Universal board certification can solve the Doctor Nurse controversy

Universal board certification can solve the Doctor Nurse controversyI’m going take on the Doctor Nurse controversy.

This isn’t a new issue, as the doctorate in nursing degree has been around for awhile. But a recent piece in the New York Times gave it new life.

The topic is a ripe invitation to “doctor bash,” with the predictable arguments about physicians protecting their turf, elitism, and the like.

Yawn.

To sample the representative comments, consider those in the Times’ health blog, Well.

To recap, doctors are worried that diluting the doctorate pool would confuse patients, and accuse Doctor Nurses of ulterior motives:

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.

Physicians, as always, are being reactionary and playing from behind the public relations curve. Those who earn a doctorate degree, whether it be in nursing, pharmacy, or psychology, deserve to be called “doctor.” Period.

What medical doctors need to do is to differentiate themselves and emphasize their more extensive training. The answer?

Universal board certification.

Have all doctorate-level clinical providers take the same board certification exam. It should be as rigorous as the ones currently provided by the American Board of Internal Medicine or the American Academy of Family Physicians in primary care, for instance. Those that pass truly deserve to be called “doctor,” no matter what their background.

Another, admittedly more realistic, option is to educate the public about the different “doctors” who may be treating them. Let them know that not all board certifications are alike. Physicians certified by the American Board of Internal Medicine have different training requirements from those board certified with a doctorate in nursing. It is up to physicians and our professional associations to emphasize and publicize that.

Trying to monopolizing the doctorate degree is a losing public relations strategy. What differentiates physicians is their more extensive training, symbolized by board certification status. We need to proactively capitalize on the strength, instead of reacting to the current trend of doctorate creep.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Anonymous

    Patients will figure out what the initials after our names represent and what is important to them in seeking out health care.  It doesn’t bother me a bit for other health care professionals to be called “doctor” when they have achieved an advanced degree in their respective field.  We’ve always had Dr. Naturopath, Dr. Chiropractor, Dr. Osteopath, Dr. Dentist, Dr. Oral Surgeon, Dr. Psychologist.  This is only an expansion of that variety of professional doctorates.

    You are right, Kevin.  If physicians are going to get sensitive over this, we are only inviting more criticism and physician-bashing.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      BriarCroft….”Let’s give our patients some credit for intelligence here. They
      will figure out what the initials after our names represent and what is
      important to them in seeking out health care…..”

      Nope. Well, the intelligence part, of course they’re intelligent. Nevertheless, day in and day out, I get patients who refer to their nurse, their PA, as “Doctor”. Gets frustrating, when I’m trying to find the address of a doctor who doesn’t exist.

      In my community, the nurses have held themselves out as specialists, let alone doctors. One here called herself a rheumatologist, because she had an interest in arthritis. That one went to the medical board and earned a formal retraction in the newspapers.

    • Blake Windsor

      Many patients are intelligent, but still call female doctors nurses and male nurses doctors.  They just don’t think about it. 

      The difference between Dr. Naturopath, Dr. Chiropractor, etc… is the sheer number.  It takes 15-18 months of (frequently) online coursework done at home after working their day job to get a doctorate of nursing.  And with all nurse practitioners being required to get a doctorate, I imagine that they will streamline the whole process and have them out in 3 years post undergrad.  With that turn over, soon physicians will be the minority of the “Doctors”.

  • Anonymous

    What patients desire is personalized attention. They want to be listened to. They want a thorough history taken and physical examination performed. They not only want a discussion of symptoms and illnesses, but also the doctor’s opinion of root causes of these. Whomever fulfills these desires, wins a loyal and proactive following, in partnership together towards common health goals. Nurses sometimes fit this profile better, but many physicians do as well. With healthcare consumers’ choices expanding, the marketplace will place a premium on better service and for optimizing results. Most physicians and their employers, now more often large groups practices or hospital based will soon learn about competitive market forces. Less emphasis has been placed over the last 3 decades on the art of medicine. There are some consequences to this transactional approach to medicine that put physicians at risk for greater competition.

