By Rebekah Bernard, MD, and Carmen Kavali, MD, with PPP (Physicians for Patient Protection)
In August 2023, we were interviewed for a Washington Post article on the use of the term ‘doctor’ by nurses and physician assistants with a doctorate degree (Medicine without doctors? State laws are changing who treats patients). While the article correctly represented our view that the use of ‘doctor’ in a clinical setting should be restricted to physicians with an MD/DO degree, it neglected essential facts that support our position.
The nurse practitioner (NP) doctorate and physician assistant (PA) doctorate degrees are not equivalent to the physician degree (MD/DO).
The path to earning an MD or DO degree is highly rigorous and standardized, requiring a minimum of 5-7 years of postgraduate education. The acceptance rate to U.S. medical schools is 7%, and due to a shortage of residency positions, only the top graduates will be selected to enter the practice of medicine. Most physicians complete a minimum of 15,000 hours of clinical experience before they are permitted to treat patients independently.
By contrast, a Doctor of Nursing Practice (DNP) degree may be completed in three postgraduate years and requires a minimum of 1,500 clinical hours of experience. Many DNP programs have 100% acceptance rates and are 100% online. While the original intent of DNP programs was to increase clinical knowledge for nurse practitioners, only 15% of DNP programs are clinical in focus. The other 85% emphasize non-clinical skills such as leadership, informatics, and research. While advocates laud the wealth of nursing experience NPs bring to the table, many new nurse practitioners have never worked a day as a nurse, with 22% entering ‘direct entry’ programs for non-nurses with a bachelor’s degree in any subject.
The physician assistant doctorate degree (DMSc) can be completed in 3-1/2 years and about 2,000 clinical hours.
There are no studies with independent nurse practitioners or physician assistants managing ‘typical’ patients.
Advocates for ‘full practice authority’ often claim that studies show nurse practitioners and physician assistants provide high-quality care. However, they fail to mention that none of these studies involve care provided by independent nonphysicians managing typical patients; instead, they involve care teams of NPs or PAs and physicians working together to manage straightforward problems in low-risk patients.
The other key element in the studies touted by NPs and PAs is that every patient was already previously diagnosed by a physician, allowing treatment management by physician-created algorithms. There are no studies that show NPs and PAs are equivalent to physicians in evaluating a patient and establishing an accurate diagnosis. There are many studies that show that NPs and PAs order more tests, prescribe more unnecessary medication, and refer less appropriately than physicians, which drives up costs and decreases access to specialists.
The truth is this: Despite over 50 years of scientific analysis of the care provided by non-physicians, there is no conclusive evidence that non-physician practitioners can provide safe and effective medical care without physician oversight. In fact, recent studies have shown the opposite: that the replacement of physicians puts patients at risk for worse outcomes at higher costs.
Patients are not in a position to assess clinical quality.
When it comes to quality medical care, the average patient has no choice other than to assume that the person in the white coat has the proper skills and training. They are supported in this assumption by marketing campaigns that assure patients that nurse practitioners and physician assistants are ‘just as good or better’ than physicians, with slogans like, ‘We Choose NPs’ and ‘Your PA Can.’
As clinicians are increasingly lumped together as ‘providers,’ the title ‘doctor’ remains one of the few distinguishing descriptors that differentiates physicians. Patients trust that a higher authority has licensed, credentialed, and authorized a clinician to use the title, and allowing non-physicians to appropriate the term blurs already fuzzy lines.
Patients are already confused about clinician titles.
Informed consent is a hallmark of the ethical treatment of patients and requires that patients are fully informed about the risks, benefits, and alternatives of medical treatments being offered, and patients must be able to express an understanding of these factors. Informed consent can only be given by a patient who understands exactly who is caring for them, including whether a clinician is a physician or a nonphysician practitioner.
Unfortunately, patients report confusion about medical titles, as reported in a 2018 American Medical Association (AMA) survey. The report found that while patients overwhelmingly prefer a physician to take charge of their care, many mistakenly believe that nurse practitioners and physician assistants are medical doctors. For example, 39% thought a Doctor of Nursing Practice was a physician, while 11% weren’t sure. That means half of all people surveyed were confused or wrong about what a DNP degree means. More than half (61%) of people surveyed thought a physician assistant with a doctorate (DMSc) was a physician.
Uninformed choices can lead to unintended consequences. No patient should ever wonder exactly who is taking care of them. With the increasing replacement of physicians by nonphysician practitioners, words matter more than ever.
Physicians for Patient Protection is a grassroots organization of practicing and retired physicians, residents, medical students, and assistant physicians (a new designation for physicians who have finished medical school but haven’t yet matched in a residency).
Our mission is to ensure physician-led care for all patients and to advocate for truth and transparency regarding healthcare practitioners.
We advance our mission by educating our colleagues, by influencing policy and legislation, and by educating our patients and the public.