“When I see a bird that walks like a duck and swims like a duck and quacks like a duck, I call that bird a duck.”
—James Whitcomb Riley (1849–1916)

As healthcare continues to evolve in the U.S., more and more “midlevel practitioners” are taking on roles formerly provided by physicians. Examples of midlevel practitioners include the physician assistant (PA), doctor of pharmacy (PharmD) and advanced practice registered nurses (APRN) such as the certified nurse midwife (CNM), nurse practitioner (NP), certified nurse anesthetist (CNRA) and doctor of nursing (RN, PhD). Some of these providers may be unintentionally called “doctor” or request that their patients refer to them as such, however it is very important to recognize that they are NOT equivalent to — or substitutes for — the traditional physicians of Western medicine.

What is a doctor?

According to Merriam-Webster, the word “doctor” literally means “teacher”. Given that around 700 years have past since its first use in the 14th century, its modern meaning includes both the academic doctor of philosophy (PhD) as well as the healing art doctors of medicine (MD), osteopathy (DO), podiatric medicine (DPM), dental surgery (DDS), chiropractic medicine (DC), naturopathic medicine (ND) and veterinary medicine (DVM).

What does it take to be a physician?

As delineated above, there are many paths to gaining the title but the training involved and the credentials earned are not equivalent. In Western Medicine there are only 2 types of physicians: the MD and the DO. While they arise from independent roots (allopathy vs osteopathy respectively), the training involved is essentially the same except for minor details that occur during medical school. To become a physician we all must take the same arduous path.

• Pre-medical school
• Completion of a Bachelor’s Degree – A 4+ year process in any field of study including the sciences (BS) as well as the arts (BA or BFA). A competitive GPA is generally felt to be 3.6 or higher.
• Prerequisite course work – Must be completed in biology, chemistry, physics and math in addition to regular course work.
• The Medical College Admission Test (MCAT) – Administered by the Association of American Medical Colleges (AAMC), the MCAT “is a standardized, multiple-choice examination designed to assess the examinee’s problem solving, critical thinking, writing skills, and knowledge of science concepts and principles prerequisite to the study of medicine. Per the Princeton Review, it is a “5-1/2 hour, computer–based test that has the reputation of being one of the most challenging standardized tests.” Over the past 2 years (2010-2011) the average score has been 25 out of 48 possible points. A competitive score is generally felt to be 30 or higher and only around 1/3 of test-takers will achieve this score.
• Other considerations – Competitive GPA and MCAT scores alone are not enough to ensure admittance to medical school. Other considerations include experiences in leadership, community service, medicine and research as well as letters of recommendation, your personal statement and of course how well you interview.
• Chances – According to the American Medical Association, “For the 2010-2011 entering class, U.S. medical schools received 580,304 applications from 42,742 applicants, an average of 14 per applicant. There were also 31,834 first-time applicants—up 2.5 percent from 31,063 in 2009-2010.” The AMA also noted that, “American allopathic medical schools enrolled 18,390 first-year students for 2009” and “nearly 13,000 applicants competed for 5,100 available slots” in osteopathic medical schools. So given 23,490 total positions and 55,742 applicants, the chance of acceptance based on these numbers alone is 42%.
• Medical school – Another 4+ year process for those fortunate enough to gain admittance. Medical school serves to form the foundation of medical knowledge that we build upon in residency. It costs an average of $30,000 per year for tuition alone; it does not include books, supplies and living expenses. Can you drink water from a fire-hose? That’s what it feels like being deluged with information, struggling to retain it and continuing to compete against peers. How well we do has a direct effect on our ability to obtain a residency position not only in a location of our choosing but also in the field of our choosing – surgical residencies (general surgery, OB/GYN, urology, etc) are more competitive than medical residencies (family medicine, internal medicine, pediatrics, etc). In addition there are 2 more standardized tests we must complete — the United States Medical Licensing Examination (USMLE) steps 1 and 2 — that along with yet another personal statement, more letters of recommendation and interviews are evaluated for residency positions. We obtain either the MD or DO degree when we graduate from medical school depending on the program.
• Residency – All residents are doctors given that we have completed 8+ years of higher education and have graduated with the degree from medical school. First year residents are commonly referred to as “interns”. Residency serves as a kind of apprenticeship or on-the-job-training and thus, in spite of our extensive education, we actually make less money than the nurses with whom we work. Residency can be as short as 3 years or greater than 5 years depending on the chosen specialty.
• Fellowship – For those of us who want to sub-specialize, yet another level of training awaits (the fellowship) with its own process of evaluation and competition. Those of us who do not complete a fellowship are loosely referred to as “generalists” and those who do so are called “specialists”.

All in all to become a physician you are looking at a minimum of 11 years of rigorous higher education: a bachelor’s degree (4+ years), medical school (4+ years), residency (3+ years) and possible fellowship (1+ years). Now that we have explored what it means to be a physician of Western medicine, let’s discuss the process of becoming a midlevel practitioner.

Types of degrees

• BA/BFA/BS – Bachelor of arts/fine arts/science (4+ years)
• MA/MS – Master of arts/science (2+ years following a BA/BFA/BS)
• PhD – Doctor of philosophy (4+ years following a BA/BFA/BS)

Physician extenders

• Physician assistant (PA) – 6+ years (BA/BFA/BS plus MS in physician assistance).
• Nurse practitioner (NP) – 6+ years (BS in nursing plus MS in nursing).
• Certified nurse midwife (CNM) – 6+ years (BS in nursing plus MS in midwifery).
• Certified nurse anesthetist (CNRA) – 6+ years (BS in nursing plus MS in nurse-anesthesia).
• Doctor of nursing (RN, PhD) – 8+ years (BS in nursing plus PhD in nursing).
• Doctor of pharmacy (PharmD) – 8+ years (BA/BFA/BS plus PhD in pharmacology).

Now I’m really not trying to dis on my fellow healthcare providers. In truth PAs, APRNs and PharmDs are needed to improve the accessibility of healthcare to citizens around the country. I am merely trying to point out that large differences remain between midlevel providers and physicians: their training is less comprehensive, less rigorous and certainly less competitive. To compare the two is to compare a Lexus with a Kia: both are cars but their builds are very different.

Why does this matter?

A recent data brief from the National Center for Health Statistics (NCHS) arm of the Centers for Disease Control and Prevention (CDC) noted that over the past 8 years (periods 2000-2001 to 2008-2009):

• Outpatient visits attended only by APRNs have increased by 50%
• People that live outside of major cities are 6 times more likely to be seen by a midlevel practitioner
• Midlevel practitioners are utilized heavily by general medicine (21%) and OB/GYN (19%) compared to pediatrics (8%) and general surgery (6%)

Summary

As we move forward in the improvement of healthcare delivery in the U.S., it is important that we don’t lose sight of quality as we push for quantity. Most aches and pains and even chronic conditions can be (and probably should be) managed by physician extenders, however under the supervision and guidance of the physicians from whom they extend. To permit the practice of medicine without the physician is egregious and frankly dangerous. The next time you see your “doctor”, make sure you understand what kind of “doctor” s/he is. If you are seeing a midlevel provider, inquire about the supervising physician and how s/he is involved in your care. If there is no physician involved I highly suggest that you find yourself a real “doctor” or be prepared for the increase in medical error that will inevitably come. And in response to Mr Riley, quoted above, I would caution: Beware the decoys! They have become quite sophisticated.