The term “doctor” has a broad definition. Many non-physician practitioners are referred to as “Dr.” in their clinical practices (i.e., Ph.D, D.D.S., O.D., etc), and rightly so. Arising also are a number of clinical doctorate programs in a variety of fields (i.e., naturopathy, speech-language, physical therapy, nursing, etc). The concern is that some non-physician doctorate clinicians desire to increase their scope of practice that typically falls under the responsibility for those doctors with an M.D. (Doctor of Medicine, from the Latin Medicinae Doctor) or D.O. (Doctor of Osteopathic Medicine). This is a concern for many state medical societies and the American Medical Association. The "doctor" term has also been loosely applied to include allied health providers such as nurse practitioners (NPs) and physician assistants (PAs). I’ve encountered numerous patients who refer to such individuals using the “Dr.” prefix, saying “Dr. XYZ referred me here.” Whether this title is self-proclaimed by the providers themselves or mistakenly applied by the patient, I’ve yet to ask.
The problem is, in the minds of many patients, the term “doctor” is associated with “physician,” the one bearing the most intricate knowledge of health and disease, who’s gone through the long and rigorous education and training to become that “doctor.” This implies the bearer of this title, without further explanation or qualification, holds a degree of M.D. or D.O.
In a reversal of circumstance, a
bona fide doctor with an M.D. or D.O. oftentimes is simply called a “provider”
and lumped into that broad “provider” category that includes all the other healthcare
practitioners. This often occurs when a
roster of “providers” is made available to patients by insurers or hospitals
that employ physicians, mixing the doctors with everyone else.
The irony is physicians are
less inclined to be referred to as “doctor,” while non-physicians are increasingly referred
to as such. I've seen this in the frustrations born by some of my colleagues, the residents who rotate with me, and the multiple posts and writings on physician sites.
The term “doctor” cannot be used for some doctorate degrees (ie, doctor in nursing) in
certain states, unless one possesses an actual M.D. or D.O. degree and then
licensed. Other clinicians with
doctorates can be referred to as “doctor” as long as they clarify their
specific qualifications. Most states
allow this usage as long as the clarification is made. In California, there is a long-standing law that prohibits
the use of the prefix “Dr.” by any advanced degreed clinician in medicine other than a licensed allopathic (M.D.) or
osteopathic (D.O.) physician.
There is a reason for this. Physicians are educated and trained
differently—much more intensely and over a much longer timeframe than any other
professional health care practitioner. They go through intense study in med school post-college and years of residency (the term resident was derived from one who literally lived in the hospital). To imply otherwise is demeaning to a profession that has a longstanding
perception as a calling, one that requires a tremendous devotion of one’s life that
goes beyond a mere occupation.
The road to becoming a licensed doctor is long and arduous, requiring
great sacrifice and a long period of delayed pecuniary gratification. Merely getting into medical or osteopathic school
is extremely difficult. Preparation for many
prospective doctors begins long before college.
Not only must one get into and then graduate from a respectable
four-year college or university—and having completed pre-med courses in general
and organic chemistry, biochemistry, physics, biology, upper level math, and
expository writing--but the applicant must graduate in the upper echelons of
their class, since the applicant pool as a whole
consists of some of the brightest students in the nation.
For instance, the average college GPA for the
pool of applicants applying to U.S. medical schools is over 3.6; for
those accepted it’s over 3.7. For
both MD and DO schools, one must also take a national standardized test called
the MCAT (Medical College Admissions Test) and score well above average (again,
in a large pool of very smart folks).
Those accepted into medical school score in the top 25% of all
test-takers. Stellar GPAs and MCAT
scores are only the beginning. One also
must also demonstrate “breadth”--extracurricular activities such as scientific
research, volunteering in a healthcare or community setting, saving baby seals,
inventing a cure for stupidity…the latter are exaggerated, but you get my
drift.
The competition is stiff. For the
2021-22 academic year, there were 155 M.D. granting schools in the U.S., with 23,000
accepted from a pool of more than 65,000 applicants (JAMA vol 11,
p.1112)
To put this in another perspective, most D.O.
schools have acceptance rates of 6-8%, while M.D.
schools on average accept 3% of their applicants. Wannabe
doctors must therefore apply to a large number of schools simultaneously in the
hope of landing an acceptance. For M.D.
programs, this is an average of 18 applications per applicant (AAMC
2023 factsTable A-1). Applications come with
fees, and if you’re lucky enough to land an interview, you’ve got out-of-pocket
travel expenses, which only adds to the debt of med students BEFORE entering medical
or osteopathic school.
Medical and osteopathic schooling comes
with brutally long hours of lectures, labs, and work in the clinical
setting. Four years of medical school is just the beginning. Graduating medical students shortly embark
upon their respective residencies—post-graduate training after med school. Residencies are a minimum of three years for
primary care such as family medicine, pediatrics and internal medicine, 5 or
more years for medical specialists and surgeons. There are 35,000 first-year post-graduate
residents (including foreign graduates) in the U.S. In my specialty of otolaryngology alone,
there are only 125 first-year residency positions available nationwide (JAMA vol 328, no 11, p.1123). U.S. residency
programs follow strict standards set forth by the Accreditation Council for Graduate Medical Education
(ACGME) to prepare physicians to provide safe and high-quality medical care,
It takes more than brains and years of education to become a doctor, but
also a strong determination and a willingness to endure abject mental and
physical hardship. The life of a
resident is no piece of cake; it is a grueling voyage of excruciating long
hours and long years that defy sanity.
To the nonmedical layperson, the demands may sound outlandish; it’s
indescribable to those foreign to medicine.
But knowledge and expertise in this complicated profession requires
years upon years of intense training, saturating oneself amongst the abnormal
and the sick. No labor laws apply
here. Truth be told with the tables
turned, as patients we’d expect nothing short of perfection when placing our
lives into the hands of another, one whom we rely upon to improve our lives and
save our lives.
The formation of a physician doesn’t happen overnight, but evolves over
a lifetime. With the brain saturated
with knowledge and accumulated experience, it is often an indescribable
presence of mind–an uncanny gestalt, one might say–that allows the doctor to diagnose an
illness, formulate a plan and act. This
nebulous intuitive process happens in a flash--in the middle of surgery, in the
emergency room, at the bedside of a critically ill patient, during a hair-raising
moment of crisis--and in a blink of an eye the doctor has already processed the
incoming stimuli and committed to purposeful action.
Some in the lay public may perceive what a doctor does comes easy, that they too can make those quick decisions or perform that surgery that looks so effortless on YouTube. They fail to grasp that such mastery comes only after years and years of education and practice; the doctor only makes it look easy. No two people are exactly alike and the same goes with patients. The enormous scope of disease, anatomic variation, treatments and skills with various outcomes requires intense and lengthy training, in the class, in the lab, in the real world of hospitals, clinics and operating rooms. And though extended and mid-level providers serve a vital role in our healthcare system, it is the doctor that everyone turns to-- the board-certified MD or DO, the one who is called in the middle of the night--when a life-threatening illness emerges, when an unusual disease process rears its ugly head, when a complication or unexpected outcome arises or simply when the figurative feces hits the fan.
©Randall
S. Fong, M.D.
For more topics on
medicine, health and the weirdness of life in general, check out the rest of
the blog site at randallfong.blogspot.com
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