Of all the nonphysician clinicians seeking additional practice rights, nurse practitioners worry physicians the most, notes AOA 2nd Vice President Joseph M. Yasso Jr., DO, who chairs the AOA Bureau of State Government Affairs. Under appropriate physician supervision, NPs provide indispensable care to patients and help redress the worsening physician shortage, acknowledges Dr. Yasso, a family physician from Lee’s Summit, Mo. But a vocal segment of NPs has relentlessly and pervasively pursued practice autonomy and other expansions of practice rights despite having training unequal to that of physicians.
Outnumbering DOs 2-to-1, nurse practitioners have secured broad prescribing authority in most states. Many states allow NPs to have collaborative practice agreements with physicians rather than requiring physician oversight. And 12 states and the District of Columbia permit NPs to independently practice and prescribe.
Beyond their strength in numbers and pursuit of practice autonomy, NPs stir up concerns because of their likelihood of being mistaken for fully licensed physicians, points out Joel A. Kase, DO, MPH, the vice chairman of the Bureau of State Government Affairs.
Unlike naturopathic doctors, who typically work in alternative medicine clinics and offices, NPs work in conventional health care settings, Dr. Kase notes. “People who go to see naturopaths typically realize that they are seeing alternative medicine providers, whereas patients who are examined and treated by nurse practitioners—in medical offices, clinics and hospitals—are apt to assume that these NPs are physicians or have equivalent training to physicians,” he says.
“Every day I observe patients calling nurse practitioners ‘doctor,’ ” adds Dr. Kase, the president of the Maine Osteopathic Association and a family physician in Auburn, Maine. “Most people are not health care literate. They don’t understand the difference between physicians and physician extenders. Nurse practitioners have used this to their advantage.”
Apprehensions about nurse practitioners being confused with physicians—and taking their place in primary care—have become magnified with the growth of NP-staffed retail health clinics and the emergence of the doctor of nursing practice (DNP) degree, which will be required of all newly licensed NPs as of 2015.
Many DOs and MDs fear that DNP graduates, who now number in the hundreds, identify themselves as doctors when treating patients, exacerbating the public’s bewilderment over the credentials of various types of health care professionals, according to Dr. Yasso. In a study conducted by the Global Strategy Group in 2008, 38% of respondents hearing the title doctor of nursing practice inferred that this health care professional went to medical school. And when nurse practitioners say they are “doctors” without first clarifying that they were trained as NPs, the potential for confusion becomes all the greater, Dr. Yasso says.
The rise of the DNP degree is one of the main reasons the Bureau of State Government Affairs submitted Resolution 298 (A/2009)—on who has the right to be identified as a doctor or a physician—to the AOA House of Delegates last July in Chicago. Eventually approved as AOA policy, this resolution triggered an hour-long debate, marked by a series of amendments to amendments to amendments—the most extensive and heated discussion of the 2009 House.
Proposing that the resolution’s title be changed from “Use of the Term Doctor” to “Use of the Term Doctor As It Relates to Physicians,” Kentucky delegate Gail D. Feinberg, DO, successfully argued that the House cannot take away the right of individuals with doctorates to call themselves doctors but can oppose misleading uses of the term in advertising and in clinical settings.
New York delegate Robert B. Goldberg, DO, was among those calling for stronger language in the resolution. “Allied health professionals don’t use kid gloves when they attack our profession and take away our practice rights,” he declared.
As finally approved, Resolution 298 stipulates that the AOA opposes the misuse of doctor by nonphysician clinicians “because such use deceives the public by implying the nonphysician clinician’s education, training or credentialing is equivalent to a DO or MD.”
“The title doctor is not owned by physicians,” says Ellen Beth Daroszewski, PhD, the director of the DNP program at Western University of Health Sciences (WesternU) in Pomona, Calif., the parent institution of the College of Osteopathic Medicine of the Pacific. “I am a doctor because I have a PhD.” She contends that physicians’ desire to reserve doctor for themselves is “ego-driven.”
Dr. Daroszewski, a nurse practitioner whose doctorate is in nursing, refers to herself as doctor in both academic and clinical settings. “Patients usually call me Dr. Ellen or Dr. D,” she says.
Dr. Daroszewski notes that she always introduces herself as an NP and corrects anyone she hears referring to her as a physician, even though California is one of 33 states in which nurse practitioners with doctorates are not legally obligated to clarify that they are NPs when patients address them as “Dr.” While she believes that most patients at the NP-managed clinic she established in San Bernardino, Calif., know that she is a nurse practitioner with a doctorate, it wouldn’t surprise her if some patients assume she is a physician.
