And Then There is This…

I feel this is devaluing to me as a doctor.  My four years of medical school and three years of residency, where I did thousands of hours of training, is being confused for this.  Tell my why I should not be upset at this attempt to belittle what I do as well as confuse patients?

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] 

  31 comments for “And Then There is This…

  1. fred powell
    April 14, 2017 at 2:29 pm

    DNP, PA, NP, ……..I am not impressed. Take the internal medicine board and pass it. Then I will be impressed. Otherwise, it is obvious that the ability to manage complex medical diseases between an MD/DO internist and the midlevels is not the same. If they want to be considered an equivalent to a physician, get the same number of years training, be governed by the board of medicine in each state, do the same MOC, be held to the same standard legally as physicians, and take/pass the same board exam –that’s the only path that will lead to what they are seeking.

  2. April 10, 2017 at 11:38 am
    Found quite a few Online MD Programs offered as well; [see above link as an example].
    Naturally, I appreciate the MDs’ viewpoint, which is why I continue to subscribe to Farrago’s Authentic Medicine editorial. And, if this is just a rant and venting commentary (like most comments sections online), I am glad you have a place where you can feel supported to say what you really feel!
    I considered online degrees for my Masters of Nursing, but questioned the programs’ ability to verify work accomplished in the internships. In California, where I earned my MSN and my FNP, there is a stringent Regulatory Board that routinely puts the programs under a microscope to ascertain adherence to the frequently updated standards for practicing nursing and medicine. The students can only choose internship and residency sites that fit within the regulations and the Regulatory Board provides a list of accepted sites. And, oh yes, the Regulatory Board includes visiting interns at their sites.
    There are many different specializations for the NP by the way. Different programs offer the specialization degrees, which must follow just as stringent requirements. But just having a Doctorate appended to one’s alphabet soup says very little about the specifics of the degree. And legitimate Doctorates will specify their specialization type.
    I do not see how any graduate nursing program could last, if they are not adhering to the laws governing the educational programs. The same sentiment goes for the above Online MD program. There is nothing new in the realm of con artistry though. . . especially now that the Internet is so easily available to anyone that get to a computer somewhere.
    I sincerely appreciate the recent comment added to this thread that stated [the commentator] preferred their nurse colleagues be as highly educated as possible. Not only is that the best for the patient, but is not this the most effective & satisfactory working environment?
    To answer the question regarding how many hours a nurse spends in internship for their advanced degree, I had to spend 40 hours a week over three years…while also working, i.e. employed, in a hospital or clinic in my role as RN. Plus, one must have at least three years of full time nursing BEFORE even beginning the Masters’ Program (the ANA is stepping that up soon too to five or seven years’ experience in the field). To enter a Doctorate of Nursing, one must be able to show specific work/accomplishments as an MSN.
    Also, there are many different types of Doctorates of Nursing. The only one that can provide care as a ‘provider’ is the DNP. That is a tough program to get accreditation for the universities, so those Doctorates are few in number thus far.
    A sideline re the comments about Dr RN: I suppose there could be nurses out there confusing patients, but that is stated as unethical in nursing programs adhering to the ANA principles of care. The patient is the centre of nursing practice. Humans will be humans; however, for a nurse to slur patients’ perspectives on the nursing care they are receiving is only hurting the profession.
    I hope that assuaged some tender feelings on the part of some of the commenters. I must say though that, if you are experiencing nurses behaving in an unethical manner, you should be reporting the occurrences to the appropriate regulatory boards. As a former Nurse Educator (Professor), I expected my students to comprehend the distinction between their personal feelings and the purpose of their profession. If they could not evidence this to me, (in their preceptorship &internships), then I did NOT pass them. I cannot name another colleague of mine in the education programs that would pass someone who did not take their role seriously.
    All the very Best to all of you and to yours! ~jj

    • Sir Lance-a-lot
      April 10, 2017 at 1:20 pm

      “Plus, one must have at least three years of full time nursing BEFORE even beginning the Masters’ Program (the ANA is stepping that up soon too to five or seven years’ experience in the field).”

