About Those Doctor-Nurses

DrRich | October 17th, 2011 - 6:32 am

Podcast:

A recent article in the New York Times discusses the growing controversy regarding whether nurses who have earned a doctorate degree in nursing practice ought to be addressed, by patients or others, as “doctor.”  The article touches upon several salient aspects of this controversy, but unfortunately does not resolve any of them.

According to the article, most doctors think nurses – even ones with advanced degrees – should not be awarded this honorific. Only physicians ought to be referred to, in any clinical setting, as “doctor.”

The reason, of course, is entirely altruistic. If the nurses are called “doctor,” it will confuse patients; they won’t know what’s going on, or who’s in charge. This kind of reasoning is entirely consistent with physicians’ well-known and unremitting efforts to make sure every patient understands exactly what is going on, at all times. Clearly, nurses calling themselves “doctor” will undermine such noble efforts.

There are other issues to consider. The Times portrays Dr. Roland Goertz, chairman of the board of the American Academy of Family Physicians (and presumably a doctor of medicine, but this is unspecified), as fretting that, should nurses be allowed to wrest control of the title “doctor” from the real doctors, the real doctors would experience a “loss of control of the profession itself.”

Dr. Kathleen Potempa, president of the American Association of Colleges of Nursing (and presumably a doctor of the nursing kind, but also unspecified) counters that nurses are getting doctorates not to take over the healthcare system or screw with doctors’ heads, but merely to boost their education and stay current. There is, she says, a lot for nurses to learn about these days.

But despite such soothing words from one of nursing’s luminaries, the Times notes that doctors remain alarmed. Nurses are really getting their doctorate degrees, physicians happen to know, to boost their credentials to practice independently – making their own diagnoses, initiating their own treatment plans, writing their own prescriptions, &c. Several states already allow them to do so. Louis J. Goodman, chief executive of the Texas Medical Association, is not fooled: “This degree is just another step toward independent practice.”

But the Times article ends with another demurral from Dr. Potempa: “Nurses are very proud of the fact that they’re nurses, and if nurses had wanted to be doctors, they would have gone to medical school.” (As if, DrRich can hear a few of his colleagues muttering, they could have gotten in.)

So, as DrRich says, the New York Times succeeds in rubbing some of the sore spots created by this controversy, but does not resolve anything. In fact, the article merely dances around the real issue, and leaves it entirely untouched.

You are therefore fortunate, Dear Reader, that you have DrRich to explain the whole matter to you. In fact, here are the six things you really need to know about the doctor-nurses controversy:

1) Nurses who decorate themselves with a doctorate degree in nursing practice have every right to refer to themselves as “doctor,” just as any other doctor in any other field has that right. DrRich was reminded of this fact several years ago, when he was severely admonished at a parent-teacher conference by his child’s history teacher for failing to address her as “doctor.” (This was after DrRich had ascertained that this person could probably not name a single event in American history that had occurred prior to 1860. But then, her degree was in “education,” rather than in the subject matter she taught.) And consider this: there are “doctors” wandering our streets whose degrees are in fields of endeavor whose names end in the word “Studies.” If these souls deserve to be called “doctor,” then nurses – who actually know a lot of very useful things – certainly do.

2) It is not the nurses’ fault that the doctors of old, when they finally became tired of being referred to as “barbers” or “chirurgeons,” and wanting a more distinctive name for themselves, commandeered the generic and widely-used title of “doctor.” No doubt they were very impressed with themselves at the time for having gained an education beyond that necessary to create a decent tonsure, but still. It is as if football players had decided to usurp the term “athlete” as referring only to themselves, and then complained when race car drivers began calling themselves the same thing. (The football players would have a point, of course, but on the whole their behavior would be unreasonable, not to mention unseemly.)

3) It seems just a tad disengenuous for physicians to complain because nurses calling themselves doctors might confuse some patients. Doctors themselves have not been particularly assiduous about disabusing their patients of various confusions. Doctors have yet to explain to their patients, for instance, that according to recently adopted precepts of medical ethics, they are obligated to covertly ration their medical care at the bedside. As a result, patients still think their doctors’ primary obligation is to them. This sort of “confusion” seems far worse, to DrRich, than a little confusion about who is a doctor and who is not. (Besides which, evidence suggests that many patients will always labor under the notion that all female health professionals are nurses, and all males are doctors – and so their confusion about who is who is pretty standard stuff.)

