From the blog of the happy hospitalist, It goes along our fight to differentiate a NP from a MD.
The start:
Here's my opinion, most patients have no idea if you are a doctor, a doctor nurse (or Dr Nurse), or the lab tech. Walk in a room. Pretend you know what you are doing. Be nice. Talk to them a little. Let them tell you how Cuddles,their little Chihuahua, likes to lick the enamel off their teeth. When you walk out, I bet just about every patient would tell their spouse, "My what a nice doctor that was."
I have come to the conclusion that some patients want everything done. They want only sub specialists. They have fallen victim to the more is better mantra. They want all the high tech equipment known to man. Usually, this comes from the highly educated and highly entitled over insured population that demand what they perceive to be the best of everything. They are clueless and are incapable of understanding that more is not always better.
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Then you have the chronically old. The chronically sick. The chronically educationally disinclined who have absolutely no clue how anything medical works. These are the folks that get the yearly case of ammonia in their lungs. The folks who get their prostrates checked every so often. The folks with the shugah diabetes. The ones who live and die without a single ounce of interest in learning about their disease process. These folks are also clueless, but for an entirely different reason. They don't care and they don't care to know.
This last population of patients are the ones who lack the intellectual capability to question anything medical. If it looks medical, it must be. I could dress up a pig in a lab coat and they would think that a doctor just left the room.
For medicine that involves the diagnosis and management of acute and chronic medical disease, there is only one type of doctor. Someone who has earned a doctorate degree in the study of medicine, not nursing. Someone who has gone on to train under the direction of medical doctors to learn their craft as defined by accredited institutions. Someone who has sat for and passed the requirements for certification as defined by the board of their medical specialty, the competency of which has been determined by other doctors who specialize in that field of training. That's what a doctor is. That's what the public expects when they get "a doctor"
And this physician assistant agrees.
My other concern is the use of the title, "Doctor". It is true that pharmacists, PT's, and others have moved to a doctoral degree. BUT, none of those professions outside of a psychologist, use the title "Doctor" when treating patients.....why you might ask?
Simple, it is confusing to the layperson, and downright fraudulent, ...
A recent article I read in Advance for NP's suggested that 47% of current NP's or NP students PLAN ON USING THE TERM DOCTOR UPON completion of their degree. This is a potential legal minefield, and I would urge the NP community to tread lightly with this. Everything will be fine as long as no bad outcomes occur.......unfortunately, BAD OUTCOMES do occur, and they will happen to everyone that practices medicine at some time. It is a simple statistical reality. When that happens, I can already see a case of fraud, or misidentity being brought easily.
I'm not saying doctor nurses are dumb. I'm not saying they are idiots. I'm not saying they don't have a role in taking care of patients. What I am saying is that patients, the intellectually disinclined, are incapable of making informed decisions on the differentiation between Dr Nurse and Dr MD unless it is spelled out for them in clear English. They may not care, because they have not experienced a problem that required a difficult differential diagnosis.
Is there a difference in care? Of course there is. That's like saying a pilot with 1000 hours is similar in quality to a pilot with 10,000 hours. That's like saying a pilot who trained on a Cessna can navigate an airplane the same as a pilot trained by the United States Air Force. Are they both granted flying privileges? Yes they are. But their scopes of flying privileges are different. Not so in the MD Dr Nurse scope of practice.
You would not certify a Cessna pilot to do combat missions on an F-16. Unfortunately, we have done just that with the creation of independent practitioners who are undifferentiated in scope and practice from the Cessna trained and the Air Force trained.
Can nurse practitioners fly with the same quality as an Air Force Pilot? Perhaps they can. And perhaps they can do it often, under certain circumstances. Until one day you have to land the plane in the Hudson. And the training of the Cessna pilot will be woefully inadequate for real life. I live that scenario every day. Every time a patient is crashing. Every time a long tail diagnosis is discovered. Every time an uncommon presentation of a common disease presents itself. Every time a complication arises that is not part of the routine practice of medicine. For me, in the delivery of health care, every day is a plane crash in the Hudson.
You often can't tell the difference between pilots until the plane is crashing. Nurse practitioners and doctor nurses like to use the argument of "no difference in quality." The problem is you can define quality anyway you want. And they do. Picking and choosing their parameters that establish quality and equality. I know the truth. That those parameters of quality are irrelevant in the debate.