“Patients tend to call everyone in a clinical setting ‘Dr. So-and-so,’ whether addressing a male RN, a physician assistant or even a lab technician,” Dr. Daroszewski points out, noting that most clinicians will correct the patients. She says there is no evidence that such initial confusion on the part of patients causes harm as long as patients are receiving high-quality care.
If patients mistakenly believe that they are already being treated by fully trained and licensed physicians, they may fail to seek appropriate medical care when they become seriously ill, counters Dr. Kase.
Published by the American Journal for Nurse Practitioners (AJNP) in February 2009, the latest version of “The Pearson Report” contains passages and statistics that seem to validate physicians’ misgivings about NPs’ intentions. “NPs must continue to strive to remove statutory restrictions that prohibit NPs with earned doctorates from being addressed as ‘doctor,’ ” writes Linda J. Pearson, MSN, the report’s author and a consultant to the AJNP.
“The Pearson Report” gives each state and the District of Columbia a grade from A to F, with A signifying the most autonomy for NPs, based on whether NPs with doctorates can be addressed as “Dr.,” require physician involvement in any aspect of practice, have the authority to prescribe controlled substances, have hospital privileges, and satisfy more than a dozen additional criteria.
“To call oneself a doctor is a far cry from being a physician,” contends Dr. Goldberg, the dean of the Touro College of Osteopathic Medicine in New York City, as well as a former president of the Medical Society of the State of New York. “The health hazards posed to patients are great when people seek medical care from limited-practice individuals in the belief that such individuals are physicians.”
To thwart such arguments, “The Pearson Report” purports to demonstrate that NPs have much better patient-safety records than do DOs and MDs. The report draws on data from the National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank, which compile the number of accumulated malpractice judgments and adverse actions, licensure actions, civil judgments and criminal convictions levied against NPs, DOs and MDs. Pearson computed the ratio of the number of accumulated reported occurrences against NPs, DOs and MDs during the previous 18 years to the number of NPs, DOs and MDs who were in practice. When she applied this formula to malpractice judgments and adverse actions, the “overall national occurrence ratios” were 1 in 173 for NPs, 1 in 4 for DOs and 1 in 4 for MDs. Applying the same formula to adverse action reports, civil judgments and criminal convictions yielded the ratios of 1 in 226 for NPs, 1 in 13 for DOs and 1 in 23 for MDs.
“NPs must use these malpractice and malfeasance ratios and figures to show legislators that the rationale for physician supervision over NPs in unfounded,” Pearson emphasizes in her report.
But physicians shoulder more responsibility than NPs, perform riskier procedures, treat more seriously ill patients, and correct the errors of NPs under their supervision, Dr. Yasso argues. In addition, trial lawyers prefer to target physicians with malpractice lawsuits because they have more substantial professional liability insurance coverage than NPs typically have.
Dr. Daroszewski insists that nurse practitioners are forced to defend themselves against repeated attacks from physician organizations on NPs’ training, ability and patient-safety records. She also points out that dentists, podiatrists, clinical psychologists and other doctoral-level clinicians have long used Dr. titles in their practices without triggering the physician outcry that “doctor nurses” have.
Coinciding with the establishment of Medicare and Medicaid, the first nurse practitioners were trained in 1965 to help relieve shortages of primary care physicians, particularly pediatricians.
To become NPs in the early years of the profession, registered nurses completed additional schooling that ranged from an intense four-month continuing education program at a university to a two-year nursing school master’s degree program. By 1986, NPs needed at least a master’s degree in nursing.
A key factor in nurse practitioners’ growing momentum, the Balanced Budget Act of 1996 gave NPs the authority to bill Medicare for their services anywhere in the country and in any practice setting allowed by state laws. Their numbers surging from approximately 250 NPs in 1970 to almost 90,000 in 2000 to more than 139,000 today, nurse practitioners have promoted themselves as both serving the underserved and providing lower-cost yet high-quality and safe health care.
While some nurse practitioners today do practice in physician shortage areas, the overall geographic dispersion of NPs resembles that of physicians, according to research by the American Medical Association.
