On Making The Nurses Behave

Posted on June 26, 2009
Filed Under Primary Care in America |

Here’s a Podcast of this post:

 
icon for podpress  On Making the Nurses Behave [11:48m]: Play Now | Play in Popup | Download (299)

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DrRich does not quite know whether to be dismayed or amused by an article appearing earlier this month in the venerable trade journal, AMANews*, decrying (their word) the recent alleged propensity of Doctors of Nursing Practice (so-called Doctor Nurses) to sow confusion about the meaning of  the word “doctor.”

As a frequent purveyor of irony himself, DrRich is open to the possibility that the writer of this article meant to make the “physician leaders” quoted therein seem particularly whiny, in order to shed subtle light on the utter bankruptcy of their position. But alas, DrRich suspects instead that the article is presenting in an entirely straightforward fashion the actual behaviors and sayings of said physician leaders, in reaction to what they see as an overly-aggressive (and “not accurate”) stance taken by certain nurses as they seek to elevate their own profession. If this latter interpretation is the case, as DrRich believes that it is, then he is dismayed (and/or amused) to see that the medical profession’s strategy when defending itself against what it sees as an existential threat has apparently been reduced to the same strategy employed by the United Nations whenever it is faced with similar threats - the issuance of the dreaded Strongly Worded Letter.

The issue at hand, of course, is that Doctor Nurses (those members of the nursing profession who have achieved, through advanced training, the degree of Doctor of Nursing Practice, or DNP) insist on referring to themselves as “doctor,” and also that they have issued “misleading” statements implying that their certification examination (written and administered by the highly-respected National Board of Medical Examiners, NBME), is the same in content and format, and that it measures the same set of competencies, as the certification exams taken by physicians. Specifically, according to the AMA, statements issued by the Council for the Advancement of Comprehensive Care (CACC, the nursing leadership group responsible for contracting with the NBME) were “deliberately misconstrued to imply there was equivalence between nurses and physicians.” And also, of course, DNPs should stop referring to themselves as doctors.

To rectify this awful situation, the “AMA and dozens of state and specialty medical organizations are asking the NBME to mandate that nursing groups clearly spell out the differences between the DNP and physician exams.” (DrRich himself is well aware of this tactic, having used it frequently himself as a child, whenever his little brother was annoying him. Unfortunately, his “Mommy Make Him Stop” tactic seldom achieved its desired results.)

Furthermore, the AMA House of Delegates is threatening “to consider. . . a resolution proposing to explore alternative physician licensing testing options.” That’s pretty serious. When one threatens to consider a resolution proposing to explore taking some action, as DrRich calculates it that’s merely five steps away from actually taking the action. The poor nurses must be quaking in their old-fashioned, boxy white shoes.

One can easily perceive why DrRich initially wondered whether the AMANews article was employing an ironic tone.

It is pretty easy to predict the reaction of the nursing leadership - and also of the NBME - to such severe, strongly worded objections. It is very similar to the response the U.N. often gets from those tiny third world countries, whose behavior it dislikes, after it has threatened to explore the possibility of considering various resolutions of disapproval, etc.  In these cases the response to such threats is very often nearly the same, to paraphrase, Screw Yourself.

While apparently Mary Mundinger (DrPH, RN, dean of the Columbia University School of Nursing, President of CACC, and bugaboo of physicians everywhere) did not make herself available to the AMANews for a direct response, she was quoted in an earlier article as saying, “If nurses can show they can pass the same test at the same level of competency, there’s no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients.”

C. Fay Raines, PhD, RN, and dean of the University of Alabama in Huntsville College of Nursing, points out that Doctor Nurses are, in fact, doctors. “Transparency is important, but the term ‘doctor’ is not exclusive to physicians,” she says. DrRich finds truth in this statement, recollecting that his phys ed instructor in high school was cheerfully addressed as “Dr. ___” by one and all, upon the pain of five laps. If this individual deserved to be called doctor, then Doctor Nurses deserve the same honorific, by several orders of magnitude.

