"Nurse Practitioners are some of the most talented and qualified physicians to ever practice medicine, albeit without being recognized as such. We are unique in our practice of medicine. We are not trained the same as MDs or DOs, but clinical data has shown that the practice of cathopathic medicine is equally as effective, and time and again patients show they not only accept it, but may actually prefer it. The time has come to break through the glass ceiling which tells nurses that a clinical doctor practicing medicine cannot be recognized in title, professional standing, or payment as a physician.

"Nurse Practitioners are some of the most talented and qualified physicians to ever practice medicine, albeit without being recognized as such. We are unique in our practice of medicine. We are not trained the same as MDs or DOs, but clinical data has shown that the practice of cathopathic medicine is equally as effective, and time and again patients show they not only accept it, but may actually prefer it. The time has come to break through the glass ceiling which tells nurses that a clinical doctor practicing medicine cannot be recognized in title, professional standing, or payment as a physician.

"Nurse Practitioners are some of the most talented and qualified physicians to ever practice medicine, albeit without being recognized as such. We are unique in our practice of medicine. We are not trained the same as MDs or DOs, but clinical data has shown that the practice of cathopathic medicine is equally as effective, and time and again patients show they not only accept it, but may actually prefer it. The time has come to break through the glass ceiling which tells nurses that a clinical doctor practicing medicine cannot be recognized in title, professional standing, or payment as a physician. Once we do, there will be no limit to what we can accomplish as a profession."

The American College of Cathopathic Physicians (ACCP) is an organization created to advance the practice of cathopathic medicine, which is based on the same scientific underpinnings and evidence-based guidelines as other physicians, albeit with a unique approach to patient care derived from prior nursing training and theory. It is the ACCP’s belief that doing so will promote the well-being of the public while simultaneously increasing access to care and advancing our professionals to their fullest potential. ​ The role of the ACCP is to protect the professional autonomy and advocate for a full, broad scope of practice for cathopathic physicians: uniquely qualified Doctors of Nursing Practice (DNPs) who practice cathopathic medicine, in order to allow them equality in every way along side our MD and DO counterparts. The ACCP is tasked with establishing policies, a code of conduct and professional ethics, as well as determining what educational standards are necessary to produce qualified cathopathic physicians and the accreditation of DNP programs to achieve that end. Of equal importance to the growth of this profession is the role of the ACCP to lobby for and help establish state licensure and interstate reciprocity, ideally as liaisons in conjunction with individual state Medical, Osteopathic, and Nursing boards but capable of working as a separate entity from them on the state and national level when necessary.

ACCP Position Paper

The Cathopathic Physician

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Who is a physician?

The term physician is commonly defined as a "doctor who practices medicine" which is "the art of healing" or "promoting, maintaining, or restoring health through the study, diagnosis, and treatment of disease". In North America there are allopathic physicians, osteopathic physicians, chiropractic physicians, podiatric physicians, homeopathic and naturopathic physicians, and more. These physicians are health care providers who practice at the highest level in each of their fields, using their knowledge, experience, and available data to make diagnoses and determine the appropriate treatments for their patients. While much can be said about how a physician practices their particular form of medicine, more can be said about why these physicians practice in the different ways they do. Contrary to the notion that every provider wants to be a MD but some can only “cut it” in other professions, each practitioner begins their journey with a personal philosophy defining what the practice of medicine means to them. This in turn guides them to seek their training within a specific theoretical framework, those that give rise to the distinct branches of physician practice. Becoming a doctor in these fields, "a person awarded the highest academic degree conferred by a university" and "skilled or specializing in the healing arts", is only the beginning. Time spent learning in the classroom is ultimately dwarfed by the countless hours spent watching, doing, and teaching. Therefore the art of healing is ultimately learned through interactions with patients and mentors, through mistakes, and through experience, all of which further influence that philosophical evolution over the course of their career. This is why doctors trained in different theoretical frameworks, even with the same scientific underpinnings, such as MDs and DOs will practice medicine in a manner that is unique to their training. Like the traditional MD or modern-day DO the Doctor of Nursing Practice, or DNP, independently practices medicine in many states and settings guided by their own unique theoretical framework, developed after years of training and practice, originating in the field of nursing. But unlike the MD or DO, the DNP is not currently accorded the title of physician and is still considered to be a ‘mid-level’ provider in terms of professional standing and autonomy.

