Word Games

If your friend called you on a November Sunday morning and asked you whether you wanted to join him or her for the big game that day at the University of Phoenix Stadium, you would safely assume he or she was referring to an N.F.L. game between the Arizona Cardinals and the visiting team. Imagine if you arrived at the stadium only to find that it was the high school state football championship game. You would feel deceived, wouldn’t you?

If a member of your friend's family indicated his or her niece was a world-renowned doctor, you would safely assume she was an osteopathic medical doctor (D.O.) or an allopathic medical doctor (M.D.).  How would you feel upon meeting her that she held a Ph.D. in communications?  After all, society assumes (and natural language definition dictates) one is a D.O. or an M.D. when one is referred to as a doctor, unless otherwise specified (and many individuals simply avoid misunderstandings by either indicating one has/holds a doctorate degree or a Ph.D. in one's non medical field of expertise).

Finally, what would your impression be if you were an airline passenger who heard an overhead announcement calling for a doctor to assist in a medical emergency, only to learn (later on) that the individual who responded to the call held a doctorate (Ph.D.) degree in education (and had no knowledge of first aid or C.P.R.)?  This is an unlikely scenario given the fact that the individual who holds a doctorate would not want to misrepresent himself or herself (and his or her capabilities) and because he or she understands the intention of the announcement.
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What Do All of Those Letters Behind Their Name Really Mean?

Nurse practitioners, nurse anesthetists, anesthesiology assistants, midwives, physician's assistants, chiropractors, doctors of pastoral science and medicine, naprapaths and naturopaths are well aware they are not doctors. They just hope that their patients and society won’t recognize they aren’t. Some may hold a “doctorate” degree but it is neither a medical degree nor equivalent to a medical degree (D.O. or M.D.). These individuals attempting to call themselves doctors in a clinical setting hold as much weight as individuals with a doctorate in philosophy identifying themselves as a doctor in a hospital. If you are seeking medical care and you are receiving it from any individual who does not have D.O. or M.D. at the end of their name, you are not receiving medical care from the most qualified and highest trained individuals in the medical field and you may be gambling with your health. Unfortunately, we have entered an era of faux pas whereby many doctors specify they are a doctor by indicating “Dr.” or “doctor” before their name and indicating their degree (D.O. or M.D.) after their name. Traditionally, it has been known an individual is a doctor if they have a D.O. or M.D. after their name (without having to specify “Dr.” or “doctor” before their name). Fortunately, this faux pas should tip patients off as to whether they are seeing a doctor or a midlevel. If a patient only sees the word “Dr.” or “doctor” before an individual’s name (without their degree after their name), they should immediately ask what the individual’s degree is. If the individual indicates they are anything other than a doctor of osteopathic medicine (a D.O.) or a medical doctor (M.D.) then the patient should seek medical care elsewhere since this can be a sign that the individual is misleading the patient. Also, if an individual walks into a room and introduces himself or herself as Mr., Ms. or Mrs., do not assume he or she is a doctor. Another tactic employed by midlevels is introducing themselves by their first name. Many patients assume the individual is an informal or a down-to-earth doctor, but it can be a psychological trick many midlevels employ to use (what they have convinced themselves to be) the Trojan horse of humility to disguise the fact that they are not doctors (a D.O. or an M.D.) with the hopes their patients won’t realize that fact.

“If you are seeking medical care and you are receiving it from any individual
who does not have D.O. or M.D. at the end of their name, you are not
receiving medical care from the most qualified and highest trained
individuals in the medical field and you may be gambling with your health.”

If a patient sees any of the following letters following an individual’s name, they should seek the medical care of a doctor since the individual whom they are researching or are about to see is not a doctor (not a D.O. or an M.D.).

Please note, the following individuals may use upper case or lower case letters when they display their degree (i.e. n.p. may also be displayed as N.P. for a nurse practitioner).  The use of upper case letters does not demonstrate a higher degree or more training.

Nurse anesthetists, anesthesiology assistants, midwives and nurse practitioners:

Physician’s assistants:

Naturopathic physicians:

Chiropractors:

Naprapaths:

Optometrists:

Doctors of pastoral science and medicine:

Acupuncturists, herbalists, doctors of oriental medicine and practitioners in Chinese medicine:

Dental therapists:
These individuals are not dentists (thus they are not doctors).  They have not enrolled in, and completed dental school.  Through political pressure, these individuals, in essence, have been permitted to attempt to practice dentistry through completion of programs that are not as rigorous as the education and training dentists undergo.

