The unsolved problem of MD + PR

In my hospital’s preoperative area, upright on her bed, sat an unhappy middle-aged lady who needed an operation to treat complications from her previous bariatric surgery.  She hadn’t lost weight and clearly was feeling discouraged about practically everything.  She was physically uncomfortable, couldn’t even keep down her own saliva because her lower esophagus was obstructed, and was in tears.

As her anesthesiologist, I came to evaluate her prior to surgery.  In fairly short order, I got her a tissue and a warm blanket, listened to her tale of woe, and finished my pre-anesthetic examination.  Nothing special.  At the end, she said,  “You’re so nice.  Were you a nurse before you were a doctor?”


No, I told her, I wasn’t.  Never a nurse; always a doctor.  She looked surprised.

And that little narrative may help to explain why we (physicians as a group) are having so much trouble with public relations, and  with the onslaught and success of mid-level caregivers who want to practice medicine without a license.  Their PR is better than ours because their PR task is easier:  patients already think mid-level health care personnel, especially nurses, are basically nicer and more sympathetic than we are.

Just look at the recent coverage of Hurricane Sandy.  News reporters on radio, TV, print, and online repeatedly and justly praised the heroic efforts that nurses made during the evacuation of patients from dark, flooded hospitals, and showed photos and video clips of nurses hand-ventilating premature infants.  But not once did I hear a mention of the attending physicians and residents who were no doubt working right alongside the nurses, let alone the respiratory therapists, orderlies, and all the other personnel.  Nurses got all the credit in the public’s view.

Anesthesiologists and nurse anesthetists represent perhaps the most visible part of the physician/mid-level conflict, but other physicians are at risk as well.  The American Academy of Family Physicians (AAFP) has recently made public its opinion that nurse practitioners shouldn’t run medical homes, but the Affordable Care Act supports independent practice for nurse practitioners–including admitting privileges to hospitals–just as it supports independent practice for nurse anesthetists.

The latest unbelievable turn of events is Medicare’s decision in favor of nurse anesthetists practicing interventional pain medicine without physician supervision.  Just so we’re clear, this means that a nurse anesthetist with no special qualification other than Medicare’s blessing can bill Medicare for performing invasive pain management procedures that physicians ordinarily train to do with four years of medical school, at least four years of residency, and a fellowship.  These are procedures so risky that my hospital wouldn’t consider me qualified to do them despite my MD degree and anesthesiology residency, because I haven’t taken advanced training in interventional pain management.

What are we going to do to turn around this public perception that doctors are curt, mean, and unsympathetic? And that nurses are always better, kinder, and maybe even smarter?  And can do everything doctors can do, just as well?

Some physicians believe that patients’ opinion of physicians can only be changed one encounter at a time.  I hope this patient thinks better of physicians after meeting me, though the next encounter she has with a physician who hasn’t quite enough time and patience could certainly reverse her attitude.

Maybe, however, we need to take a cue from Madison Avenue and market ourselves better.  The image and the brand are everything today.  And many Americans, while they pay lip service to valuing education, hate to acknowledge that some people know more than others because they have studied harder and longer.  Physicians are perceived as elitist; nurses as nurturing.  The stereotypical TV physician is still an old white guy who’s probably a Republican, while nurses come from all ethnic groups and their unions support Democrats.  Let’s face it: in this dichotomy, nurses are “cooler” and certainly easier to like.

So we need to change the brand.  We don’t need to pretend that “Grey’s Anatomy” has done us any favors. Although the young doctors on that TV show certainly are a diverse group, their behavior isn’t what most of us would view as professional.  But somehow, physicians need to demonstrate these truths to the public:

We are becoming as diverse as many other professions in America today, by gender, ethnicity, or any other measure.

The standard Wednesday afternoon off for the doctor to play golf ended sometime in the 1950s.

We do care about our patients.  Often we wish we had more time to listen, but other patients need our time too.

We worked hard to gain the extensive education we have, and we take pride in using it to care for our patients.

 Until Americans become convinced of these facts about their physicians, and like us just as much as they like nurses, we have more work to do.


Noel Domingo, MSN, NP

Hi Dr. Sibert,

I have all the respect and admiration for physicians like you. I know the length of education and training a doctor had to go to become one. I have physician relatives as well as physicians for friends. I am an NP and started obviously as a bedside nurse in critical care, medical surgical floor, acute dialysis, and ER. As an RN and an NP I like what I do.