  • Anonymous

    I agree – anyone who earns a doctoral degree deserves to be called “doctor.”  But I disagree re universal certification, at least as you propose it, which implies all disciplines must meet medical criteria. That won’t fly nor should it.  I also disagree re your statement that “what differentiates physicians is their more extensive training” and board certification status.  Not true, as within other disciplines, there are advancement tracks that require extensive training and certifications.  What differentiates each disclipline from each other is their areas of study and research and approaches to practice.
     Nurses, physicians, dentists, osteopaths, psychologists, physical therapists, etc all have right to practice according to their education and expertise and there are licenses to protect patients from those who do otherwise and oversight boards to monitor compliance.  As far as “turf”, there are plenty of patients with lots of needs.  At different times, some will need doctors who are physicians, and some will need doctors who are physical therapists or nurses or psychologists…..there’s room for everyone.

  • Anonymous

    I agree – anyone who earns a doctoral degree deserves to be called “doctor.”  But I disagree re universal certification, at least as you propose it, which implies all disciplines must meet medical criteria. That won’t fly nor should it.  I also disagree re your statement that “what differentiates physicians is their more extensive training” and board certification status.  Not true, as within other disciplines, there are advancement tracks that require extensive training and certifications.  What differentiates each disclipline from each other is their areas of study and research and approaches to practice.
     Nurses, physicians, dentists, osteopaths, psychologists, physical therapists, etc all have right to practice according to their education and expertise and there are licenses to protect patients from those who do otherwise and oversight boards to monitor compliance.  As far as “turf”, there are plenty of patients with lots of needs.  At different times, some will need doctors who are physicians, and some will need doctors who are physical therapists or nurses or psychologists…..there’s room for everyone.

    • Close Call

      I have yet to hear how a someone who has a doctorate in nursing would approach medicine differently than a family medicine physician.

      Applying the biopsychosocial model of medicine? Check. 
      Being a patient advocate and caring for someone from birth until death? Check.
      Taking into account a patient’s finances, social situation, role in the family, and cultural preferences? Check.

      I wonder where the medical home model came from?  (actually, I think that was peds, but who says there’s a monopoly on good ideas)

      And the classes on statistics, epidemiology, and health care economics… well, that’s being taught in med school now too.  

      You should talk to these youngsters coming out of family medicine residencies now-a-days.  If they thought you needed an acupuncturist, they’d refer you off in a flash.  Wouldn’t even bat an eye.  Really, really granola-y and full of bio/psycho/social/cultural feel-goodery.  

      These youngsters even learning to spurn pharma now!  And I say good for them!  Well, I guess that’s one difference between an NP and a family physician.  NPs sure still don’t see much wrong with the free lunch…

      http://www.policymed.com/2011/02/nurse-practitioners-and-the-pharmaceutical-industry.html

       

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    From the linked NY Times article:
    “…..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…..”

    The docs are just jealous that they had to waste all that time on call taking care of patients and taking responsibility for their decisions.

    • http://pulse.yahoo.com/_DB2ZZIMLXLEPDUKD7NJMQI34ZQ Been there

      No, they are annoyed that they wasted all that time taking generic biochemistry classes and memorizing, memorizing, memorizing!

  • http://twitter.com/PolicyRx Policy Prescriptions

    The idea of board certification will probably only add to the confusion – especially if DNP boards are separate from MD/DO boards. If DNPs want to call themselves “doctor”, hang their own shingles, and set up shop next to physicians I think most doctors will still have full appointment schedules and plenty of patients to see. 

    Doctors, er, physicians: are we really worried about public confusion, or its it professional self-preservation, or genuine concern for patient safety? If it’s about safety: My earlier post on KevinMD about nurse practitioners and physician assistants (http://www.policyprescriptions.org/?p=1670 or http://www.kevinmd.com/blog/2011/07/role-nonphysician-clinicians-primary-care.html) should allay some fears that we MDs have towards the clinical effectiveness of non-physician clinicians/MLPs (whether they are “doctor-nurses” or just regular NPs).If we’re just worried about self-preservation: physicians better find some other value to add aside from just taking care of patients because the policy makers out there don’t care about physicians being the highest paid professionals out there just because we wasted a bunch of our time learning biochemistry and goofing off during 4th year medical school. If it’s about confusion: why don’t we restrict the use of the long white coat? Plenty of patients think the nursing supervisors and case managers are doctors anyway.  We could easily end the confusion if we just start calling ourselves PHYSICIANS again.

  • http://twitter.com/mtdoonmeister Doc Holliday

    As a paramedic who has a doctorate I would never insist on being called anything. I show up in the shiny ambulance with flashing red lights and I still get mistaken for ‘EMT’; nurse; or doctor – although my nickname is ‘Doc,’ which makes it worse at times. Over the years I have been a paramedic, I have seen nurses lust after what I do. It’s like they want to overtake every  aspect of healthcare.

