For years, this blog has discussed the issues of others referring to themselves as doctors. This “trend” has now reached a point such that patients, not knowing who is who, are placed at risk. A few of our writers had been discussing the term “Cultural Appropriation” and how it relates to the field of medicine. We came to the conclusion that a similar phenomenon is occurring with nurse practitioners (NPs), physician assistants (PAs) and other non-physicians (NPPs). The new term we have coined is “Professional Appropriation”. Examples of this issue are ubiquitous:

  • The use of terms/phrases such as “residency”, “fellowship”, “board certification” and “attending” which, in reality, do not resemble anything remotely consistent with the medical version of these titles.
  • Claiming to be a “specialist” or possessing self-proclaimed medical “expertise” in a given specialty without completing medical school, a medical residency or taking mandated medical licensing exams or designated specialty boards(ie: cardiology, dermatology, anesthesiology, neurology, family medicine, intensivist, hospitalist, etc.).
  • Demands to be referred to as “collaborators” or “physician associates”, which implies that their practice is equivalent to that of physicians.
  • NPs’ use of the idiomatic expression, “brains of a doctor”, managing to offend anyone who is not a physician.
  • NPPs failing to inform patients that they are not physicians.
  • Claiming equivalency with 1/10 the training and education of doctors.
  • And so on and so on and so on……

The misappropriation we personally find most offensive is the hijacking of the “White Coat Ceremony”. A ritual that is deeply rooted in the history of medicine and which signifies the journey of a medical student towards earning the long, white coat associated with physicianhood. It represents a symbol of not only professionalism, but the compassion we must give to and the trust we must earn from our patients. Now PAs and NPs have their own white coat ceremony…not at all representative of its significance when it was created for doctors by Arnold Gold, MD.

Call it what it is. Theft. Misappropriation. Deception. Dishonesty. Fraud. All for a fallacious sense of achievement. Stealing what is good and rejecting the bad while simultaneously truncating the journey. No concept of not having earned that right by paying your dues. It is that which incenses physicians. It is not about turf. It is not about money. It is not about ego. Those are accusations that make us easy scapegoats. It is about ethics. It is about decency. It is about honor. There exists an innate sense of entitlement with appropriation in which there is absolutely no recognition of it as being offensive or inherently disrespectful. 

“In the broadest sense, cultural appropriation is the adoption or taking of specific elements (such as ideas, symbols, artifacts, images, art, rituals, icons, behavior, music, styles) of one culture by another culture.”

We submit that “professional appropriation”, in medicine, is the usurpation and perpetration of perceived ideas, symbols, behaviors, roles, practices, etc. by a separate and distinct OTHER discipline to gain acceptance, prestige, respect and/or acknowledgment for actions promoted as medical accomplishments, when those “accomplishments” have not actually been appropriately earned. 

There are reasons why certain groups support the “professional appropriation” by non-physician practitioners. And we are not just referring to the lobbying groups behind NPs, PAs and other NPPs. Of course they are behind it because that is their purpose; to perpetuate falsehoods in order to advance their agenda, which is to achieve parity with physicians without the investment required to become a physician. However, other contributors underwriting this disturbing trend are hospitals and insurers. You know, the same ones fighting price transparency. For them, it is about money and nothing else. 

What truly disheartens us is when some of our physician colleagues endorse these acts; that is training, then enabling the use of non-physician practitioners to practice in roles/specialties that takes physicians decades before they are permitted to do the same. In their complicity, they place patients at risk and demonstrate contempt for their colleagues when they are dismissive of an educational model that has withstood the test of time for over 100 years. This blog has said it for almost twenty years and we will say it again. Education and training matters. Titles only garner respect after the journey to success is complete. Attempts to bypass and shorten the journey simply to expedite reaping the rewards are nothing to be admired. No one likes a cheater.

So, where do we go from here?  Well, that is up to you. Do you want to save the profession? Do you value what you’ve earned? If the answer is yes, then spread the term. Make “professional appropriation” an accepted phrase (but unacceptable act) so that those organizations who claim to represent us (AMA, AOA, AAFP, AAP, ACP, etc) use it and do their job to protect us. Most importantly, you need to push back when NPPs attempt to appropriate your job.  Because if you don’t, then someday you may not have one. 