      That may be the case now, or where you are located, but I can tell you that I have personally worked with an NP (practice contained 2 FP Drs, 1 FP PA, 1 Urgent Care Dr, & 2 UC PAs, and this particular FP NP), from roughly 7 years ago, up until about 3 years ago, in New England, who was about 55 years old, and who completed nursing school, then rolled right into NP school with ZERO experience, completed NP school, and was then hired by this hospital, where she worked with me. She was completely incompetent, made bad and dangerous medical decisions regularly, and was a thorn in the side of everyone there who was a competent clinician. She was a smart person, but utterly inexperienced, and was a danger to the whole practice.

      There is another thing that I wouldn’t have bothered to make a separate post about, but I will mention:
      I completely disagree that nurses with more education are universally better.
      In my own experience, I can say without exception that the best RNs I have worked with have had ADNs or diploma school degrees. Some of those also had diploma-mill BSNs, but only because they were forced to get them by their hospitals. Nurses I have worked with who had BSNs straight out of the box have been less efficient, less observant, and generally less clinically skilled. I have had to teach several how to place IVs, or how to recognize sick patients.

      I will work with a nurse with a diploma-school degree and plenty of experience over a nurse with a BSN, an MSN, or a DN any day.

      Lest you label me a misogynist for this, let me add that the same goes for doctors – As a general rule, doctors who are double-boarded, have extra fellowships, have MBAs, MMMs, PhDs, and whatever other letters you can think of, tend to be annoying pricks.

      • Pat
        April 10, 2017 at 3:52 pm

        Amen Lance. A nurse with “doctoral” training is of no added benefit to me in the ER, but give me another experienced RN any day!

      • April 11, 2017 at 7:19 am

        Lance, not just any three years will do. One must still provide specific experience in the three years that is beyond ordinary occupational nursing. Most nurses have no desire to become a nurse practitioner, in my experience. It is so damn hard to just to become an RN! that few are interested to sacrifice more of their life to the written, oral, and practicums ad infinitum of the higher degrees. Believe me when I say to you, it is a form of hardcore slavery to the principles … in practice. And once, you begin the higher education trajectory, you are expected to still hold down a job as a nurse as well. We do not get to be only students. I was an ER/ICU RN in one of the largest trauma centres in San Diego. Prior to that I was in oncology. As I say, it is rare that you see young upstarts actually being allowed to go for the clinician role, because they have to have quite a bit of proven relevant experience to pass entrance specs.
        I am curious as to why you feel you must speak so ill of your supporting and collaborative team? Your comments come across rather emotional… I am sure you do not mean these statements personally to me as you do not know me. Perhaps you might find it more productive to point your finger at the real cause of your unhappiness… the whole system of healthcare in America? We are all just players in a odd game that has become more about corporate money than actually about caring for vulnerable people. Jus’ sayin’ …
        All the Best sincerely; I am always willing to be present for folks going through a rough period. ~jj

  3. David Taylor, MD
    April 9, 2017 at 10:09 am

    I’m coming to this exchange rather late, so forgive me if the discussion has moved on to other topics…. I remember attending a meeting of the medical/surgical nursing faculty at our university’s school of nursing many years ago, and was at first surprised to hear women (the whole med/surg nursing faculty were female then) call each other “Dr. Smith” and “Dr. Jones,” especially since they were “Barbara” and “Vivian” on the hospital units…. It occurred to me that many of these women had earned doctorates (in nursing as well as other fields), but couldn’t be called “Doctor” in clinical settings since that would be confusing and inappropriate, so these private settings were the only place they could use a title they had in fact earned. As faculty members at a university, they certainly had the same right be be called “Doctor” as the PhDs in arts and science departments — they just had to be careful about confusing patients and other staff about their qualifications.

    Fast forward to the present, an increasing number of nurses are receiving doctorates, but I’ve never run into a case in which they use the title “Doctor” in a clinical setting. Perhaps we are a little more cautious about the possibility of confusion, but I prefer to think that it is, on the whole, better for my nurses to be better educated, whatever degree they hold, than less….

