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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


What Your Doctor Is Saying What Your Doctor Is Saying
 

Who's Who in Your Health Care, Part 2: Non-M.D.s


February 27, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center


Last reviewed and revised February 27, 2013

If you have ever been a patient, you may have run across a number of people who were not your doctor but played some other role in the delivery of your health care. There is the person at the front desk who greets you at appointments, the person answering the phone when you call, the person who sees you when your own doctor is away, and various specialists whose exact title or role may be mysterious to you. Some call themselves doctors and even perform surgery and yet have never gone to medical school. Who are these people, and what exactly are their roles?

In a previous column I discussed the names and roles of physician specialists, medical doctors who focus their practice in one area of medicine such as lung disease or heart disease. In this column, we’ll cover some of the non-physician health care professionals or assistants whose roles may be confusing to you. After all, it’s not always enough to understand what your doctor is saying — it’s also important to know who is saying it. Read on to learn more about folks involved in your health care who may not have gone to medical school but whose roles may be vital to your health.

Non-M.D.s You May Encounter During a Visit to Your Doctor

On the phone

When you call your doctor, do you know who it is on the other end of the line? Once you get through to a human being, you are probably speaking with a member of the clerical staff. For appointments, leaving a message about refilling an existing prescription, a request for a referral to another doctor, or billing questions, you probably don't need to speak directly to your doctor. However, for a specific medical question, a new symptom, or a request for medical advice, the person on the phone will take your number and pass the message along to your doctor (or other health care professional with whom your doctor works), especially if it is urgent. (Of course, for serious or life-threatening emergencies, such as chest pain, trouble breathing, or bleeding, it's often best to proceed directly to the closest emergency room rather than calling your doctor).

Some front-desk staff become so familiar with certain patients or common problems, you might think he or she is a nurse or doctor; and some experienced clerical staff can be a big help to you by knowing when to interrupt your doctor with a message and knowing which questions or messages can wait.

Nights and weekends, your doctor’s calls may be forwarded to an answering service that takes the message and contacts your doctor, the doctor on call or another health professional, such as a nurse trained to "triage," that is, to decide which problems can be handled over the phone and which should be referred to the emergency room or other facility. In general, non-physicians practicing "telephone medicine" have guidelines about common problems that they follow carefully and they have physician backup if they encounter an issue that is more than they can handle. Increasingly, there are online options to contact your doctor's office with quesitons, scheduling requests or medicine refills. In most cases, they are handled much as a phone call would be.

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At Your Appointment

After you arrive for your appointment (hopefully, without a long wait), you may meet a health assistant who checks your blood pressure, heart rate, temperature and weight, and he or she may perform an EKG and draw your blood if those tests are requested. Health assistants typically receive training to perform these specific supportive roles on the job or in a one- to two-year vocational program. In some offices the clerical staff and health assistants perform similar or overlapping roles.

The actual medical care is delivered in most offices by a doctor, a nurse practitioner or a physician assistant (P.A.). In the United States, nurses have graduated from nursing school or college and many accept positions at hospitals providing care to admitted patients alongside doctors. In order to practice independently — to see patients, gather relevant information, perform a physical examination, arrive at a diagnosis, and then recommend tests or treatments — additional training is required. Nurse practitioners, for example, concentrate on one area of medicine, such as obstetrics and gynecology or primary care, and are then licensed to see patients on their own (with physician backup). P.A.s perform a similar role to nurse practitioners but require fewer years of training, are trained in a broad range of medical areas, and provide medical care with a physician as one part of the overall care for a particular patient — that is, the M.D. and P.A. are teammates, and the physician is ultimately responsible for the care delivered. Nurse practitioners, on the other hand, are responsible for their own patients and refer patients to physicians who require specific medical care.

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At a Visit to a Specialist

While physicians commonly specialize in one area of medicine (for example, cardiologists deal primarily with heart disease), non-M.D. specialists also may be a part of your health care team. Common examples include:

  • Podiatrists — Specialists who take care of common problems in the feet, including bunions, corns, flat feet and nail care for those who cannot handle it themselves. People with diabetes, especially those with nerve damage in the feet, typically get regular foot care from podiatrists. Many podiatrists, though not all, perform foot surgery. They are "doctors" because they are "Doctors of Podiatric Medicine" (or D.P.M,), but not "medical doctors," as they do not go to medical school. However, after college, training includes four years at a college of podiatric medicine, and most graduates go on to complete at least one year of residency seeing patients with supervision before practicing on their own.
  • Optometrists — Also called Doctors of Optometry, these are eye-care specialists who typically examine eyes, determine whether vision is normal and what type of corrective eyeware (such as glasses or contact lenses) may be needed to maintain adequate vision. Optometrists typically screen people during examinations for common eye diseases such as glaucoma, cataracts, and retinal problems — in fact, they provide most primary eye care. However, most medical or surgical treatment for these and other eye diseases are provided by ophthalmologists, medical doctors who specialize in diseases of the eye. Optometry training does not include medical school; doctors of optometry are not M.D.s, but instead receive four years of training at an accredited optometry school.
  • Chiropractors — In the United States, licensure of chiropractors (also called doctors of chiropractic or chiropractic physicians) requires four years of training at a chiropractic college. Although the term "doctor" is common to describe chiropractors, they do not go to medical school and are not medical doctors. They commonly provide care for back pain, neck pain and other painful conditions using manipulation or other treatments that do not require medications. The discipline is based on a theory that many health problems develop as a result of abnormal balance in the musculoskeletal and nervous systems, and that proper spinal or vertebral function can be rebalanced through adjustments and manipulation.

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And Still Others Who Aren't M.D.s

At least two other areas of medical care deserve mention when considering medical care by providers other than medical doctors (M.D.s).

  • Osteopathic physicians (also called Doctors of Osteopathy, or D.O.s) — These are the same as M.D.s in terms of training and practice, with the exception that training to be a D.O. tends to take a more holistic approach — that is, it centers on the patient in his or her environment, not limited to specific signs or symptoms of disease. This approach includes the patient, his or her family, health promotion, disease prevention and primary care. In addition, some D.O.s use osteopathic manipulative treatment to diagnose and treat injury and illness; this type of treatment includes the application of pressure to specific parts of the body in the hope of encouraging natural healing and realigning structures into a healthier position.
  • Nurse anesthetist — If you have ever had anesthesia, you may not recall the person actually administering it; the medical doctor (the anesthesiologist) probably introduced himself or herself to you before your operation, but during the surgery itself it is common for nurse anesthetists, nurses with additional training in the provision of anesthesia, to monitor and maintain sedation and pain control. In fact, nurse anesthetists administer approximately 65% of anesthesia in the United States. Training is extensive. After college, nurse anesthetists must graduate from nursing school, have a year of experience in a hospital or other acute medical care facility, graduate from an accredited graduate school of nurse anesthesia (which takes at least two years), and continue training in a hospital setting before taking a certification examination. While anesthesiology physicians usually provide anesthesia for people requiring unusual surgery, who have complicated medical problems or whose anesthesia is not routine, it's often a nurse anesthetist keeping people asleep and comfortable through common, uncomplicated operations.

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The Bottom Line

When you are ill, it may be difficult to keep track of the names, faces and responsibilities of everyone involved in your care. The teams of doctors, nurses and other health care professionals in the doctors' office or hospital may seem impossible to keep straight. Everyone involved in your care should wear a nametag and introduce him or herself, but even then, their role may not be clear. If you are receiving care from someone whose name or job you don't know, make it your job to ask. Or ask your own doctor. But don't hesitate to find out — medical care is scary enough without being left in the dark.

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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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