Tools Midlevels Employ which May Mislead Patients

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Dressing like a Doctor

In the medical field, wearing a white coat is sacred and has been traditionally reserved for doctors. Medical students start their education and training by wearing a waist-length white coat during their clinical rotations. With each passing year, they wear a slightly longer white coat as they gain more knowledge and experience. This culminates in doctors being presented with a long knee-length white coat to wear upon completion of their medical residency training. This long white coat symbolizes the years of hard work and sacrifice they have dedicated to their patients. Midlevels, on the other hand, wear the long white coat nonchalantly without regard to the customs, practices and hard work required to become a doctor. Most doctors view midlevels wearing a white coat akin to the Stolen Valor Act whereby it is a crime to fraudulently claim to be a recipient of certain military decorations or medals in order to obtain money, property, or other tangible benefit. Simply put midlevels deceivingly dress like doctors without actually being doctors (though some may have a “doctorate” degree, which is not equivalent to a D.O. or M.D. degree). What’s worse is the fact that many patients assume an individual in a clinical setting wearing a white coat is a doctor, and many midlevels prey upon this notion.

“Most doctors view midlevels wearing a white coat akin to the Stolen Valor Act whereby
it is a crime to fraudulently claim to be a recipient of certain military decorations
or medals in order to obtain money, property, or other tangible benefit.”
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False and Questionable Statistics

During their training, midlevels are indoctrinated with the belief that the quality of care they provide is equivalent to that of a doctor. This assertion has not only been disproven by numerous studies, but also by direct observation of patient care provided by midlevels and the need for doctors to make critical saves as a result of errors made by midlevels. In addition to this, review of studies have demonstrated that the trends and statistics provided by midlevels seemingly disappear and/or reverse when groups of data are properly combined (consistent with Simpson's paradox). To indulge the assertion of equivalent care provided by midlevels is unwise as:
1. The admission requirements to be accepted to a school educating nurse practitioners, nurse anesthetists, anesthesiology assistants, midwives, and physician assistants are low. Please reference the profound differences in average acceptance rates and average grade point averages of students demonstrated in the tab titled "You Be the Judge of the Care You Have Received / Will be Receiving."
2. The duration (in years) of education and training for these individuals is low (only a fraction of that of a doctor).
3. The actual number of hours (per year) of education and training for these individuals is incredibly low (less than a fraction of that of a doctor).
4. The quality of the education and training (compared to that of a doctor) for these individuals is very low, especially given the fact that part or all of their training and education can be performed online or via “distance learning.”
With all of the above, it is difficult to accept the assertions regarding the quality of care they render compared to that of a doctor. Logic counters their indoctrination. Many midlevels will cite studies and statistics, but if you look at self-serving studies from other industries, we know that statistics can be manipulated (and it appears they have been). One does not need to look further than the tobacco industry to see how they denied their products cause cancer. Because observations of the quality of care midlevels attempt to provide are so incongruent with the statistics midlevels provide, many query whether the methodology of these studies is flawed, who may be funding these studies, what the agenda of those who fund or conduct these studies may be (including their financial interests) and whether results of studies are published if they do not support the agenda of those conducting and/or funding these studies.

As previously mentioned, doctors refuse to allow economy to dictate morality or reality. While midlevels will dispute facts and statistics, no one can dispute hard work and dedication in the form of sacrifice. The intentions of midlevels appear (on the surface) to be benevolent, however it is not just our words, but also our actions that define us. You will hear many stories from midlevels about how they wanted to, and intended to help their patients (through their compassionate words), but did not do so by obtaining the full breadth of knowledge doctors acquire during the course of their education and training (through their lack of action). Furthermore, you will hear stories of supposed hardship that pale in comparison to what your typical doctor faces during the course of their career.

The act of committing themselves to their patients is demonstrated by doctors each and everyday through their thoughts, their feelings, their words and their actions. The same cannot be said of midlevels and what it is they practice.

“This assertion has not only been disproven by numerous studies, but also by
direct observation of patient care provided by midlevels and the need for
doctors to make critical saves as a result of errors made by midlevels.”
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“Customer Service”

During their education, midlevels are repeatedly imparted with the importance of “customer service” (i.e. keeping their patients happy, smiling at their patients, etc.). In fact, some studies demonstrate that midlevels rank higher than doctors in this one parameter. Unfortunately, the medical field is not like other industries. According to one article describing a landmark study, “patients who had the highest satisfaction were more likely to be admitted to the hospital, spent more on healthcare, spent more on prescription drugs, and were 26% more likely to die than those who had the lowest satisfaction.” When you seek medical care, you expect care of the highest quality; a doctor who is thorough and up-to-date and someone who will educate you when you don’t receive what you may hope for. Midlevels on the other hand are considered by most doctors to be “prescribers for hire” whose priorities appear to be “customer satisfaction” which calls for giving the patient what they want, rather than what they may need. This is done with the hopes of keeping patients coming back to the office while attempting to boost their patient satisfaction scores. A smile can go a long way when conducting business, but when it is a façade for enrichment, many ethical concerns can be raised and many doctors have raised them about midlevels and the care they provide.

