What kind of doctor is your doctor?

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You have more health care provider options these days than your grandparents did. Going to your doctor is no longer necessarily going to a medical doctor, in the traditional sense. It’s fantastic that we have choices, but it can also be confusing.

Every type of provider plays an important role in the healthcare landscape and I urge you to seek care from the type of provider that suits you. But, if you’re a savvy health consumer, you want to be informed and understand the differences between your choices of healthcare provider. So, I’ve done the legwork to break it down for you in this blog as well as a table at the end, for quick reference.

Let’s first review the types of providers I will cover here:

Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
Hippocrates (c. 460-c. 370 BCE) is most commonly cited as the father of modern medicine owing to several medical works from ancient Greece attributed to him and his students. “Hippocrates and his followers were the first to describe many diseases and medical conditions.” Merriam-Webster defines “medicine” as “the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease.”

“Allopathic and osteopathic physicians use a biological approach to healing. Physicians diagnose, treat, and work to prevent human illness and injury.“
“Osteopathic medicine also incorporates a treatment modality- Osteopathic Manipulative Medicine (OMM)- which is a form of musculoskeletal manipulation that is used both for diagnosis and treatment. MDs and DOs practice in all the same specialties. Work is in progress to combine the two types of residencies.” (http://www.purdue.edu/preprofessional/documents/Physician.pdf)

Medical doctors are required to pass the three-part United States Medical Licensing Exam (USMLE) in order to obtain a license to practice. The first 2 parts (aka steps) are taken during medical school. The last step is taken during the first two years of residency training after medical school. After completion of residency training (lasting 3-6 years), medical doctors must pass a speciality certification exam (aka board certification exam) in order to be “board-certified.” Board certification is not required in order for a medical doctor to start practice, but it is highly encouraged. A medical doctor may elect to do one or more training programs after residency (called fellowships) lasting anywhere from an additional 1 to 3 years each.

You can look on the American of Medical Specialities website to see if your doctor is board-certified.

MDs and DOs are licensed in all 50 states.

Doctor of Podiatric Medicine (DPM)

The first school of podiatric medicine opened in 1911. Podiatrists are trained to take care of issues related to the foot and ankle, including surgical or medical treatment. Doctors of Podiatric Medicine complete a 4-year doctorate degree during which their studies are focused on diseases of the foot and ankle. Some courses overlap with material covered in medical school. Podiatrists complete a 2-4 year residency program that may include rotations with medical students in areas like emergency medicine, anesthesia, sports medicine, infectious disease, and radiology. Their scope of practice is diagnosis and treatment of diseases and disorders relating to the leg below the knee. There can be variations from state to state.

Podiatrists are licensed in all 50 states and must pass a certifying exam. They can prescribe medication but only those related to diseases and disorders within their scope of practice.

Certified Registered Nurse Anesthetist (CRNA)
Certified Registered Nurse Anesthetists (CRNAs) became a credentialed profession in 1956. CRNAs most often work under the supervision of an anesthesiologist, a medical doctor who has performed residency training and certification to provide anesthesia, but in some states they may practice under the supervision of a surgeon or other physician, and they provide a lot of the anesthesia care in hospitals in rural areas.
“They work in collaboration with surgeons, anesthesiologists, dentists, podiatrists, and other professionals to ensure the safe administration of anesthesia. Some of their responsibilities include providing pain management, assisting with stabilization services, and overseeing patient recovery. These services may be used through all phases of surgery and for diagnostic, obstetrical, and therapeutic procedures as well.” (https://www.nursepractitionerschools.com/faq/what-is-a-nurse-anesthetist)

CRNAs are licensed in all 50 states and are allowed to practice independent of a physician in some states. (https://nursinglicensemap.com/advanced-practice-nursing/certified-registered-nurse-anesthetist-crna/)

Physician Assistant (PA)
The physician assistant (PA) profession was created in the mid 1960s “to improve and expand healthcare.” The medical community helped to establish a standardized certification process, exam, and ongoing continuing education requirements, mirroring the MD and DO certification process in many ways. PAs work professionally under the supervision of a licensed MD or DO, either directly (eg physically present while the PA is providing direct patient care) or indirectly (eg providing ongoing education, training, and review of charting or cases). As of December 2016, there were more than 115,000 PAs in the United States.
“A PA is a nationally certified and state-licensed medical professional. PAs practice medicine on healthcare teams with physicians and other providers. They practice and prescribe medication in all 50 states, the District of Columbia, U.S. territories, and the uniformed services.” (https://www.aapa.org/what-is-a-pa/)

PAs are licensed in all 50 states.