(This article was written by a group of authors here at Authentic Medicine.  No one person will be taking credit or blame. Any comments that come off as vicious attacks will be deleted).

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A Collaborative Work From Some of the Writers at Authentic Medicine

These editorials are from some of the writers here at Authentic Medicine. The opinions expressed by these authors do not necessarily purport to reflect the opinions or views of other writers of this blog. Each collaborative work may, in fact, be from different authors.

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33 Responses

  1. Joe Smegma says:

    Many of my patient’s children are pursuing degrees in NP programs. “They don’t want to do all those years of training required to be a physician”. I understand not wanting to sacrifice your younger years studying and training in medicine. Don’t pretend you are a physician, don’t convince yourself that years of training do not matter. A seasoned clinician told me as a medical student, “you don’t know, what you don’t know”. One of the residents in our residency program was a former PA. He was sharp. He told me “I had no idea what I did not know or understand”. Hospitals and insurance companies will try to replace physicians. Too costly and difficult to recruit and retain. Hire the alternative. No one will know the difference. It’s all about the almighty dollar.

  2. A concerned citizen says:

    The title states what this conversation is about…no more, no less.

    For the record, medical teams have existed and collaborated for decades. It is not a new concept. When medicine became corporatized, patients were no longer a priority. All health care professionals became cogs in the wheel. Medicine, as a business, is run by people who do what businesspeople do–focus on profits and pleasing the shareholders. Patients are commodities, nothing else. An essential part of the business included downsizing the workforce and hiring cheaper labor. If they could outsource U.S. medicine, they would. When NPPs began their acts of “professional appropriation”, they became opportunists. Much as many would like to believe physicians have a problem with this issue because of ego and financial greed, it is the skillet calling the kettle black. NPPs were egotistical and predatory in their motives when they decided to take advantage and advance their positions seeking parity with physicians, without doing the work required. And no where is this better demonstrated in the proliferation of hundreds of sub-standard degree mills, various types of online doctorates and deterioration of a standardized educational structure. Who cares about quality when one is in a rush to commandeer a role for which they are neither qualified nor trained? It’s all about the title and prestige, right? When physicians pushed back on this unethical and immoral behavior, we were referred to as territorial and greedy. Who in their right mind would expect physicians to accept non-physicians as physicians? Let alone untrained? That is absurd.

    When one engages in theft and misappropriation of a profession, how can one expect collaboration and cohesiveness with that same profession? It defies logic. Is it reasonable to expect respect where none is given? The NPPs error was their refusal to acknowledge physicians as the experts in medicine that they are and have trained to be, for years. Instead they chose to demean our extensive education to further their own agenda. And no where in their decision making did the effect of this deceit on the public enter into the conversation. Well, the misappropriation is wrong and the public has a right to know. And no amount of pontificating will change that.

  3. Douglas Farrago MD says:

    Well, it usually takes a day or so before the mob effect occurs. Here they come. This article was about the attempt by others to appropriate a profession. It was not about intellect, not about teamwork, not about having a role in healthcare, etc. So, please save your time if you want to go that route as I will be deleting any more comments like some of the ones above.

    • David G says:

      When you have a blog and share your views, you have to choices, only keep the comments that support your argument, which is your right, or have the respect for another point of view. Your article is the same as all the other politics of the day, fear selling, replacement, and subversion. There are many points you make that discuss just that, and to that point you aren’t talking about teamwork. You’re stating that your colleagues need to stop training their replacements, because if they don’t, then someday they may not have a job.

      You Know, there are plenty of health professionals right now that can and will be replaced by automation and AI. Just ask your Radiology colleagues. It won’t end there. I’ve seen where it will go.

      Respectfully, this isn’t the mob run amuck, just someone who doesn’t share the degree of rhetoric your statements or your media snippets suggests.

