Letter: Readers comment on Medical Economics stories

March 10, 2011

Letters discuss the status of primary care, autonomy of nurse practitioners, DNP degree, doctor nurses, and residents.

Time to speak up for primary care

I couldn't agree more with the assessment by Terry Nye, MD, FACP, of the status of primary care ("Seeing all doctors as equals," January 25 issue).

As a practicing internist with over 20 years experience, I am appalled at the lack of respect we are given by our colleagues. I have even met "midlevel providers" in my colleagues' offices when I was the patient!

I think that we primary care physicians need to better organize to make our voices heard!

DOMINIC CUSUMANO, MD
Detroit, Michigan

Defending the integrity of primary care

I can't relate how happy I am that someone actually wrote about the disrupting trend of condescending behavior exhibited toward primary care doctors ("Seeing all doctors as equals," [by Terry R. Nye, MD, FACP], January 25 issue). I am a resident in internal medicine and hope to practice primary care upon completion of my training.

I have been following this trend of increasing autonomy of nurse practitioners (NPs) and physician assistants (PAs) with great interest. The latest action that seemed almost unbelievable to many of my colleagues is the new "DNP" degree conferred on NPs. This "doctorate in philosophy" degree allows NPs to not only work autonomously without physician oversight, but it also allows them to call themselves "doctors" in a clinical setting. An NP can obtain such a degree by completing an additional 1,000 hours of clinical clerkship in the field he or she desires.

So essentially a DNP could be called Dr. X, a practicing dermatologist or cardiologist simply by virtue of completing a small amount of clerkship hours. On average, a third-year medical student completes about as many hours as a full DNP in his or her core surgery clerkship alone. As of now, there are plans to grant many of these degrees by 2012, when over 200 new schools will graduate their first batches.

It will be truly an embarrassing and humiliating day when these "doctor nurses" are allowed to mislead patients and possibly train future residents. Recently, many of these DNPs were given the USMLE Step 3 exam. This exam is by far the easiest of the three licensing parts to pass. The results were, not surprisingly, a more than 50% failure rate. What is even worse is that the nursing association stands firmly behind these advanced NPs and the new DNPs, even going as far as to cite studies stating that they provide more superior care than MDs/DOs because they take a holistic approach.

In essence, it's high time we actively did something to take back our own autonomy. We are not to be clumped together as "healthcare providers." We are physicians, and we have trained and worked hard to earn that title. In general, internists get a lot of flak from many of our colleagues, due to the fact that we are labeled as a timid bunch of physicians. Even our societies are inept, being politically correct and ambiguous on where we stand regarding these issues. The American College of Physicians and the American Medical Association both have come out with soft, ambiguous statements that do not get our point across. I agree that it is "insulting when a subspecialist thinks his or her midlevel is more competent" than a board-certified internist.

With the latest numbers showing a dire need for primary care physicians, how can anyone expect medical students to go into primary care when they will have to deal not only with the usual insurance reimbursement and authorization issues, but now they will have to defend themselves from midlevel competition? What many people don't realize is that, to the general public, anyone in a white coat is a doctor. It is up to us to make sure that we defend our integrity and autonomy while ensuring patient safety.

ALI RAZA, MD
Philadelphia, Pennsylvania