Okay, I'm not trying to be bitter but this year has been my first real interaction with PAs and NPs since where I trained for residency didn't have many (none that I worked with) and I would really like some clarification on a few points. Also, before you continue, I encourage you to glance over this article if you have not already read it: http://www.nytimes.com/2011/10/02/health/policy/02docs.html?scp=4&sq=nurse practitioners&st=cse Okay, so I really REALLY think that this whole concept of midlevel providers is progressing to an unhealthy extent for several reasons. I am open to the notion that I do not know all of the facts, and that is what I would like clarification on, because what I know now really bothers me. First of all, I have been having more and more frequent encounters with midlevels that only introduce themselves as titles such as "hospitalist" and "orthopedist" without portraying their true titles, either to other providers or the patients. I think this is a gross misrepresentation of their training and knowledge base (yes I understand that some midlevels have more experience, etc than some physicians) but it doesn't justify them arguably misleading others to think they have a degree of which was not earned. In my new hospital/area I have also encountered midlevels who have PRIVATE practices and do not have to practice under the license of a physician. Are you kidding me?!?!?! Why then are we going to medical school for 4 years and THEN doing a full length residency. Many will say we still receive a higher salary. It seems that is even changing, as I have met PAs and NPs who easily make over 100K doing primary care. On top of this, midlevels have MUCH more flexibility in their careers and lifestyles than physicians (again, as it appears to me so far). Not only are their hours much better but they are able to switch between specialties on almost a whim. I have seen several switch between vastly different fields such as pediatrics and orthopedic surgery almost seamlessly. It would be a much more difficult transition for any true physician, causing major disruptions in lifestyle and salaries while they go back and repeat a residency. It seems they have all of the benefits of a physician but lack many of the taxing limitations/burdens. And they are constantly fighting for MORE responsibility and equality with physicians. It's the little things that happen around my hospital that really irk me throughout the day. As an example, where I trained and also where I am currently a fellow, the 1st year residents (interns) are not allowed to write prescriptions and must get all outpatient scripts cosigned. One of the people who can cosign these is a MIDLEVEL. In fact, we will have PAs and NPs graduating in December who are able to cosign scripts for interns who have already been doctors for 6 months! How effed up is that? These interns went to undergrad for 4 years, med school 4 years and are already halfway through their internship and someone who has 2 years of formal medical training is essentially supervising them???? It's essentially like a 3rd year med student cosigning their scripts. That just makes no sense whatsoever. A recent medical school grad cannot even practice until they do at least 1 year of post grad training and in some states two, yet someone with 2 years can start working immediately. And these studies which the nursing association cite showing that midlevels care is equivalent to physician care. Keep in mind that the diagnoses and treatments they are administering are possibly more straightforward cases AND the studies have been done by the nursing association....which is an inherently biased study. That is equivalent to a drug company showing their drug is superior to other drugs. Why have more formal studies not been done on this??? And the article that I posted earlier, how utterly ridiculous is that???? This additional year of training to make them "doctorates" is not even clinical training. Within a few years they will fight to be formally called "Dr so and so" and they will most likely win that battle. Sadly, nurses have the numbers in terms of population size, and it appears they will keep fighting for autonomy and get what they demand. It seems absurd that they could refer to themselves as doctors. I have seen medical students with PhDs, but there are rules preventing them from introducing themselves in the hospital as "Dr. so and so", and appropriately so. If they truly want to be called "doctors" and practice independantly , they should at least be required to complete a formal residency. So the counter argument is that "midlevels are needed to fill the gaps in healthcare". Is that REALLY the answer? I don't know of any other country that requires such a significant amount of midlevels (if any) and they seem to do just fine. Should one of the answers be to decrease midlevel positions and decrease the length of residency? It seems unheard of to allow recent med school grads to start practicing immediately or even after a year, but maybe that is what we need. We are having less qualified individuals do exactly this. There are an abundance of FMGs dying to practice in the US, and instead of making this an easier transition for them, we are allowing individuals with a master's degree equivalent practice medicine. Yes, I may sound petty in this post, but it is a rant, so take it for that. Also, I admittedly do not know how the system works in its entirety and may be missing some crucial points. I want to understand these missing points so I can appreciate the growth of midlevels in population and responsibility. As a final point, should we as physicians finally become unionized? I mean, both nurses and PAs are unionized and have been extremely successful in fighting the medical system with seemingly absurd demands. Okay, rant completed.