4) DrRich knows that you family practitioners out there have bigger things to worry about, but what the heck is the story with Dr. Roland Goertz*, chairman of the board of your professional society? Can it be he’s actually worried that nurses calling themselves doctors will lead to doctors losing control of their profession? What control is that? Gentlemen and ladies, you have elected a chairman who thinks that you family practitioners still have control of your profession! What are you people thinking?

____

*DrRich notes that Dr. Goertz is aptly named. The original, according to the Song of Roland, also sacrificed himself fighting a futile rear-guard action against vastly superior forces.

____

5) Dr. Potempa, president of the American Association of Colleges of Nursing, seems like a very reasonable person, and perhaps doctors (the physician kind) might be able to work with her. But DrRich has noticed that there are several different professional societies representing nurses, and some are less mild-mannered and less “reasonable” than others. The nursing organization which perhaps most directly represents those kinds of nurses whom doctors are most concerned about (i.e., nurses who become “doctors” and then want to be addressed that way) is the American College of Nursing Practitioners. The ACNP is much less demure than is Dr. Potempa’s organization about its long-term goals, which it has publicly expressed in a Strategic Plan published in 2005. Anyone examining this plan will note right away that it has been published in ALL CAPS, which, by tradition, indicates a shouting, in-your-face, screw-you sort of an attitude. In this manifesto, the ACNP states (among other things) that “INTERDISCIPLINARY NON-HIERARCHICAL TEAM CARE IS THE HIGHEST QUALITY OF CARE” (i.e., we’re not taking any guff, or orders, from you know-it-all doctors, rather we will practice as fully independent agents); and declares that their goals will not be met until nurses are “PRACTICING WITHOUT RESTRICTION IN EVERY SECTOR OF HEALTHCARE DELIVERY” (i.e., there are no limits to our scope of activity). Overall, this document is breathtaking in its breadth, straightforwardness, and attitude. This Strategic Plan, DrRich points out to his physician friends, reveals what the nurse practitioners are really up to.

And it’s just what you thought.

6) There is an overriding fact that renders all of the above entirely moot. It does not actually matter what doctor-nurses call themselves, or even that there is such a thing as doctor-nurses. It does not matter that the ACNP appears to be a predatory organization. It does not matter that Dr. Goertz may suffer from an acute lack of clues, or that Dr. Potempa seems like a nice lady.

None of this matters, Dear Reader, because Obamacare, the law of the land, has promulgated a new definition of Primary Care Practitioner. By law, today, physicians who practice primary care medicine, and doctor-nurses, and nurse practitioners (not to mention various other forms of non-physician medical personnel), are all PCPs. They are all equally qualified under the law.

It is a done deal. Only the details need to be worked out.

It is not convenient to acknowledge this fact. Primary care physicians and their professional organizations would rather not think about the implications. It means that the American Academy of Family Physicians is fundamentally an obsolete organization, as are its officials, such as Dr. Goertz. It means nearly the same for the American College of Physicians. Neither of these organizations is about to admit that. Furthermore, if this fact were to be acknowledged by the academic programs which are training our primary care physicians, they would become obligated to inform their applicants that the 8-10 years of medical training they are signing up for will place them in the same position, legally speaking, as a nurse practitioner (or, if they want to cushion the blow a little, as a doctor-nurse). This is truly an inconvenient truth. So it is being publicly ignored.

And so primary care doctors, and their professional organizations, go on pretending that the big issue facing primary care doctors is what these new-style PCPs will call themselves. And they are happy to fulminate about that issue to reporters from the New York Times. It seems safer than facing the truth.

But the truth is still the truth, and only the primary care doctors who face up to it will stand a chance of bucking the system, and maintaining their professional standards.

DrRich has heard several primary care physicians argue that their training is just so much better than the training of a doctor-nurse that it’s absurd to suppose those lesser professionals can offer equivalent care. This would certainly be true if primary care doctors actually did the things their training prepared them for. But if they continue following the path the system has laid out for them in recent years – avoiding the management of hospitalized, acutely ill patients altogether; seeing the outpatients who constitute their entire practice at a rate of one per 7.5 minutes; spending that 7.5 minutes making chits on Pay for Performance checklists from On High; sending anyone who actually seems a little sick to the emergency room or to a specialist – it is actually difficult to see what the big drop-off will be if doctor-nurses are doing the job.

