Advocacy

AOA statement on physician-led care, physician assistant title change and non-physician clinician use of the title ‘doctor’

Organization is deeply concerned by the potential harm to patient care and patient safety resulting from the erosion of physician-led, team-based care.

On Friday, the AOA released the following statement on the recent vote to change the title of physician assistant and its stance on the title ‘doctor’ in the health care setting:

The American Osteopathic Association calls for truth in advertising, intellectual honesty and transparency with the use of professional designations of non-physician clinicians in service of the public interest. We also call for organized, collaborative discussions among stakeholder organizations in the Physician, Advanced Practice Registered Nurse and Physician Assistant communities to find common ground on these important topics.

The American Osteopathic Association (AOA), which proudly represents its professional family of more than 151,000 osteopathic physicians (DOs) and medical students nationwide, is deeply concerned by the potential harm to patient care and patient safety resulting from the erosion of physician-led, team-based care. A physician-led team ensures that professionals with the highest level and most extensive degree of medical education and training are adequately involved in clinical decisions and patient care. “Physician-led” does not imply “physician optional.”

The AOA, and the physicians whom we serve, value the important contributions made to our healthcare system by our non-physician colleagues. Advanced Practice Registered Nurses (APRNs), Physician Assistants (PAs), and others have worked tirelessly with physicians to care for patients prior to and throughout the COVID-19 pandemic, often under suboptimal and emergency conditions that put their own health and safety at risk. Their selfless service is to be commended. However, it is important to recognize that there is no substitute for the unique and extensive education and training that provides the foundation for physician-level medical decision making.

Non-physician clinicians, including APRNs and PAs, are an integral part of physician-led healthcare teams. Healthy discussions and collaboration regarding safe and appropriate skill set substitution, roles and responsibilities are in order, and we welcome them. However, recent rhetoric has limited this important discussion to claimed territory and optical positioning through the use of professional titles, such as “Doctor” in a clinical setting by non-physicians and “Physician Associate” without consultation with the physician community. Further, we recognize the struggle of achieving professional parity (i.e. scope of practice, prescribing and compensation) between APRNs and PAs. However, efforts to seek parity among non-physician clinicians must not be at the expense of the truth in advertising and clarity of roles in our healthcare system.

There are important differences between the education and training requirements for physicians and non-physician clinicians. Physicians across the United States, osteopathic (DO) and allopathic (MD) alike, must meet the same education, postgraduate training and testing requirements and practice in supervised environments that afford progressively greater autonomy before ultimately becoming eligible to treat patients on their own through licensure competency assessment and rigorous board certification standards. These requirements ensure that all patients are treated safely and with the same standard of care.

DOs complete four years of medical school, which is comprised of two years of didactic study and two years of clinical rotations, followed by 12,000 to 16,000 hours of supervised graduate medical education (i.e. “residency”) before becoming eligible to independently diagnose and treat patients.

The American Academy of PAs (AAPA) has begun a push towards autonomy for PAs, first through their “Optimal Team Practice” model which was adopted in 2017 and advocates for the total elimination of any legal or regulatory requirements that PAs must maintain a relationship with a physician, and now through their recent vote to change the PA name to “Physician Associate.” According to their press release, the name change followed several years of study by an international marketing and communications firm. Professional credentials, titles and how we convey such information to patients is of great import and not a matter of marketing. This title change could easily create confusion for patients and put their safety at risk. Likewise, there are nurse anesthetists who seek to use the title “nurse anesthesiologist,” and other nurses with academic doctorates in nursing philosophy who use the title “Doctor” in a clinical setting, allowing patients to conflate their doctorates with the rigors of physician-level education and training. Many states have truth in advertising laws in place to protect against these situations, and help ensure that patients know that important medical decisions are being guided by physicians. (Editor’s note: See examples here, here, and here)

We strongly believe that all patients deserve access to high-quality medical care provided by a fully trained and licensed physician. The House of Medicine needs to collectively support the practice of medicine and work to ensure physician leadership for patient care. We are calling on our peers in the healthcare community to join together with policymakers to support policies that recognize the importance of the physician-led medical team model, ensuring that physicians, the only professionals with comprehensive medical education and training, are appropriately distinguished from non-physicians and are adequately involved in the care of this nation’s sick and injured.

33 comments

  1. Pingback: AOA statement on physician-led care, physician assistant title change and non-physician clinician use of the title ‘doctor’ – Kent County Osteopathic Association

  2. We strongly believe that all patients deserve access to high-quality medical care provided by a fully trained and licensed physician and work to ensure physician leadership for patient care. This post is important so, thanks for sharing.

  3. Well-crafted statement. We (physicians) are behind the curve regarding the proper integration of APPs and we need to be steadfast and diligent to ensure the best care for the people of this country.