  4. Judith Harvey
    April 6, 2017 at 9:38 am

    The latest and greatest name change in our community is the re-naming of physician assistants and nurse practitioners to ‘advance practice clinicians.’ It goes along with the renaming of physicians to ‘providers.’ Of course I am told that the term ‘provider’ is a designation for all clinicians, to make it easier on people. So now I hear ‘providers and advanced practice clinicians’ used all the time. I have offered to turn my panel over the the advanced practice clinicians so they get the best of care. No takers so far.

  5. Pat
    April 2, 2017 at 7:35 pm

    Doug, this article should have run in April 1, because “nurse-doctors” are a $(@&#% joke.

    Before I went to med school, and after, I noted how quickly teachers, preachers, economists, and any other non-physician doctorates fall all over themselves to be called “doctor.” Since I’m not that insecure, I never use that title outside of work.

    • Fred Powell
      April 14, 2017 at 2:22 pm

      I have also noticed that anyone who comes to my clinic and identifies themselves as “Dr” this or that is never a physician. Always a dentist, chiropractor, or PhD thus far. And I, like you, never use that title away from work.

  6. drhockey
    April 2, 2017 at 12:27 pm

    Here is the current link to this:

    Be sure to click on the link at the bottom titled, “Online and Evening program disclosures (26 month program)” It gives the cost, time involved, etc. Be sure to read the asterisks as well. They are all quite informative.

    N.B. Be sure you are sitting down, do not have within easy reach something you might throw and break a tv or hurt a child, and have a sock or other suitable cloth item to mute any terrifying screams that could cause a neighbor to summon the police.

  7. Sir Lance-a-lot
    April 2, 2017 at 12:08 pm

    “Tell my why I should not be upset at this attempt to belittle what I do as well as confuse patients?”

    Because if you are, you’re a reactionary filthy sexist pig who hates women and wants to repress them back to the dark ages. You want to do this because you are afraid of women and will do anything to prevent them from being powerful, so that you can continue to enjoy the privileges of the Patriarchy.

    Why? Because, statistically, most nurses are women. Therefore, if you do not want to see nurses as your equals, with equal titles, then you’re anti-woman.

    Now you need to apologize to all of the women in the world who are struggling so hard against male patriarchal domination, for the injury that you have caused to them by your vicious and irresponsible hate speech.

    Oh, and screw your patients – they’ve got nothing to do with this, and their lives have no value compared to the importance of overthrowing patriarchal society. And screw you, too, because you have used your white male privilege to gain the advantage throughout your entire life, so all of the hard work that you think you did in medical school and residency wasn’t really hard, compared with how hard women have to work even when they’re not even employed at all, such as when they’re on Disability for fibromyalgia. Because, since you are a privileged white male, your opinion has no value, including your so-called medical opinion, and the medical opinion of a woman who has not had training even remotely as thorough as yours is far more valuable, because she speaks from years of struggle, and her opinion needs to be heard more than yours does, even if it results in a few people dying of undiagnosed cancers, because she has struggled so hard.

    You see?

    • J
      April 2, 2017 at 1:04 pm

      As a woman physician (MD) reading this, OMG! Who’s the filthy disgusting misogynist?

      Yes, women can go to medical school!

      • Sir Lance-a-lot
        April 2, 2017 at 1:51 pm

        Ever hear of a thing called “sarcasm”?

        How about “parody”?

        I bet you think Stephen Colbert is an arch-conservative.

        • D$
          April 2, 2017 at 1:55 pm

          Satire/parody is usually funny and to point. Yours is neither. Go back to troll school

          • Pat
            April 2, 2017 at 7:37 pm

            Sometime good humor has a bite, D$. Own up.

          • Sir Lance-a-lot
            April 2, 2017 at 10:53 pm

            Oh, my goodness. A critic.
            Since my post does not meet your personal standards, it is neither satire nor parody, and I am a troll.

            I’m sorry, but if you lack a sense of humor, that does not mean that I’m not funny, any more than if you were colorblind it would mean that I’m not pink.

