Wednesday, October 12, 2011

Should NPs call themselves doctors?

No. It's confusing. There, that was easy.

The NYTimes opened this bag of worms recently. The blogosphere took the cue. For me the question itself fails to excite. Nurses are more trusted as a profession than doctors. Few of them are going to want to be confused with a doctor. Among those that do, most will have the common sense to realize that in the common usage, a medical doctor is a DO or an MD, and regardless of what brilliant etymological arguments one can bring to bear to illustrate that this should not be the case, it is so and a non-physician introducing themselves as the patient's doctor is going to destroy trust with that patient, who will feel deceived.

The story is more interesting for what it says about the state of healthcare today than the question getting all the attention. For instance, consider this fun fact:
For decades, a bachelor’s degree was all that was required to become a pharmacist. That changed in 2004 when a doctorate replaced the bachelor’s degree as the minimum needed to practice. Physical therapists once needed only bachelor’s degrees, too, but the profession will require doctorates of all students by 2015 — the same year that nursing leaders intend to require doctorates of all those becoming nurse practitioners.
Doctorates for all! And you're welcome to 'em. But might I ask, what for? As the article points out:

Nursing is filled with multiple specialties requiring varying levels of education, from a high school equivalency degree for nursing assistants to a master’s degree for nurse practitioners. Those wishing to become nurse anesthetists will soon be required to earn doctorates, but otherwise there are presently no practical or clinical differences between nurses who earn master’s degrees and those who get doctorates.
We have a huge labor shortage barreling down on us in healthcare, as the baby boomers move out of their healthcare jobs and into the stretcher in the hallway. Is this really the time to be raising barriers to those entering the profession?

 It would be one thing if those extra months and years were to be spent running codes in the sim lab, treating hundreds of standardized patients, or drilling deeply into pathophysiology or pharmacology. But that's not what they are doing:

While instruction at each school varies, Dr. McCarver took classes in statistics, epidemiology and health care economics to earn her doctor of nursing practice degree. These additional classes, at Vanderbilt University, did not delve into how to treat specific illnesses, but taught Dr. McCarver the scientific and economic underpinnings of the care she was already providing and how they fit into the nation’s health care system.
Nursing phD degrees focus on research skills, administration, public health. They don't go back to the basics and forge exceptional clinicians; they're not for that. It's hard to escape the gnawing sense that these are advanced degrees mostly for the sake of advanced degrees; mail-order MBAs for the ambitious and upwardly mobile healthcare worker.

I think a lot of this is about credential inflation; the tendency to value and require more and more postsecondary education regardless of whether it actually effects the person's ability to do their job. And the artificial scarcity of physicians that creates and maintains a massive hunger for mid-levels; that's in there too. I mean, if you have bright people who want to study for eight years to go work in a primary care clinic and call themselves doctors, the $64,000 question is why you don't just train them as doctors.

But those are posts in themselves, so stay turned for part two: Credential inflation in healthcare.


  1. I may be in a small percentage of nurses, but I really don't understand the NP role, especially if a doctorate is soon to be required. Less than half the pay for often as much of the responsibility.
    As a mid-level provider you have to have other sign off on your orders, yet you are responsible totally for care.
    I just don't get it.

  2. I can certainly see the attraction -- and the value to society -- when you take an experienced nurse from the bedside, put them through an intensive 18-month program, and then can use them as a mid-level.

    If you do an NP straight through, it makes a lot less sense. And if you require a doctorate, even less.

    And then there's the other, selfish problem that I have -- we've lost three of the best ED nurses we have to NP programs in the last year alone. What's going to happen to bedside care when advanced degrees are seen as the natural progression for smart and talented nurses? I would never tell someone not to seek a different role (as an EMT-B to medic to physician, I'd be a screaming hypocrite if I did) but I worry about bedside care.

    As an aside, love you blog. Thanks for visiting.