The Delete Button


Let me state, for the record, one more time that I believe that training and education matter.  No sane person would disagree with that statement.  Right now the militant wing of the midlevels (NPs and PAs) are trying to attack me on this site because I continue to bring up this point.   They always go around the issue of training and education and bring up other circumstantial evidence that proves nothing.   I will not back down on this.  Training and education matter.  Midlevels have less training and education – FACT.   Midlevels are not doctors – FACT.  Is my job threatened by midlevels ? YES.  Administrators can pay them less and it is all about economics for them.   Does that mean they are equal to doctors.  NO.  Do I fear they can do my job as well – NO.  Why?  Because training and education matter.

I have baited a NP before by asking her why she thinks a nurse is the same as a doctor.  “A nurse? I am not a nurse”, she said, “I am a nurse practitioner!”.

“What’s the difference?” I asked.  I knew the answer but wanted her to set the hook.

“I had two years of advanced training to become a nurse practitioner”.

“So tell me, why does that make a difference when you want to separate yourself from an RN but it is doesn’t make a difference when you claim to be the same as a doctor?” I asked.

“Um….Um…..” No answer.


I have found, that on this site, it doesn’t matter when I publicly state that I believe there is a role for PAs and NPs.  I believe we can work together collaboratively.  I have worked with really crappy doctors at an urgent care where I felt some PAs and NPs were definitely better than those docs. I have also stated, however, that the line was crossed once the NPs wanted total independence to COMPETE with us; letting their leaders claim they are as the same as us.  But for the militant wings of the NPs and PAs, they don’t hear that. All they know is to attack back against anyone questioning their tactics.

Here is a recent paragraph from an article in the NYT on the same topic:

Nurse practitioners believed that they could lead primary care practices and admit patients to a hospital and that they deserved to earn the same amount as doctors for the same work. The physicians disagreed. Many of the doctors said that they provided higher-quality care than their nursing counterparts and that increasing the number of nurse practitioners in primary care would not necessarily improve safety, effectiveness, equity or quality.

Yep, that is what we are up against.  And if you look at the comments from that NYT article you will see that the militant wing went after the author, the doctors, and anyone else who dared to question them.  Hundreds and hundreds of NP and PA militants claiming they are the same.

But I own this site.  Never before, in 12 years, have I had to use the delete button on ANYONE.  I always let everyone say their peace even if they hammered me.  The problem with the militant wing of the midlevels, however, is that once they put a jihad on you, they never stop.  So…I will stop them by pressing the DELETE button.

If you are from that faction and want to respond then build your own website. Call it UNAUTHENTIC MEDICINE because that is what it is.  For my loyal readers, I would love to hear your thoughts.

Man, it feels good to be the King of Medicine!

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  30 comments for “The Delete Button

  1. Reltney McFee
    February 22, 2014 at 7:16 pm

    Having been an RN since 1979 (still RN licensed, today!), I get asked why I went to PA school. I tell them, Okay, I’m gonna practice medicine, but I’m not going to go to med school. Now, which course of action seems to better pass the Jewish Carpenter Test: embrace a partnership with folks who HAVE gone to medical school, or alienate myself from those folks? Which seems likely to be in the patients’ best interest? THAT is why I went to PA school, because generally the Suits in PA-dom embrace that alliance, in contract to the NP Suits.

  2. Steve Deputy
    February 19, 2014 at 3:28 pm

    You go Doug! As a specialist, I frequently am referred patients by NP’s with wrong diagnoses, simple stuff that could easily have been handled by any even half-comatose pediatrician. If they want to “screen” patients and triage them to the MD’s to handle the patients that need more help as opposed to immediately shunting to subspecialty care.
    As an aside, let the NP’s take some overnight call if they want to get paid the same as the Md’s!

