As NPs push for expanded practice rights, physicians push back
- Posted March 19, 2010, 12:02 p.m.
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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.