Making Room For 'Dr. Nurse'
April 2, 2008; Page D1

As the shortage of primary-care physicians mounts, the nursing profession is offering a possible solution: the "doctor nurse."

More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degree, says Mary Mundinger, dean of New York's Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

To establish a national standard for doctors of nursing practice, the non-profit Council for the Advancement of Comprehensive Care plans to announce Wednesday that the National Board of Medical Examiners has agreed to develop a voluntary DNP certification exam based on the same test physicians take to qualify for a medical license. The board will begin administering the exam this fall. By 2015, the American Association of Colleges of Nursing aims to make the doctoral degree the standard for all new advanced practice nurses, including nurse practitioners.

But some physician groups warn that blurring the line between doctors and nurses will confuse patients and jeopardize care. Nurses with doctorates use DrNP after their name, and can also use the designation Dr. as a title. Physician groups want DNPs to be required to clearly state to patients and prospective students that they are not medical doctors. "Nurses with an advanced degree are not the same as doctors who have been to medical school," says Roger Moore, incoming president of the American Society of Anesthesiologists.

"With four years of medical school and three years of residency training, physicians' understanding of complex medical issues and clinical expertise is unequaled," adds James King, president of the American Academy of Family Physicians. While nurses with advanced degrees play an important role in delivering care, Dr. King says they should work as part of a physician-directed team.

Although there are no precise statistics on the number of nurses with doctorates because the programs are relatively new, there are about 1,874 DNP students currently enrolled in programs nationwide, up from 862 students in 2006, according to the American Association of Colleges of Nursing.

Nurses have increasingly been moving into more specialized and advanced roles over the past few decades. Advanced-practice nurses include specialists in fields such as nurse midwives and nurse anesthetists, and there are now more than 125,000 nurse practitioners in the U.S. Nurse practitioners in some states are required to work with or be supervised by physicians, but often have independent practices in family medicine, adult care, pediatrics and oncology.

A study led by Columbia's Dr. Mundinger and published in the Journal of the American Medical Association in 2000 showed comparable patient outcomes in patients randomly assigned to nurse practitioners and primary-care physicians.

Nurse practitioners fear the doctoral programs might be raising the bar too high for their profession. The American Academy of Nurse Practitioners says it supports access to a higher educational degree for nurses, but wants to ensure that members won't be marginalized or required to go back to school for a costly advanced degree. Nurse practitioners can write prescriptions, are eligible for Medicare and Medicaid reimbursement, and often act as the primary health-care provider for their patients.

"Nurse practitioners with master's degrees are already filling the primary-care shortages and providing quality, cost-effective care, many times in places that physicians are unwilling to practice," says Wendy Vogel, a nurse practitioner specializing in oncology at Blue Ridge Medical Specialists in Bristol, Tenn. There are "as yet no data to support the need for increasing the amount of education required to practice in this role," she says.

With an acute shortage of nurses, some medical professionals worry that the doctoral programs, with promises of higher-paying jobs and prestige, will lure more nurses away from the critical tasks of day-to-day bedside care.

But program proponents say they could help bring more nurses into the profession by increasing the number of faculty candidates to train a new generation of nurses. The U.S. Bureau of Labor Statistics says that more than one million new and replacement nurses will be needed by 2016. Still, nursing schools had to turn away 40,285 qualified applicants to bachelor's and graduate nursing programs in 2007 in part because of an insufficient number of faculty, according to the American Association of Colleges of Nursing.

Dr. Mundinger, of Columbia, says the primary aim of the DNP is not to usurp the role of the physician, but to deal with the fact that there simply won't be enough of them to care for patients with increasingly complex care needs. As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

In addition to training in diagnostic and treatment skills, doctors of nursing practice can have hospital admitting privileges, coordinate care among specialists, help patients with preventive care, evaluate their social and family situations, and manage complex illnesses such as diabetes and heart disease, says Dr. Mundinger, who has been leading the effort behind the National Board of Medical Examiners' planned certification exam.

A spokeswoman for the medical licensing board, which provides examinations used by licensing authorities for several health professions, says the planned DNP exam will be narrower in scope than the three-step exam that doctors take, including tests on organ systems and a range of medical disciplines. A number of physicians have supported the efforts to advance nursing to the doctorate level through the Council for the Advancement of Comprehensive Care.

All nurses currently are licensed by the state in which they practice and are certified by specialty groups. The planned certification exam won't be a requirement for licensing of DNPs, and it is too early to say whether it will catch on broadly as a desirable credential for practice. Jeanette Lancaster, president of the American Association of Colleges of Nursing says "we are keeping an open mind as to whether it will add another level of validation of competency."