In the early 20th century there were a wide variety of options for learning the practice of medicine. Students of these distinct philosophies were guided by their mentors, based on the scant and conflicted science of the day, and some on theories subsequently disproven and dismissed. Over time a limited number of prevailing philosophies have survived. Medical Doctors (MDs) are schooled in the "allopathic" model of medicine (Greek: allos=other pathos=suffering), a term coined in 1810 to describe the use of modalities which created "other", "different" or "opposite" effects than those produced by a disease. A common example of this would be the use of a medicine that lowers blood pressure to treat high blood pressure. Osteopathic physicians (Greek: osteon=bone), or Doctors of Osteopathic Medicine (DOs), treat patients guided by the philosophies of A.T. Still taught at his college in 1892 and outlined in his book "Philosophy of Osteopathy" in 1899. Dr. Still believed that the body had a natural ability to heal itself, and that dysfunction and disease were primarily the result of disorders in the musculoskeletal system which prevented this natural tendency to heal. These principles can best be demonstrated by the use of Osteopathic Manipulative Treatment (OMT), a hands-on manipulation of the musculoskeletal system to alleviate somatic dysfunction. OMT has become one of the few practice distinctions between MDs and DOs, which is now used less than 5% of the time by modern DOs. More often their practice of medicine is closer in technique to that of MDs, albeit informed by a unique philosophical approach.

The evolution of these branches of medicine did not occur simultaneously or cordially. The philosophies and practices of chiropractic, homeopathic and naturopathic physicians have been considered part of the broader approach of complementary and alternative medicine (CAM) and separated from the practice of “mainstream” or “western” medicine. The various branches of allopathic medicine consolidated their philosophies and educational models to become the standard “physician”, initially controlling the title and authority to practice medicine on a state-by-state basis. Over the course of decades, and following numerous lengthy legal battles, osteopathic medicine was able to uncouple the concept of “physician” from exclusively allopathic medical models. In every state in America and in several countries throughout the world the term physician is still a doctor practicing medicine, but this title is no longer solely owned by MDs.

Who is a nurse?

Nursing, which is considered by many outside the profession to be the 'property' of allopathic physicians, actually self-identifies as its own field of study, separate from the practice of medicine and guided by its own theoretical and philosophical framework and models of practice. One of the oldest of these theories was developed by Florence Nightingale, the founder of modern nursing. Nightingale's Environmental Theory, written in 1860, is still in use by nurses today. This theory highlights the importance of considering all aspects affecting the patient, beyond the disease process itself, in restoring health: the importance of nutrition, cleanliness, safety and removal of environmental hazards, and perhaps most critically the importance of knowledge. Nurses have been trained to consider all of these factors and more when caring for a patient. When a nurse assesses a patient's needs in order to restore or promote an optimal state of health, they are trained to take an all-encompassing view of the situation: do they have adequate nutrition, clean water, a safe environment which will allow them to become or remain healthy, and most importantly have they been given the knowledge necessary understand what is trying to be accomplished? What do they know about their health and disease? What do they know about their medicine or treatment? Do they know and understand their treatment options, and the goals of the provider as well as their own? Nurses at all levels of practice believe that examining these relevant factors as a whole is just as important to healthy outcomes, and in some cases more so, than the administration of a medicine or surgery on its own.

Unfortunately nursing as a profession has been as vocal as the field's detractors, or perhaps more, in advocating the idea that "nurses practice nursing, they do not practice medicine". The ‘bed-side’ nursing profession has defined its role through modern theorists like Watson as a "carative" practice, performed in support of healing and curing, yet distinct and complementary to it. But times have changed. Advanced practice nurses in multiple settings have long-since transcended the role of a 'supportive' or 'mid-level' provider. At the time of this writing nearly half the states in the country, the District of Columbia, and all Veterans Affairs Health Centers around the globe allow full, independent practice for nurse practitioners. These providers determine diagnosis and provide treatment without the need for supervision or collaboration, and therefore legally practice their own form of medicine in these states, with others soon to follow suit.

What is Cathopathic Medicine?

These providers practice medicine based on the same scientific underpinnings and evidence-based guidelines as other physicians, albeit with a different theoretical framework which is unique to their prior training as nurses. Those in the nursing profession who have earned the highest practice degree in the field, the Doctor of Nursing Practice, bring their prior experience and training in evaluating the whole, all-inclusive picture of the patient into each of their interactions. This theoretical framework can be called "cathopathic" (Greek: kath=through, throughout; holos= the whole, or catholic=all-inclusive, universal). Practicing cathopathic medicine is much broader than traditional allopathic or osteopathic models. A Cathopathic Physician, for example, would routinely evaluate factors in the patient’s environment including their diet, their surroundings, their stress, and most importantly their opinions and understanding of their own health and disease, that contribute to hypertension, diabetes, or other conditions in order to help successfully treat them. They incorporate their ‘carative’ or supportive training in making sure the overall needs of the patient are managed to the optimal level, so they may be in the best possible position to manage or overcome their disease. While other philosophies have recently begun to incorporate these factors into their own practice with some improvement in patient satisfaction and outcomes, it is not what has traditionally defined them in the same way that it has for providers from a nursing background. By acknowledging cathopathy as a unique philosophy guiding the independent practice of medicine by DNPs, rather than trying to ignore key tenets of their practice to align with an outdated or ill-fitting definition of 'advanced practice nursing', it allows those in the field to advance the understanding and science of this practice. This is of critical importance because the truth is, for those who practice cathopathic medicine, the days of practicing nursing confined by the model of Watson and others may have helped shape them, but is now behind them. It is time to move forward.