Pharmacists:
These individuals are not doctors.  They are pharmacists who, in essence, have been enabled to attempt to practice medicine without receiving a medical education and without undergoing medical residency training.

Miscellaneous or unclassifiable:
These individuals are not doctors as they are not psychiatrists.  They are not psychologists either.

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“We don’t rise to the level of our expectations, we fall to the level of our training”
-Archilochus

The Patient Safety Guide wholeheartedly supports nurses and the noble profession to which these individuals have dedicated their lives. Nurses, along with doctors, form the core around which patient care is delivered. Many nursing organizations (and even physician’s assistant and anesthesiology assistant organizations) along with midlevels who were once nurses (nurse practitioners, nurse anesthetists and midwives) but no longer are, have made and will make false claims about the information in this Patient Safety Guide. Even major medical organizations (that were once historically supported by doctors) may speak out against this Patient Safety Guide because they may be more concerned about enrollment in their organization (for which they have extended membership opportunities to midlevels in addition to doctors) and the annual dues (profits) that come with that enrollment than they are about patient safety (like the media, it appears the focus of many medical organizations has shifted from upholding standards to engaging in universal appeal.  It is also worthwhile to note that it was under the watch of these major medical organizations that a nationwide shortage of doctors was permissively enabled).  Some may offer artful and elegant appearing statistics and charts, but they do not change the fact that midlevels are not doctors and cannot provide the same quality of care doctors do. They may go so far as to offer endless, emotional, stories about increasing patient access to healthcare or of purported lives saved, but these stories may be outweighed by numerous untold, unknown and/or unknowable instances of errors in patient care by midlevels.  Many nurse practitioners, nurse anesthetists and midwives falsely identify themselves as doctors (since the common knowledge of a doctor is one who holds a D.O. or an M.D. degree, not any other type of “doctorate” in the medical field). When they are identified by doctors, and the public at large, as not being doctors they hide behind the field which they abandoned: Nursing. One cannot claim to be a “doctor” when it suits them then retreat behind those (nurses) still in the field that they abandoned (especially since midlevels still claiming to be nurses no longer carry out the essential duties and functions of a nurse and have not retired from the profession of nursing (which would still afford those retirees the honorable title of being a nurse)). This is tantamount to a doctor (who has completed training) claiming to still be a medical student or a medical resident; this does not occur.  The word games they play are transparent to doctors and they are deceiving very few despite their best attempts. Although the term “midlevel” also encompasses physician’s assistants and anesthesiology assistants, it is truly apt in describing midwives, nurse anesthetists and nurse practitioners. The reason for this is because they have abandoned the noble profession of nursing, but they have not fully dedicated themselves to becoming doctors. Thus, they fall in the trough of patient care. Would you want someone caring for you who is no longer a nurse but is not a doctor? We wouldn’t either.

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Infighting Between Nurses and midlevels (midwives, nurse anesthetists and nurse practitioners)

Even within nursing communities, few recognize midwives, nurse anesthetists and nurse practitioners as doctors (or legitimate providers of healthcare). Almost as few even recognize them as being nurses any longer.  Adding to the resentment is the fact that many nurses (who are working for organizations that are already short staffed) know that there is a greater shortage of nurses in the United States than doctors (and midlevels attempting to practice medicine) and thus each nurse who abandons the field of nursing to become a midlevel magnifies this problem.  Conversely, many midwives, nurse anesthetists and nurse practitioners look down upon nurses (based on conversations with midlevels, they frequently denigrate nurses by referring to them as "drones" or by describing them as "mindless").  Make no mistake, there is a hierarchy within the nursing community. We have observed, in many instances, registered nurses (R.N.s) reporting licensed practical nurses (L.P.N.s) and certified nursing assistants (C.N.A.s) for identifying themselves generally as nurses (rather than the specific type of nurse they are as the common notion is that a nurse is an R.N. unless otherwise specified). It is worthwhile to note midlevels were once precise about their identification of members in the healthcare field when they were nurses, but choose vagueness when they attempt to self-identify as doctors. We have also received commentary from nurses about the quality of care rendered by midlevels. Many nurses have expressed concern, if not fear, for their patients who have been under the unfortunate care of a midlevel.