Columbia University's Columbia Advanced Practice Nurse Associates, which includes several DNPs, has for several years been taking care of patients with complex illnesses, working with medical doctors and specialists affiliated with the university. ****** Gleason, a 76-year-old writer and researcher, says she became a patient of the practice after her family physician died. Now, she counts one of Columbia's DNPs as her primary physician.

Ms. Gleason says she liked the practice's emphasis on preventive care. More significantly, when she complained of a throbbing headache on one side of her head, Edwidge Thomas, a doctor of nursing practice, noticed something in her blood test that indicated a form of rheumatic infection linked to her arthritis. The diagnosis was confirmed when Ms. Gleason was referred to a neurologist, who prescribed medication. "They are patient-oriented, and they always pick up the pieces, so to speak," says Ms. Gleason. "Edwidge is my primary-care provider now."


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I think the last thing that the medical profession needs is a bunch of nurses running around the hospital calling themselves "doctor." I personally see a NP for most of my doctors visits, and she's great...but they need to be very careful about blurring the distinction between a nurse and a physician. To say that a nurse, with an extra year of school and an extra year of internship, is anywhere near comparable to a family physician with 4 years of medical school and at least 3 years of residency, is just ridiculous! Sometimes, I really don't know where people get off saying things like that.

A physician should not have to walk into a patient's room and say that they are a medical doctor, to distinguish themselves from anyone else in the hospital. And patients should not have to worry about the false impression that their nurse is a medical doctor either. The doctorate degree is really beginning to get out of hand.

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AUC 2nd Semester
Rectouterine pouch!!
http://slevit1.blogspot.com

Give a man a fish and he will eat for a day; teach a man to fish and he will eat for a lifetime; give a man religion and he will die praying for a fish. --Unknown

simple economics really.....where i'm from, the wait time to see a FP is ridiculous because there simply are not enough. NPs can help fill the gap, but there is no comparison as far as education is concerned.

it will be interesting to see what effect, if any, the results of the election will have on the healthcare system. i guess that is where auc and other caribbean schools will come in, seeing how many graduates will go into primary care fields.

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AUC 5th Semester
Undergrad: UC Riverside

I don't think the election will have any impact at all. Presidents don't have the ability to make laws...just veto them. They can propose an idea, but it still has to pass through the house and senate, just like any other law. If congress wanted universal healthcare, it would have already happened. Lets not forget that Hillary has already tried this crap before, and made a ginormous political failure out of it.

As far as getting doctors into primary care fields...all the government has to do is stop thinking its ok for them to decide what doctors get paid. Until doctors are appropriately compensated for their work in primary care, I don't know how they expect any new doctors to want to do it. I may not be 100% sure what I'm going to do after medicine, but I am 100% sure that it will not be primary care, or any other job in which my salary would be dependent upon medicare.

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AUC 2nd Semester
Rectouterine pouch!!
http://slevit1.blogspot.com

Give a man a fish and he will eat for a day; teach a man to fish and he will eat for a lifetime; give a man religion and he will die praying for a fish. --Unknown

Why would this be moved to the nursing forum? I posted this to allow my fellow MEDICAL SCHOOL students see what's going on in the medical community and how this will be affecting them not nurses!! Read the article before you decide to move it.

I totally agree...this does not belong in the nursing forum....please move it out mods!!!

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AUC 2nd Semester
Rectouterine pouch!!
http://slevit1.blogspot.com

Give a man a fish and he will eat for a day; teach a man to fish and he will eat for a lifetime; give a man religion and he will die praying for a fish. --Unknown

Here is a link to article that I posted earlier that a mod felt the need to move because they didn't feel it was relevant to MEDICAL STUDENTS and felt it was more appropriate to go into the nursing forum. Why, I have no idea.

http://www.valuemd.com/nursing-schoo...on-nurses.html

Again, I post this to see how future physicians feel about the nursing community invading the medical community.

So what's the difference between these new nurses and PAs?

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Birth is exciting, death is peaceful, its the transition that troublesome--Azimov

There is a huge difference between these new "doctor nurses" and PA's! The first obvious difference is that a PA is not a doctorate degree, and do not tell their patients that they are doctors. Further, PA's have a lot less autonomy than even current nurse practitioners. NP's can have independent practices and be someone's primary care provider, PA's can't. From what I understand, these new nurses will be no different than current non-doctorate NP's, as far as scope of practice. My nurse practitioner, surprisingly to me, thought that making nurse practitioner a doctorate degree was a horrible idea.

__________________
AUC 2nd Semester
Rectouterine pouch!!
http://slevit1.blogspot.com

Give a man a fish and he will eat for a day; teach a man to fish and he will eat for a lifetime; give a man religion and he will die praying for a fish. --Unknown

PA's also fall under the AMA while nurses do not.