      I travel a great deal, see a lot of healthcare facilities and have customers from DOD, VA, as well as for profits and non profits. There is a great deal to be concerned about, like the 3000% growth of administrators since the 70’s, or the fact that administrative overhead climbed from 3% to 8% of our Healthcare GDP expenditures in the last decade. That’s 8% of a 17% $3.7 trillion annual GDP cost just in administrative overhead. On the contrary, these healthcare costs are expected to hit $6 Trillion by 2024. This plus the boomers, and the backwards movements in overall mortality. Trust me, lots of work to go around.

      I get where you we going, but agree a better option could be pushed.

      All on the same team I hope.

      • Douglas Farrago MD says:

        Nope, this blog was created for docs and made for their opinions.

        • David says:

          Well there it is right there. Nothing more to be said or justified by a non physician.

          Blogs are open source. So is the feedback and content. Perhaps you should make your blog a subscribed or private event then you could hear the echoes of your thoughts and ideas.


      • Pat says:

        Nope. Your attempted conciliatory tone is failed cover for rationalizing bogus “team” members supplanting physicians. That is deceitful.

        • David says:

          I’m sure that’s what the taxi drivers thought ten years ago. Yeah, I get the angst and the emotion, but most people aren’t out doing the things you say. They just want to be respected and make a living.

          Sure there are individuals out there propping their titles up, but almost all non physicians are working for a physician. Making money while in a sharecropper model of delivery and payment. As long as someone is making money, someone is determining their worth, and efficacy.

          Look, healthcare’s changing from traditional models of delivery and care, no matter how much we try to keep it from happening. It’s reality. The key is find a process and an industry that works. If you feel your being displaced through deceit, talk you your PACs and political adversaries.

          I’m actually amazed at the level of giving into the billions annually so Washington can spend your money, while we continue to have a declining healthcare model. I put my money in other areas that actually impact the care of others, and this includes patients and my healthcare colleagues. To me, I can sleep at night knowing I’m making a direct impact on others.

          Money and prestige don’t really matter to me. Education, outreach, training, and building cross functional team practices and processes are much more important than fighting for other things.

          • Natalie Newman, MD says:

            Money and prestige may not matter to you, but this post is not about you. It is about professional misappropriation, just like it says. That behavior represents one of the unacceptable changes that is occurring in health care. Some physicians are exposing it and doing something about it. Why? Because people need to know when someone is perpetrating a physician. If CNAs were appropriating the nursing role inappropriately, I’m certain you would not be amenable to that deception and might feel compelled to do something about it. Or not.

            If NPPs are working in a “sharecropper model of delivery and payment”, they should exit left. They have a choice. No one is holding a gun to their head. Other viable options exist, but may not be desirable. Nevertheless, the choice still remains. No one determines your worth but you. If you allow others to, that is your faux pas and you have willingly relinquished your control.

            Again, this post is about individuals arrogating a role they have not earned. We have coined a term that describes the act aptly and is relevant. Legislators are just as clueless as the much of the public about this fraudulent matter. We aim to educate them. No one should be offended by us addressing this issue, they should be appreciative. Information nearly always empowers the receiver. And an informed patient is an empowered patient.

          • Pat says:

            Money doesn’t matter to someone who just bemoaned “a sharecropper model of delivery and payment.” Count me a skeptic.

            And I reiterate that phraseology like “cross-functional team practices and processes” is intentionally obfuscatory, and reeks of the phony egalitarian instincts underlying it. Anytime someone tries to twist or dilute language, we should react with suspicion, at least.

  4. David G says:

    It’s all about public perception. Most patients don’t understand their morbidity, much less the names of the medications they are on, or worse why they take them. Many just always assume that some historical authority figure is caring for them, despite provider or precessional archetype. It’s a cultural thing. Happens all the time.

    Instead of fighting, or worse posturing some egotistical degree of high intellect, it seems prudent to find a way to work together in today’s healthcare. The funny flip side to political correctness is that one day it just might become politically incorrect to discriminate against a provider type, seeing as there is no definitive proof that one group or profession is in the business to maim or kill people. No research supports this. Their are bad actors in every profession, and to say that’s not true is disingenuous.