Ronald H. Kienitz, DO, who practices occupational medicine in Honolulu, notes that in pushing to expand their practice rights state by state, nurse practitioners continue to insist that they will improve access to health care. “We have a word for this in Hawaii: shibai, meaning pure unadulterated b.s.,” says Dr. Kienitz, the immediate past president of the Hawaii Association of Osteopathic Physicians and Surgeons. “Nurse practitioners don’t tend to practice in physician shortage areas. They tend to practice in urban areas and compete with fully licensed physicians.”
The immediate past president of the Idaho Osteopathic Physicians Association, Kathleen M. Farrell, DO, dismisses NPs’ argument that they provide more cost-effective care than do physicians. While nurse practitioners draw lower salaries and charge lower fees on average than do physicians, they do not reduce the overall cost of health care, says Dr. Farrell, who practiced family medicine at Valley Family Health Care, a rural clinic in New Plymouth, Idaho, until February.
“Both nurse practitioners and physician assistants tend to increase the cost of medicine by ordering extra tests,” Dr. Farrell says, noting that she observed the work of NPs and supervised PAs during her four years at Valley Family Health Care. “They don’t have the training and experience to rule things out.”
DNP degree takes hold
The dean of the Columbia University School of Nursing in New York City from 1984 through 2009, Mary O’Neil Mundinger, DrPH, has been among the foremost champions of both the autonomous practice of NPs and doctoral level clinical nursing. In 2000, she organized the Council for the Advancement of Comprehensive Care (CACC), which describes itself as “a consortium of distinguished health policy leaders who are committed to assuring high standards of doctoral nursing practice.” Four years after the CACC’s formation, the American Association of Colleges of Nursing (AACN) mandated that by 2015 all entry-level NPs and other advanced practice nurses obtain DNP degrees.
Currently, 123 universities with nursing schools have DNP programs, according to the AACN. Among the parent institutions of osteopathic medical schools, three offer the DNP degree: Touro University at its campus in Henderson, Nev., and Ohio University in Athens, as well as WesternU.
Especially worrisome to the AOA, the AMA and other physician organizations, the CACC has partnered with the National Board of Medical Examiners (NBME) to develop a voluntary certification examination for DNPs that is based on the blueprint for Step 3 of the United States Medical Licensing Examination (USMLE). However, the examination is shorter than USMLE Step 3 and has different standards for passing.
Many osteopathic physicians question why the NBME is involved in an examination for certifying NPs, who are licensed and regulated by state nursing boards not state medical boards, notes John R. Gimpel, DO, the president of the National Board of Osteopathic Medical Examiners."The other concern has been the misrepresentation by the CACC that this examination is equivalent to the examinations taken by physicians," Dr. Gimpel says.
Indeed, many DOs suspect that the DNP degree and certification exam constitute a deliberate attempt to mislead the public into thinking that DNPs are equivalent to physicians, Dr. Yasso adds.
Dr. Mundinger seemed to corroborate such suspicions when she was quoted as follows in the Jan. 16, 2009, issue of the Chronicle of Higher Education: “If nurses can show they can pass the same test at the same level of competency [as physicians], there’s no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients.”
“If nurses want to be doctors, they should go to medical school,” Dr. Yasso contends.
“My students are training to be doctors of nursing practice—they don’t want to be physicians,” counters Dr. Daroszewski. The nursing model of doctoral level practice focuses on population health, disease prevention, and whole-person care, she explains, noting that students in DNP programs become skilled in information technology, health policy, professional collaboration, leadership, clinical inquiry and research translation, in addition to increasing their clinical practice knowledge.
In fact, Dr. Daroszewski objects to the NBME’s DNP examination, which she does not encourage WesternU DNP graduates to take, because it is based on an examination for physicians. “Although I have great respect for Mary Mundinger and what she has done for our profession, I disagree with her about the need for this exam,” Dr. Daroszewski says. “Mary argues that DNPs need the exam because as nurse practitioners, we are constantly pressured to prove ourselves, to prove what we can do. But we already have a credentialing process for our profession.”
The NBME’s DNP examination has been slow to catch on. In 2009, only 19 DNP graduates took the exam for the first time, with 57% of them passing, according to the American Board of Comprehensive Care, which was established by the CACC to oversee DNP certification.
Lawrence Edward Suess, DO, PhD, an AOA health policy fellow, completed his PhD in nursing in 1989, two years after earning his DO degree. A child and adolescent psychiatrist in Hanson, Ky., Dr. Suess asserts that it is important for physicians to understand that the nursing profession faces many of the same pressures that osteopathic and allopathic physicians confront. The DNP degree evolved in part because nursing has to keep up with a growing body of knowledge, he notes, as well as respond to the demand for safer, more cost-effective evidence-based health care, spurred by a series of reports by the National Academies’ Institute of Medicine, beginning with To Err Is Human: Building a Safer Health System in 1999.