I get emails all the time asking me what I have against nurse practitioners. There are nurses at my place of work who ask me what I have against nurse practitioners. Why I think they are stupid. I am here to say, I don't think they are stupid by any means. Nor do I think they are incapable of taking care of patients, in a defined scope. They have a very important role in delivering health care to the masses. But I don't believe for a second that the quality they provide is equal or better than the quality that MDs provide within the same undifferentiated scope of practice.
Why? Because I don't define quality the way nurse practitioners or doctor nurses or patients or the government will. I define it by characteristics that can't be measured in a randomized trial or tracked with outcomes data, but is at the same time, the most important aspect of independent patient care.
For me, that greatest determinant of quality care, which you won't find in any journal or on any government compare website, or in any patient satisfaction survey is the strength and quality of the differential diagnosis generated by that doctor, nurse or other. Doctors are differential diagnosis generators. This is by and far the most important skill set a physician can offer their patient, something that cannot be learned in nursing level training or nursing level graduate school. It is what separates physicians from all other providers of independent care.
The only way you can appreciate the importance of this statement is to complete a physician residency. I don't expect you to understand because you have not lived it. You can't possible understand why I am so passionate about my belief in this defining characteristic for patient care because you don't experience it. You don't see it. It's not documented. It's fully compartmentalized in the mind of the physician providing the care for that patient.
When I sit in front of that computer looking at patient data, absorbing their words, feeling the bumps on their skin, listening to their heart; when I sit there for 5 minutes thinking, I am developing a very large expanded differential diagnosis. I am documenting it in my mind. This process decides my evaluation. It defines my care plan. It is what I do. It is the most important aspect of what I do. Ordering the HgbA1c to meet quality indicators is not what I do. Getting 90% on my patient Happy scale is not what I do. Making sure the patient gets their flu shot is not what I do. What I do is generate differential diagnoses. Not a day goes by where I don't think to myself, "What else could this patient have?"
Until you do that day after day, night after night. Until you do that 1000s upon 1000s upon 1000s of times. Until you have had the education, direction and mentoring of physicians before you who teach you that differential diagnosis and how to apply it to every single patient, every single time, you cannot possibly comprehend the glaring holes in your own differential diagnosis from nurse practitioner school or doctor nurse school. It is the act of completing a physician residency that develops that process of differential diagnosis. All other training tracks are great imitators in duration and rigor, intensity and experience.
If you don't want to accept this fact, no amount of explanation will help you understand that your training as a nurse practitioner pales in comparison to the process used to develop physicians into great differential diagnosis machines.
And I'm not just talking about one differential diagnosis. Most patients come in with more than one complaint. As a physician, my job is to create a thorough differential diagnosis for every single complaint, and then try to put the puzzle together. Let me give you an example:
Let's assume I was an outpatient doctor. A 75 year old patient presents with a complaint of shortness of breath. The history reveals it has been going on for 2 months, progressively worse. Gets worse with lying flat. Gets lightheaded with walking and sitting. One episode of passing out. Feels palpitations. Intermittent diarrhea and difficulty urinating. Sometimes the legs swell and cramp. Also falling, weak fatigued, not eating well. Lost 15 pounds.
I don't have the inclination to write out my differential diagnosis, but suffice to say at least 50 medical conditions immediately popped into my head when I created this common scenario. They ranged anywhere from hormonal abnormalities, to common and uncommon cancers in this age group, to coronary syndromes, to cardiac syndromes ischemic and otherwise, to acute and chronic pulmonary conditions, both common and not. It included hematological, infectious, allergic and autoimmune processes. The list goes on and on.
Deciding how to evaluate is determined by the process of cross referencing, in my mind, all the likely probabilities of each of the differential diagnoses for pertinent positives and negatives on history and physical examination. This is not protocol driven medicine. This is not guideline driven. This is not EMR driven.
This is internal medicine. I wish I could walk you through the process of defining exactly how the differential is developed. But I can't. That's what the lay public and those who are trained in non physician level programs can't accept. The constant bombardment by nurse practitioners on my site calling me an ass, demanding data I claim regarding their lack of quality. Here it is. Your differential diagnosis skills are inadequate to practice independently. You want to believe that your training prepares you for it.
It doesn't. Not even close. Not--Even--Close. It simply comes natural for me. Medical school trained me for it. Residency trained me for it. That's the only way you can train for it in a manner that provides your patients with the highest quality care that can be delivered.
Here's a small peak of what I do for every single issue that arises in patient care. It's automatic. And it's automatic for every patient I see of every day of every week of every year.