And as for the NBME (the “mommy” in the “Mommy Make Him Stop” tactic), representatives of this organization also saw fit not to talk to AMANews. But in an earlier response to physicians’ concerns about its underhanded collaboration with the nurses’ attempts to confuse poor, unsuspecting patients, the NBME said, “Current and future patients of these nurse clinicians deserve a system that assures them that the clinician providing services meets appropriate quality standards. Our support for the DNP assessment process helps provide that assurance.”

Well.

What are the AMA and other physician organizations supposed to do when their traditional and time-honored methods of putting nurses in their place - blustering and fulminating at them from their elevated position of authority - no longer work? DrRich is put in mind of video of the Romanian dictator Ceausescu, taken mere moments before his summary execution. DrRich recalls the look on his face at the moment it begins to dawn on him that that he really is no longer in charge, and that he is, in fact, well and truly screwed. The article in AMANews presents a similar visage to the world.

DrRich’s message, which he has delivered many times before, is to individual physicians (especially to those of the primary care persuasion) and not to their professionally bankrupt organizations. Your leadership has allowed your profession - primary care medicine - to become devalued to the point where it is not logical, feasible, or ethical for you to try to block the ascent of nurses. Well-trained nurses can follow prescribed treatment guidelines every bit as well as you can - probably better. You should do nothing to impede their sincere attempts at getting the advanced training they need, and the professional certification they deserve. It appears that they will be supplying primary care to American patients - possibly most of the primary care - in coming years. The rear-guard actions of your professional organizations to prevent this will fail, and will merely make you look ridiculous. Just read the article in AMANews to see exactly how ridiculous.

You are fighting history when you try to impede these nurses. The nurses are just fulfilling their rightful destiny in a technological society, where new knowledge and new tools allow individuals with progressively less special training to carry out jobs that heretofore required experts. Rather than wasting precious time and energy trying to hold back those behind you, figure out how (DrRich suggests how here) to parlay your superior training and knowledge - and it is superior - into a new role within the healthcare system, one where you and the doctor-nurse-primary-care-practitioners (whatever they end up calling themselves) can complement each other rather than compete with each other. This would be the best thing for you, for the nurses, and for the patients.

Oh, and get yourself some new leadership.

*DrRich is among the large majority of physicians who is not a member of the AMA. In fact, to the best of his knowledge none of his physician friends or acquaintences are members of the AMA, either, at least, not that they’ll admit to. He does, however, read the AMANews regularly, inasmuch as DrRich remains intrigued with the schizophrenic machinations of the AMA, in its need to seem politically relevant (resulting in sundry liberal-sounding statements of principle), while at the same time being obligated to strive mightily to hold the old guild together.

Comments

9 Responses to “On Making The Nurses Behave”

  1. Red Baron on June 26th, 2009 6:58 pm

    Ah Rich, I hadn’t been by in a while so I thought I would stop by and see what you were up to. Today’s post really gave me a big chuckle. And by the way, I couldn’t agree more.

    Keep up the good work but more importantly please be well.

    Red

    PS- I am not an AMA member either.

  2. Hal Dall, MD on June 26th, 2009 11:41 pm

    In a few years, Mary Mundinger will be sending the strongly worded letter. The occasion will be the transfer of the National Guideline Computer’s algorithms from newly unemployed DNPs to the DCNAs (DCNA=Doctor of Certified Nursing Assistant, 10 hours clinical work required).

  3. annie on June 29th, 2009 12:07 pm

    You know I can’t resist:

    It would behoove physicians and nurses (of all stripes, degrees and titles) to quickly identify common interests and opportunities for collaboration instead of continuing to lob spitballs at one another.

    The economy of numbers speaks to me, and I hope to you: 2.9 million licensed registered nurses (about 2.7 are practicing) and about 750K MD/DO’s licensed (don’t know how many are practicing).

    Together, that makes a formidable informed special interest group. Apart, just a lot of sturm and drang with self-destructive tendencies (See DrRich/sternly worded letter).

    And, not for nothing - if nurses’ practice conditions and patient case loads were tolerable, safe and manageable, and clinical career advancement opportunities were sufficient, nurses wouldn’t be likely looking to become shadows of physicians. When nursing is practiced without much external non-nursing interference and with sufficient professional support and development, patients and nurses are empowered, and the profession is more than amply rewarding as a distinct, but complementary to medicine, profession.