Moreover, the nursing profession needed to counter criticism that NPs were educated only to the master’s degree level while other health care professions increasingly are requiring doctorates, Dr. Suess explains, citing the example of pharmacists now needing PharmD degrees to enter their profession.
Dr. Suess cautions physicians against ascribing deceitful motives to nurses obtaining DNP degrees. Most NPs are well-trained, he adds, urging his physician colleagues not to focus on a few “bad apples.”
In 2006, two years after the AACN announced its DNP mandate for advanced practice nurses, the AMA established the Scope of Practice Partnership (SOPP), a coalition of national, state and specialty medical associations dedicated to studying the qualifications of “limited licensure health care providers.” The AOA participates in the partnership and contributes to the SOPP-supported AMA Scope of Practice Data Series. This series, which includes a module on nurse practitioners, is intended to provide the data needed by medical associations and physicians to educate policymakers on the training disparities between nonphysician clinicians and fully licensed physicians.
In addition, the Scope of Practice Partnership strives to enact “truth in advertising” legislation that would require nonphysician clinicians to clarify that they are not MDs or DOs in all marketing communications. The SOPP also supports state medical associations and medical specialty societies in their battles to stop scope-of-practice advancements at the state level.
The partnership sparked immediate outrage from many nonphysician clinician organizations. The American Academy of Nurse Practitioners (AANP) spearheaded the formation of the Coalition for Patients’ Rights (CPR), which now consists of more than 35 organizations, including 26 national nursing organizations, as well as organizations representing naturopathic doctors, chiropractors, psychologists, occupational therapists, physical therapists, optometrists, and audiologists and speech pathologists.
“We call upon the SOPP member organizations to cease their divisive efforts,” urges the CPR’s position statement. “It is inappropriate for physician organizations to advise consumers, legislators, regulators or policymakers regarding the scope of practice of licensed health care professionals whose practice is authorized in statutes other than the medical practice acts.”
Issuing a draft of its nurse practitioner module in October 2009, the AMA solicited feedback from the NP community. “The document contains numerous factual misrepresentations and misleading conclusions,” 20 nursing organizations wrote back on Dec. 8, 2009. “We do not accept the AMA’s attempt to change the perceptions of NP practice as anything other than fully qualified professionals working within a legally established scope of practice.”
Team approach to care?
Despite the rancor engendered by both the Scope of Practice Partnership and the Coalition for Patients’ Rights, both sides express commitment to the team approach to care.
“Nurse practitioners have a lot of respect for physicians,” Dr. Daroszewski says. But because fewer physicians are entering primary care, NPs have to help fill that void, she notes.
AOA Trustee James J. Dearing, DO, agrees that nurse practitioners are a critical part of the nation’s health care system. With the gap between the demand for primary care services and the supply of primary care physicians widening, countering NPs’ scope-of-practice advancements has become increasingly difficult and even ethically ambiguous, acknowledges Dr. Dearing, who preceded Dr. Yasso as the chairman of the AOA Bureau of State Government Affairs. “This is not a black-or-white issue,” he says.
Dr. Dearing, who oversees nurse practitioners in his Phoenix family medicine practice, notes that NPs can become highly skilled in the tasks they perform repeatedly, whether taking patient histories, performing physical examinations, prescribing medications for routine ailments, or providing follow-up care. “There are a lot of things they can do as long as they are properly supervised,” he says.
But nurse practitioners sometimes “miss the subtleties” that physicians discern because of physicians’ more extensive training, Dr. Dearing maintains, noting that he periodically has to modify recommendations made by NPs on his staff.
Dr. Farrell has found NPs to be “too quick to jump on the bandwagon” when it comes to new drugs. She says that the nurse practitioners she has worked with lack the training to look at research studies critically and that they are more likely than physicians to accept without question the sales pitches of pharmaceutical representatives.
Dr. Suess, on the other hand, finds osteopathic physicians’ overall attitude toward NPs to be overly defensive. “We need to take the high road,” he urges. “Let’s worry about our own profession of osteopathic medicine. We must provide the best possible care based on research evidence that is replicable. We must produce clinical outcomes that prove we are worthy of our doctor title.”