TWT is a one-year-old, guys!!! Big whoop, right? I don’t honestly expect anyone to give a flying Funion about my blog's fake birthday. But this does officially mark the fact that I have been consistently writing for an entire year and still going strong! My therapist says I have trouble celebrating my accomplishments. It's deep stuff that’s linked to my childhood and the way I was parented. It’s also deeply embedded into the foundation of my type 1 enneagram personality. Yadda, yadda, yadda. I’m sure you are bored with all of this already. Moving on... A year ago I ranted/"eloquently" surmised my ambivalent feelings about celebrating Doctor’s Day. This ambivalence is, of course, a symptom of a much larger problem--my complicated relationship with the institution of medicine itself. Ask almost any physician (except maybe a private Dermatologist or a Plastic Surgeon who is positively raking in the cash all while dictating their hours and their clientele) and they will tell you that going into medicine is not at all what they expected. Most of us would not choose to do it again with the benefit of hindsight. Post-COVID, many physicians are retiring early, scaling down their hours to part-time, or taking sabbaticals with no end date in sight. Yet the demand for physicians has never been higher and the pay continues to increase. What gives? I could never presume to speak on behalf of all physicians out there but I can speak for myself and others who share my sentiments about life and career. I am a wife, mother, and writer who is entrenched in the woes of a primary care specialty. Granted, Internists, Pediatricians, and Family Practice docs don’t tend to have the biggest egos in constant need of stroking. I work at an LTACH. Most people have no idea what that is or assume it’s a nursing home rather than what it is--a specialty hospital designed for medically complex, critically ill patients who are expected to take a month or longer to get well enough to move on, that is if they don't die first. I could regale you with the many ways in which the staff there often make me feel like little more than a warm body with a medical degree but I, instead, choose to focus on being a blessing to this vulnerable population and their shell-shocked families. Now, I’m taking steps to branch out into wound care, yet another unglamorous field that will send me back into nursing homes for a third round but in a different capacity than my previous forays. Docs like me are clearly not in it for the glory but we do want basic respect for our roles and our responsibilities. Even this can be surprisingly hard to find. When I got out of the military, I thought I was just slow to deprogram from the indoctrination of its many customs and courtesies. It turns out, this wasn't the case at all. The fact of the matter is that I honestly don’t care for the "first name culture" in the professional clinical setting. Not to beat a dead horse, but I can’t stress enough how unhelpful this culture has become. Travel with me down this rabbit trail for a moment. Imagine that you are a 'racial' minority, or from a low socioeconomic background, or a woman, or perhaps all three. Not even 40 years ago, even one of these factors would have strongly worked against your chances of ever going to college, let alone getting into medical school. Now imagine that the playing field has become flooded with people from these similar backgrounds. It’s exciting and enormously validating to see the tide turn so quickly. And yet, as this tide is turning, another, much larger wave is washing over it, effectively canceling out the effects of the smaller tide. In short, people who have had to claw their way into a respectful position are earning the credential of DO or MD, only to find that physicians aren't all that respected anymore and they might have to awkwardly insist on being addressed by their title. This is just one effect I believe the rapidly growing sect of Advanced Practice Providers (APPs)/ Physician Extenders otherwise known as PAs, NPs, APNs, and CRNAs has had on our profession. First, let me stress that I highly value good APPs. I have worked with some excellent ones and with some terrible ones. The same can be said of the many doctors I have worked with over the years. The problem is that the titles and lines have been blurred and patients can't tell the difference. While there are some pushy APPs out there who detest working under any amount of supervision and feel they are superior to physicians, they are few and far between. They may introduce themselves to patients initially as PA or NP such and such, but every moment thereafter, they will likely only refer to themselves by their first name. Likewise, all of their colleagues refer to them on a first-name basis as well. Additionally, all other staff in the hospital are also on a first-name basis. Patients then think that it’s appropriate to call every clinician they interact with by their first name because everyone seems to be on the same playing field now. Or worst, the patient mistakenly calls someone Dr. so and so and no one bothers to correct them.
