A REAL Doctor

Was seeing a patient for the first time the other day when, toward the end of my visit with her, she asked, “So…are you a real doctor?”

I wasn’t quite sure how to respond.

Missing a beat, I then replied, “Well, no, actually. I’m just a resident. Training. Dreaming big dreams of one day being the real thing.” I felt a bit like Pinocchio.

“What I mean is,” She continued, unperturbed, “are you really just a nurse. You know, one of those nurses that acts like a doctor…or are you actually a doc?”

“OH!” I reply, thinking oh yes…THIS stupid conversation. (It’s endless, it goes on and on. It’s like the circumcision debate) “Yeah. I’m a real doc. Except for the ‘in training’ thing.”

“Great, because I normally see a nurse, but I’d much rather just see you.”

Obviously, this kind of thing makes me feel a bit pleased that I have impressed a patient enough to want to see me again. But it could be simply that this patient wants to see me instead of her nurse largely because of the interaction of their two personalities. My medical acumen may have very little to do with it.

ARNP’s, PA’s, NP’s and the rest all serve important roles. In all honesty, many of them know more than I do about medicine and sometimes I frankly can’t come up with any good reason why a patient should go to me rather than to them.

When I DO get my hackles up, however, is when I find that those professions not only disrespect mine, but see family doctors as superfluous. A recent circulating rumor I heard is that the latest national NP conference displayed a HUGE banner on their wall claiming that in time, they would put family medicine out of business. I’m the kind of guy who isn’t too competitive until you try to crush me under your boot…or, white nurse’s shoe, as it were. Then I get a little riled.

First, let me present a very basic sketch differentiating between the training demands of MD’s like me and some of the other midlevels:

Clinical training hours:
DNP: 1000* (this is the latest nursing degree you can get…a doctor of nursing. Sounds a bit oxymoronic to me, really).
PA: 2400
MD/DO: >12,000

*Can be done PT & online

Look at the difference. It’s unbelievable. MD’s and DO’s train more than 5 TIMES longer than the next highest mid-level. This doesn’t mean these people aren’t smart, or that they don’t know lots of medicine. At times, they might know more than an MD about a particular ailment. But on average, their training pales in comparison.

More concerning is that limited training can lead to limited humility. I once heard the a guy say that the definition of an expert is someone who is exquisitely familiar with what s/he does NOT know. The more training you have, the more likely you will know when you are beyond your knowledge or abilities, and avoid the dangers of the Dunning-Kruger effect (read ’bout it here). The D-K effect is the phenomenon where people who know little tend to think they know more than they do, while people who know a lot tend to think they know less than they do. Given the propensity for medicine to hurt you, or save you from something terrible, let me assure you the best doctor is in the latter category, not the former.

I don’t have any problem with mid-level medical providers, of all shapes and sizes. But I do think that – aside from my own bias as a result of all the training sacrifices I’ve made over the years – MD’s and DO’s should be understood to be the best-trained, and certainly not replaceable. Although my first inclination about why my patient wanted to drop her NP to stay with me had to do with their personalities, it is also true that poll after poll shows that patients would rather be taken care of by a doctor, not a PA or a ARNP or NP.

Finally, an analogy:

In college I went to this church called Calvary Chapel. These churches pride themselves on the fact that most of their pastors don’t have a seminary degree (they were “called by God”, just like the original mostly uneducated disciples). At the church I went to, one guy had been to seminary and all the other pastors hadn’t. Guess who I liked the most? The seminary guy. He just knew stuff. He taught better, and I learned more.

I think it’s the same way for many patients. Most would rather be seen by a person who has taken care of people in hospitals, been there when they were born, held their hands when they died. They would rather have a doc who has worked in ER’s and has actually done CPR on a real human not a doll named Annie.

So much of medicine is about experience. Every day, people come in with a cough and need me to tell them if it’s gonna kill them. Odds are good it won’t. But is it MRSA pneumonia? The sentinel case of pulmonary anthrax? PCP pneumonia? Not likely. Only God really knows. The rest of us have to rely on knowledge and experience. Doctors have simply see more bad stuff than mid-levels; there’s a better chance we’ll make the right call.

Fundamentally, when an MD says, “In my experience…” it’s a very different statement than when a mid-level says it. We pay a heavy price to see all that we have, but in the end, that experience may just be what saves your life.

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