            And as for trolls, which one of us subscribed to the PJ from the beginning, had material printed in it, and has been posting in this blog since its inception, and which one just posts here to stir the pot?

            Have a nice day.

      • J
        April 2, 2017 at 2:05 pm

        Also, since about 2010, women make up a larger percentage of medical school (MD) classes, in the range of 52-54%.

        • Sir Lance-a-lot
          April 2, 2017 at 2:11 pm

          I don’t care how many women are in medical school. That is an irrelevant fact.

          I was creating a sarcastic parody, and suggesting that the words that I typed would be uttered by those defending the “Doctor Nurse” programs.

          Did you have your sense of humor surgically removed while you were in medical school?

          • Pat
            April 2, 2017 at 7:29 pm

            Lance, that was an excellent parody. And it of course, proved how pathetically, grimly humorless so many of our female colleagues are. So to all you upset ladies ????????????????????????????????

          • Sir Lance-a-lot
            April 2, 2017 at 10:58 pm

            To be fair though, Pat, I’ve run into my share of humorless, self-important male (or should I say “male”?) doctors as well.
            I’d associate the attribute with doctors in general before I associated it with female people in general, though it is true that I haven’t had a laugh with a whole lot of female doctors over the years (female nurses, on the other hand, seem to laugh and enjoy life much more easily. Could be why I married one.).

    • Dr. Laci Waner
      April 2, 2017 at 1:57 pm

      As one of thousands of very hardworking female physicians (doctorate of medicine/M.D.) that now make up over 50% of the female/male demographic, this response is a great representation of exactly why this propaganda is such a problem.

      • Sir Lance-a-lot
        April 2, 2017 at 11:04 pm

        “… this response is a great representation of exactly why this propaganda is such a problem.”

        Not to sound obtuse, but there are by now a whole lot of posts flying around here – Could you possibly clarify which response and which propaganda you are referring to, so that I can decide whether to agree with you or get pissed off?

        Thank you.

    • Carmen
      April 2, 2017 at 2:13 pm

      Woah… ever consider that women could be physicians too? Ever consider that thes WOMEN Physicans are frustrated with the devaluing of the trained MD/DO? In your attempt to be a feminist you forgot that women can be doctors too.

      • Sir Lance-a-lot
        April 2, 2017 at 11:01 pm

        “In your attempt to be a feminist you forgot that women can be doctors too.”

        Ummm… I don’t think I did. I work with a few of them (at the moment, 5 female and 1 male doctor, plus me, in my workplace).

        I think you kinda missed the point.

    • Susan
      April 3, 2017 at 8:43 am

      I have taken nurse practitioners students in my practice and while I am working with them during their rotations most are unable to develop an appropriate differential diagnosis.
      They lack adequate education in radiologic diagnosis.
      Most of my students spend more time on learning “nursing theory” rather than studying pharmacology and desired use of evidence-based alternative therapies, allied health and when watchful waiting and reassurance are most appropriate.
      I am sure not every single nurse practitioner or doctor of nursing student fits in this category but I feel they are not given the educational background to provide standard of care in a good number of primary care situations they may find themselves in.
      My supervision of nurse practitioner students has led me to now say no to taking new students.
      I can’t with good conscience teach them I an 80 hour rotation once a week for a two months what they need to be considered competent practitioners.

      I am female and a physician.
      My feelings are not based on so-called patriarchy.
      By the way, approximately 47% of medical students am ARE female.
      My own practice- ALL FEMALE – has made the conscious decision not to hire nurse practitioners of doctorate of nursing graduates because we have experienced that their training is inferior.
      I feel this type of degree for clinical education does devalue me as a physician.
      Maybe the problem is that I am white?
      Maybe the problem is the physician in the article is giving an accurate assessment not based on his gender or race, but you want to view him this way whether accurate or not?

      Physician training is lengthy, extensive, and rigorous.
      It is broad and then narrows down to a particular, specific area of expertise in residency.
      A doctorate in nursing falls short of this and is confusing to patients who don’t understand the difference ,but think they are getting the same level of care when in fact they often are not.

