, or should they be obligated to work under physician supervision, and if the latter, what should be the arrangement? This barely scratches the surface, but these are the kinds of issues and controversies that are being worked out (and fought over) in individual states. States are the primary regulators of medical practice in the U.S. The current answers to those questions will vary by state. People who are very freedom-oriented know that there is also a valid argument that none of these activities should require permission from a government entity, but the current reality is that healthcare is highly regulated in the U.S. Recognizing this reality, medical professional licenses are defined and governed by the states.
PHYSICIAN SHORTAGES ARE A CERTAINTY: Many parts of the country have shortages of physicians (for this article, defined as MDs and DOs). To learn more about the physician shortage check out this article in Time and this report from the AAMC.
As this shortage has increased, nurse practitioners and physician assistants have increasingly done tasks that were traditionally done only by physicians. To see how tasks have changed see this article from Greater Than One and this article from AANP.
There has also been growth in complementary and alternative medical practice, such as acupuncture, naturopathy and chiropractic, presumably driven by consumer/patient demand rather than by shortage of physicians.
These medical professionals also overlap in diagnosing and treating some of the same problems that physicians address. There are other medical professionals, many of whom also have doctorate-level degrees, some of whom are called “doctor,” and who may have expanded their roles, including dentists, podiatrists, optometrists, nurse anesthetists, physical therapists, etc.
HONESTY ABOUT TRAINING AND ROLES: Whatever you think about the issues of who should do what, what the laws should allow or forbid, and how the physician shortage should be alleviated, it seems that deception should never be a part of it. Patients/customers deserve full honesty and clarity. The types and amounts of formal training of these different medical professionals are very different and many patients/customers know little about these details. Traditionally, the term “doctor” in the medical setting often meant an MD to many people. Now, DO and MD have enough in common that their graduate medical education programs (residencies) have merged under a single accrediting organization.
MDs and DOs are both considered as physicians for my purposes in this article. Even the term “physician”, though, is often used for those who are not MDs or DOs, such as podiatrists (“podiatric physicians”), naturopaths (“naturopathic physician”), and chiropractors (“chiropractic physician”). So, when patients think they are seeing a doctor, or a physician, who are they really seeing, and what kind of expertise are they getting? The term “provider” may have originated to lump everyone together, for whatever reason, but there is certainly a loss of information, and the feeling of commoditization. This is why I am again writing under the theme of honesty, because the responsibility to be honest and to provide full and accurate information primarily resides within individuals and organizations. Governments alone cannot cause honesty to occur, and sometimes create conditions which encourage dishonesty. Honesty is a value and a virtue.
DECEPTION DOES OCCUR, AND PATIENTS/CUSTOMERS NEED TO ASK QUESTIONS: Patients/customers should feel empowered to ask, if full information on medical professionals is not provided. Many Nurse Practitioners and their organizations have pushed hard to be called doctor in the clinical setting when they have a DNP degree.
However, patients with a traditional understanding of the meaning of the word doctor may be confused, or may not be provided with the information they need to understand the qualifications of the person they are seeing. They might even think that the training is the same, which it is not.
My personal experience is illustrative. I am ordinarily a pretty agreeable person, but a lot less so when it comes to medical practice, where it can be extremely important to get things right. I am an MD with ten years of rigorous formal medical training after college (two specialties), and many years of clinical experience. I am very particular about who I see and who my family members see, for very good reasons. My mother was staying with us for several months in 2020, and I arranged for her to get a medical procedure that her specialist physician back home recommended for her. I asked on the phone who she would be seeing, and whether it would be a doctor, and the answer was “yes, she will see Dr. Madison” (name changed, but it was a name that works both as a surname and a first name). When we were in the office, this person’s name tag said, “Dr. Madison,” with no additional information. I asked what her degree was, and she said that it was DNP (Nurse Practitioner with a doctorate). Most people would likely assume that this person had an MD or DO based on the phone conversation and the badge, and that she was a specialist in the field. That’s what I thought before I asked, but she did not have an MD or DO, and was not a specialist physician. I think that “Dr. Madison” did a fine job with my mother’s clear-cut problem, and it gained my mother access for the procedure she needed with the surgical specialist who did the procedure. However, I think this medical group practice and this practitioner were being terribly deceptive. We should have been told that my mother would be seeing a nurse practitioner for the initial evaluation, and the name badge should have had her degree, DNP, on it, without “doctor.” It should have also said “nurse practitioner.” I haven’t had “doctor” on my name badge or embroidered white coat or signs on the building, either; it has said “MD.”
THE BILLING AND CODING SYSTEM DOESN’T HELP: One of the things that encourages deception and lack of choices for patients is the medical billing and coding system, owned by the AMA, and used exclusively by Medicare, Medicaid and commercial insurance in the U.S. Even though medical practice is a sophisticated skill set and an art that takes much study and experience to master, medical visits have been categorized into levels of care and levels of payment by a complex set of rules independent of the degree of skill and type of training of the person doing the work. For example, an initial medical evaluation by one of the world’s top cardiovascular surgeons will have the same billing code applied as an initial medical evaluation by a physician who only completed an internship and who was at the bottom of the class. The same code would be applied if the evaluation was done by a Nurse Practitioner. The payment rates are either the same for nurse practitioners as for physicians, or 85% of the physician fee, according to various rules.
QUALITY: Whether the service provided to the patient is of the same quality or not when provided by different people with different qualifications cannot be accurately determined by billing codes. There are attempts to measure quality of medical care, but only the most straightforward things are easily measured and compared, and medicine is often complex and extremely challenging. Further, hospitals and medical practices are now commonly delegating straightforward issues to non-physicians upfront, regardless of patient preference. However, how is one to know that a patient/customer does not have a more complex and/or serious problem until they have been evaluated? What if they have something serious that is missed or misdiagnosed? Anyway, I am opposed to adding more rules to the coding and billing system to incorporate measures of skill and quality. Instead, I am in favor of full honesty with patients. I am in favor of patients seeking out the best care available. Patients will have limitations in their knowledge but will know their own values and preferences. I personally believe that patients can do a pretty good job of choosing, if they care to exert the effort. Whether patients realistically get a choice or not of who they see, knowing the degree and qualifications of their medical professionals will at least give them some accurate information. As always, I encourage patients to be active and informed in their own medical care, and to ask questions. If the state, hospital or medical practice does not require the medical degree to be stated on a badge, patients can still ask and can still find out. And, they should do so.