  4. My wife and I have proudly been Doctors of Osteopathy for 30 years and take the sacred trust of being a teacher in the true meaning of the title “doctor”. Not to say that other members of the patient care team cannot teach but, we are the ones who are given the title which by its nature, encompasses the totality of what is known as medicine. The difference in the educational approach to patients by nursing curriculum is not a global but a focused/task based training. No nursing degrees require the undergraduate scientific rigor of pre-medical education, therefore, I submit that nursing education is less robust in breadth and depth to that required of a physician. Not to mention, but I will, the CME and board certification requirements of physicians. I totally agree that even on the surface this is a truth in advertising issue being presented to a literal minded public that still is not widely aware of the difference between DO’s and MD’s (another huge topic).
    One of our daughters holds a Doctorate in Physical Therapy and NEVER refers to herself as “doctor “ nor requires that she be addressed as same.
    The way to devalue anything in our society is to devalue the language used to describe something resulting in a word, title or phrase becoming meaningless.
    I wholeheartedly support the AOA statement but encourage our physician sisters and brothers to continue to not only illustrate but advocate for a clear distinction which will better serve and inform the public.

    1. Well stated.
      This scope of care “creep”has been ongoing in the hospitals and clinics for years. Many of my surgical associates are allowing more and excessive freedoms of their (midlevel’s)ability to treat and diagnose with little or no supervision.
      I have practice’d anesthesia in WA, an early sign off state, for 30 years. We as a profession need to control the “creep”, misrepresentation, and unproven declaration of skills without experience we are/will be dealing with in the foreseeable future.

  5. I see a number of patients who have received substandard care by PA’s and APRN’s in our area. The notes always say that the doctor was available for consultation, but is never consulted. Maybe the way clinics are using these people need to be addressed also.

    1. You probably don’t see enough of them. The “harm argument” is inherently weak because the APRNs are risk averse.

    2. YES I’ve seen this in consult notes endless times. I wonder “should the PHYSICIAN have been consulted during that visit?” And “did the patient receive the standard of care regimen”?

  6. It is a no brainer people. I believe the definition of the title of doctor in medicine is to go through a four year program in an accredited medical school. Otherwise, if we can call a PA or NP a doctor, then we can call a nurse a PA, an MA a nurse and l ( a GP ) can call myself a cardiologist without going through the formal training. This idea does not help or protect the public. It may help certain people make more money, but it does not protect or help the public. Am l wrong?

    1. My second reply, Dr Zamora, to your fine comments. GPs do some cardiology, and then refer the tough cases, and cause no harm, just like NPs most of the time. The difference is that physicians are not that political and do not try to appropriate titles, and blur and erase boundaries between the disciplines. Nursing does and now PAs are doing so. They abuse the cooperative nature of the medical system. Do stuff, avoid trouble, then push for more privileges. It’s corrosive to our profession.

  7. I concur with your position statement and that you bring out many important distinctions between a physician [DO/MD] and PAs/APRNs. Now Physical Therapists are getting Doctorate Physical Therapy to gain rights/privileges to independently diagnose and treat musculoskeletal disorders.

    1. Most physical therapists nowadays go through a DPT program. I agree that it doesn’t mean the scope should include diagnosing disorders – but perhaps more concentration and expertise within the therapy realm.

      Nurses now also have a doctorate program (DNP programs) – even Duke has one. Figure that!

  8. Thank you for this common sense statement of principle. Many physicians helped to open this Pandora’s Box over the years by supporting increasing autonomy of physician extenders for their financial gain – witness the owner of five urgent care centers, none of which may be staffed by a physician on any given day (in our state “supervision” of a PA means being accessible by phone and within 25 miles). We primary care physicians face the frustration of referring patients to specialists only to have them seen by a PA or APRN. In large systems like the VA a PA may be a primary care PA one day and be assigned to be a urology PA the next week, doing consultations! When I send a patient to an oncologist who does their own bone marrow biopsies, I know that the patient will have that done by someone who has a lot of training and experience. When I am forced to send a patient to an oncologist who has a PA who does all of their bone marrows, I have (and the patient has) no idea how experienced that person is. This is our own doing, and the birds have come home to roost…

    1. So many people want to play “doctor”, but don’t bother going to medical school. They want the accolades and respect, but aren’t willing to pay the dues.
      Physicians turned the reins over to “assistants, associates, etc., in order to make more money and free up the physicians’ time. We have handed over the practice of medicine to lesser trained, lesser learned people.

  9. I wanted to make a small comment from a new OMS IV’s perspective. As a medical student in 2021 facing a transition into a professional field that I have dedicated and sacrificed for diligently these past 15 years (including two undergraduate degrees and a masters degree, a year of overseas research, and a year in private sector microbiology), hearing and seeing things like this take place creates an added, unnecessary fear that is piled onto everything plus an already tumultuous 2 years of chaos through a pandemic.
    Along with the constantly changing modalities of medicine, both in diagnostics and treatment, we are also adapting to a completely different lifestyle, many of us in parts of the country in which we have never stepped foot. Now, stepping into the final stretch of our journey, we see not only is there already an established tension between nursing and physician staff at many hospitals and clinics, but now we are also facing a completely new landscape of political and legal aggression that will put even more strain on learning the vast amount of information and training that must be completed both effectively and cooperatively with all members within our health care team.
    Speaking specifically to the osteopathic side of things, this reminds me too much of the chiropractic battle that has plagued the proper treatment of somatic dysfunction for decades.