      I hope we can all grow not to see problems and issues as a group of “ists’ and ‘ archys’ , or race issues, but as the truth of the information being presented us.

      • Pat
        April 3, 2017 at 10:43 am

        Wow Susan, you mean training and experience actually matter? Great post ????

  8. Ana
    April 2, 2017 at 11:39 am

    This is insulting. If you want to be a doctor go to medical school. Patients are being put in danger. This madness will stop only after people are dying from the ineptitude of these mid level providers.

    • Doug Farrago
      April 2, 2017 at 12:30 pm

      I am not saying ineptitude. Many are really great but to create confusion over an online degree is insulting.

    • fred powell
      April 14, 2017 at 2:24 pm


  9. Steve O'
    April 2, 2017 at 10:59 am

    It’s amazing. the business community will follow the playbook of Karl Marx, even though his ideas are ancient and broken. When he rails against the capitalists, they seem to figure – “Gosh, if Marx said it, it must be true!” I am astonished. I do not believe there’s any sense left in Marxism. But our business community has somehow picked up in its mission some Marxist ideas of how to manage the proletariat, that don’t work well, and are a bit demeaning.
    Wikipedia speaks of commodification as “the transformation of goods, services, ideas and people into commodities, or objects of trade. A commodity at its most basic, according to Arjun Appadurai, is “any thing intended for exchange,” or any object of economic value. People are commodified—turned into objects—when working, by selling their labour on the market to an employer. One of its forms is slavery. ”
    When some beancounter says, “Let’s add an FTE of doctoring here.” that’s commodification. Whatever the labor parcel is, it costs an FTE for the company. If they get an equivalent from a Doctor of Nursing or Doctor of Emergency Response Therapy, they will go for the cheapest.
    Marx extensively criticized the social impact of commodification under the name commodity fetishism and alienation.[
    “Karl Marx’s theory of alienation describes the estrangement …of people from aspects of their [existence]…as a consequence of living in a society of stratified social classes. The alienation from the self is a consequence of being a mechanistic part of a social class, the condition of which estranges a person from their humanity.” Wikipedia. I also think that the destruction of the medical society and its cohesion is deliberate.
    Commodity fetishism: In the marketplace, producers and consumers perceive each other by means of the money and goods that they exchange.” This describes the transition of the medical relationship and its deterioration. A person, a patient no longer presents for care – they present to obtain a ticket to buy a Z-Pak, and seethe with anger that it costs them a doctor copay to get the product.
    Again, be mindful – I consider Marxism to be false and ugly. It comes from the aspect that individuals are invisible molecules, and the only thing worth considering is collective entities of humans. Individual ones are too small to care about. This is inimical to Jeffersonian democracy. It’s creepy to see that the only ones who believe in it are not the proletarian workers’ unions, but the companies.

    • Sir Lance-a-lot
      April 2, 2017 at 1:28 pm

      An excellent analysis, Steve.

      I would add that an easy way to think of “commodification” is to think of what a commodity is, in the economic or financial sense. If you listen to the news and hear about the day’s variations in the commodities markets, those are the markets in things that are completely generic and interchangeable, such as crude oil, wheat, soybeans, or pork bellies. Yes, there can be some variations in different lots of these things, depending on locality, weather, etc., but they are, overall, interchangeable, in a way that, say, hamburgers (McDonalds? Homemade? Local brew pub?) and cars (Kia? Chevy? Mercedes? Rolls? Lamborghini?), are not.
      So, when you talk about treating people like a commodity, you are talking about treating them like a few thousand tons of wheat scooped out of the hold of some bulk freighter and into rail cars.

      As far as the economic (Marxist) analysis of alienation, you can also add the Sociologic analysis of anomie (as espoused by Durkheim in his 1897 book “Suicide”). I am not a big fan of Sociology (bunch of BS gut courses…), but Durkheim and Marx are barking up the same tree, and describe the way that having a job in which you are treated like an interchangeable machine part affects the human being, and if you read him, you will see that his ideas describe much of what we in the medical field now feel, as well.

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