Just Call Me Doctor, Doctor.

After writing the first draft of a blog post a month or two ago, I read it out loud to my partner, who happens to be a nurse. The point of the blog (and it seemed perfectly sensible to me) was that pharmacists were the “sleeping giants” of the medical field and that their training qualified them to do a lot more than count pills, such as administer vaccinations, run cholesterol checks, conduct blood pressure  screenings…..suddenly I heard an emission of steam from my partner’s ears. “That is absolutely NOT within the purview of the pharmacist! Those are nursing duties. I don’t know why everyone thinks they can intrude on nursing territory and do our jobs better than we can!” I always thought that nurses had good relationships with pharmacists and saw them as invaluable resources of support and information but as the bullets flew overhead I found myself in the middle of a turf war I never knew existed.

The main war over territory, however, is not between pharmacy and nursing. That’s just a little skirmish compared to the battle between non-physician clinicians, such as nurse practitioners, nurse anesthetists, dentists, optometrists and chiropractors and the current kings of the hill – the MD’s. Now that the PharmD degree, with its emphasis on clinical training is the educational standard, you can add pharmacists to the list of those battling for a piece of ground to call their own. Some of the arguments seem little more than schoolyard bickering to someone outside the profession, like who deserves the title of “doctor”. Non-physicians are seeking a larger role in medical care and the physicians are digging in for a long siege. Some MD’s don’t just bristle when they hear a doctorate level nurse or pharmacist addressed as “doctor” – they believe patient confusion over titles is a real issue. Not that you will be surprised, but the American Medical Association (AMA) has conducted its own (!!) research and found that patients are mystified by the trails of initials which follow names on practitioners’ badges and has found that “ambiguous provider nomenclature” used to market health services is “exacerbating patient uncertainty”. Health services are being marketed to us, all right, and the current health care system is nothing if not confusing but is that really what docs are most concerned about? Or is the real conflict over  who will ultimately control health care services and the status and pay that come along with them?

The struggle over medical turf is nothing new. The physician assault on midwifery, for example, dates back to the 1700’s. Midwives have always believed that the process of childbirth is normal and that the move to “medicalize” it and turn it over to obstetricians did nothing for women except rob them of its potential for spiritual transformation. More recently the Western Australia news site Watoday.com posted a story that the Australian Medical Association had criticized a company’s plan to open 180 pharmacy-based clinics staffed by nurse practitioners. Patients would use these clinics for help with common illnesses like infections or flu. But the Association, predictably, does not think nurse practitioners are qualified and labeled the clinics “supermarket medicine”. Never mind the fact that countless studies, in Australia, Europe and the U.S. show that care provided by nurse practitioners is at least as good as that provided by MD’s. And now pharmacists are jumping into the fray – what’s a poor physician to do?

The healthcare system in America is a mess, pure and simple. Yes, we’ve got some cutting-edge machinery and knowledge available, if you can afford them. Losses of coverage swelled the ranks of the uninsured to 52 million in 2010, according to a study by a New York foundation, the Commonwealth Fund. Rural communities suffer the worst of it. HealthReform.gov says one of five of the uninsured lives in a rural area where accessing quality health care is not only difficult but costly. The number of uninsured is even higher for rural minorities, the poor and those with less than a high school education. The number of primary care physicians in the U.S. is dwindling because primary care doesn’t pay as well as most specialties. As a result, both rural and urban areas are underserved; 23% of all patients said they had to wait six or more days to see their doctor the last time they were sick.

If you’re elderly, things are even worse, especially if you’re on Medicare. Doctors who specialize in geriatrics are increasingly rare, with just one geriatrician for every 5,000 seniors, according to the American Geriatrics Society. Treating older patients with multiple, often complex problems is a terrible way for physicians to make money because Medicare just doesn’t compensate them for the time that’s required.

It doesn’t end there, either. 11.6% of all children in the U.S. are uninsured. Many adults who do have insurance don’t go to the doctor because their co-pays are too high or because they have gaps in their coverage. The system is inadequate, so alternative methods of delivering health care are popping up everywhere. In addition to the vaccination services in all the big chain pharmacies, MinuteClinic, a retail-based operation, is opening walk-in medical clinics in CVS stores. Pharmacists are partnering with patients and physicians to promote safe and effective use of medications through medication therapy management programs. Today I received a call from my Walgreen’s store inviting me to a conference call with two pharmacists and other customers to discuss medication questions and concerns. And although physicians may complain about other providers muscling in on their territory, they are increasingly staffing up with nurse practitioners and physician’s assistants to help them squeeze in more patients.

Like a piece of Swiss cheese, our for-profit healthcare system is shot full of holes and millions have fallen through. It’s no mystery – there are plenty of skilled, experienced health providers aside from doctors so wherever physicians don’t or won’t meet the need, non-physicians are simply stepping up to serve their communities. People in need don’t care much about titles or turf. They just want competent, accessible help with their health care. Today I read about a pharmacist who found himself providing grief counseling to a woman who showed up at his counter about her blood pressure medication. She had just lost her husband and God knows nobody has mental health coverage anymore. So he just filled in a bit of the hole, as best as he could. Nature, if you’ll remember back to your 9th grade science class, simply abhors a vacuum.

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4 thoughts on “Just Call Me Doctor, Doctor.

  1. You know, change is always hard. I’m a pharmacist and saw an interesting note from a doctor the other day. It was a refill request that had been sent to the doctor’s office and returned with his authorization for the refill as well a comment from him. The standard refill request asks for the “provider’s signature”. He had crossed through that phrase several times and added that he was not a “provider” but a “physician” and had earned that title. At first I chuckled when I read that and thought about what a dinosaur he must be.

    But then I thought about an article I had just read a few days earlier about the very issues discussed int this blog. Doctors don’t like nurse practitioners or physicians assistants calling themselves doctor and none of them like pharmacists calling themselves doctor. And lots of times patients don’t know who is who. One state had an interesting idea. When a providers introduce themselves to patients as “Dr. So-and-so” then must follow that statement with a identification of their profession, such as “Hello. I’m Dr. So-and-so. I’m a nurse practitioner and I will be treating you today”. I thought that was an interesting approach. But I’ve been wondering why we have to use the title doctor anyway.

    I know that people who have attained the status of doctor in any field have worked very hard and very long and probably spent a lot of money to get there, but does it become some to be announced to the world. In the Quaker tradition titles are not used. All people are equal in worth. Self-worth comes from accomplishments and contributions to society, not titles. Maybe this should be the national discussion?

  2. The turf wars are very real in the healthcare system. The laundry list of various providers in this country are looking to secure and expand their roles in the healthcare system. NPs are a great example of a group that has done well to make themselves an integral part of patient care. I think pharmacists haven’t fought for expanded roles nearly as well as a group. As the drug information experts of the healthcare system pharmacists are simply underutilized. Our roles are quite limited in scope but that is slowing changing. There are individual bright spots for pharmacy scattered across the country if you look hard enough.

    The situation reminds me of the criminal justice system and all it’s various departments and organizations. There are turf wars there as well. But in the end all that really matters is catching the bad guy. And for healthcare, we would all be better served if we put the focus back on the patient instead of worrying about who does what role. We could all work together to tackle the two main problems with our healthcare system: access and affordability. But so many things complicate those simple goals. And as the government gets more involved in the healthcare system things inevitably will get even more complicated going forward.

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