When DrRich’s 15-year-old automobile displays some horrible new symptom, he wants a well-trained and experienced mechanic to diagnose the problem and fix it the right way. But if he’s only taking it to one of those 10-minute places for an oil change and a filter, it’s fine with him if the technician just learned the job last Tuesday from Stu. Primary care doctors have allowed themselves to be converted into Jiffy Lube. The training advantage they have over doctor-nurses matters less and less.

The Central Authority is assembling panels of experts to determine which medical decisions are to be made under which circumstances for which patients, and all it asks of doctors is to follow their instructions to the letter. Further, the Central Authority has determined that doctor-nurses will be very, very good at following those instructions – better than physicians, almost without a doubt. Indeed, the nurses’ lesser training – enough to allow them to recognize common conditions, and also enough to teach them that medicine is extraordinarily complex and there’s a lot they don’t understand and never will – is aimed at rendering them satisfied to comply with the directives handed down by panels of experts, and to be very thankful they can do so. Their reduced training is a decided advantage to the Central Authority.

To the Central Authority, the role of an ideal “practitioner” will be much better filled by a nurse, whose training is brief, to the point, focuses on following treatment plans, and is not burdened by centuries of professional pride and embarrassing oaths to dead Greek gods.

Primary care doctors who still value their professional pride, oaths, &c. had better light out for the territories while they still can, and quit worrying about the doctor-nurses (who soon enough will have big problems of their own).

Doctors need to face what is happening to their profession, and avoid getting distracted by battles over nomenclature. If they want to maintain their professional integrity, they will need to clearly distinguish themselves from the checklist checkers and the guideline followers, and demonstrate how the individual expertise and the personalized care they offer will be a big advantage to many patients.

If primary care doctors believe they really do add value to patient care over and above whatever nurses can provide, then they had better learn to articulate exactly what that value is. And once having articulated it, they will need to organize themselves to deliver and market that value, at a reasonable price, to the people they expect to pay for it.

And the “people they expect to pay for it” had better be their patients – because the Central Authority and other third party payers have made crystal clear precisely what they want, expect, and will tolerate from a PCP. What that is, of course, is complete compliance with central directives, and an end to the annoying expectations physicians have traditionally expressed for individual decision-making.

And as for those within the Central Authority, DrRich humbly suggests they carefully read the ANCP manifesto, and ask themselves whether the object of their affection, when finally won, is going to prove quite the demure, compliant little partner they’ve been pining for all this time.

13 Responses to “About Those Doctor-Nurses”

  1. Stwart Jenssen says:

    I totally agree w/Vixen’s comment, about CNA’s, MA’s, etc., using the title as “nurse”; even on their name badges. That’s a real pet peeve of mine. I worked very hard for my RN license & in my career. I ask MA’s in the dr.’s offices, when I see “Nurse” on their name badges, “Oh, where did you go to Nsg school?” I don’t think the State Boards for Nursing should allow this. It’s no different than if I were to misrepresent myself as an attorney, MD, etc. I have also been in the situation when a pt “assumes” a male nurse, RN or LVN, is a Dr., & I’m “just the nurse”, because I am a woman. People w/Phds have been using the title of Dr. for yrs, so, why shouldn’t a nurse who has their Doctoral degree be accorded the same courtesy? I had professors in Nsg school, & we addressed them as Dr.

    Stwart Jenssen
    FindRxOnline.net

  2. pj says:

    It is obvious to those of us who are physicians,that,(at this point in time),Primary Care physicians do add value to
    patient care over and above what others(sic) can provide… “. Sadly, those who should “articulate exactly what that value is”, e.g., our specialty societies and the AMA,have sold us out to Central Authority for political or monetary gain. The media is clearly on the side of Central Authority’s social revisionism. Any suggestions?

  3. Matt says:

    The battle of the professions is essentially a progressive battle. To fight it, one must first accept that the State is the final arbitrator in all decisions of relative value. Essentially, participants in this game are competing for grants of monopoly rights, or in economic terms, rents, that are handed out by the State in the form of licenses — not based on competence, but on political contentedness. But victory is a bitter pill. Because physicians fought this game many decades ago and “won,” they now find themselves the toys of the State. Good luck to the participants. That they are fighting this battle at all is an indication that they have already relinquished all power to the State.

