Are you a "doctor doctor" or a "doctor nurse"?

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Are you a "doctor doctor" or a "doctor nurse"? The confusion is killing me!

April 2009 -- Recent news items illustrate important aspects of the nurse practitioner experience today. A February 22 report on National Public Radio's All Things Considered provided a basic look at the doctorate of nursing practice degree, and even allowed articulate nurses to explain its value. However, parts of Sally Herships's piece appeared to accept unsupported physician claims that calling nurses "doctor" would cause confusion or harm patients, despite the absurdity of the supposed linguistic crisis. Meanwhile, veteran NP and DNP student Diane Caruso published a March 14 op-ed in the Winston-Salem Journal (NC) urging the public to support health care financing reform, in order to enable the 45 million uninsured U.S. residents to obtain care. Caruso refuted some basic arguments of those who oppose reform, but the most powerful element in her column was the story of a disabled patient who has fallen in the cracks of the current financing system. We commend Caruso and the "doctor nurses" included in the NPR piece for their advocacy.

The NPR piece does a fairly good job of explaining some of the basic aspects of the DNP degree, but the report's troubling elements are evident right in its online headline: "New Degree Creates Doctor Nurses -- And Confusion." This amounts to accepting physician claims that the degree has created confusion, without providing any support. Instead, we hear this from Arizona physician Steven Knope:

"If you're on an airline," he jokes, "and a poet with a Ph.D. is there and somebody has a heart attack, and they say 'Is there a doctor in the house?' -- should the poet stand up?" Knope laughs. "Of course not."

Ted Epperly, president of the American Association of Family Practitioners, reportedly says that having nurses share the "doctor" title could even "harm" patients.

I can just imagine a patient of mine walking into my exam room and saying, "Now Dr. Smith, are you a doctor doctor, or are you a doctor nurse?"

Are these weak jokes and hypotheticals a basis for sound health policy? Does any research show that patients cannot understand this difference when a modest effort is made to explain it? And is there any reason to believe patients would be harmed even if they did wrongly believe that a DNP was an MD, since a great deal research shows that the care of masters-prepared nurse practitioners is at least as effective as that of physicians? The NPR piece's omission of this last point is a critical one. In addition, Knope's "joking" comparison of a poet with no health training to a nurse with at least 7 years of college-level health education does not exactly convey respect for nurses. The article fails to mention that although the DNP degree is fairly new, nurses have been receiving doctorates (such as the PhD and the EdD) for decades. The piece does not note that the DNP is set to become the required educational standard for U.S. NPs in 2015. And the report's suggestions that nurses themselves wish to be referred to by the half-mocking "doctor nurse" title is unsupported.

Fortunately, the piece does include comment from Ray Scarpa, who "works in the department of surgery" at New Jersey's University Hospital.

"I am a doctorally prepared nurse," says doctor nurse Ray Scarpa. A doctor, he says, "is a doctorally-prepared physician. ... I am not here to practice medicine, I am here to practice nursing. ... And I practice it at an advanced level, and I have earned the right to be called doctor."

Scarpa (right) explains the situation well. The piece also relies on him for the idea that while there is "some overlap" between DNPs and MDs, "doctors diagnose and treat while nurses have a wider focus including family, support and community." The piece commendably notes that it can take six years to get the DNP after college. Of course, despite Scarpa's explanation, the piece does not seem to get that one way out of the supposed linguistic morass it presents is simply to refer to physicians as "physicians," not "doctors" as if they owned that graduate degree, and no one else could earn one in any field. Psychologists like Dr. Phil (who are not physicians) have long used the title "doctor," and we can't recall an outcry from physicians. In any case, note that Scarpa does not ask to be called "doctor nurse."

Another helpful aspect of the report is its suggestion that DNPs may help fill "the void" in primary caregivers. It describes Louis Boeckel, a patient of Scarpa's who has throat cancer. Boeckel has just had a tracheotomy, so "when asked if he's worried about mixing up his physician with his nurse [Scarpa], Boeckel writes, 'Best doctor.'" Boeckel's wife Carol adds: "We view [Scarpa] as a doctor, because he does come and take care of all [Louis's] immediate needs as any doctor would do."

The piece also quotes Mary Mundinger, dean at Columbia's nursing school, which pioneered the DNP. Mundinger argues that the physician concerns are more about turf, "status," and "ego" than patient confusion. The piece underlines this by noting that physicians and "doctor nurses" agree that "physicians feel threatened." It quotes medical student Janet Pullockoran, who suggests that with "all these new people"--meaning NPs and physician's assistants--the MD training may not lead to such a "secure position."

Diane Caruso's Winston-Salem Journal op-ed about health financing reform is a good example of spirited patient advocacy by an NP who, as the short credit at the end notes, is "pursuing her doctoral degree in nursing practice at Duke University." The op-ed's title, "Waiting in health-care wastelands," signals the central role that Caruso gives her 48-year-old disabled patient Jenny, to illustrate "the daily impact that our current health-care system has on our most vulnerable citizens." With a genetic disorder that now prevents her from supporting herself or living alone, Jenny cannot get affordable health insurance because she has a pre-existing condition. Yet her applications for disability benefits have been denied, apparently because she was well enough to hold a job long ago.

Caruso argues that such stories show why it's so important that President Barack Obama and others who seek meaningful health reform succeed. She notes that some opponents of reform argue that universal coverage requires a single payer, government-run system like Canada has, but in fact other nations like Germany and Japan provide universal coverage through public/private hybrids at a fraction of the cost of the US system. Caruso does not directly address whether the Canadian system is really as bad as these opponents claim.

Caruso explains that opponents will also suggest that reform will imperil the "world's finest" health care system with "socialized medicine." She agrees that the U.S. has "top-notch" care, but also stresses that "it is absolutely unconscionable to argue that we have the best medical care in the world" because

(1) life expectancy is higher in other industrialized nations--including Canada!;

(2) "American children are twice as likely to die by the age of 5 as children in Slovenia;"

(3) "American women have a lifetime risk of dying in childbirth that is three times higher than women in Germany or Greece;" and

(4) "[o]ur rate of overweight citizens is one of the highest in the world."

Caruso links these problems directly to the U.S. insurance system, seeming to suggest that poor coverage creates a disincentive to people seeking care, though this is not spelled out. Of course, the U.S.'s lagging public health indicators may also relate to our failure to emphasize long-term preventive health measures that may seem inconsistent with short-term economic or social interests. Caruso also notes that although opponents suggest there is "something in place" for those like Jenny--usually this is the emergency department, though Caruso does not say so--that is "a myth."

Caruso closes with a plea for health care reform on behalf of patients like Jenny: "As I look into their eyes, I see their anguish, and know that we are at a crossroads. We need health-care reform now."

Listen to "New Degree Creates Doctor Nurses -- And Confusion" on NPR by Sally Herships from February 22, 2009. Also, see Waiting in health-care wastelands: 45 million Americans hope for reform that could lead to fair, affordable insurance in the Winston-Salem Journal by Diane Caruso, March 14, 2009

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