  3. Jonathan Bechtel, PA-C
    February 19, 2014 at 1:53 pm

    I can’t speak for all of my colleagues; I can only tell you this about myself. I know my place in medicine, and that is collaborating with my supervising MD. When he has something to say about a patient, I listen because he has more education and training than I do. I listen even though we both know I’ve been in practice longer than he has. I don’t pretend I’m something I’m not, but I think a great deal of mid-levels are making that exact mistake right now. They see themselves doing a lot of similar things that doctors do and they think that makes them just as good. Wrong. It makes you a good collaborative partner.
    (I hope some of my colleagues are doing a double-take right now)
    I don’t know what the solution is Doug, but I don’t blame you one bit for fighting back. I wish more docs would do the same.

    • Doug Farrago
      February 19, 2014 at 2:22 pm

      Thanks, Jonathan. Prepare for some hate mail, though, from your colleagues.

    • Fred Powell
      February 19, 2014 at 3:04 pm

      If there were only more Jonathans.

      • Doug Farrago
        February 19, 2014 at 3:14 pm

        There are! Probably 80%. The other 20% are militarized like killer bees. The problem is that they cannot be ignored as they have a lot of power and spread a lot of misinformation to patients. Beware the militant NP or PA.

      • Jonathan Bechtel, PA-C
        February 19, 2014 at 3:28 pm

        There are a lot more. And if any of us ever get the notion of independent practice I think I’ll go back to bartending. I’d still take history and diagnose people, just prescribe everyone EtOH! With a lot of refills!!

        • Doug Farrago
          February 19, 2014 at 3:31 pm

          Dude, way off. The answer is weed. Medical marijuana. You would make a killing. I have seen lowlife docs go into this (not that it doesn’t help some patients) who get cash up front and guess what he does? Prescribes weed for everyone.

          • Jonathan Bechtel, PA-C
            February 19, 2014 at 3:40 pm

            Totally off-topic but here in California those so-called “clinics” are everywhere. I’m very interested to see what happens to them if and/or when marijuana is legalized here like they did in Colorado and Washington. Maybe those tool doctors will end up working at a minute clinic…

  4. fredlave
    February 19, 2014 at 1:08 pm

    In college I was a history major and one thing I learned in six years worth of history courses is that people get the governments they deserve. That principle can be extended to medical care as well. Patients (or their insurance) may pay the same for a visit to a PCP or a midlevel but the depth of knowledge in not the same and “routine” symptoms may mask a serious problem and are less likely to be missed by a physician. Midlevels exist because 85% of office complaints are from self limited illnesses. The patient will cure themselves regardless of treatment.

    • Pat
      February 19, 2014 at 4:32 pm

      Great points

  5. Cynthia Freel, MD
    February 19, 2014 at 12:35 pm

    Good on ya Doug!!!
    Don’t back down, I am with you on this.

  6. Kurt
    February 19, 2014 at 10:27 am


    They can admit patients to the hospital…….. The “hospitalist” will take care of ’em!!

  7. Scribe
    February 16, 2014 at 1:21 pm

    Doug, you are 100% correct regarding training. For the 20 years I was a physical therapist, the more militant PTs were fighting for autonomy. Autonomy was the last thing I wanted. I didn’t want to have to buy a ton of malpractice insurance and I didn’t feel qualified to rule out things like bony metastases or rheumatic diseases as causative of the pain I was treating. Still, there was the push for more and more training to the point that DPT is pretty much entry-level standard now. They work in the same jobs as their predecessors with the plain old BSPTs, and now that I transcribe some of their notes, I see no difference in their abilities compared to those of my generation. Longer periods of training aren’t necessarily better training.

    I also transcribe for various and sundry clinics and hospitals which includes PAs, NPs, and all specialties of MDs. As a rule the NPs/PAs associated with a specialist seem extremely competent. Once the specialist has set the primary plan of care, the NP takes over for routine labs, ordering routine meds, and as triage if anything at all is out of the ordinary. On the other hand are the ones that are only minimally associated with a physician “supervisor.” Of course there are some that seem quite competent from my point of view, those who are good at referring anything at all questionable to the physician. However, there also tend to be more of the quackish, anti-vax, try an herb, vitamin, or supplement (that I sell here in my office) for that, types than you see in the typical MD office.

  8. DrPhil
    February 16, 2014 at 6:58 am

    Maybe we should all retrain as NPs – better insurance, better job opportunities and less responsibility!

