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Doctorates in Health Care, a Fight Over a

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NASHVILLE — With pain in her right ear, Sue Cassidy went to a clinic. The

doctor, wearing a white lab coat with a stethoscope in one pocket,

introduced herself.

“Hi. I’m Dr. Patti McCarver, and I’m your nurse,” she said. And with that,

Dr. McCarver stuck a scope in Ms. Cassidy’s ear, noticed a buildup of fluid

and prescribed an allergy medicine.

It was something that will become increasingly routine for patients: a

someone who is not a physician using the title of doctor.

Dr. McCarver calls herself a doctor because she returned to school to earn a

doctorate last year, one of thousands of nurses doing the same recently.

Doctorates are popping up all over the health professions, and the result is

a quiet battle over not only the title “doctor,” but also the money, power

and prestige that often comes with it.

As more nurses, pharmacists and physical therapists claim this honorific,

physicians are fighting back. For nurses, getting doctorates can help them

land a top administrative job at a hospital, improve their standing at a

university and win them more respect from colleagues and patients. But so

far, the new degrees have not brought higher fees from insurers for seeing

patients or greater authority from states to prescribe medicines.

Nursing leaders say that their push to have more nurses earn doctorates has

nothing to do with their fight of several decades in state legislatures to

give nurses more autonomy, money and prescriptive power.

But many physicians are suspicious and say that once tens of thousands of

nurses have doctorates, they will invariably seek more prescribing authority

and more money. Otherwise, they ask, what is the point?

Dr. Roland Goertz, the board chairman of the American Academy of Family

Physicians, says that physicians are worried that losing control over

“doctor,” a word that has defined their profession for centuries, will be

followed by the loss of control over the profession itself. He said that

patients could be confused about the roles of various health professionals

who all call themselves doctors.

“There is real concern that the use of the word ‘doctor’ will not be clear

to patients,” he said.

So physicians and their allies are pushing legislative efforts to restrict

who gets to use the title of doctor. A bill proposed in the New York State

Senate would bar nurses from advertising themselves as doctors, no matter

their degree. A law proposed in Congress would bar people from

misrepresenting their education or license to practice. And laws already in

effect in Arizona, Delaware and other states forbid nurses, pharmacists and

others to use the title “doctor” unless they immediately identify their

profession.

The deeper battle is over who gets to treat patients first. Pharmacists,

physical therapists and nurses largely play secondary roles to physicians,

since patients tend to go to them only after a prescription, a referral or

instructions from a physician. By requiring doctorates of new entrants,

leaders of the pharmacy and physical

therapy<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtop\

ics/physicaltherapy/index.html?inline=nyt-classifier>professions

hope their members will be able to treat patients directly and

thereby get a larger share of money spent on patient care.

As demand for health care services has grown, physicians have stopped

serving as the sole gatekeepers for their patients’ entry into the system.

So physicians must increasingly share their patients — not only with one

another but also with other professions. Teamwork is the new mantra of

medicine, and nurse

practitioners<http://topics.nytimes.com/top/news/health/diseasesconditionsandhea\

lthtopics/nursing_and_nurses/index.html?inline=nyt-classifier>and

physician assistants (sometimes known as midlevels or physician

extenders) have become increasingly important care providers, particularly

in rural areas.

But while all physician organizations support the idea of teamwork, not all

physicians are willing to surrender the traditional understanding that they

should be the ones to lead the team. Their training is so extensive,

physicians argue, that they alone should diagnose illnesses. Nurses respond

that they are perfectly capable of recognizing a vast majority of patient

problems, and they have the studies to prove it. The battle over the title

“doctor” is in many ways a proxy for this larger struggle.

For patients, the struggle has brought an increasing array of professionals

trained to deal with their day-to-day health woes, but also at times

confusion over who is responsible for their care and what sort of training

they have.

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.

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.

Last year, 153 nursing schools gave doctor of nursing practice degrees to

7,037 nurses, compared with four schools that gave the degrees to 170 nurses

in 2004, when the association of nursing schools voted to embrace the new

degree. In 2008, there were 375,794 nurses with master’s degrees and 28,369

with doctorates, according to a recent government survey.

Dr. Potempa said that nurses with master’s degrees were every bit as capable

of treating patients as those with doctorates.

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.

Nurse practitioners must generally graduate from college and take an

additional 12 to 16 months of classes, which include months of treating

patients for both mild and serious illnesses in clinics and hospitals under

the watchful eyes of instructors. Those earning doctorates must generally

take a further four semesters or 12 to 16 months of additional classes.

While instruction at each school varies, Dr. McCarver took

classes<http://www.nursing.vanderbilt.edu/dnp/courses.html#410>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. Studies

have shown that nurses with master’s level training offer care in many

primary care settings that is as good as and sometimes better than care

given by physicians, who generally have far more extensive training. And

patients often express higher satisfaction with care delivered by nurses,

studies show. Physicians say they are better at recognizing rare problems,

something studies have trouble measuring.

The benefits to patients of nurses receiving doctorates is unclear, since

there is no evidence that nurses with doctoral degrees provide better care

than those with master’s degrees do.

Given the proven effectiveness of nurses with master’s degrees, even some

nursing leaders have asked why nurses should be required to get doctorates.

“If it ain’t broke, why fix it?” asked Dr. Afaf I. Meleis, dean of the

University of Pennsylvania School of Nursing.

Some health care economists say the push for clinical doctorates across

health professions could be misguided. They argue that anything requiring

students to spend more time and money getting trained will invariably result

in longer waits and increased costs for patients, because fewer students

will meet the increased requirements and those who do will eventually demand

higher compensation.

“Everyone’s talking about improving patients’ access to care, bending the

cost curve and creating team-based care,” said Fraher, an assistant

professor of surgery and family medicine at the University of North Carolina

School of Medicine. “Where’s the evidence that moving to doctorates in

pharmacy, physical therapy and nursing achieves any of these?”

Depending on their area of specialty, nurse practitioners earn a median

salary of $86,000 to $90,000 annually, according to the Medical Group

Management Association <http://www.mgma.com/> — a bit less than half of what

primary care physicians earn. Nurses with doctorates generally earn the same

salaries as those with master’s degrees since insurers pay the same rates to

both. Physician groups fear that the real reason behind the creation of the

doctor of nursing practice degree is to persuade more state legislatures to

grant nurses the right to treat patients without supervision from doctors.

Twenty-three states allow nurses to practice without a physician’s

supervision or collaboration, and most are in the mountain West and northern

New England, areas that have trouble attracting enough physicians. Nursing

groups have lobbied for years to increase that number. “This degree is just

another step toward independent practice,” said Louis J. Goodman, chief

executive of the Texas Medical Association.

Not true, Dr. Potempa said — the new degree simply ensures that nurses stay

competent. “It’s not like a group of us woke up one day to create a degree

as a way to compete with another profession,” she said. “Nurses are very

proud of the fact that they’re nurses, and if nurses had wanted to be

doctors, they would have gone to medical school.”

via

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