Nurse Practitioner (NP)
An Advanced Practice Registered Nurse (APRN) is a Registered Nurse with an advanced practice degree, like NPs, Certified Registered Nurse Anesthetists (CRNA), Clinical Nurse Specialists (CNS), and Certified Nurse Midwives (CNMs). Training for APRNs varies across specialities, States and over time and requires an additional 2-3 years of training after nursing school. Over 50% of NP’s are Family Nurse Practitioners (FNP) whose education is geared toward primary care medicine. Some NP degrees are offered as online degrees.

“According to the American Association of Nurse Practitioners (AANP 2016), nurse practitioners (NPs) are licensed, autonomous clinicians focused on managing people’s health conditions and preventing disease. As advanced practice registered nurses (APRNs), NPs often specialize by patient population, including pediatric, adult-gerontological, and women’s health. NPs may also subspecialize in areas such as dermatology, cardiovascular health, and oncology.” (https://www.nursepractitionerschools.com/faq/what-is-np)

APRNs are licensed in all 50 states with state-specific requirements and clinical privileges. Many do not require any oversight by a medical doctor (MD or DO) to diagnose, treat or prescribe.

Nurse Practitioner (MSN, DNP)
A Master of Science Nursing (MSN) is a nurse who has completed a Master’s degree (1-2 years) in order to focus on a specific area of interest, like nurse midwifery, women’s health, or business administration.

“A master’s in nursing program will equip you with the skills and advanced training you need to give high-quality nursing care in a specialized role, such as nurse practitioner. Earning your MSN qualifies you to deliver many of the same health care services that physicians are qualified to do, which is particularly important in today’s health care field.” (https://www.allnursingschools.com/msn/)

A Doctor of Nursing Practice (DNP) is a degree completed in another 1-2 years that allows a nurse to focus on clinical practice-oriented leadership. Some DNP programs offer online degrees.

“While it’s not required for all advanced nursing jobs, a DNP can help you move into nurse leadership roles. Different from a nursing PhD, which is necessary for teaching and research, a DNP can advance your career on the clinical side. If your career plans include working at a manager or executive level, a DNP will help get you there.” (https://www.allnursingschools.com/dnp/)
The American College of Cathopathic Physicians (www.cathopathic.org) is an organization of DNPs and nurses. “The purpose of the ACCP is to protect the professional autonomy and advocate for a full, broad scope of practice for DNPs as a “cathopathic physician” completely equal in every way to our MD and DO counterparts.”

The curriculum and duration of study varies between schools, but include courses covering research methodology, quality improvement, health policy and leadership. Here is a sample curriculum from Vanderbilt University and Simmons College.

I’ve included a table at the end of this blog, comparing the educational and clinical background of the different types of health care providers to clarify the educational differences between a DNP and MD or DO for you, the savvy consumer.

MSNs and DNPs fall under the umbrella of Advanced Practice Registered Nurse (APRN), which are licensed in all 50 states with state-specific requirements and clinical privileges. Many states do not require any oversight by a medical doctor (MD or DO) to diagnose, treat or prescribe.

Doctor of Optometry (OD)

Doctors of Optometry (OD) are professionals with an advanced degree focusing on diagnosing and managing conditions relating to the eye. They are frequently confused with ophthalmologists, who are medical doctors (MD or DO) who have completed a 4-year residency training program covering internal medicine and disorders and treatment of the eye and eye-related structures. This may include surgical procedures, which ODs do not perform. A bachelor‘s degree is required by some schools of optometry, but not all.  College-level courses in certain areas of science are required. Optometrists are allowed to prescribe certain medications relating to eye health, but this is state-specific.

To obtain the Doctor of Optometry degree, students must complete a 4-year, accredited program. In order to be a licensed optometrist, you must pass a certification exam.

“Doctors of Optometry (O.D.s/optometrists) are the independent primary health care professionals for the eye.  Optometrists examine, diagnose, treat, and manage diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identify related systemic conditions affecting the eye.

  • Doctors of Optometry prescribe medications, low vision rehabilitation, vision therapy, spectacle lenses, contact lenses, and perform certain surgical procedures.
  • Optometrists counsel their patients regarding surgical and non-surgical options that meet their visual needs related to their occupations, avocations, and lifestyle.
  • An optometrist has completed pre-professional undergraduate education in a college or university and four years of professional education at a college of optometry, leading to the doctor of optometry (O.D.) degree. Some optometrists complete an optional residency in a specific area of practice.
  • Optometrists are eye health care professionals state-licensed to diagnose and treat diseases and disorders of the eye and visual system.”

