I work with three nurse practitioners. I think the world of all of them. The way our practice is structured, we each have a panel of patients for whom we are the primary providers, but we take care of each other’s patients when we’re in the office and they’re not. The nurse practitioners often see “my” patients, and I often see “theirs.” I have great confidence that the quality of care delivered does not vary between that provided by the physicians in our office and that provided by the NPs. Sometimes patients will mistakenly refer to one of the NPs as “Dr. X,” but it’s never served any purpose to correct them, so I don’t. What would be the point?
It does not belie my deep respect for these colleagues of mine to note that I have a lot more training than they do, any more than it would for them to note that a couple have a lot more experience than me. Both are true. I went to school for a lot longer, and also completed a residency and a fellowship. By virtue of this training, I have somewhat broader clinical responsibilities than they do. Upon my graduation from medical school (but still midway through my training), I became a physician and earned the title of “doctor.” Upon their graduation from school, they earned a master’s degree, which does not typically confer a change in title. None of these differences between my training and theirs or my title and theirs implies superiority on my part.
Further, if they decided to go back to school and complete a doctoral program like some of the nurses in this New York Times article, of course I would refer to them as “Doctor.” People deserve to be called by the title they’ve earned. In my medical school, we would be joined on rounds by PharmDs as a matter of routine, and we referred to them all as “doctor.” (They also contributed a great deal to patient care and our education, and were patently worthy of our respect.) While “doctor” in a healthcare setting typically implies “physician,” I wouldn’t begrudge others their due respect if they’d obtained a doctorate in their fields. However, with regard to nurse practitioners I do wonder what the practical value of a doctorate is.
From the article:
Six to eight years of collegiate and graduate education generally earn pharmacists, physical therapists and nurses the right to call themselves “doctors,” compared with nearly twice that many years of training for most physicians. 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. [emphasis added here, and in later excerpt]
But why?
Dr. Kathleen Potempa, dean of the University of Michigan School of Nursing and the president of the American Association of Colleges of Nursing, said that the profession’s new doctoral degree, called the doctor of nursing practice, was simply about remaining current. “Knowledge is exploding, and the doctor of nursing practice degree evolved out of a grass-roots recognition that we need to continuously improve our curriculum,” she said.
[snip]
Dr. Potempa said that nurses with master’s degrees were every bit as capable of treating patients as those with doctorates.
If you need to improve the curriculum, then improve the curriculum. But if a person as deeply involved in the issue as the president of the American Association of Colleges of Nursing can’t come up with a meaningful distinction between the clinical skills of an NP with a master’s degree and one with a doctorate, what’s the point of the doctorate? How is it anything other than pursuit of a title for its own sake? What is the doctorate adding that makes the providers better able to care for patients?
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.
Color me skeptical, but those additional classes look an awful lot like what I’d get if I obtained an MPH degree. It would help be a lot if I wanted to work in administration, or if I wanted to help craft policy. It would have much less impact on how I care for patients. Nowhere in this article is there any indication that NPs with doctorates will have additional expertise that will aid them in their clinical skills. Dr. McCarver didn’t learn any additional pharmacology, physiology or physical diagnostics. So what about her doctorate is of such value that it should become a requirement for others in order to deliver the same patient care that has been given by master’s-level NPs up until now?
I don’t think it is patriarchal or professionally territorial or chauvinistic to wonder why there would be a push to demand a doctorate of non-physician medical providers. NPs can already prescribe medication, and I really have no beef with them practicing without physician supervision. But I can’t help but suspect that this movement is driven by a desire to have a title for its own sake, which makes it seem less valuable, not more. If getting a doctorate helps NPs practice medicine better, then they should pursue it. If not, then I question the merit in and motivations behind making it a prerequisite for working in the field.
I might be showing my ignorance, but would the value of the doctorate be another zero after one’s future paychecks?
One might wonder that. However, nothing that I can see from this article explains why that additional zero would be merited, or who should be willing to pay to put it there.
It isn’t a plus zero, it is a minus zero, to the real physicians who can now be replaced (at lower cost) by pseudo-doctors, and the patients won’t know the difference – since they are all called “doctor”.