It is the strength of that differential diagnosis that guides ICU evaluation and management. That guides ED evaluations and admissions. That guides questions subspecialists ask of me in consultations. That guides outpatient clinical medicine. It is the strength of that differential diagnosis that deciphers life and death medical conditions. You don't have time to Google it. You don't have time to call the critical care specialist. You are it. You are all alone in rural America, and it's your job to save the patient. It's your job to save them. Every time. It's your job. And it must be automatic. There cannot be any doubt.
And your patients deserve the best differential diagnosis, every time, without fail. Not by nursing or doctor nurse standards. But that which is developed by physician level training and is verified by testing bodies that credential you as an expert of the differential diagnosis in your field. That's what your patients deserve.
The only way you get that good is to know your differential diagnosis. And the only way you get to know your differential diagnosis is to learn it in a physician level training program.
When you call yourself a doctor nurse, you are portraying yourself as a master of the differential diagnosis. Your patients will not know otherwise. But I know that's what they deserve. And other doctors know that's what they deserve. Even you know that's what they deserve. Your job is not to put your signature on a protocol. Your goal is not to achieve 85% compliance with HgbA1c data gathering. Your job is not to get high satisfaction scores. Using these markers to define your quality is a slap in the face to your patients. Your patients deserve an extensive differential diagnosis, every time.
Your job is to diagnose and manage disease in the scope of patient care. To develop an aggressive differential diagnosis. It's your duty to your patient. Your duty to your profession. Your duty to excellence. You can't measure it. You can't study its outcomes. Only you physician, nurse practitioner and doctor nurse know how good your differential diagnosis is. And if you have any doubts as to your ability to generate one on par with your board certified physicians practicing in your same scope of practice, you owe it to your patients to relieve yourself of your independent duties and practice your scope in a fashion limited by your capabilities.
They may not know it, but when your patients call you doctor, they are expecting the best differential diagnosis of their problems. If you can't, in good conscious offer them that, you owe them the truth. You owe them the right to know your limitations.
Just telling it like it is.
The start:
Here's my opinion, most patients have no idea if you are a doctor, a doctor nurse (or Dr Nurse), or the lab tech. Walk in a room. Pretend you know what you are doing. Be nice. Talk to them a little. Let them tell you how Cuddles,their little Chihuahua, likes to lick the enamel off their teeth. When you walk out, I bet just about every patient would tell their spouse, "My what a nice doctor that was."
I have come to the conclusion that some patients want everything done. They want only sub specialists. They have fallen victim to the more is better mantra. They want all the high tech equipment known to man. Usually, this comes from the highly educated and highly entitled over insured population that demand what they perceive to be the best of everything. They are clueless and are incapable of understanding that more is not always better.
Post a Job!
$50 for 30 days
Then you have the chronically old. The chronically sick. The chronically educationally disinclined who have absolutely no clue how anything medical works. These are the folks that get the yearly case of ammonia in their lungs. The folks who get their prostrates checked every so often. The folks with the shugah diabetes. The ones who live and die without a single ounce of interest in learning about their disease process. These folks are also clueless, but for an entirely different reason. They don't care and they don't care to know.
This last population of patients are the ones who lack the intellectual capability to question anything medical. If it looks medical, it must be. I could dress up a pig in a lab coat and they would think that a doctor just left the room.
For medicine that involves the diagnosis and management of acute and chronic medical disease, there is only one type of doctor. Someone who has earned a doctorate degree in the study of medicine, not nursing. Someone who has gone on to train under the direction of medical doctors to learn their craft as defined by accredited institutions. Someone who has sat for and passed the requirements for certification as defined by the board of their medical specialty, the competency of which has been determined by other doctors who specialize in that field of training. That's what a doctor is. That's what the public expects when they get "a doctor"
And this physician assistant agrees.
My other concern is the use of the title, "Doctor". It is true that pharmacists, PT's, and others have moved to a doctoral degree. BUT, none of those professions outside of a psychologist, use the title "Doctor" when treating patients.....why you might ask?
Simple, it is confusing to the layperson, and downright fraudulent, ...
A recent article I read in Advance for NP's suggested that 47% of current NP's or NP students PLAN ON USING THE TERM DOCTOR UPON completion of their degree. This is a potential legal minefield, and I would urge the NP community to tread lightly with this. Everything will be fine as long as no bad outcomes occur.......unfortunately, BAD OUTCOMES do occur, and they will happen to everyone that practices medicine at some time. It is a simple statistical reality. When that happens, I can already see a case of fraud, or misidentity being brought easily.