I don’t blame APPs or allied health professionals for this phenomenon. I place the blame squarely where it belongs, on the shoulders of physicians. Our predecessors went along with whatever seemed like the path of least resistance and remained silent as the culture in medicine dictated to them how things should go. We never bothered to speak up regarding the vast differences between the training of a physician and that of an APP. Medical school is four years long as opposed to 18-24 months for most PA and NP programs. Residency programs mandate 10,000+ hours of clinical training depending on specialty while PA/NP programs often require 500 hours or less. Our continuing medical education requirements and board licensing processes are far more rigorous and tightly governed. In short, there is a world of difference between a physician and an APP but most people would rather not engage in this conversation. Physicians have contributed to lots of other problematic dynamics that are currently at play as well. A prime example is the way our field responded to the critical physician shortages that became apparent a few decades ago. Rather than examining our training practices and doing the work to establish more credible training programs for doctors, our predecessors clung stubbornly to the old way of doing things and insisted on a plan that made little sense. More medical schools opened their doors but there was not a commensurate increase in available residency training programs to meet this response. Hundreds of newly graduated doctors found themselves without a residency program in which to complete their education. Some went overseas or to the Caribbean to train. Others took on non-clinical research or administrative positions.
In response, our government turned to the governing bodies over APP training programs and pressured them to meet the crisis. Seemingly overnight, APP training programs began to pop up left and right. They had widely disparate curriculums with very little oversight and began churning out APPs at the speed of light. When the question of the day is: What can be done about the critical shortage of primary care doctors in America, the answer should not be: train more PAs and NPs. This has been a recipe for role confusion and misconceptions. This is not merely extending the reach of physicians through skilled mediaries, it is replacing them altogether. This is the version of "replacement theory" that actually carries some credibility. Doctors have stood by quietly for decades while health systems have replaced their vacancies with clinicians who do not have equivalent training and who they can pay far less. We, doctors, have a tremendous PR problem on our hands among many other things. We work alongside APPs who are told to supervise but we can’t possibly do so appropriately given our own large caseload of patients. We maintain this supervisory facade because we are told by the powers that be that it is necessary. We dump our work on our APPs and call that supervision. But that’s dishonesty and it causes them to resent us. We get dictated to by administrators and business people who own the healthcare systems and universities because our forefathers and foremothers didn’t want to deal with the hassles of managing a practice. Delegation is one thing, burying your head in the sand altogether is another. In short, we have created multiple monsters that we now have no hope of controlling.
As for the handful of APPs who are gunning to practice autonomously, I say, we let them. Let their governing bodies create a clear path to practicing independently from physicians with the caveat that they cannot misrepresent themselves as physicians or advertise that they are practicing under a physician's license. Allow them to bear the full consequences of being solely responsible for their patient’s outcomes. The best APPs I have ever worked with didn’t buck against the hierarchy. They recognized that they were under a protective shield from legal ramifications along with the benefits of proximity to mentorship, knowledge, and experience. Better guidelines are needed to structure these supervisory relationships and maintain accountability on both sides of the equation. I suspect the best among APPs will fall in line with guidelines intended to foster actual collaboration between the two parties. As for the administrators and businessmen who run the working lives of doctors, let’s be honest about the fact that they are running our healthcare system into the ground. Why is this happening? Because human bodies are not products to be bought and sold. Capitalizing on illness and injury is wrong. Health executives cashing in several million-dollar salaries annually was never supposed to be part of the plan. Physicians are the power button that turns on the entire healthcare machine. It’s our knowledge, skills, and medical orders that generate the workflow of the nurses, CNAs, lab techs, phlebotomists, radiology techs, PTs, OTs, SLPs, social workers, case managers, pharmacists, and more. How is it then that we continue to hold none of the playing cards? Your local doctor’s office and your local hospital may be running on a business model fashioned after Chick-Fil-A or WalMart. It's no wonder I often feel like I'm running a drive-thru window or a cash register rather than a team of medical professionals doing all we can to restore people to health. Are you comfortable with that? I'm not. Stay Thoughtful.