We’re already seeing this with physician’s assistants, but patients are onto the game because the name tag reads differently than the /real/ physician in the office.
Trust me, it is all about the Benjamins.
This seems ridiculous. “Keeping current” in medicine is an ongoing commitment (and a legitimate issue at all levels of practice), not a one-time set of courses and an additional degree.
I think, and hope, some of our problem with health care cost inflation can be solved by shifting patient care more to PAs, NPs, and such and requiring less MD involvement, but credentialing inflation runs counter to that.
One of the things I do is project my experience onto everybody else.
As such I suspect that your day at the office is similar to my day in the lab insofar as in any given week you are going to see 99 problems that you have seen before. Oh, yeah. This. This is the solution. Oh, yeah. That. You need to use this workaround until we get the fix from back East. Oh, yeah. That other thing. It’s supposed to do that. The reason it hurts is because it’s telling you to stop.
And so on. It’s not likely that you see something that makes you say “holy cow, what the hell is that???” but, oh, once a month or so (if that).
Am I completely off on that? (I also imagine that humans have more redundancy and more time spent on application development than the stuff in my lab but that’s another discussion.)
Additionally, when you are dealing with the same things over and over again (password resets, post downtime cleanup, gentle reminders to testers of the proper use and care of applications), you can outsource those tasks to someone who doesn’t have the most knowledge depth on the team and it *MIGHT* even be better to give those tasks to the person who is best at customer service/bedside manner… which would allow the strongest folks on the team to do their stuff.
Has my analogy broken down?
Not so far.
Jaybird is describing more than just his experience, for the record.
I get that a lot, but, being in development, I’m generally working with stuff on the bleeding edge.
Further complicating the issue is the role of the P.A. I’ve treated with a P.A. twice in the past year for what turned out to be routine problems and for all intents and purposes, the guy functioned exactly as a doctor would, with the same results I would have expected had I seen the M.D. in that practice. Why see the P.A.? Well, his fees are lower. Seems pretty much the same with with the N.P.
I think the value of the M.D. is the same as the value of having a human pilot in an airplane. Fact is, the robotic autopilot can take off, pilot, and land the airplane on its own in a normal situation. But the human is there for when things go wrong, for when unusual situations arise, situations that are factually too complicated to program into a computer. That’s why I want a doctor involved somewhere in the practice, even if I never see her.
Congratulations/Condolences on all the email you will receive now that your blog has been picked up by RWJF. Speaking of distinctions without differences, the history of the Doctor of Medicine degree in North America offers another example. British universities granted a degree in Medicine in the early-1800s. Since the degree was specialized, but not a research degree, it was called a Bachelor of Medicine degree. The persons completing this degree were call MB’s — and are still called MB’s (check with your British colleagues).
This second bachelor’s degree was adopted by universities in the eastern US at about the time of the Civil War. Being insecure colonials, we elevated the degree to a doctorate, and called the recipients MD’s. These degrees (and JD’s) are awarded in graduation ceremonies just after the other bachelor’s degrees, followed by master’s degrees, and PhDs. So the nurses with master’s degrees do outrank MDs academically. Sorry.
More readers? Fantastic!
And the history of the MD degree is interesting, but isn’t particularly relevant to the questions at hand. I’m not particularly concerned with the question of who outranks whom, which seems rather a petty thing to dispute. What I would like to know is what additional benefit accrues with a doctorate in nursing that doesn’t already come with the master’s degree. Perhaps you can enlighten me?
well, if I had my way, we’d have ’em do research, and take a course on statistics. You’ve read the stats on how many doctors can’t figure out statistical significance? Blippin scary.
We should teach statistics in high school instead of calculus.
(/brokenrecord)
Agreed.
And while I still find biostats a bit daunting, I was required to take the class in medical school.
I took two biostats classes for my MSN, I can read papers with the best of ’em, and I do. I read about 60 papers a week, across the board, because my patients will not confine themselves to neurological disorders, no matter how I beg. A Nurse Practitioner can learn anything she or he chooses to learn, I bring everything I have, the patients are depending on me.
