Tuesday, October 4th 2011

The Doctor’s Ego

As more nurses, pharmacists and physical therapists claim this honorific [title doctor], physicians are fighting back. For nurses, getting doctorates can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients. But so far, the new degrees have not brought higher fees from insurers for seeing patients or greater authority from states to prescribe medicines.

So the debate over scope of practice and titles begins again in The New York Times.

As ancillary staff within the healthcare system get more and more advanced and as more and more independent care falls to them the lines between physician and other health care practitioners has blurred. Nowhere more vain than in the use of the title “doctor.”

We know the lengthy history of the title in Europe; rising with emergence of the post-Medieval university. In the United States however almost exclusively in social and professional spheres it has been used to refer to physicians. Not chiropractors or pharmacists or nurses or physicists or poets or mathematicians or lawyers. When you introduce yourself to a patient, or indeed anyone, as a “doctor” their first question isn’t, “Doctor of what?” or “What type?” There is a norm and understanding that you’re introducing yourself as a physician. And there’s nothing wrong with that norm; it merely is the way it is.

As Doctor Steven Knope put it in an NPR article from several years past,

“If you’re on an airline and a poet with a Ph.D. is there and somebody has a heart attack, and they say ‘Is there a doctor in the house?’ — should the poet stand up? Of course not.”

It’s ego partly, admittedly. But especially amongst primary care physician, it may also be about future competition and scope of practice,

[M]any physicians are suspicious and say that once tens of thousands of nurses have doctorates, they will invariably seek more prescribing authority and more money. Otherwise, they ask, what is the point?

Dr. Roland Goertz, the board chairman of the American Academy of Family Physicians, says that physicians are worried that losing control over “doctor,” a word that has defined their profession for centuries, will be followed by the loss of control over the profession itself. He said that patients could be confused about the roles of various health professionals who all call themselves doctors.

I see slippery slope and the worry from physicians. “Doctor” has always been an unregulated honorary title. It has become socially acceptable only for use, outside academics, by physicians. To use it otherwise was to draw snickers or scorn. But the rise of a largely independently practicing class of advanced, doctoral degree holding nurse practitioners provides a challenge to the title. Here are practitioners holding advanced degrees, performing many but not all of the same health care delivery that physicians give. There may still be quizzical looks at cocktail parties when the title “doctor” is used but there are bound to be fewer and fewer of such in the clinic as “physician extenders” with professional doctoral degrees take on more and more responsibility.

In the end while I support the expanded scope of practice for ancillary providers, I’m with Razib Khan. Blogging on the Discovery Magazine website,

[I]n this case we’re seeing greater and greater credentialism in fields which were traditionally perceived to be auxiliary to medical doctors. This is not a good sign. Instead of challenging the unquestioned prominence of medical doctors in domains where nurses are sufficient and more cost effective, the nursing profession is “fighting fire with fire.” This is not going to end well

Whatever my opinion I think the tide likely favors the advanced non-physician practitioners. It will be a slow generational shift but no doubt someday in the future it will be almost universally socially accepted that there are non-physician “doctors.”