  9. Pat
    February 15, 2014 at 10:59 pm

    The wizards in the Ivory Tower and in the citadels of Organized Primary Care should follow this latest fight here on A.M. because:
    1. This is what they have caused by destroying the perceived worth and fight of primary care physicians, and,
    2. The NP’s and PA’s will soon be the majority of those represented by the likes of the AAFP et al.

    The noctors are the economic carrion eaters feeding off of a dying discipline and yes, I am very, very sad to see it happen. Direct medicine can still work for the discerning patient but the majority in the thrall of Big Insurance-Big Gov’t will be shuttled off to the cheaper alternative.

    • Robert
      February 21, 2014 at 11:00 am

      It seems very clear that the AAFP now considers a NP working in a NCQA-certified medical home as more worthy than a board-certified family physician who has rejected that monstrous style of practice management.


  10. Melinda
    February 15, 2014 at 5:32 pm

    I’m curious how often the NPs and PAs get sued for malpractice and have overstepped their bounds into things they really didn’t have the expertise to handle. Are they currently protected by being under MDs, so it is the MD that bears the lawsuit for what they do? When enough of them get hit with malpractice suits and don’t have the background education and training to defend themselves or even to understand why something went wrong, perhaps they will start to “get it.” The malpractice attorneys have picked up a lot of medical knowledge and a good attorney can hang even an MD in a courtroom–how much easier to hang an NP or a PA?

    Stand your ground, Doug. You’re right on this one.

    • fred powell
      February 15, 2014 at 6:03 pm

      The attorneys usually go for the deep pockets, the 1M/3M policy holder. The PA/NP/CRNAs don’t know how good they have it now. For the most part it’s the supervising doc who gets thrown under the bus.
      Prediction: As they begin practicing independently and begin getting sued more often, look for them to lobby for tort reform.

    • Doug Farrago
      February 15, 2014 at 6:20 pm

      Thank you!

  11. Mary K
    February 15, 2014 at 10:25 am

    I fear you lost this battle when I (and the insurance companies) pay the same fee in the office whether I see the the doctor or the PA or the NP. To my mind the pay level should reflect the expertise. If the insurance industry had developed a two-level reimbursement–lower level of course for the PA and NP–it would reflect the amount of education and training each has. Here in Michigan the NPs and PAs are attached to a hospital or doctor so when you go into Dr. X’s office you are billed the same whether you see the doctor or the PA even though the PA is supposed to consult with the doctor about your care.

  12. Cecilia Pinter, MPAS, PA-C
    February 15, 2014 at 10:06 am

    I have been a PA for over twenty years and have never considered myself to be an independent practitioner. I have been fortunate to work closely with my supervising physicians and meet regularly with them on a weekly basis as well as acutely if need be.

  13. Fred Powell
    February 15, 2014 at 8:00 am

    Well said. Never thought I’d see myself write this but I believe it. The unlikely heroes here will be the attorneys who hold the noctors financially responsible for the stuff they don’t realize they missed when it ultimately injures someone.

  14. February 15, 2014 at 7:03 am

    I agree about the non-equivalent education and training. This is most obvious when you ask an MD (vs a NP or PA) to provide a differential diagnosis for any particular complaint. Midlevels may be well trained to take care of the 80% “basics” (and can perform as well as MDs) but they will likely miss the 20% of issues that are complex, unusual, or require advanced testing/diagnostic acumen. In healthcare, a 20% failure rate is unacceptable. That’s why we need to work together to make sure we get to the right diagnosis, and hand-off treatment plans when/where we can.

    I urge all physicians to leverage their additional training to do what we do best – establish a correct diagnosis and treatment plan. Sometimes the frenetic pace of medicine distracts us from thinking carefully, which decreases our diagnostic accuracy to the detriment of patients. The “militants” take this as evidence that MDs don’t provide a diagnostic advantage after all. Not true. But if we are constantly taken off task to fill out insurance forms, then what good IS our extra training? What good is a computer if it’s being used as a paper weight?

    • Doug Farrago
      February 15, 2014 at 7:05 am

      Val, good points.