    The most prudent approach is to find a respectful way to work together as colleagues that serve others, and that’s patients. That takes a great deal of humility and grace.

    Everyone in today’s healthcare provider/professional chain is an ally. It’s the business of healthcare that’s changed. You assume that everyone has the patient’s best interest at heart. That’s a ruse. Costs keep climbing because everyone is in a professional civil war, and while we bicker in social back alleys, administrators and large corporations limit your ability to sit at the table and make decisions that affect your ability to care for your patient.

    I’m here to tell you, and I see it everyday, hospitals don’t care about you or your perceived value, if they see a way to cut you out, regardless of your profession for something they can bring in for cheap , they will continue to treat those liabilities as the cost of doing business. All the research supports threat, and it was said by a huge healthcare CEO in an interview. That’s what we all fail to see. Each of us have become commoditized by an industry instead of figuring out ways to have civil discourse in ways that benefit us all and our ability to negotiate.

    I’m proud of the fact you went to school and pursued your medical specialities, but it’s not the path we all take, and it has nothing to do with intellect. That doesn’t make anyone less capable when caring for patients.

    I’m proud to be a CRNA, and I’m proud to work along side any profession that respects another for the benefit of serving others. If patients only knew the dirty underbelly of this industry. The actions of a few can tarnish an industry like a cancer, eroding its faith in a system that’s already compromised.

    Seems we’ve lost appropriatenes, rather than gained some semblance of disappropriation.


    • Pat says:

      David, for all your posturing, I never saw you or your type on long, painful nights through years of medical school and residency.

      No matter what education you claim, or technical skill set you may acquire, you are not now, nor will ever be my colleague.

      Claiming otherwise is disrespectful, and indicative of low self-esteem.

      • David says:

        If you define yourself by the nights you stay up for your training, as a means to justify your profession, I did years of nights, evenings, and weekends actually doing anesthesia. Trauma, OB, etc. This is where things take a turn for reality, and only because you went there and then insulted me.

        Lol, I spent countless nights on watch in the military, I wouldn’t dismiss you as anything less than American or patriotic. Makes no sense right?

        Today’s managed ACT practices discuss the priority of supervision. While I do respect my colleagues physicians or otherwise, and have many great friends, I’m the one doing the work while they sleep. I’m safe enough to do that and handle all types of emergencies, but when politics and posturing come into play I’m dangerous. Pre med is not med school, I love seeing that touted as an educational discipline. It’s not. I took everything you did for my masters save the MCAT.

        Most new anesthesiologists coming out of your hell laden sleepless nights go into managing and in most practices never actually sit cases ever. I know plenty of supervisors who haven’t physically done and anesthetic in decades. Aviation doesn’t even allow this, competency has to be maintained through recurrent training, which this industry is afraid of introducing. Experience and respect is earned, and that also means the ability to lead or govern. Just because you have a title, doesn’t grant you any prestige you aren’t willing to give to another. Don’t think Jesus told everyone he helped or healed we was God every time.

        This simple act of humility would go along way it seems. I’d still respect you and even work with you even though you though I was scum and undeserving. I don’t need my ego strokes. All my post have been pretty fair and egalitarian.

        Cheers Mate!

        • Pat says:

          So all of those nights you are an independent operator? And if so, was that in the patient’s best interest?

          You can tuck your veteran card away, I’ve got one too, which I bought from many long nights in the air and on ship. Military service was an early, very valuable demonstration to me that education and training (and yes, currency) DO matter, and that when deficiencies are papered over, and qualifications falsified, there are very bad, sometimes fatal consequences. I would like to think you and I learned the same lessons there.

          “While I do respect my colleagues physicians or otherwise, and have many great friends, I’m the one doing the work while they sleep.” First, you are equating yourself with physicians. That is incorrect. Second, for a guy in the conversation above denying any interest in money, here you are again referencing it, working while others sleep.

