Monday, April 14, 2008

Doctors and Nurses - Doctor Nurses

The U.S. is now 30% short of primary care doctors and nurses. As the shortage intensifies, two schools of thought about doctor nurse relationships are becoming evident, as expressed in a series of letters to the editor in the Wall Street Journal onApril 6, 2008.

1. Doctors and nurses complement and should work together as a team. Sherri Osborne, a nurse practitioner in Kernersville, North Carolina, expressed this view in a recent WSJ letter to the editor, “Each profession has a lot to learn from the other, and the problem of access to health care needs to be addressed by the physician and nursing professions working together as a team.”

3. Doctors and nurses can co-exist competing, independent professions with equal treating and admitting privileges. Carla Millis, Nurse Practitioner and president of Maverick Health in Naples, Florida, says it this way, “I fully respect the skills doctors posses, as well as their education and training. However, as a nurse practitioner, I, too, have skills, experiences, and expertise doctors don’t possess. Within my scope of practice, studies have shown my care is equal to or superior to physician care.”

4. Doctors and nurses have different backgrounds and their roles as “doctors” should not be confused. Says Edward Langston, MD, Chair of the AMA Board of Trustees. “I have the deepest respect for nurses. However, it’s an undeniable fact that a nurse with a graduate degree doesn’t have the same education as a doctor who has completed medical school and residency.”

What set off this debate? An article in the April 2 WSJ “Making Room for ‘Dr.Nurse’” The article, by Laura Landro, reports that 200 nursing schools have launched doctorates in nursing programs to produce nurse with skills “equivalent to primary care physicians.” These new doctor nurses will have two years of additional training and a year of residency beyond their nurse practitioner training.

Mary Mundinger, PhD, dean of the Columbia School of Nursing and a not-for-profit organization, the Advancement of Comprehensive Care, staunchly back the doctor nurse concept. Furthermore, the National Board of Medical Examiners is developing a voluntary Doctor of Nurse Practitioner (DNP) certificate test, similar to that given to primary care physicians, to quality, doctor nurses to practice.

It is proposed that these new nurse doctors will.

1. Have RN and NP licenses with DNP certification.

2. Be capable of managing complex diseases in hospital, ER, and office settings.

3. Concentrate on preventive and coordinating care.

4. Prescribe medications.

5. Refer to other doctors

6. Qualify for admission to medical staffs.

Whether “doctor nurses” should be considered the “equivalent of primary care physicians” is an issue that should be met head on It represents a sea change in doctor nurse relationships. There are now 125,000 nurse practitioners. Many of these could soon qualify as “doctor nurses,” as will as thousands more as nursing schools ramp up to produce more of nurses functioning as doctors.

As physicians, what are your attitudes towards this development? A good or bad thing? A potential solution to the primary care shortage? A threat to the medical professional? Please comment.


Dr. Bonis said...

In Spainard primary care system (National Health System) there is more or less a ratio of 1:1 between family physician and primary care nurse.

The nurse use to work in cronical diseases control, preventive medicine (vaccines), etc.

The nurse works independently to the doctor (but ideally coordinated with him). For example she has a room like the doctor, her own list of patients, etc, etc.

Unfortunately some nurses does want the independency but not the responsabilities. For example some of them want to be able to prescribe drugs, but do not want to do the chronic prescriptions (that is a great workload for family doctors in Spain).

They do not want to assume workload in general. In some cases (not majority) the nurse works just 5 hours per day, delegating the responsabilities to the doctor and the family physician have to work 9 hours to solve the problems of the patients under his responsability (for example).

I agree with Doctor Nurses. But take into account:

To cover more responsabilities you need more years of education. More years of education means higher salaries.

So what is the gain (in health care system terms) of having nurses working as doctors???

At the end, if you keep the salaries of nurses fixed, no nurse (or few) will want to assume the extra responsabilities.

That phenomenum (low salaries for high responsabilities and longer education period) are the root of the shortage of primary care physicians.

Gary M. Levin said...

I assume these "nurse practitoners will be licensed by individual states, just as physicians are at this time. Or will there be a federal act to supercede their licensure process? Will they be reimbursed by CMS as physicians, or have a separate code?...I assume these NPs will have to carry their own malpractice coverage and not be covered under an 'entity'.
It is obvious that physicians have been take out of the loop in setting national policy for healthcare.
I am not certain what physicians have to learn from nurses?? Sherri Osborne and Carla Mills exhibit self serving statements. No one is saying nurses are not skilled. What studies is Carla Mils referencing about the "equal or superior care of nurses over physicians.
In my limited previous experienc, "Doctors of Nursing" go on the administrative roles for managed care, or run departments, not patient care.
Mary Mudlinger is a PhD and probably has not seen a patient in many years.
If this is a sea-change about to happen then I am happy to be very near retirement.

kevinh76 said...

Once they have their Dr. Nurse, what makes one think they are going to take up primary care? They will be opening their own Botox and Laser dayspas. Regardless, since this is a heavily skewed female population, they won't be working full time, will take long breaks for childrearing and likely won't return to the workforce. If these candidates are so motivated to do primary care, why don't they just go to med school? The RNs in my med school class went into surgery, radiology, dermatology, etc... This will be of little help to maintaining high quality primary care for the future.

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