    • Steven Gilles
      February 18, 2014 at 11:15 pm

      Dr. Val
      Do you work with NP/PA providers? It is an honest question. Is your assumption that I only get 80% of the diagnoses based on some solid data you are aware of? Some study that was done? A meta-analysis of the work that PA providers provide? These are fair questions. I’m not a doctor. Doug is correct. I don’t have the training a physician does. Doug is correct. However…I can tell you without a question or a doubt that I see very complex patients in my practice. Physicians come to me with questions. My supervising physician will say “Hmm, I hadn’t thought of that” during a chart review.

      My point is, you are making untrue statements. If PAs are missing 20% of diagnoses, we are probably killing off or causing morbidity that could have been avoided for 20% of our patients if that patient had just happened to see a physician and not a PA. Is that happening? Are 20% of patients being poorly managed because they didn’t see a physician? No. That isn’t what is happening.

      Delete me Doug, apparently by being truthful, I’m being militant.

      • February 19, 2014 at 5:11 am

        Steve, the medical literature suggests that approximately 1 in 5 US patients has the wrong diagnosis. (See NYT article here – I am estimating that less training/awareness of full differential diagnoses will have an additional 20% error rate over MDs/DOs… Which would actually put misdiagnosis at closer to 2 out of 5 or 40%. This estimate is based on 20 years of experience working with PAs/NPs, discussing their impressions of patient complaints – there is no way to test the validity of the statement until we have a patient population who is treated exclusively by mid-levels without MD input. But I suspect that opportunity is not far off. Misdiagnosis rates are alarmingly high already, which are exacerbated primarily by lack of time physicians have to think carefully about patient cases due to time/financial pressures in the system. If the clinical treadmill is further increased with mid-levels as sole PCPs, I wouldn’t be surprised if half of patients have at least one active misdiagnosis.

      • Doug Farrago
        February 19, 2014 at 6:01 am

        I am leaving this in only because Dr. Val answered. Your definition of truth is militant.

        • Tom Drahos
          February 19, 2014 at 9:23 am

          Doug, as a loyal reader for years, I have agreed with you on literally almost all points. Indeed I agree that PA’s/NP’s aren’t doctors and do have less training. However, typically when something comes up that you disagree with, not only do you point out why it’s wrong, you offer solutions. I’m disappointed this has digressed into a proverbial pissing match between two well-respected professions.

          If doctors are worried that mid-levels are going to be taking over medicine, endorse a realistic bridge program between the professions: An NP/PA to MD/DO program. This way it keeps the terminal degree in a medicine as an MD/DO. Both groups would be happy — physicians continue to be highly trained regardless of their path to MD/DO and mid-levels have an opportunity to truly be equal. What’s holding this back? I would assume the same universities and academia that you have railed on for years.

          To be clear, I don’t know if the above is the answer. But it is AN answer.

          I understand it’s hard to extend an olive branch when you’re being attacked, but the problems facing this country with the primary care shortage and increased government regulation is much bigger than all of us. A realistic solution is typically one where each side makes concessions but also gets benefits. Currently, both sides are militant. It’s a touchy subject, people get angry, people get hurt. Both sides feel their careers are being attacked.

          Basically we have a choice to continue the status quo where one side will definitely lose and quality will be sacrificed no matter who wins — or to work together. I’m not talking about holding hands singing kumbaya, let’s get real, that’s for the administrators. But as professionals, we need to iron out something that is beneficial to both groups and the public.

          Doug, as a leader and someone I’ve looked up to for years, I would really enjoy hearing some of your solutions.

          • Doug Farrago
            February 19, 2014 at 9:42 am

            The only solution for doctors (especially PCPs) is to walk. Walk away from hospital employment. Walk away from insurance. Go directly to Direct Primary Care. Then the hassles are gone, the pay issues are gone and the patients come to you because they are paying for a value. And they will shop around for it. My value is a board certification in family medicine with 20+ years in healthcare. I also do……, etc. Then, if someone wants to shop around and pick an NP or PA over me, god bless them. Could my scenario still having us work together? Possibly. That’s called collaboration. But they (the militants) don’t want that. They want competition. That is what has got me so riled up.

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