Doctor: “We have seen the enemy, and he is us…”

By Dr. Richard Kimble | Posted on March 28, 2018

No introduction needed. No extra dialogue. Sometimes a post is so clear, so concise, and so hard hitting that it forces your eyes open. This is one of those posts: (unedited for effect)

“I had such a great comment and lost it. Darn it. I shall paraphrase. I attended 4 years of college, graduating near the top of the class. I was 22 years old. I entered medical school, studying every morning in didactics, every afternoon in labs and every evening reviewing for the upcoming test. Halfway through those 4 years I took part 1 of the USMLE* and passed it, thus being allowed to continue onto the second half of medical school. 

Where we learned to apply the anatomy, biochemistry, physiology, histology, pharmacology to actual patients. We have to know which drugs to use in which situation, at what dose and for how long. We had to know WHY we did these things (hint: to avoid killing the patients). I took part 2 of the USMLE early in the 4th year, and again I passed and was allowed to move on. So, what was I doing between testing and making rounds and writing notes? For hours or even days at a time? Reading up on a procedure that I might’ve expected to perform the next day. Appendectomy on no sleep? Why sure! Why not? “You’ll never learn any younger.” Just hope that a physician assistant student or a nurse practitioner student doesn’t sneak in behind your back and wheedle the table time in the OR away from you and to him/her self such that they get to perform a procedure. Wow that might have been the only appy you ever would get to assist with. Oh well. And now at the end of medical school I graduated and chose my specialty and my program location. The programs chose the residents that they wanted, and voila! The Match is the most stressful scary dating service ever. Now a resident at age 26 I spend every third night in the hospital seeing new admissions through the ED, or a patient transferred to your unit from elsewhere. You may deliver babies, start IVs, run a Code Blue, splint a fracture after interpreting the x-ray and, try to calculate drug doses on a sick child with kidney damage. You have to know enough pharmacology, pathology, pathophysiology, anatomy, histology and you have to remember to check the child’s weight and make sure he’s not allergic to the drugs that you hope will save his life. And you have to supervise the medical students on your team. And juggle lab results and field phone calls from floor nurses about abnormal vital signs, new symptoms, answering family’s questions about how Grandma is doing and why Grandma is swelling and scratching and coughing and turning blue? Oh, darn neither the medical student nor the intern got the piece of history that Grandma is allergic to aspirin and is having anaphylaxis after receiving aspirin for fever. Which turned out to be, not a fever, but a reaction of some of her new and old medicines. So, after 36, 48, 60 or maybe more months of these all-night circus side shows that occur every 3 days, you finally finished residency and you are a full-fledged doctor…um…wait. You have to take and pass part 3 of the USMLE. THEN you are a full-fledged doctor except you will want to be able to market yourself as a board-certified residency trained physician. So, you must take a board certification exam after completing all components of the residency. Now! Now? Now I am an “RD” a Real Doctor” who is board certified and residency trained. And indeed, I was RTBC, 29 years old and deeply in debt. And who must stay certified and take recertification exams and perform endless continuing medical education activities. All of which are expensive and time expensive. Oh, and somewhere along the line one must obtain a license to practice medicine in whatever state you plan to set up practice. And if you want to have hospital privileges, you must be credentialed by the hospital. Pretty much every scrap of data about you has to be assembled and presented to the hospital Credentialing committee. Don’t forget medical malpractice insurance. More hoops, also expensive. By this time, I had no savings or retirement, crappy old beater for a car. No clothes except scrubs and old work-out clothes which didn’t fit because I never had time to work out. The NP, in contrast, finished nursing school right out of high school at about age 21-22. Working here and there to make some money plus not having to spend quite so much money for schooling, allows NPs to finish with much less debt. At the end of NP school, a new graduate in certain states with a couple of years of bedside nursing, a couple of years of online school and little debt can open a clinic and stay seeing patients totally unsupervised. They do not train in residency programs. They do not spend hours upon hours in the hospital or the outpatient clinic, doing hands-on patient care. They do not have to pass multiple rigorous standardized tests. They do not have to be certified (deemed adequately and appropriately trained) in the specialty of one’s choosing. Note I said “specialty” because doctors specialize in one area at a time. Doctors may have multiple board affiliations, but they studied each specialty individually and was tested and found worthy in their various specialties. They don’t hop Willy Nilly from family medicine to pediatrics to endocrine to psych to plastic surgery to dermatology without at least 3 years of residency in a specialty and proper certification in that same specialty. So, the NP, calling her/himself a Doctor well before their late 20s thanks to rapid transit online diploma mills can hang out their shingle still young and energetic and with little debt. Those that prefer to work in a hospital setting can start out making the same salary as a new doctor only at an earlier age and with better financial status.

Hospital admins love NPs because they follow algorithms which dovetails nicely with the lockstep mentality of current electronic medical records software. And best evidence or best practice models, which have sketchy evidence and little road practice to see how well they really work as far as providing safe, cost-effective healthcare.

Doctors don’t follow algorithms; instead, we talk to a patient, ask certain specific questions to tease out the pertinent details, and then we do an exam designed to evaluate the organs directly and indirectly involved. We look for certain pieces of information because we know what we are looking for. And we do not order tests unless we have a good idea of what the test will show and what the next step should be, no matter what the result. We know what we don’t know. We’ve spent enough time in the trenches to know the enemy when we see him, even though he may be well disguised.

We have seen the enemy, and he is us. We physicians who were not paying attention when NP diploma mills and the AANP began their well-organized drive to level the playing field. Such that when insurers and healthcare giants such as CVS and Aetna can merge to form a mega-powerful entity driving the healthcare industry onto the rocks. NPs will be poised to take over positions of power and leadership. Instead of physician extenders, they will be physician extinguishers. They’ll save money for corporate Medicine and not give back attitude about policies and procedures. NPs will be malleable and all-too-willing to be team players. Until they want to take over the team. But that’s another rant for another night.

I haven’t even touched on issues of medical malpractice, medical ethics, patient satisfaction versus true excellence in delivery of patient care. When you wake up in the ED, the ICU, the OR, and you are critically ill, who do you want behind the mask at the head of the table, holding your Health, well-being, yes even your very life in their hands? The physician whose training has been long, arduous, rigorous, strictly regulated and tightly standardized, who has tens of thousands of hours of hands-on intense, personally invested patient care hours. Or, the NP whose training has been short, simple, loosely regulated and not standardized, who has had maybe a couple hundred hours of shadowing another NP or perhaps a doctor, not personally or professionally invested, or just simply not there at all. . .

Sweet dreams as you’re going under anesthesia. I surely hope a qualified individual is there to bring you safely back from the land of “Nod” . . .

*www.usmle.org/

The United States Medical Licensing Examination (USMLE) assesses a physician’s ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease.

How does it feel to compete with Nurse Practitioners for salary?

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