I'm not saying doctor nurses are dumb. I'm not saying they are idiots. I'm not saying they don't have a role in taking care of patients. What I am saying is that patients, the intellectually disinclined, are incapable of making informed decisions on the differentiation between Dr Nurse and Dr MD unless it is spelled out for them in clear English. They may not care, because they have not experienced a problem that required a difficult differential diagnosis.
Is there a difference in care? Of course there is. That's like saying a pilot with 1000 hours is similar in quality to a pilot with 10,000 hours. That's like saying a pilot who trained on a Cessna can navigate an airplane the same as a pilot trained by the United States Air Force. Are they both granted flying privileges? Yes they are. But their scopes of flying privileges are different. Not so in the MD Dr Nurse scope of practice.
You would not certify a Cessna pilot to do combat missions on an F-16. Unfortunately, we have done just that with the creation of independent practitioners who are undifferentiated in scope and practice from the Cessna trained and the Air Force trained.
Can nurse practitioners fly with the same quality as an Air Force Pilot? Perhaps they can. And perhaps they can do it often, under certain circumstances. Until one day you have to land the plane in the Hudson. And the training of the Cessna pilot will be woefully inadequate for real life. I live that scenario every day. Every time a patient is crashing. Every time a long tail diagnosis is discovered. Every time an uncommon presentation of a common disease presents itself. Every time a complication arises that is not part of the routine practice of medicine. For me, in the delivery of health care, every day is a plane crash in the Hudson.
You often can't tell the difference between pilots until the plane is crashing. Nurse practitioners and doctor nurses like to use the argument of "no difference in quality." The problem is you can define quality anyway you want. And they do. Picking and choosing their parameters that establish quality and equality. I know the truth. That those parameters of quality are irrelevant in the debate.
I get emails all the time asking me what I have against nurse practitioners. There are nurses at my place of work who ask me what I have against nurse practitioners. Why I think they are stupid. I am here to say, I don't think they are stupid by any means. Nor do I think they are incapable of taking care of patients, in a defined scope. They have a very important role in delivering health care to the masses. But I don't believe for a second that the quality they provide is equal or better than the quality that MDs provide within the same undifferentiated scope of practice.
Why? Because I don't define quality the way nurse practitioners or doctor nurses or patients or the government will. I define it by characteristics that can't be measured in a randomized trial or tracked with outcomes data, but is at the same time, the most important aspect of independent patient care.
For me, that greatest determinant of quality care, which you won't find in any journal or on any government compare website, or in any patient satisfaction survey is the strength and quality of the differential diagnosis generated by that doctor, nurse or other. Doctors are differential diagnosis generators. This is by and far the most important skill set a physician can offer their patient, something that cannot be learned in nursing level training or nursing level graduate school. It is what separates physicians from all other providers of independent care.
The only way you can appreciate the importance of this statement is to complete a physician residency. I don't expect you to understand because you have not lived it. You can't possible understand why I am so passionate about my belief in this defining characteristic for patient care because you don't experience it. You don't see it. It's not documented. It's fully compartmentalized in the mind of the physician providing the care for that patient.
When I sit in front of that computer looking at patient data, absorbing their words, feeling the bumps on their skin, listening to their heart; when I sit there for 5 minutes thinking, I am developing a very large expanded differential diagnosis. I am documenting it in my mind. This process decides my evaluation. It defines my care plan. It is what I do. It is the most important aspect of what I do. Ordering the HgbA1c to meet quality indicators is not what I do. Getting 90% on my patient Happy scale is not what I do. Making sure the patient gets their flu shot is not what I do. What I do is generate differential diagnoses. Not a day goes by where I don't think to myself, "What else could this patient have?"
Until you do that day after day, night after night. Until you do that 1000s upon 1000s upon 1000s of times. Until you have had the education, direction and mentoring of physicians before you who teach you that differential diagnosis and how to apply it to every single patient, every single time, you cannot possibly comprehend the glaring holes in your own differential diagnosis from nurse practitioner school or doctor nurse school. It is the act of completing a physician residency that develops that process of differential diagnosis. All other training tracks are great imitators in duration and rigor, intensity and experience.
If you don't want to accept this fact, no amount of explanation will help you understand that your training as a nurse practitioner pales in comparison to the process used to develop physicians into great differential diagnosis machines.
