The official American Academy of Dermatology and American Society for Dermatologic Surgery responses to a recent New York Times article about treatment of skin cancer by unsupervised physician assistants focused on the fact that, as a group, board-certified dermatologists treat patients ethically and well. However, what was most striking to me was the article's reference to “physician-dermatologists.” Is there another kind? Are there “non-physician” dermatologists or plastic surgeons or others in specialties defined by the American Board of Medical Specialties (ABMS)? Our boards make a point of saying “see a board-certified [fill in the specialty].” Do they need to add the word “physician”?
Perspectives from Across the Pond
Doctor. The word derives from the Latin for “teacher,” and reportedly was first used for a learned person in any area, including medicine. In the middle ages, as the university system took form and degrees were conferred, the title became a more formal designation for those dedicated to teaching and study.
In a commentary for British Medical Journal, Nevil Cheesman writes:
“As doctors we have a duty to teach, as highlighted by the General Medical Council's guidance on teaching medical students…Medical students are not routinely taught how to teach, but after qualification they suddenly become aware that this is one of their responsibilities.”(careers.bmj.com/careers/advice/view-article.html?id=20000148)
Physician extenders, including physician assistants (PA) and nurse practitioners (NP), have become common place in core cosmetic specialty offices. They can perform the labor- and time-intensive procedures for which physician skills are not needed, like noninvasive fat reduction and tissue tightening. And now that many of those procedures can now be handed off to less expensive medical assistants and aestheticians, patients are being offered appointments with NPs and PAs as an alternative to the physician for injectables and other minimally invasive procedures. In many offices, a consultation doesn't have to include the physician. Is it surprising to anyone that patients may see these individuals as interchangeable to us?
The change in healthcare policy terminology from “physicians and patients” to “healthcare providers (HCP) and consumers” is, in part, to blame. Initially, it was an issue of getting necessary medical care to underserved areas by any means necessary. But it has spread to well-served regions and elective care. Policy makers and employers prefer lower cost solutions. One method is to provide services using the least expensive worker. As stated above, physicians do the same thing in our offices. But should PAs and NPs be considered our substitutes for everything? Where should the line be drawn?
The field of players has become more confusing for our patients because of the plethora of non-MD, non-DO, “providers” in the US who call themselves “Doctor.” NPs who have earned a PhD consider it par with their diploma. It is true that a PhD degree is a doctorate. University scientists with PhDs also commonly refer to themselves as “Doctor.” Chiropractors have the DC and naturopaths the ND, giving them both the same title. PAs completing two or three years of training now want to call themselves “Physician Associates” and some want to be called “Doctor.” On the other hand, lawyers holding the JD (juris doctor) degree are never called “Doctor.” And if you ask the average person from what school a doctor needs to graduate, he or she will more often than not say medical school. [Editor's Note: For more on the Society for Dermatology Physician Assistants (SDPA) position on PA Practice Models, read their statement in Practical Dermatology® magazine, available online: PracticalDermatology.com/2017/03]
Medical school and medical training are rigorous. Lack of sleep, poor body hygiene, and financial debt are just symptoms. En route to becoming a physician and particularly a specialist or subspecialist, trainees absorb encyclopedic knowledge about bodily functions that become the backdrop of everything else they do. More important, trainees develop the ability to not only access these details but to assign appropriate value to each in order to figure out a diagnosis, design a treatment plan, and deal with complications. Most important and most unlike all other doctorate holders, physician trainees are driven by the knowledge that errors can cost lives and the buck will ultimately stop with them. Knowing they will be the decision maker imbues an intrinsic fear of doing harm. As physicians rise in seniority and responsibility, we balance that fear with the confidence of knowledge and experience. Our reward is the privilege of having our patients' trust. The moniker “Doctor” or even “Doc” represents that earned trust.
Perhaps the answer is to define the title based on the environmental expectations. In an office of core cosmetic specialists, patients expect that the person in the white lab coat or scrubs is a physician, unless they are told otherwise. Because there is no two letter prefix for NP or PA, in many offices, the physicians and staff will say “Let's have you see Dr. Nancy our NP,” or, “We'll make an appointment for you with our PA. Tell the front you'll see Dr. Paul.” Despite job descriptions in the “About us” section of practice websites and designations on name tags, all the patients hear is “Doctor.”
Is this a petty territorial issue? I say no. Physicians carry the weight of rising regulations, public distrust, and, in aesthetics, huge liability for so-called “unnecessary” procedures. Plus, like an athlete, any procedure-based specialist is at the mercy of his or her body. Break a bone and you can be out of work for months. Develop a progressive neurologic disease and you can be out forever. A practice owner still needs to pay staff and overhead. An associate in a cosmetic practice is unlikely to be on salary, and needs to be active to earn a living. Despite certifications touted by extenders, it is only the board certified physicians who have the unique strain of completing ABMS maintenance of certification (MOC).
Ultimately, physician extenders are important members of our teams, but their training is different and their jobs are different. Our academies and societies need to not only emphasize finding a physician who is board certified in our fields but also to know if he or she is a physician. In our own offices, we need to be sure that physician extenders are not referred to as physicians. Certainly, highlight your staff's excellence, but give them the correct job title when you do it. If not, one day when someone is introduced to you as “Dr. Smith,” the onus will be on you to find out whether or not he or she graduated from medical school at all.