One thing that physicians are at a disadvantage is inadequate amount of time spent with patients. I am well aware of this. A doctor cares for more patients in one day than an RN whose patient load is only 5 if we are lucky. In the inpatient setting the patient always sees the RN 24/7. When patients get into trouble it is the RN who is always at the bedside who initially “does” something; from executing standing orders, staying with the patient providing physical and psycho-emotional care and comfort. Of course the physician is always notified as you are aware. We nurses never take the credit. We always tell the patient how great their doctor is and that he/she is doing everything within his/her power to get them well.

We cannot do anything about how the media portrays the RN. We all know that they (media) like “drama” because it connects with our humanity. That is how they make their living. I am sure if the doctor was their bagging the patient, they will be acknowledged as well. You and I know that physicians have far better use of their expertise/education than to operate an ambu bag, this is best left to the RN who is also trained to do it properly, not that doctors aren’t.

As for the term “mid-levels” which I personally find insulting, Nurse Practitioners, Nurse Anesthetists, and Physician Assistants, are all advanced practitioners. Before an RN becomes an NP, he/she must have had 4-5 years of bachelor’s degree in nursing and 2 years of Master’s degree in nursing. Some of us have PhD and Doctor of Nursing degree. One cannot become an NP without years of bedside nursing experience. We are educated not as doctors but as nurses with our own unique medical knowledge and with advanced training in diagnosing and treating minor illnesses. There are some of us who were mentored by physicians who are experts in their field to perform highly specialized task one which you referred in this article.

We never tell our patients that we are physicians we always introduce ourselves as Nurse Practitioners or Nurse Anesthetist. Legally we are not physicians hence we cannot say that we are. We have advanced training in some tasks that are normally under the domain of physician responsibility. We were trained by your fellow physicians who are experts in their own fields to perform these tasks safely. We are providing services that are in all honesty recognized by other physicians to be of value to the community.

Going back to your term “mid-levels”, are you implying that physicians are “upper levels” and non-physicians as “mid or even low levels”? What about pharmacist, psychologist, therapist, are they mid-levels too? Just what exactly do you mean by the word mid-levels?

Thank you for your very interesting viewpoint.


Mary Gawlas, RN BSN

While I am not an advanced practitioner, I am however a very experienced RN who went to a lot of schooling to be a “mid level” caregiver who, by the way, is expected to catch any and all physician’s (upper level practitioner) errors when transposing orders written by someone who never saw the working end of a penmanship class. But I digress. You probably are a terrific doctor and person but you have come across in this article as someone weaned on pickle juice. Get a grip and if you and your colleagues ( which nurses, are too by the way) feel you are dwelling at the low end of the nicety scale with patients, be nicer to them. This is not an us vs them game. Go get some sleep and you may just feel a little better about life as a physician. After all, you could always go to nursing school and enter the more glamorous profession of nursing.


Marilyn Adams

Hi Dr. Siebert
I thought the article was excellently written and expressed exactly how a lot of patients feel in regards to nurses and physicians. I think that the reason there is such an exponential difference in expectations from patients of their physicians is because they almost always seem to be in hurry. When one rushes, it doesn’t necessarily mean that whomever/whatever you are addressing does not matter, but when people are sick and it has elevated to the status of hospitalization, patients require more attention and proof of concern about their status.
Nurses do quite well at relieving patients fears and doubts, but the “big Chief” needs to do his/her part and this probably could be done if, he/she utilizes their bedside time expertly. Notice what if you were the patient, might make your immediate environment more conducive to a frightening hospitalization.
Thanks for a well written caring article.


Donna Verret

After 35 years in healthcare (E.R. nurse, Director of Nurses, COO, healthcare consultant), I am very pleased to see nurses gaining respect. Likeability is great, but respect is critical to any professional. So why are physicians different? Patients see less of the physician and certainly fewer of them than they do nurses. It only takes one negative physician encounter to “dirty the water” for other physicians. Nurses have embraced the concept of self-governance. Physicians, on the other hand, have historically tended toward ignoring or making excuses for their fellow physicians, especially when it comes to “personality” problems. So, what is it going to take to change this perception? Old proverb still holds true: Physician, heal thyself!