And I'm not just talking about one differential diagnosis. Most patients come in with more than one complaint. As a physician, my job is to create a thorough differential diagnosis for every single complaint, and then try to put the puzzle together. Let me give you an example:
Let's assume I was an outpatient doctor. A 75 year old patient presents with a complaint of shortness of breath. The history reveals it has been going on for 2 months, progressively worse. Gets worse with lying flat. Gets lightheaded with walking and sitting. One episode of passing out. Feels palpitations. Intermittent diarrhea and difficulty urinating. Sometimes the legs swell and cramp. Also falling, weak fatigued, not eating well. Lost 15 pounds.
I don't have the inclination to write out my differential diagnosis, but suffice to say at least 50 medical conditions immediately popped into my head when I created this common scenario. They ranged anywhere from hormonal abnormalities, to common and uncommon cancers in this age group, to coronary syndromes, to cardiac syndromes ischemic and otherwise, to acute and chronic pulmonary conditions, both common and not. It included hematological, infectious, allergic and autoimmune processes. The list goes on and on.
Deciding how to evaluate is determined by the process of cross referencing, in my mind, all the likely probabilities of each of the differential diagnoses for pertinent positives and negatives on history and physical examination. This is not protocol driven medicine. This is not guideline driven. This is not EMR driven.
This is internal medicine. I wish I could walk you through the process of defining exactly how the differential is developed. But I can't. That's what the lay public and those who are trained in non physician level programs can't accept. The constant bombardment by nurse practitioners on my site calling me an ass, demanding data I claim regarding their lack of quality. Here it is. Your differential diagnosis skills are inadequate to practice independently. You want to believe that your training prepares you for it.
It doesn't. Not even close. Not--Even--Close. It simply comes natural for me. Medical school trained me for it. Residency trained me for it. That's the only way you can train for it in a manner that provides your patients with the highest quality care that can be delivered.
Here's a small peak of what I do for every single issue that arises in patient care. It's automatic. And it's automatic for every patient I see of every day of every week of every year.
It is the strength of that differential diagnosis that guides ICU evaluation and management. That guides ED evaluations and admissions. That guides questions subspecialists ask of me in consultations. That guides outpatient clinical medicine. It is the strength of that differential diagnosis that deciphers life and death medical conditions. You don't have time to Google it. You don't have time to call the critical care specialist. You are it. You are all alone in rural America, and it's your job to save the patient. It's your job to save them. Every time. It's your job. And it must be automatic. There cannot be any doubt.
And your patients deserve the best differential diagnosis, every time, without fail. Not by nursing or doctor nurse standards. But that which is developed by physician level training and is verified by testing bodies that credential you as an expert of the differential diagnosis in your field. That's what your patients deserve.
The only way you get that good is to know your differential diagnosis. And the only way you get to know your differential diagnosis is to learn it in a physician level training program.
When you call yourself a doctor nurse, you are portraying yourself as a master of the differential diagnosis. Your patients will not know otherwise. But I know that's what they deserve. And other doctors know that's what they deserve. Even you know that's what they deserve. Your job is not to put your signature on a protocol. Your goal is not to achieve 85% compliance with HgbA1c data gathering. Your job is not to get high satisfaction scores. Using these markers to define your quality is a slap in the face to your patients. Your patients deserve an extensive differential diagnosis, every time.
Your job is to diagnose and manage disease in the scope of patient care. To develop an aggressive differential diagnosis. It's your duty to your patient. Your duty to your profession. Your duty to excellence. You can't measure it. You can't study its outcomes. Only you physician, nurse practitioner and doctor nurse know how good your differential diagnosis is. And if you have any doubts as to your ability to generate one on par with your board certified physicians practicing in your same scope of practice, you owe it to your patients to relieve yourself of your independent duties and practice your scope in a fashion limited by your capabilities.
They may not know it, but when your patients call you doctor, they are expecting the best differential diagnosis of their problems. If you can't, in good conscious offer them that, you owe them the truth. You owe them the right to know your limitations.
Just telling it like it is.
This made my day. Time to add another bookmark to my daily reads.
) tells me, "well you know the phrase, 'when you hear hoofbeats you should think zebras.'" I correct her, and say the phrase is actually, "when you hear hoofbeats, DON'T expect to see a zebra." She tells me that the EKG and Echo were normal but they never checked enzymes "which is the first thing we do" and that without those, "you can't rule out a heart attack, which I'm sure she had." 