Ah, but what would Sir Issac say to such blasphemy? Just teasing, Pat. To think as a kid, he invented sundials, wooden clocks, water mills–he even made a kite that had a small lantern in it which scared the hell out of the citizenry thinking it was a ghost flying around. And why haven’t we used his brilliant mill which ground wheat into flour and guess what powered it—MICE!! Okay, granted, musophobia probably played a role, but still…
He was a very poor student and in the field of mathematics, was completely self-taught–mastered Euclid’s Elements himself as well as inventing calculus, discovered the laws of universal gravitation, the three laws of motion, (no Newton, no rockets or jet propulsion),the solar system and celestial movements, the motion of bodies in a resisting medium, Universal Arithmetic, curves, optics, analytical geometry—not bad for a kid who was believed to be have mild mental retardation and was frequently suspended from school for his daydreaming.
Guess what else this great man did– From the first word of the Old Testament to the last word of the New Testament, he memorized every single word of the Bible! It was his passionate lifelong love—take that all you atheists!
Pat–would also make mastering harmony and counterpoint mandatory for graduation.
Newty also (supposedly) died a virgin, so there’s even some mysteries he couldn’t plumb.
There’s nothing wrong with doing both. Its not like the american mats curriculum is particularly heavy or demanding.
I meant maths
I have only once gone to an MLP (not sure if she was a PA or an NP) and the results were… lackluster. I’m not opposed to doing it again, but I think generally speaking I’ll only go to another one if the wife recommends them.
A part of me thinks “Gosh, if the MLP’s call themselves Dr it’ll be harder to tell” and that this is the point of the push towards PhD’s. To paper over a distinction *with* a different, namely MD/DO vs. PhD.
(I should note that my wife holds no ill attitudes towards MLPs. Many of them are fantastic and my wife speaks more favorably of them than some docs. There is a problem, though, that the worst of them are worse than any MD/DO’s she has worked with.)
Just to clarify, I think a doctorate in nursing is different from a PhD.
Agreed. My bad.
Part of the issue is that nurses are not physicians and physicians are not nurses. Two different but related professions. Doctorally prepared nurses are not trying to be physicians. Their care to patients produced different results than physician care.
I have been a Nurse Practitioner for over eight years, trained in primary care for the adult, I have only practiced in Neuroscience specialties, both Neurosurgery and Neurology, my patients call me “doctor” I always ask them to call me Anne, I only call them by an honorific and their last name. I see my patients alone, many of them have never met a neurologist at our practice. I think I do a pretty good job, not perfect but most of my patients are happy. I am passionate about my work, I excelled in academia, but I would only take a further degree that enhanced my care of patients, I daren’t say practice of Medicine. I will not be taking either a DNP or PhD, I don’t believe either could help me treat my patients better. I don’t give a toss for the title of Doctor, and while the PhD might help with grants I don’t need any grants.
So I heartily concur that this pursuit of further degrees is about rank and standing, and I need neither to care for, and treat my patients. And I’m pretty sure they would rather I had clinic every day than closed clinic a couple of days a week so I could obtain a degree I neither want nor need.
Thanks very much for your comment, Anne.
I’ve actually asked two of our office’s NPs about the push for doctorates among their colleagues. One said she would like to get a doctorate at some point, with an eye toward more research in her career. The other expressed sentiments very much like yours.
I’ll take this opportunity to again express my deep respect for NPs. I have worked with probably two dozen (or more) throughout my career, and have a(n almost) uniformly positive impression of them all. I think they reliably deliver fantastic care with the training (and degree) they already get. I simply don’t understand what benefit would come from requiring a doctorate.
I am currently enrolled in a DNP program, almost halfway done. The university in which I’m enrolled switched their FNP program from a master’s level to doctorate level about 2 years ago. There are certainly times that I wish that I had enrolled before the switch. Many of the clinical courses are the same. Some of the additional courses I’d call “fluff”, like leadership and informatics. However, the differences between the two programs are: 1) an additional 400+ clinical hours (about 50% more) and 2) more emphasis on translating research into clinical practice. I agree with your opinion, more pathophysiology, pharmacology, etc. type courses would add more credibility to the degree. However, I have 9 hours worth of electives that I plan on using to improve my clinical knowledge. One such course that I’ve already taken focused on managing mental health issues in primary practice.
Honesty demands that I admit that some of my classes in med school were fluff.