Maybe now you’ll understand the Republican Party has a branding problem. You said it yourself, Nurses are probably “caring” Democrats and physicians are “mean” Republicans. Perception is reality. I’ll give it to Barack and the Democrats, the MSM, also known as the Obama PR arm, they did a great job of furthering the falsehood of the Republicans and Romney being Mean Rich White Guys, which couldn’t be further from the truth.


You hit the nail on the head. Unfortunately your hammer is about 50 years too late. In an age where style trumps substance, and image is more important than action, doctors are indeed behind the curve in protecting their brand. The fact of the matter is that it’s not an accident that the medical profession has bad PR. This phenomenon derives from several causes: professional organizations which are stuffy and outdated in their approach to publicity and who don’t represent the best interests of their membership, competing special interest groups which are aggressively trying to expand their scope of practice, (nurses, PAs, optometris, pharmacists) , and a popular media which is liberal and therefore aligned with government policy initiatives which benefit from a negative narrative (real or contrived) being focused on “rich” physicians. On top of these factors you have a group of people, eg doctors, who are extremely busy and make business decisions between cases, or at 7 PM after they are done with the day’s pile of superfluous paperwork. While some doctors are more market savvy than others, for many practitioners they are worried about a long list of things, patients at the top, besides their Google ratings.

At least your article doesn’t suffer from Stockholm syndrome, where you put on the hair shirt, bemoan how doctors are all meanies and we need to redeem ourselves in the eyes of the Huffington Post. But don’t worry, the wonks behind the PPACA and the ACOs and the rest of the alphabet soup will start grading you soon on “niceness” and you’ll soon find your pay docked if you don’t follow the edicts of the thought police.


Hello Doc:

Great blog, raising a few issues, which seem to strike a nerve. That is why I love blogs like this, because it shows the human side of doctors, which, when sometimes exposed, is controversial.

But doctors are human, and they have opinions, and do not have to please everyone, all the time. We doctors are raised in a very political environment, which we find out quickly in medical school, and we discover there is a pecking order, which we must follow, or get somehow punished. I found that out in Med School, by telling a joke while scrubbing with a Urologist in the OR, and he flatly told me that HE was the one who was supposed to be funny. Lesson learned.

And, now Dr. Siebert, you are laying out your opinions, which might be dangerous in the hospital, but, hell, you are not on duty, and you are human, so congrats, and keep posting thought provoking subjects.

I put a link to your blog on a big website I am building for the digitalization of medicine, which includes a section on Best Anesthesia Blogs, and Penned Point is now in it!


Rosanne Aulino RN, CMHN

My apologies for coming to this discussion at so late a date, but I just discovered this blog.

I really appreciate the post and the comments here. I agree with many points on both sides of this issue.

I believe that “mid-level” providers can be an excellent addition to the medical team.

As an RN with 30 years of experience, I firmly believe that nurses as mid-level providers would provide better and safer care if there was an experience as well as educational requirement. Nurses are not, as NP Domingo stated in his post, required to have any experience in the field in order to receive a master’s degree. There is not even a requirement that the undergraduate degree be in nursing.

The difference in competency between an experienced nurse with a master’s degree and a non-nurse with a master’s degree in nursing is breathtaking in its proportion. It is dangerous to patients and has been damaging to the profession.

I believe that a big part of the issue that physicians have with master’s prepared nurses performing some traditional medical functions is because they have witnessed the results of the lack of experience of a growing number these practitioners. Many physicians that I know have a great deal of respect for some nurse practitioners. But despite what these ill-prepared graduates and their educators think, it is painfully obvious to EVERYONE which among them are experienced nurses and which are acting “as if.”

I think most physicians appreciate the contribution of an experienced nurse at the bedside, or especially in the ED and CCU to the care of their patients.

Unless (notice I didn’t say ‘until’)our nursing educators develop respect for the role that experience plays in the development of a competent nurse and stop promoting short-cuts, the rest of us will have to suffer the consequences.

I’m sad to report that for the past 15 years, I have sometimes found it necessary to hesitate before identifying myself as a nurse. I have too much dignity to have myself considered part of the current group.


Wow! I read your piece on Dr. Kevin and was surprised. I detest mid level providers and will never willingly put myself at risk with one of them. My main experience was with an utterly arrogant crna, but since my debacle I have extended that to include NP’s, PA’s and the like. Opposite of your experience! If you don’t prostrate yourself before them, if you question anything or deny them anything they want to do, they attack like a pack of wild animals. The comments on Dr. Kevin say it all.




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