    1. I understand your frustrations with your medical education journey – mine was similar. Wake up and smell the roses though – to be frank. It is your future at stake. Most DOs in our profession support and will do everything to help and encourage you. However NP and PaA lobby groups legislatively do not agree with or cooperate with us in terms of scope of practice legislation. Yes cooperate with other members of your team – we have long stood for that. But there comes a point where you need to stand up for yourself and our profession too.

    2. To all medical students including Mr Landry:

      Grab the horns of your future rather than letting it take you for a ride. People in the medical community – including nurses – will respect you for it. Im hopeful that new graduates will be able to stand up for us: scope of practice, reimbursement, student debt are all legislative efforts and issues you as students can help with. Some students and younger physicians have been some great legislative tools in our legislative efforts.

  10. When we call a pharmacy…the phone prompts are “to speak with a pharmacist….perscribers (or in some pharmacy “clinician’) hit 0” . Note: Pharmacist have preserved their brand. The brand for Osteopathic Physicians has been hard earned and defined for over 150 years. For “physicians” thousands of years over EVERY culture. To surrender our “brand” and give up our cultural prerogatives to be because some corporate or another business entity says so…is absolute professional suicide. What is our brand and what is our brand promise. And who gets to use our brand, and who gets to redefine our brand?

    1. I sure agree with you Dr Kamajian. In the California medical society, we are always encouraged to think and advocate for access, and nursing joins in aggressively. So do pundits everywhere. Nursing becomes the route to access to primary care. At the first sign of trouble, they refer, or as noted elsewhere on this site, the put in their notes that a physician is available for consultation, and perhaps this is mentioned to the patient. Now they are protected legally at least to a great extent, and if trouble occurs, they caused no harm. The physician always is a safety net. I don’t see how this is less costly.

      They are thus dissolving the line between the physicians and nursing.

      Look a little closer, and you will never see them give an inch on their boundaries. They fight for their brand, and boundaries, while we are distracted by some grand vision and grand bargain. Access, competition, cost, blah, blah.

      My physician colleagues in the California Medical Association (which includes some DOs-including a very prominent one) don’t seem to apprehend the brand erosion. If they are motivated to push back on nursing, then it is always by using the “harm argument”.

      “Paradoxically” (their word) they cannot find much proof of harm, but they still insist on dwelling on it. This teped defense of the physician profession ends up with miserable results.

      The nursing profession has the brains and brawn to muscle us around. My colleagues don’t like hearing this.

  11. This is a well written article. I’m not sure it is strong enough. I started my career in medicine as at PA in in 1978. After two years I went back to medical school and realized the significant difference in training, education and knowledge base not provided by the PA profession. There is no way that I could practice my specialty from what I learned from a PA education. The eight years of additional training was needed to practice the quality of medicine that a traditional medical education provided. There is a role or advance practioners and but they still need oversight from an MD or DO. Just think about the liability that if a PA calls them self as a Dr. and malpractice occurs. The public is not ready for this nor is the trust the public has in our profession if we dilute the title of physician.

  12. As a newly graduated physician, I am happy to see the AOA recognize and issue a statement on this ongoing threat to patient care. Scope creep, obfuscation with terms such as “provider” (which I never use as a point of principle and I advise others do the same) and the recent obsession with non-physicians pursuing new titles and non-sensical names are hazardous developments. I believe our everyone gets a participation trophy culture coupled with the industry’s desire to reimburse as little as possible is driving these malignant forces forward. Physicians share the blame, too as a previous commenter pointed out.

  13. Physicians should step to the side and quit supporting the PA’s and NPs. They are eroding our profession ( what’s left of it ) and taking our livelihood. Corporate employers are replacing physicians with PA’s and NP’s and use the few physicians( MD and DO’s) they hire to make it legal.

    Why we sit back and assume the risk while we complain about the title is beyond me. There will be no change unless we act.

  14. Excellent and timely article. The use of Doctor by non-physicians is on par to physicians being put in the box of ‘provider’. We went to MEDICAL SCHOOL (DO/MD) and were educated on the entire spectrum, level and intensity of medical knowledge. While I totally support and respect everyone on the medical team, if you want to be a physician and practice in that capacity, GO TO MEDICAL SCHOOL. There are no shortcuts other than political action committees that have shortcuts to ‘convince’ politician$ to do their will for ‘safety and access to healthcare’. It’s not enough to just boast that we are the quarterbacks of the medical team. We as physicians need to start playing politics as well. If we don’t join the fight and stand for what we know is right, then we will certainly lose. And most importantly, our patients lose.

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