          “Just because you have a title, doesn’t grant you any prestige you aren’t willing to give to another.” I have absolutely no idea what that sentence means – why would I ever grant someone something they have not earned? And in rhetorical terms, whenever someone invokes the Almighty to serve their partisan interest, they are immediately revealed as scoundrel, and their argument a con.

          And so we come to your honest admission of being “egalitarian.” That is the poor self-esteem that drives so much of those seeking to be “doctors” without actually taking the trouble to earn the title of “physician.” It is wage and prestige envy, written increasingly into public policy and crony corporatist practices under the camouflage of helping underserved patients in a time of tightening health care dollars.

          You call for humility? Humility does not involve participation in falsehoods, which is what you are advocating. Whether stating so plainly insults someone is of no concern to me.

        • Nick says:

          “Lol, I spent countless nights on watch in the military, I wouldn’t dismiss you as anything less than American or patriotic. Makes no sense right?”

          It would make no sense dismissing someone thus, unless perhaps they falsely claimed that they that they had also served. There is a term for that: they call it “Stolen Valor.” Look it up on Google.

  5. Loren says:

    Every time I read one of these divinely inspired messages of urgent alarm and catastrophe I chuckle at the vision of Dr. Stuart Smalley finishing at the keyboard with self affirmations and back patting. Then, there is the local Dr. Smalleys’ guffaws as they discuss the outlandish notion that a nurse is providing primary care. Except, while they guffaw, the nurse is doing just that. Taking care of patients. Legally, within scope of practice, safely, and effectively. My favorite is when Dr. Smalley and friends complain about who’s taking care of patients but when I take my family to the clinic . . . Guess who takes care of us? Yep NPs. Employed by Dr. Smalley. Getting a bill of $180-220 for NPs patient care. Making the money. That’s what it’s really about isn’t it? Come on. This blog has been around almost 20 years? There might be just a little too much time behind the keyboard. Better get some sunshine.

    • Pat says:

      The economics are indeed screwed up, made so by government intervention and crony corporatism.

      That’s not what this piece was about. This discussion is about non-physicians masquerading as something they are not.

  6. Rick says:

    I would like to comment extensively but I don’t have time. I am doing my grammar and spelling homework for my PhD degree from Grand Canyon University. I’m exhausted. This degree is taking me THREE MONTHS! Brutal.

  7. arthur gindin says:

    I am a retired board-certified neurosurgeon. The message I have just read needs to be stated BETTER.

  8. Steve O' says:

    I do not endorse the terminology PROFESSIONAL APPROPRIATION. That seems to imply an impolite use of something without respect for its origins.
    I rather suggest Counterfeiting and perhaps Embezzlement.

    counterfeit: made in imitation of something else with intent to deceive : forged (Merriam-Webster)
    To counterfeit means to imitate something authentic, with the intent to steal, destroy, or replace the original, for use in illegal transactions, or otherwise to deceive individuals into believing that the fake is of equal or greater value than the real thing.

    Embezzlement is somewhat similar, but not as definitive as counterfeiting. If licensure as a physician involves a conveyance of something objective, then it does perhaps fit.
    Embezzlement: The fraudulent conversion (taking) of another’s property by a person who is in a position of trust, such as an agent or employee.
    These are terms of criminal law, because they involve intrinsically disordered and forbidden claims.
    Falsification of a medical diploma or license is not an impolite act; it is a crime. It is punished or tolerated depending on how the society punishes or tolerates crime itself.
    The Zimbabwe Dollar is a good comparison to the Medical License. Zimbabwe allowed the creation and distribution of its dollars under the inference they were backed by some sort of value. They discovered, like many governments do, that this seems to create money out of nothing. But the public caught on, and discovered that ZimBucks were declining in value.
    If there is no resistance to fraud, then it spreads unchecked. Medical degrees, board certification and specialty training are items limited by the amount of energy needed to achieve them. If a little counterfeiting around the edges, such as the six-month pharmacy “residency” and such, one does not notice deleterious effects; rather, the horrible deficiencies in primary care providers are now apparently ameliorated.
    But as soon as one gets on board, they wish to pull away the gangplank for the next ones. Why not prescribing EMT’s? Why prescribing in the first place, now that we have the internet?
    The actual measure is not clear, but the ZimBuck bottomed out near 10^-25 US dollars. If each of the world’s 6.5 billion people were handed a TRILLION ZimBucks for their savings accounts, alas, they could not pool their assets and buy an American penny.
    It is no more “cultural appropriation” than the Holodomor, the deliberate Soviet famine, could be called a “weight loss plan.”
    The problem with these things always is that they are started by the people with the best intentions; and are finished by the people with the brass knuckles.

