As NPs push for expanded practice rights, physicians push back
- Posted March 19, 2010, 12:02 p.m.
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“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.
The DO and other AOA publications use the title Dr. for all individuals with a doctoral degree in an established field.
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.