“Midlevels on the other hand are considered by most doctors to be
“prescribers for hire” whose priorities appear to be “customer satisfaction” which
calls for giving the patient what they want, rather than what they may need.”
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Purported Dedication

Many midlevels purport dedication to their patients without undergoing the education and training to support their claims. As we all know, it is the foundation of a house that is more important than the façade. It is also the foundation that is not seen, but is most important. In the case of the quality of care they provide, they lack the foundation of a doctor in terms of knowledge required to best serve their patients (they lack the background work in the form of education and training). What is just as misleading is the fact that midlevels in rural areas purport to be more willing to live in those areas than doctors. Studies have debunked this fact and the lack of doctors in rural areas (along with the rest of the nation) is the result of governmental issues and lack of allocation of funds to educate and train more doctors. Ironically, in many well-populated areas, one can find a plethora of midlevels providing cosmetic services (i.e. Botox, fillers, etc.) and/or owning / managing med spas, rather than providing patient care in any non-cosmetic capacity. To many of these individuals, becoming a midlevel was the fastest track to becoming a “prescriber for hire” or having access to a prescription pad so that they could profit handsomely while ignoring and/or minimizing what it was they claimed to want to accomplish by becoming a midlevel in the first place. Many people view midlevels entering the healthcare field as nothing more than a strictly calculated business decision.

“In the case of the quality of care they provide, they lack the foundation of a
doctor in terms of knowledge required to best serve their patients
(they lack the background work in the form of education and training).”
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Claiming to be a “Specialist”

Midlevels are not doctors. Midlevels have not matriculated in and successfully completed medical school. Because of this, they are not trained in a medical residency program (which would confer a medical specialty upon a doctor). Additionally, because they have not trained in a medical residency program, they cannot undergo medical fellowship training (which would confer a medical subspecialty upon a doctor). As a result of all of the aforementioned facts, midlevels cannot have a medical specialty and thus cannot claim to be a medical specialist that doctors undergo rigorous training for. An analogy often cited in the medical field is that “wearing a badge does not make one a sheriff.” Thus, simply claiming to be a specialist does not make it so. One has to undergo the education and training required to become one. Many midlevels may use even more word games to confuse patients by indicating they “have a focus in/on,” “extra training in,” “concentration on,” “certification in,” "expertise in" and/or “experience in” the following medical specialties. They may also cite who they may have worked with/under or where they may have previously worked which does not change any of the facts mentioned above. Midlevels (despite having undergone less education and training) have invented their own set of specialties. Although not an exhaustive list, below are medical specialties that midlevels cannot ethically (and in some cases legally) claim to have:
- Addiction Medicine
- Allergy and Immunology (Allergist and Immunologist)
- Anesthesiology (Anesthesiologist)
- Cardiology (Cardiologist)
- Critical Care Medicine (Intensivist)
- Dentistry (Dentist)
- Dermatology (Dermatologist)
- Emergency Medicine (Emergency Medicine Doctor / Physician)
- Endocrinology (Endocrinologist)
- Family Medicine (Family Medicine Doctor / Physician)
- Gastroenterology (Gastroenterologist)
- Geriatrics (Geriatrician)
- Hematology / Oncology (Hematologist / Oncologist)
- Hospice / Palliative Care
- Hospital Medicine (Hospitalist)
- Infectious Disease (Infectious Disease Doctor / Physician)
- Internal Medicine (Internist)
- Medical Genetics (Medical Geneticist)
- Nephrology (Nephrologist)
- Neurology (Neurologist)
- Neurosurgery (Neurosurgeon)
- Nuclear Medicine
- Obstetrics / Gynecology (Obstetrician / Gynecologist)
- Ophthalmology (Ophthalmologist). They should not be confused with or mistaken for optometrists who are practitioners with less training.
- Orthopedic Surgery (Orthopedic Surgeon)
- Otolaryngology (Otolaryngologist)
- Pain Management (Pain Management Doctor / Physician)
- Pathology (Pathologist)
- Pediatrics (Pediatrician)
- Physiatry (Physiatrist (Physical Medicine and Rehabilitation))
- Plastic Surgery (Plastic Surgeon)
- Podiatry (Podiatrist)
- Preventative Medicine. This specialty also encompasses Occupational Medicine.
- Psychiatry (Psychiatrist). They should not be confused with or mistaken for psychologists who are not doctors.
- Pulmonology (Pulmonologist)
- Radiation Oncology (Radiation Oncologist)
- Radiology (Radiologist)
- Rheumatology (Rheumatologist)
- Sleep Medicine
- Sports Medicine
- General Surgery (General Surgeon)
- Urology (Urologist)

In cases where midlevels are limited by laws regarding false advertisement and self-misidentification, they may employ tactics which they perceive as clever workarounds to mislead patients. Midlevels who do not claim to have a medical specialty (as listed above) may attempt to allude to, imply and/or insinuate they have one by employing terms synonymous to medical specialties. Some common examples include:

Heart and cardiovascular health in place of Cardiology
Skin health and beauty in place of Dermatology
Hormone and anti-aging in place of Endocrinology
Stomach and digestive health in place of Gastroenterology
Women's health and reproduction in place of Obstetrics / Gynecology
Children's health in place of Pediatrics
Behavioral and mental health in place of Psychiatry

In terms of advertising, midlevels often employ marketing, consulting and/or public relations firms to project an image of something they are not: Being a doctor. It seems many midlevels are constrained only by their imagination, the limits of their license and the thickness of their thesauri.