“Many nurses have expressed concern, if not fear, for their patients
who have been under the unfortunate care of a midlevel.”

Even many pharmacists frequently express concerns about the prescribing habits of midlevels.  Pharmacists are in the precarious position of treading lightly when dealing with these "providers" as they are mindful of the midlevel's fragile clinical skills while subtly prodding them in the direction of correct prescribing orders.  In many instances, to save time and to ensure patient safety, they will simply circumvent the midlevel and call their supervising doctor (in states where midlevels are not permitted to practice autonomously) for correct prescription orders.

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Midlevel Tactics and Attempted Justifications

Midlevels hiding behind those in the field they abandoned was demonstrated by a social media post by Arizona association of nurse anesthetists who claimed to have “thoroughly reviewed the website and bullet points" of an organization representing doctors. They indicated, “AZANA will continue to work with all APRN groups and the Arizona Board of Nursing to protect our profession against organizations that openly disregard the nursing profession.” Oddly enough, although claiming to have “thoroughly reviewed the website” of an organization representing doctors, they appear to have missed the passage that indicated that the organization representing doctors “wholeheartedly advocates for nurses alongside doctors.” This lack of attention to detail is troubling as it is a false representation of the organization representing doctors and demonstrates the lack of attention to detail by this midlevel association and thus corroborates the aforementioned points.

You will hear many midlevels express outrage about this Patient Safety Guide. The outrage stems from the fact they can no longer hide behind white coats and vague terms, however their outrage will be expressed in the form of accusations of arrogance of doctors. This Patient Safety Guide is not about arrogance, rather it is about patient safety and upholding a standard of care of the highest quality. This is best demonstrated by the Greek poet Archilochus who once stated, “We don’t rise to the level of our expectations, we fall to the level of our training.” Arizona association of nurse anesthetists appeared to be only concerned about money as they stated, “the intent of the [organization representing doctors] is to eliminate competition in the market…” Fairness in terms of marketplace competition refers to comparing apples to apples. As they appear to fail to grasp, patient safety is the highest priority for doctors, we are uncertain of what their priorities are. If we were comparing apples to apples, they would undergo the level of education and training required to become a doctor rather than a piecemeal training course which (in many instances) incorporates online courses and “distance learning” into their curricula. Furthermore, they would be subject to the same regulations, licensing and oversight as doctors. The statement that nurse anesthetist organization made appears to embody the mentality of many members of their society: financial convenience without sacrifice. The nurses who choose to become midlevels view this change in their career as “easy money” because they can continue to work full time and work towards a higher income with minimal education and lifestyle sacrifice.

“The nurses who choose to become midlevels view this change in their career
as “easy money” because they can continue to work full time and work
towards a higher income with minimal education and lifestyle sacrifice.”

Many midlevels assert that doctors are intimidated by them. To many doctors, this is true because many times when they identify midlevels misidentifying themselves to patients and/or identify medical errors by midlevels and bring those errors to their attention and/or the attention of hospital administrators, they resort to radical means to undermine doctors. Hospital rumors, negative online remarks, threats and attempts to get doctors fired (and even frivolous complaints to state osteopathic medical and state medical boards) are but a few of the ploys midlevels use to attempt to silence or eliminate doctors.

• Regarding online remarks and commentaries, many midlevels are social media savvy individuals who are adept at organizing crowds to bombard the profiles of doctors with derogatory posts.  They are aware that most (if not all) doctor rating sites do not verify a commenter’s identity far beyond a valid email address.  Because of this, many may leave negative remarks (under the cloak of anonymity via the creation of "burner" (disposable) email addresses) without ever having been under the doctor's care or even having met the doctor.  Seeing a surge of negative remarks about a doctor in a concentrated time span (i.e. hours or days) or a large amount over a gradual time period (i.e. days, weeks or months) should tip a legitimate viewer off as to whether a doctor has been victimized and defamed by midlevels.