    • Pat says:

      It is those things too. But Professional Appropriation has the value of descriptive, combined with catch, in a contemporary tone. It comes off as more focused than the generic terms you suggest for the very real fraudulence on the rise.

  9. Jesse L.Belville,PA-C says:

    Please start to Lead.
    As a Physician Assistant-Certified I wear a name badge and introduce myself to al my patients as Jesse Belville,PA-C.
    I never misrepresent myself as a Physician. If called Doctor,I thank them kindly for the promotion but correct them and again explain that I am aPhysician’s Assistant. I do 70 to 90 % of what my supervising physician does,so he or she can take care of their more complicated patients. They are the guide/the spirit of the practice. I just follow along and do my best to help. Improve patient care,provide more timely care,more access to care,supervised by my Physician supervisor.
    Am I called Doc? yeah,when I was a combat medic in the army in Vietnam in 1969 and 70. I have been a PA-C for 43 years. Still love being a PA-C, still love being of service. MD or DO #1 me #2. Always
    Now Physician’s, Please FIGHT and take back your Leadership Roles in Medicine in all facets.
    That will serve our clients/patients best. After all Everything is a Business Model. Medicine, Government,Military/defense , Church, Tech.. All follows the bottom line.. Maybe we offer MORE than a simple business model? or Not?

    • Dr. Nick says:

      Thank you for your service, and thank you for being a respected part of the team. PA’s, NP’s, and other physician extenders are incredibly important in today’s medical landscape, but like you said, they (should) help take care of the routine medical issues, leaving the issues that need the extra training to the physician. I love my NPs and PAs, I couldn’t take of as many people without them, but I love that they know to ask for help when they have any doubt. It’s a team, with everyone having their role to play.

    • Samuel says:

      I’m starting medical school next fall and I can’t imagine how furious I’ll be when all the years, licensing exams, training, health sacrifice, and money my family and I put in and have any group of people disrespect the M.D. behind my name; given I almost shout out loud reading this blog while traveling in Taiwan right now!

      Any NPPs, regardless of the degree, training, and experience, will never be equivalent to a physician who completes medical school and residency training. Period.

      Anyone who attempts to masquerade a physician’s role and title is a cheater and liar in the healthcare world.

      One only deserves what one earns.

  10. Dr James C Tinsley says:

    I made a comment on FB about this topic this weekend. It starts with re-labeling. When we are addressed by other team members we should insist on being addressed as “Doctor”. In the military every member’s name is preceded by their rank. If not you are written up and punished for disrespect. Why did we ever accept anything less? Look what happened. That includes the staff that cares for the patients(Nurses down to the phlebotomists), pharmacists, anyone with patient contact especially insurance companies. Next, we need to educate the public on exactly what these made up insurance terms mean like provider, board certified, state licensed. After this article I think we need to consider changing our coat color and place the Rod of Asclepius above our names. IMHO.

  11. sudha prasad says:

    It’s time to stop whining, which is something that physicians have perfected. Let’s take a quick analytical look at how we got here, learn from it and then fix it. We claim to have holistic and intellectual approaches in our discipline. One of the biggest favors that we do to all of the other organizations is refuse to band together and persist in pointing out our differences and our superiority to other specialties within our profession. On top of that, we refuse to seriously counter the financial pressures that hospitals and insurance companies place on us with serious lobbying efforts (even email campaigns would be worthwhile). There are certain organizations that you have mentioned such as the AMA, which have been quick to get into bed with anyone with money so I don’t think they are trustworthy. But I would stand behind the Authentic Medicine group to take action!

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