It certainly sounds as though your program has added clinical value to a master’s level NP program. If this is the norm for most, then the article (and people quoted) failed to communicate the benefit.
I too am in a DNP program and have found it to be a good experience. I am an FNP and found when I got my Masters there were several “fluff” classes then too. I am adding a psychiatric specialty to my family designation by going back which was the driving force to my returning to school but I have found that in this program there is a heavy emphasis on best practices and how to get that into practice and measure its success. I think for those people who are in the program as BSN students going for the DNP that they are going to graduate with a higher level of critical thinking than I did from my masters program but I don’t think that means a DNP has to be the level of entry for practice. But like teachers who are required to obtain continued education as part of their career development I think the DNP is a degree worth obtaining for advanced practice nurses
IMO, the DNP adds some clinical value. Not even close to double that of a MSN, which one would expect since the number of post BSN credits is close to twice that required for a master’s (90 vs 50ish). I think nursing at all levels would benefit greatly from the development of a true residency/internship after the completion of didactic coursework. The IOM agrees. However, based on the struggles that I’ve seen with the addition of physician residencies, probably not going to happen anytime soon.
Thank you for generating a discussion that is not just another “my profession is better than your profession” that I’ve seen ad nauseum.
I think nursing at all levels would benefit greatly from the development of a true residency/internship after the completion of didactic coursework.
I learned so much more during residency than I did during any of my didactic experiences. Adding an equivalent experience for NPs (at whatever degree level) would be a step I would wholeheartedly support.
My NP program in Ohio was very competitive to get into in 1999 and required 5 years of hospital experience post BSN. The program was 3 yrs full-time for NP (you could get a MSN in 2 years but didn’t qualify to sit for NP boards). It then required 500 hrs of clinicals during the program and 1000 hours externship after graduation to obtain the privleges to prescribe. I believe all programs have different requirements and they should be more standardized.
The doctorate is useful for those who want to teach in higher education settings where credentials are used as a shortcut to evaluating competence to instruct or conduct research.
For clinical practice though, I agree that, given the content of the DNP curriculum, it’s not much different than an MPH program.
@Kolohe. HAH!! Never thought about the fairer sex angle (no pun intended!)
But yes, that could have been his final compoundment. The unfathomable, mysterious, nature of sex and love. He also had some other contributors–he rarely slept more than two hours a night/day and when awakening he would never know what day it was. Also a junk food junkie! He was the ultimate Absent-Minded Professor! Thanks for the reply, Kolohe. Almost all of my comments get deleted, so doubt you’ll ever get this reply, but thanks anyway.
I’ll let these stay, KoG. Just don’t press your luck.
Thanks Dr. Saunders, I sincerely appreciate your good-heartedness, and have the utmost respect for you as a great physician and a good guy.
I’ve recently been hounded by Ph.Ds and MDs at Harvard Medical School–they need my genes. A long story short–certain genes have been identified as being associated with myoclonic dystonia–specifically, SGCE, DRD2 and DYT1–the nature of the mutations is not completely understood at this time but they seem to be making some progress in identifying gene mutations responsible for certain characteristics of MDystonia. I’m not Jewish, but there is a very strong prominence among the Ashkenazi Jewish population in regards to early onset dystonia.
My type of dystonia was caused by playing the piano and it migrated to both hands–it manifests itself as a perfect symmetrical, stereophonic mirror between both hands. Apparently, I’m the only person they have ever found who has this type of focal dystonia which, I guess, makes me a true freak of nature. During a fMRI experience they could see digital smearing in the sensorimotor cortex of both hands. My hands lost the ability to differentiate between which finger is which–the feedback loop doesn’t give you Bach, but complete, utter, digital chaos.
Sorry for going on so long. And many thanks for your patience.
I forgot to ask you, Dr. Saunders–have you ever treated any children with general early-onset dystonia?
I am not convinced of the practicality of the nursing doctoral degree. Given that fewer students will be able to meet the requirements of a longer program, it is likely to reduce the dwindling number of primary care providers available to take care of patients. As an aside, professors and psychologists already use the title “doctor” freely and have done so for years – it’s suddenly only a problem when nurses want to use the title. I appreciate your comments about granting those with doctorates their due respect.
