Making Room For 'Dr. Nurse'


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. Judith 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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