    I think it is important to realize: ‘doctor’; nurse; family nurse practitioner; paramedic; respiratory therapist; physical therapists; are not titles, they are job descriptions. You can get all the education in the world and you still will have the same job description. I don’t see my MD friends being threatened by my abilities in the practice of pre-hospital care or because of nurses abilities; because they realize, however well educated they are, pre-hospital care is my ‘job description and my love. Effective delivery of pre-hospital care will deliver critically ill or injured patients with much less morbidity than in the ‘old days’ The MDs and nurses I work with recognize that and embrace me for my speciality. As I embrace them for their ability to participate in a team that works to reduce morbidity and mortality in the patients we treat.

    In my experience, there is a great deal of title bigotry in medicine. It is based on hierarchies. Doctor; nurse, (including FNPs); pre-hospital care specialists – paramedics; and technical allied health professionals. Doctors are trying to maintain this hierarchy from the top down. It is pretty sad when Doctors think their titles earn them their place in the hierarchy of medicine. So are nurses. So are some paramedics. 

    This is stupid. We all go in there, in a concerted effort, to treat the patient. I am not a better person than you are, because of my education. You are not a better person than I am because of your education.

    My suggestion is that we call everybody, “Ralph,” or whatever their first name is. I have done this for years. Health care professionals know which person is the MD, which doctor is the nurse, etc. (My view on this is different, but no less valid, because one of the reasons I choose to a paramedic was the short duration of care for each patient. That and I, mostly, deal with patients who are critical so I get to know critical care doctors, rather than family practice physicians. I do everything to ensure my patients arrive alive in the ED. I may know how to keep MVA patients alive, but I will never replace the surgeon – no matter how much education I have – because I can’t do a laparotomy and a splenectomy in the field. The surgeon can’t do theses surgeries unless the patient arrives alive in the hospital.)

    We need to concentrate on delivering the best patient care we can, regardless of what it says on your diploma. It qualifies you for what you do, it doesn’t make you the top dog in the hospital.

    I have a friend who is a NNP and works at the children’s hospital at Stanford. She is, undoubtedly, the best at what she does – nursing very sick children at a very advanced level. She, also, has a doctorate. Like she’s never called me ‘doctor,’ I haven’t ever called her ‘doctor.’ She just does her job and I do mine. If I had a baby in NICU, you can bet I would insist that she be on the team, (notice the importance of ‘team’), working to deliver the best care to my baby. I hope she would prefer to look up and see me, if she was in an accident.  It is our job experience that make us outstanding in our respective fields, not JUST our education.

    The Times article said that doctorates will soon be required of physical therapists. This is absurd. I have friends who have master’s degrees in kinesiology, etc. They don’t want to go to school to become doctors. Some of them have huge debt from completing their educations to be physical therapists. Forcing all of them to go back and get doctorates would force them to take on tremendous debt and they would do the exact same thing they are doing now, only at 3 times the cost.

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    What about if a midwife with a PhD in Russian Literature walks around labor-and-delivery calling herself DOCTOR Jones in front of patients? Technically, it’s valid, but is it morally appropriate?

  • http://pulse.yahoo.com/_DB2ZZIMLXLEPDUKD7NJMQI34ZQ Been there

    Actually, Dr. Roland Goertz of the American Academy of Family Physicians, is completely wrong.  The term “Doctor” has for centuries been used to describe disciplined scholars who earned the “PhD” or doctor of philosophy. People who did his work were called “barbers and surgeons”.  So, the term “doctor” properly refers to those who have earned the highest level of academic training.  For further perspective on this, you can pretty much consider that the “profession of medicine” in the US is approximately 100 years old.  In 1910 Abraham Flexner’s report was published which offered a scathing evaluation of American medical education.  This report, written by a non-physician, lead directly to the closure of over half of the American medical schools by 1935 and created a format for education which has prevailed to this day.  Physicians should not feel embarrassed to be called physicians, nurses nurses, nor PhDs “doctor”.  Cheers!

  • jeeperswagener

    I finish my NP in June of 2012.  I don’t ever want to be called Doctor, and when someone does, I correct them.  Not because I believe it is a bad thing, its just not my thing, and I did not earn it.  Like wearing a Chicago Marathon shirt and having not run the marathon – just not appropriate in my mind.  Education is the best way to make sure patients know what the difference is.  The only way that medical professionals as a whole will succeed going forward is if we work together – right now there are too many patients and not enough care givers.  So I cannot wait to collaborate with an MD, work as a team and get people the care and services they deserve.  All while being proud to be an NP. 