(https://www.aoa.org/about-the-aoa/what-is-a-doctor-of-optometry)

Doctor of Chiropractic (DC)
The roots of chiropractic started when, in 1895, the founder of the field, DD Palmer, performed an adjustment to what he felt was a misplaced vertebra in the back of a deaf janitor, resulting in improvement in the janitor’s hearing. Now, chiropractic doctors look for misplaced vertebrae (aka subluxations) of the spine which are felt to cause nerve pressure, blocking nutrients from reaching organs and muscles throughout the body. This is felt to be effective for treating many ailments like asthma and herniated discs.

“Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic services are used most often to treat neuromusculoskeletal complaints, including but not limited to back pain, neck pain, pain in the joints of the arms or legs, and headaches.” (https://www.acatoday.org/Patients/Why-Choose-Chiropractic/What-is-Chiropractic).

“The chiropractic adjustment is a quick thrust applied to a vertebra or a limb for the purpose of correcting its position, movement or both. Adjustments are often accompanied by an audible release of gas that sounds like a “crack.” The sound sometimes shocks people a little bit the first couple times they get adjusted, but the sensation is usually relieving.” (http://www.thecpmc.co.uk/what-is-the-theory-behind-chiropractic-treatment/).
Doctors of Chiropractic are licensed in all 50 states, with variation in scope of practice (what procedures, actions and processes a healthcare practitioner is allowed to undertake) being state-specific. Here’s an example of the DC scope of practice in Massachusetts: https://www.mass.gov/policy-statement/board-policies-and-guidelines-chiropractor.

Naturopath (ND or NMD)
The first class of naturopathy graduated in 1902 in New York City. The first school of naturopathy was accredited in 1956. The practice of naturopathy focuses on natural methods of healing including herbal medications, nutritional therapy, physiotherapy, mind-body connection therapies, homeopathy and body manipulation. There is some controversy regarding whether naturopathy practices are grounded in scientific methods.
“Naturopathic medicine is a distinct primary health care profession, emphasizing prevention, treatment, and optimal health through the use of therapeutic methods and substances that encourage individuals’ inherent self-healing process. The practice of naturopathic medicine includes modern and traditional, scientific, and empirical methods.”
(https://www.naturopathic.org/content.asp?contentid=59)

A bachelor’s degree is not required to enroll in a school of naturopathy. There are a lot of different opinions on how the ND curriculum compares with the MD or DO curriculum.  It can be unclear where the truth lies. However, Bastyr University, one of the oldest Schools of Naturopathy, has a total of 244 faculty listed for 2017-2018, 15 of which are medical doctors (MDs), and one of which is listed as teaching courses in Western science topics (anatomy, embryology, clinical skills).

I will provide links to two differing opinions on the matter as I have no personal experience:
https://aanmc.org/resources/curriculum/
https://sciencebasedmedicine.org/nd-confession-part-1-clinical-training-inside-and-out/
https://sciencebasedmedicine.org/nd-confession-part-ii-the-accreditation-of-naturopathic-medical-education/

Naturopaths are licensed in 21 states in the US.

AANMC-Licensed-States-Jan-2018-PNG

Naturopath scope of practice (the type of care they are legally allowed to provide) varies depending on the state.

This is an example of the scope of practice for naturopaths in California (http://www.calnd.org/scope-of-practice):
NDs Can:
• Identify themselves as doctors. (Un-licensable naturopaths may continue to call themselves naturopaths but may not use the terms ND or Naturopathic Doctor.)
• Perform physical exams, including gynecological exams
• Order lab tests as well as diagnostic and imaging studies
• Perform CLIA waved tests in office, such as urinalyses and pregnancy – however, this requires applying for lab director status
• Collect gynecological and venipuncture specimens
• Diagnose
• Treat with diet, herbs, nutrients, homeopathics, hydrotherapy, and neuromuscular technique Grades 1-4
• Independently prescribe natural and synthetic hormones (although testosterone and HCG require a DEA number)
• Under MD/DO supervision, prescribe legend* and Schedule IV-V controlled substances, and prescribe Schedule III drugs under a patient-specific protocol checked by a supervising MD or DO (find out more about supervision and prescribing here).
• Dispense drugs or any other substances an ND is allowed to legally prescribe or furnish, as long as all specific requirements are met (labeling requirements, etc.)
• Administer IV/IM/SC injections and IV preparations
• Hire Naturopathic Medical Assistants
*a drug, that under law, can only be obtained by prescription
NDs Cannot:
• Identify themselves as physicians
• Prescribe Schedule I-II drugs. (These are largely drugs with high abuse potential such as heroin, cocaine and methamphetamines.) Cannabis is a Schedule I drug.
• Perform Grade 5 manipulations
• Perform or interpret diagnostic or imaging studies
• Suture
• Practice midwifery (unless they are also licensed midwives)
• Hire and give orders to medical personnel beyond naturopathic medical assistants

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If you want to make an appointment to see me via telemedicine, go to http://www.rowedocs.com/irenetien.

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