An email received by an organization representing doctors from Charley Leamons (a midlevel in training as of June, 2018) speaks to this when he messaged “NPs [nurse practitioners] are RNs [registered nurses] first and can make doctors lives hell. Just a thought.”

Another midlevel named Mike MacKinnon appeared to be so distraught by facts presented by the organization representing doctors that he accused that organization's President of “possibly being mentally unhinged” despite never having met that individual. In Mr. MacKinnon's email to the organization representing doctors dated June 19, 2018 (with the bizarre subject line "We are onto you bro.") this past president of Arizona association of nurse anesthetists demonstrated his contempt for the osteopathic medical education of over 6,000 doctors by describing that organization's president's osteopathic medical school as "a middling DO school."  He appears to have strong (negative) feelings about the organization representing doctors extending membership opportunities to doctors specializing in podiatry and dentistry (we presume he does not consider Podiatrists and Dentists to be Doctors).  He also made a slang reference to "drinking the “Kool-Aid”" with which we were unaware, however (according to "The Urban Dictionary”) it is derived from "a reference to the 1978 cult mass-suicide in Jonestown, Guyana."  While this individual appears to be unable or unwilling to acknowledge doctors' concerns regarding midlevel practice, he frequently demonstrates negative views about anesthesiology assistants.  In fact, some of the learning objectives from a recent presentation he gave included "Discuss and describe the limitations of AA [anesthesiology assistant] practice including billing fraud risk and inability to expand access to care in a fiscally responsible manner" and "Identify and articulate the historical strategies used to combat AA [anesthesiology assistant] encroachment and discuss new strategies to limit expansion."  While he appears to be proud of his job title, we query why he is attempting to rebrand / remarket his title to "nurse anesthesiologist" (a term he helped to invent) from nurse anesthetist which may confuse patients (Please refer to the tab titled "Are They a Doctor?").  Coincidentally "The Urban Dictionary," in our opinion (and in the opinion of many healthcare professionals), provides an accurate description of the newly invented (but not recognized) term "nurse anesthesiologist."

Yet another midlevel named Brian Stephenson messaged us with eyebrow raising remarks by indicating, “I’m sorry you are threatened by NPs and PAs. Your solution is to have a lot more foreign doctors to work in the United States. No offense, but most Americans cannot understand the foreign doctors which leads to medical errors, miscommunication and prescription drug errors.”  An NBCNews.com article dated October 29, 2018 appears to directly contradict his generalization with a quote provided by the Association of American Medical Colleges:  "Foreign-born doctors are vital to the national health system.  The U.S. is grappling with a doctor shortage that's expected to grow to as many as 120,000 physicians by 2030." The Educational Commission for Foreign Medical Graduates (E.C.F.M.G.) administers examination(s) to test for English proficiency of international medical graduates (I.M.G.s) who are applying to medical residency or medical fellowship programs certified by the Accreditation Council for Graduate Medical Education (A.C.G.M.E.), which we believe the majority of medical residency and medical fellowship programs are certified by.

And yet another midlevel named Laurel who appears to live in Oregon has resorted to transposing patient safety concerns regarding midlevel practice into a “#genderequality issue.”

In a social media post which demonstrates the most disdain for doctors and the medical profession we have observed, a midlevel named Charlie Buscemi remarked, "NPs [nurse practitioners] will steal all of physician's jobs.  Physicians are dumb and pissed they're in 200k debt & wasted years of their life in school.  NPs do everything MDs do in 1/2 the time.  MDs are losers.  We are the new doctors.  I always make sure all my patients call me doctor."  One would want to believe this is a rogue statement by one individual, however his sentiments may be shared by others in the "academic" community as this individual (as of March 7, 2018) has served as the vice chairperson of graduate nursing at Florida International University's Nicole Wertheim College of Nursing and Health Sciences.  We have little doubt he will imbue his false, derogatory and inflammatory views upon students as he indoctrinates subsequent generations of midlevels.

Carin Eling (a midlevel who appears to work in Oregon) posted the following unconscionable message on social media, "There is a reason MD's a (sic) committing suicide & using substances & it's because u refuse to admit u are motivated by money & lack integrity!"  This healthcare "provider's" statement appears to speak for itself.

It appears that individuals from the field of midlevels will resort to any means including false justifications to justify themselves.