  • Anonymous

    RESPONE TO DOCTOR/NURSE CONTROVERSY:
    I cannot help but detect cynicism between the lines.  The issue discussed is that the Doctor fears  the public will become confused between the “Doctor” and the “Nurse with a Doctorate”.   One of the solutions the good Doctor offers is that the Nurse take the same….”rigorous… board certification exam”.  If the Nurse passes then she deserves the Doctor title.  The Doctor contradicts himself.  He is saying that Doctors go through much more extensive training and this should be recognized (and I agree) but the public still will not be able to differentiate the Nurse with the Doctorate and the “Doctor” of medicine.  Passing the exam does not change what the patients will perceive.  To me it will only satisfy the Physician.  I agree that the Doctor of Medicine does go through a more rigorous training program but the patient only sees the title.  I believe there SHOULD  be limitations to what a Nurse with a Doctorate Degree can do.  However, a Doctor of Medicine also has to realize that  becoming so involved with his title leaves little for learning.  I have found very few Doctors that will actually say: “I don’t know” and that is far more dangerous than a Nurse with a Doctorate.   Set your EGO aside Doctor and work with the Nurse who has her Doctorate.  Odds are she will be more than willing to work within her limitations.  The question really is:  Can the good Doctor set aside his EGO so that both can come to an understanding that benefits the most important person,
    THE PATIENT.   Hey, chances are, the nurse can teach a physician alot.  We can start with a better bedside manner.   THE MOST DANGEROUS CAREGIVER (DOCTOR OR NURSE) IS THE ONE WHO HAS NOTHING TO LEARN.  Please set aside your ego so that you can SEE the patient.  I can only HOPE this response gets posted.  As long as we continue to ignore the elephant in the room NOONE wins. We should be focusing on our mutual goal:
    Nothing but the best for the patients that need us.
    Margie H.
    Pennsylvania

  • http://pulse.yahoo.com/_EZXKT5WPRABUZU7LVO7AWMEHGQ Josh

    I spent quite a bit of time as a Risk Manager in an academic/research hospital with more doctors (MD, DO, PhD, PsyD, DN, ND, DC, DHSc, DPH, DPT, D. Pharm, DSW, etc.) than you can shake a stick at. There was an openess and respect that each one had and there weren’t turf wars because everyone knew what their roles were. There was no disrespectful attitudes because people were well aware of each person’s scope of practice. In the academic setting, everyone referred to doctors as designated by their degree.

    However, there was an unspoken rule in the clinical settings that only physicians were called ”doctors” by the staff. This was not a sign of disrespect for the professional, rather it was a courtesy to the patient. The only exception to that were psychologists, as they needed the title of doctor with some patients as they were more comfortable with talking to a “doctor.” Interestingly, the doctor of social work never wanted to be called a doctor either.   Additionally, everyone had a badge that identifed their position and highest degree. So if a person really needed the ego boost and show off a doctorate degree, they could.

    Once, a dean from the medical school was in the hospital for a procedure. Everyone that came into his room he asked to see their badge. If they had a doctorate, he made sure to refer to them as “doctor” out of respect. But we cannot ask all patients to do that.

    My biggest problems were physician assistants, without doctorates, in the ER calling themselves and answering to “doctor.” I repeatedly had to inform them they could not misrepresent themselves as physicians. Some were physicians from other countries but were not licensed in the US. I held that in an ER setting, calling someone a doctor who is not a licensed physician is not allowable ethically as it could result in a new nurse taking an inappropriate order from a PA or the patients confusion. They were the only one’s that did that.

    By the way, Dr. Laura Schlesinger billed herself as Dr. Laura but her doctorate is in physiology and she did not dispense physiology advise on the air.

  • http://profiles.google.com/molly.ciliberti Molly Ciliberti

    As a nurse I
    dislike it when people who are not MD’s or DO’s call themselves doctor. To the
    patient “doctor” is a physician, not a nurse, pharmacist, chiropractor,
    etc. So to have multiple kinds of “doctors” floating around is not
    helpful to the patient. Since we are all about the patient, we should show it
    by our behavior.

  • Anonymous

    I used to tell my students, “doctor” is a title, not an occupation. Molly, you take exception to nurses and pharmacists with doctoral degrees calling themselves doctor, but I’ll bet you wouldn’t think twice about addressing a PhD in English Literature as doctor.