As of this writing the American Medical Association (AMA) has drafted a resolution to oppose the authority of NPs to practice without physician oversight (Resolution 214). They site concerns that APRNs practicing independently are trying to “act as physicians” and are “unqualified to provide timely, effective, and efficient care”. They state that the role of the AMA is to “continue to advocate that physicians are best qualified by their education and training to lead the health care team”. In the setting of those states where a DNP can independently practice medicine from their own cathopathic perspective, it could be asked if they are in fact ‘acting as physicians’ as the AMA contends. But how can the public determine if the practice of cathopathic medicine is safe? Osteopathic medicine had to overcome allegations of providing lower quality of care and even outright accusations of public harm from the allopathic community initially. It took decades of practice to overcome this stigma, and it still persists in some parts of the country today. However in our modern, data-driven age the safety and effectiveness of medicine delivered through a cathopathic model has been well-validated by over 30 clinical studies, of which over a third of these have been prospective, randomized controlled trials, the gold standard of clinical data. These studies repeatedly show that totally independent advanced practice nurses, who are by definition practicing cathopathic medicine, have equivalent or in some cases superior patient outcomes in quantifiable metrics like blood sugar control in diabetics, as well as lipid, asthma, blood pressure control and more in primary care patients. In addition, they spend more time with the patients, provide more patient-education, and have near universally superior patient satisfaction scores. Therefore the argument that it is imperative to ‘protect’ the public from harm caused by DNPs one day practicing medicine as cathopathic physicians has no factual basis. The reproducible and solid clinical data disproves the notion that there is inherent public harm when that care is delivered through cathopathic educational and practice models on its very face.

Addressing Critical Needs

Our nation faces a worsening shortage of primary care physicians that is already forcing the current medical establishment to consider drastic changes. The Congressional Budget Office expects the demand for primary care physicians to grow by 18% or more by 2023, and the Association of American Medical Colleges warns that the US will face a shortage of as many as 90,000 physicians by 2025. Either in response to this shortage, as recognition of the importance of hands-on experience versus classroom training like the DNP model of education, or both, allopathic medical schools are evaluating new models including a shortened 3 year academic program and longer experience-based post-graduate clinical training. In addition, the number of osteopathic colleges in the United States is expected to triple in the next 10 years. States which have passed independent practice laws for nurse practitioners have done so specifically to improve the quality of care for those in critical access areas, and data has shown states without these laws have higher cost, less accessible, and less efficient care.

Nurse practitioners are required to have a graduate-level degree in clinically-focused Nursing Science on top of a baccalaureate degree in the same in order to practice. Therefore they have extensive academic preparation and clinical experience, in most cases totaling more than foreign medical graduates who practice as physicians in the US with undergraduate degrees such as the MBBS (Bachelor of Medicine-Bachelor of Surgery) from the UK and elsewhere. Unfortunately this pool of experienced and well-trained professionals are rarely able to become physicians due to the burdens of the current medical educational model, which provide no advanced credit or standing beyond that of the average pre-med college student. Most NPs face a minimum of 7 years of ‘re-education’ beyond the 7 or more already spent getting their NP license before they would be allowed to practice again at their present level as MDs.

The DNP, a Doctor of Nursing Practice, is a clinical practice doctorate created less than a decade ago and distinct from academic or research-focused PhDs in nursing. It was intended from the outset to be the terminal professional practice degree for advanced practice nurses. Although not specifically created as a pathway to physician-level practice for these NPs, early in its inception some had asked if this would finally provide the tool nursing so desperately needed to break through the glass ceiling that has separated nurses from physicians for centuries. While most DNP programs are 4 years or more of education beyond an undergraduate degree, as are MD and DO programs, the DNP is required to hold a baccalaureate degree in nursing, with the commensurate years of bedside, hands-on clinical practice prior to beginning their advanced training. In comparison most MD or DO students have no clinical experience in medicine until the terminal years of their program. Practically speaking, a medical student may be two or more years into their program of study, learning anatomy and foundational science, before they start their first IV or perform their first clinical exam. Compare that to the level of practical clinical knowledge and experience of a DNP student who may have performed hundreds or even thousands of these same procedures before their first day of class. Because of this difference, the graduate MD or DO is still required by law to have several years of supervised clinical training in order to reach the same level of experience as the graduate DNP and before they may independently practice, which constitutes their internship and residency. In reality there is no paucity of education or training when comparing the DNP to the MD or DO’s preparation to practice, but rather the opposite. It is a matter of alternative timing in the training itinerary that allows the DNP to legally and safely practice independently immediately after completing their degree and licensure exams.

