Medicine’s Creepy Problem – Part 1: The Turf Wars

A Spectre is Haunting Medicine – the spectre of creep. For many years the growing conflict between physicians and mid-level providers has served as the ugly backdrop for souring relations in the hospital workplace. What once was a holy alliance of healthcare workers banding together against the ravages of disease is now increasingly tainted by professionals regarding each other with suspicious eyes, wondering when the turf-carving knife will plunge into their backs next. As newly minted professionals on the front lines, we are left looking at each other and wondering: “How did this all start?” In this three part series, I will first begin by setting the stage for understanding the origin of the conflict.

Turf Wars – The Good, The Bad, and The Ugly

In essence, the problem of creep can be looked at as a turf problem. In the healthcare industry, we use rules to regulate who is allowed to do what job. Nose doctors can’t cut off your toes, kidney doctors don’t try their hand at therapy, and your eye doctor doesn’t pull out your molars. Whereas other fields might leave such questions up to the free market (hey if you’re willing to go to your dentist for heart surgery why not?) medicine finds it more necessary to ensure patients are protected by regulating these domains and preventing overlap. 

Fighting over turf is nothing new in medicine. Famous turf wars in history include ENTs vs plastic surgeons, dentists vs ENTs, and interventional radiologists versus just about everyone else (this one has yet to be resolved). Anyway, what’s wrong with a little turf disagreement? Specialization is a necessity in medicine; no group of physicians can ever hope to master all aspects of every detail of medicine. It makes sense to have physicians become masters of a certain section of anatomy and then treat everything related to that. Disagreements are bound to arise, and this seems like the natural and logical conclusion to a system where residency training gives unchanging titles and where “cases” must be doled out to ensure everyone has a healthy practice.

Yet despite this precedent, none of these fights seemed to have soured relations quite like the battleground of “creep.” Indeed, if other turf wars could be seen as polite (if not strained) disagreements on who should have access to the most profitable cases, the battle between physicians and the “Middle Alliance” feels more like Van Damme and Yeung wrestling in Bloodsports. Who are the members of the “Middle Alliance”? Nurse practitioners (NPs), certified registered nurse anesthetists (CRNAs), and occasionally physicians assistants (associates? Assistant to the regional physician? PAs) are named as “the usual culprits”, and they seemed to have launched full–scale organized campaigns against the entire MD/DO establishment for the right to independent practice. Allegations of greedy doctors trying to take away care from patients are put up against accusations that under-qualified nurses are LARPING as doctors when they couldn’t get into med school. 

Yet amidst all the dust and smoke, most of what has resulted is students and patients alike looking on in horror, wondering where it all went wrong and whether it was their fault that mommy and daddy are getting a divorce. 

Jeepers Creepers

To set the stage of the conflict, let’s look at the contentions and points of frustration that seem to come up repeatedly for both sides, who have in the process already received considerable PR damage.

On one side, physicians have grown bitter over the behavior of certain mid-levels (especially the AANP). What does the slogan “brain of a doctor, heart of a nurse” try to achieve? Why are alphabet soup credentials necessary? What are the actual goals of nurses that obtain “doctorate of nursing degrees”? Why do mid-levels dodge the question of “are you a doctor”? For what reason is our expertise being called into question?. We underwent all these hard years of theoretical and clinical training to be the leader of the team, and this is the field we graduate into? All these bitter feelings can be felt most clearly in the subreddit r/noctor where the most egregious of this behaviour is documented.

From the side of the nurses, there are questions about why “things are the way they are.” As frontline workers, they are often the ones elbows deep doing what doctors normally consider “scut work.” These include cleaning patients, administering medication, and many of the activities one would consider the basis of patient care. From the perspective of nurses, after all this back breaking work, ‘why do I have to put up with snide remarks from arrogant physicians demeaning and minimizing my role when all we do is catch their potentially fatal dosage mistakes!’ Nurses who have been in their role for decades find themselves in a position where they have seen, heard, and administered the treatment of numerous bread and butter cases. Many times they can handle patients with more familiarity than a fresh-faced doctor in a much earlier phase of their training. Yet the letters that go before and after their names form a deep chasm and create what feels to be an entirely unfair power dynamic. The allegations of abuse are supported by extensive studies and interviews that show up to “74 percent [of nurses] experienced physicians’ “condescending or demeaning comments or insults,” and “26 percent of nurses have had objects thrown at them by doctors.” 

All of this is entirely unacceptable. The blatant unprofessional behaviour by select members of each profession should not and cannot be tolerated. Yet, why are we all so quick to generalize the behavior of those few to the rest of their professions? Physicians and nurses have coexisted for decades, why has the ugly beast of creep only reared its head now?

We explore the deeper reasons and systemic factors that led us to this state in part two of Medicine’s Creepy Problem – The Congressional Tango