Published 9/1/2009
Charles N. Hubbard, MD

Just who is a doctor?

By Charles N. Hubbard, MD

“Healthcare reform is coming … soon,” announced Steven Ondra, MD, neurosurgeon and healthcare advisor to the Obama administration, at this year’s National Orthopaedic Leadership Conference in Washington, D.C. “While the details have yet to be worked out,” he continued, “it is clear that promoting primary care is essential. There will be winners and there will be losers.” He didn’t say who would be in the latter category but he obviously felt we needed to hear that. And since we are not considered “primary care” … well.

These are truly troubling times. The new administration and Congress are determined to bring healthcare reform now with little apparent regard for what it will look like and what it will mean to providers and patients alike. They are convinced the main culprit that has put health insurance out of reach for so many is too much specialized care. If, they believe, they can offer everyone a “public insurance option” like Medicare and return to the days of the family doctor, coverage can be affordable for all. What is left unsaid, however, is that in this new environment, either the public will have to curb its appetite for specialized services or those services will have to be … uh, “controlled.”

Although many allege that the “model” for the new system is Canada, it appears that the eyes [of legislators] are trained on something more domestic. Several years ago the Commonwealth of Massachusetts legislated universal coverage for its citizens. The program—not surprisingly—has struggled mightily, due, it is thought, to a profound shortage of primary care providers (PCP). Hence the emphasis on bulking up primary care.

Recognizing that it might take many years to train enough MD/PCPs to handle the patient load thus generated, [legislators] see expanding the role of physician extenders as the remedy, since [physician extenders] can be trained much more quickly. And those who train them are more than happy to oblige, although the extenders chafe a bit at the notion they are an “extension” of a physician. If they could blur the distinction between the two by upgrading their degrees to a “Doctor of Whatever”, then what’s to deny them the ability to practice independently?

“Surely not!” you think, but there are very influential people in academia who believe this is exactly what needs to happen. Doctor of Nursing Practice. Doctor of Physical Therapy. What’s in a name?

What’s in a name indeed? It is well known that loads of people desire the title “Doctor” but are put off by the rigors of what is required to earn it—the prerequisites, the certification, the recertification, and the mentored experiences so critical to making tough decisions. Many covet our station in life—perhaps even our lifestyle—but few envy what is demanded of us.

One thing you hear over and over again is “the current system is unsustainable.” It is also generally agreed that whatever system replaces it will be equally costly … in the trillions of dollars. But is the American public also aware that an additional cost may be that the care they receive will be delivered by people with scaled-down training?

I was once advised that it’s bad to have to apologize for how much of other peoples’ money you have spent, but not nearly as bad as having to apologize for what you bought. As our elected officials begin to draft this landmark legislation, they would do well to remember this admonition. Physician assistants, physical therapists, and nurse practitioners are an important part of how care is delivered today but it should be understood that their training is tailored to be a valuable member of a “team.” Time spent in training and in learning still matters.

Charles N. Hubbard, MD, is a representative to the AAOS Board of Councilors from Georgia. This article first appeared in the Georgia Orthopaedic Society News, Vol. 14, No. 2, and is reprinted with permission.