The professional societies of allopathic physicians have argued against and in some cases legally interfered with the right to even address the DNP by the title of “doctor” as earned by their academic degree. They often site a concern for patient safety, as they did with regards to DOs practicing as physicians initially, despite allowing those foreign medical graduates without actual doctoral degrees to use the title freely. However the vast amount of clinical data demonstrating high-quality outcomes from cathopathic medicine, coupled with the critical need for more physicians, supports the creation of a unique pathway to physician-level practice for NPs who complete their doctoral degree via the DNP. There is a large and crucial role for both Nurse Practitioners at the Master’s Degree level functioning as independent providers in active collaboration with a physician as well as nursing-focused PhDs as educators and researchers in the nursing field. But in the future those who wish to continue their education and professional development could become doctors of nursing practice specifically with the goal to practice as cathopathic physicians. In addition to helping fill this critical shortage in high-quality physicians, the role of the DNP as a cathopathic-trained physician is uniquely valuable in the pathway it creates for talented, experienced bedside nurses and talented, experienced NPs to capitalize on this experience to become talented, well-trained physicians without needing to start their educational process entirely anew; a pathway many outside the healthcare profession are surprised to learn does not currently exist.

The Pathway Forward

Allopathic physicians have historically resisted allowing those with different training the authority to practice on equal footing with them. Before osteopaths became fully licensed physicians across North America and around the world, the allopathic physicians argued that the DO was simply not equivalent in knowledge, training, or experience to the MD. They claimed there was risk of public harm in allowing those with a unique training and philosophy to practice medicine. Over time both of these arguments have been disproven, and DOs now work side-by-side with MDs in all settings of medicine. The AMA has already begun making this same tired argument about NPs practicing independently and predictably they will argue this about the DNP practicing as a Cathopathic Physician as well. Indeed the education of the Doctor of Nursing Practice is different than MDs, or even that of DOs. But it is no less valuable or effective in training high quality practitioners and substantial amounts of clinical data now supports this.

Osteopaths struggled for decades to establish their right to practice independently as physicians. Much of the difficulty osteopathic physicians faced came from attempting to license themselves through state-based allopathic medical associations, who discounted their training and experience in order to obstruct their expansion. Eventually they won their right to do so and proved that MDs do not own the title "physician". All any school of knowledge actually owns, be it MDs, DOs, naturopaths, or DNPs, is their own philosophy. Each group has the right to practice as "physicians" in their own individual fields. As a group, cathopathic physicians can learn from the experiences of osteopathic physicians in order to gain their own independent practice authority. Cathopathic physicians should expect the same, or based on the idea that NPs traditionally work "for" physicians, perhaps even more adversity than their DO counterparts. Ultimately, osteopathic physicians developed their own professional association, which finally provided them with the tools and support they needed to advance to full and equal practice authority. To this end, we have formed the ACCP, the American College of Cathopathic Physicians (www.cathopathic.org), an organization with free membership open to all. The purpose of the ACCP is to protect our professional autonomy and advocate for a full, broad scope of practice as a physician completely equal in every way to our MD and DO counterparts. The ACCP is tasked with establishing policies, a code of conduct and our professional ethics, as well as determining what educational standards are necessary to produce qualified cathopathic physicians and the accreditation of DNP programs going forward to achieve that end. Of equal importance to our profession is the role of the ACCP to lobby for and help establish state licensure and interstate reciprocity, ideally as liaisons in conjunction with individual state Boards of Nursing but potentially working separate from them on the state and national level if necessary.

Summary

Nightingale herself wrote "I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices”. She believed it ought to signify more, and over time it has. Those who trained under her theories, and the theories and philosophies of many other nurses over the centuries, have become some of the most talented and qualified physicians to ever practice medicine, albeit without being recognized as such. We are unique in our practice of medicine. We are not trained the same as MDs or DOs, but clinical data has shown that the practice of cathopathic medicine is equally as effective, and time and again patients show they not only accept it, but may actually prefer it. The time has come for these children of Florence Nightingale to break through the glass ceiling that tells them a clinical doctor practicing medicine cannot be recognized in title, professional standing, or payment as a physician. Once we do, there will be no limit to what we can accomplish as a profession.