    Just sayin’

  4. Barbara Olson on July 7th, 2009 4:10 pm

    Just wanted to let you know I included your post in one I put up this afternoon. Thanks for the cross-discipline practice endorsement! Here’s the link to my post at the Medscape blog: http://boards.medscape.com/forums?128@@.29f49698

    Best,
    Barb

  5. Dr. X on July 8th, 2009 5:51 pm

    DrRich,

    LOVED the blog on “doctornurses.” I used to argue all the time with the “primary care thought leaders” in my Internal Medicine residency program, as with them everything was “primary care this” and “primary care that.”

    One day I got so P.O.’ed at my staff physician (who is a brilliant internist but was drinking too much of the primary care koolaid) that I screamed: “LOOK at your Residency Certificate!! it will say you have completedd training in INTERNAL MEDICINE, and not “primary care.”

    LOOK at your Board Certification!!! it says you are Boarded in “Internal Medicine” and doesn’t say a damn thing about “primary care.”

    Let the doctornurses and the nursenurses and the chiropracters and the podiatrists and the psychologists and the hugtherapists and the optometrists and everyone else claim to be doctors if they want to . . . I will practice REAL Internal Medicine in a REAL HOSPITAL and bill for my REAL services to my REAL sick patients. That is what I was trained to do.

    Let these pretenders try and do it if they want to . . . it will be simply chum in the water for the soon-to-be-medical-malpractice feeding frenzy of the plaintiff attorneys . . . !!!!

  6. anon on July 11th, 2009 5:35 pm

    “a few years, Mary Mundinger will be sending the strongly worded letter. The occasion will be the transfer of the National Guideline Computer’s algorithms from newly unemployed DNPs to the DCNAs (DCNA=Doctor of Certified Nursing Assistant, 10 hours clinical work required).”

    HAHAHAHA

    Classic and right on!

  7. RN Darren on July 15th, 2009 4:24 pm

    As a Registered Nurse in Australia, what can I say. Isn’t it time as healthcare professionals that we moved beyond the stereotypical behaviours of the “different” professions, and looked towards what is really important- providing the best healthcare available to the patients that we care for. Yes, I understand that the medical profession claims ownership of the title “Doctor”, but let’s give credit to those who have worked hard to achieve that title- one that’s earnt, and not one that is bestowed as an honorship like it is for the medical profession. In Australia, you need to have a bacclaurate degree to be a physician. I understand that the nurses in question have undertaken a doctorate, which really is a higher degree anyway!

  8. stephanie dyer on July 15th, 2009 11:03 pm

    Darren et al - as a BSN, RN lapsed, MD- trust me, the doctorate of the medical profession in the US is NOT honorific. Most of the nurses in this country couldn’t do the first week of our med school. In the states, the title doctor means a doctor of medicine, not a PhD of ANY discipline. You wanna be called doctor GO TO MED SCHOOL OR SHUT UP. But I do agree with the post regarding chum for the malpractos.
    Anesthesia has been warning of this for many years- folks laughed. We had research that showed the dangers- nobody cared- because they never thought it could happen to them. Ain’t life grand….

  9. Allie on August 1st, 2009 7:59 am

    As a RN,MSN,NP who is enrolled in a DNP program at present, I find it so intriguing that the flap seems to be about the title ‘doctor’. Who cares what we’re called? And why are many MDs so very insecure and protective about their role, title and domain? Is this a leftover from the old ‘keep nurses in their place?’

    We have a shortage of providers in this country. If NPs can provide excellent care within their scope of practice in order to provide better access to healthcare … where’s the problem? Why are we being attacked and maligned for wanting to further our education so we can provide better care to our patients? Is our goal not the same here? Why are we not focusing on the patient and how well they’re taken care of?

    All Allied Health professions are moving to the earned doctorate as entry level degrees - pharmacy, audiology, physical therapy and soon physician assistant. Do many physicians have a problem with these people using the title of their earned doctorate?

    How will I introduce myself to my patients? By my first name and whole title, as I have always done. I will just hope that I will be more educated, more competent, and better able to serve the needs of my patient.

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