  4. Diogenes says:

    Doctor Nurses? Is that like Sergent Majors? : – )

    Anyway, my rule is: if the degree is an actual Doctor of Medicine/Dentistry/Vet Medicine/Psychiatry (M.D., D.D.S., D.V.M), then call’em “doctor.” All other Ph.D.s get the honorific “professor”. Keeps things clear, concise and valid.

    • Lydia says:

      The Doctor of Nursing is actually an doctorate degree – Doctor of Nursing Practice. THere is also a pHd in nursing for teaching and education.
      So then you agree that Nurses that have completed the clinical doctorate of nursing could be called Doctor?

    • Joe Gabin says:

      When you use “Sergent Mejors” as an example for nurse-doctor, it is like comparing milk of magnesia with magnesium chloride. There are not “nurses-doctor” there are Doctors of Nursing Practice, what means nurses with a doctor degree in advance nursing who are board certified to deliver primary care. Is there anything wrong when a PCP introduce himself/herself to the patient in consultation by staying:- My name is Dr.JP,I am a doctor of nursing practice”…? The problem for some MD;s is not the “patient confusion” or the “practice experience”, or the “level of education of DNP” which is known to be compatible with MD’s in primary care.. and “who knows??; even many foreign doctors make the transit into advance nurses in US because advance nursing philosophy is different and fascinating in medicine. The problem is their arrogance, and why not to say ,their absolete “bullying”, their SUPREME CONTROL of patients,their MONEY MAKING MACHINE and their FEAR of loosing the DOCTOR DEGREE strictly for them…all very OLD FASHION. Hope some day this battle will finish and all Primary Care Practitioners will understand that a collaborative practice,intead of the hierarchic prepotence, is what helps to achieve the final goal which is the quality of patient care.

  5. [...] role of non-physicians in providing autonomous, unsupervised care to the American public.  As pointed out by other authors, physicians need to quickly demonstrate to patients the value they offer, and [...]

  6. What an interesting debate and social conundrum. In our industry, we crank out BSN’s and MSN’ nurses. It has gone around the office a couple times (with varying proponents and detractors) about the “DR.” titling debate.
    I can say they have earned it, to be called such but clinically, I see it WOULD confuse patients indeed. We dont refer to our nurses as “RN” or any other degree of distinction, to the patient, there is no distinction of the various levels of nursing and none are the wiser.
    Interesting, this calls for a trackback or tweet or something !!

    Thanks for the interesting podcast !

  7. Personally, I feel that if the person has earned the degree, then they should own the title that accompanies it (this point has been driven home to me on several occasions by co-workers). This debate does raise interesting questions though on exactly where the line should be drawn for medical titles, and the implications of that line becoming blurred in certain situations.

  8. Nina says:

    Nurses ARE NOT qualified or trained to be Doctors. The second and last time I seen a NP was when I was diagnosed with chest congestion. Let it go until one morning I told my wife I needed to be seen by someone immediately, a trained Medical Doctor recognized it as an anxiety attack that hand been going on for over two weeks. I slept for 24 hours straight but it literally almost took me down completely that morning. So no a nurse is not a Doctor.

  9. Era Helmers says:

    RN’s are no better, and probably worse. My hospital hasn’t hired an RN in 20 months..that is almost 2 years! You shouldn’t have to “Hope” when so much time and money is invested..Bottom line, no matter how much you want to be in it, the health care field is, for the moment, closed; and not just RN’s. LPN’s are gone for the most part, as everyone is an RN/BSN. In my state, over half of the nursing licenses are inactive.My advice is to do what no one on these boards has done. Talk to a WORKING nurse that works in a hospital(ER, Med Surge, ICU, etc) and ask if they have seen any new hires around for the last few YEARS, and what the job climate is. Blindly going to school on the hope it MAY lend you a better job is foolish, don’t you think? (8 years as a trauma nurse and flight nurse..and working) Bottom line, we can’t ALL be nurses. I got in at the right time. You did not. I would give it some VERY deep thought..

  10. Jessia Porst says:

    I have to say that for the last couple of hours i have been hooked by the impressive posts on this website. Keep up the great work.

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