I can’t really fathom why someone who had earned a doctorate wouldn’t be entitled to be called “doctor.”
I also share your concerns that making a doctorate a requirement may make becoming an NP somewhat less appealing, thus limiting the number of otherwise qualified people who would seek to pursue that career path.
The articles and debates about the DNP (doctorate of nursing practice) are truly exhausting. I am not sure why there is so much energy being placed on this issue. I am a nurse practitioner who completed my DNP. Initially, I was unsure how this degree could truly improve the care that I provided to individuals on a day to day basis. I saw the degree as a mechanism for nurse educators to increase their job security, schools of nursing to increase their financial revenue, and a potential mandate from nursing regulating bodies for NPs (nurse practitioners) to return to school. While I feel that some of these mechanisms are true in part, the debt I incurred is my only regret.
The DNP degree is a clinical doctorate and it will enhance and improve the quality of care that nurse practitioners and other nurse clinicians provide. The DNP enhances your ability to develop new ways of thinking and providing care to patients. A successful graduate of a DNP program will have the ability and qualifications to influence and develop health policy, new models of care, new leadership roles in health care as well as data and technology. All of which are extremely important aspects of health care in our society today and in the future.
Health care is more complex and no longer just involves the providers and the consumers. It encompasses a vast amount of systems such as: politics, policies and economics. I agree that most DNP programs will not improve or enhance your clinical skills, but there are various ways to make this happen such as finding a great teacher/mentor, working at an academic medical center, and diversifying your experience. We fool ourselves, if we think that having excellent clinical skills and knowledge is the only thing needed to improve our health care system and/or our health outcomes.
Thanks for sharing your experience, Karol. It’s very helpful to hear from someone who’s actually completed a DNP program.
I concur with everything you’ve said. I agree that there’s much more to patient care than simple clinical skills, and clearly a DNP helps those who earn it expand their expertise and broaden their career opportunities.
My only concern is that a DNP will become a requirement for practice. As everyone in the article bends over backwards to point out, and as I have witnessed over and over, NPs with a master’s degree deliver excellent care. I would understand an NPs decision to pursue a doctorate, but I question whether the added benefit is worth the onus of making it mandatory.
“I don’t want my wife to be cared for by just a nurse! I want her to be cared for by a DNP!”
That’s the first thought that popped into my head.
And Jaybird, at what point does experience practicing as an NP, surpass the much vaunted skills of your DNP. I’ll put my skills, any day of the week, against the skills of the DNP, and I think you might even ask me to assume care of your wife. Yes, I am that confident of my training and abilities, I am human and not infallible, but plenty of MDs consult me for their care. I need to confer with colleagues, as does any clinician but my care is that good.
Oh, Ms. Jarman, I am in complete agreement with you.
It seems to me that there are huge amounts of intangibles when it comes to health care and one of the biggest things that needs to be overcome is mistaken valuations.
The creation of a new tier of Nurses will immediately cause a re-ranking of the worth of the old established tiers… and the creation of a tier between any two tiers will elevate the one above it and devalue the one below it even if nothing else has changed.
This is a psychological response on the part of people… it works for toothpaste, it works for breakfast cereal, and it works for New and Improved NPs.
You make my point for me. The PhD track is the place for policymakers and health care global concerns. The topic asks the question does the course work for the DNP improve the quality of the practitioner clinically. In other words, will they practice medicine better for the patient. (And while I do bring a little different paradigm to the process, I am, to all intents and purposes, practicing the art and science of medicine. Read the Oregon Nurse Practice Act, or Washington State’s Act)
And as the curricula stand currently I do not believe that clinical care at the bedside or the office will be different from the MSN prepared NP. And as Karol Ellis so eloquently described, perhaps those very pursuits away from the bedside are exactly what makes the DNP superfluous for a clinical care provider. If those are the areas of interest, then a PhD track is the way to go.
On a personal note, sorry about the debt, I went the other route and worked 6 twelve hour shifts most weeks and went to school and clinicals in the time left. It was brutal on my family but I have no debt. Divorced, but no debt. And my children still love me and certainly respect me. And their work ethic is impeccable, all three.