On nursing and doctoring…

Happy National Nurses Week!

A fellow nursing student sent me this article (it’s a pretty quick read) from The Atlantic. The Association of American Medical Colleges predicts a shortfall of nearly 30,000 primary care physicians by 2015, and more than 65,000 by 2025. How will we fill the gap? John Rowe, the author of the piece, is a physician and a professor in the department of health policy and management at the Columbia University Mailman School of Public Health. He believes that Advanced Practice Registered Nurses (APRNs) can fill the gap. The Institute of Medicine (IOM) and others agree. RAND Corporation, a nonprofit policy institute, even said that could save states money.

I see an APRN (she is also called a nurse practitioner, or NP) instead of a primary care physician for routine physical exams, prescriptions or when I am ill. You may have encountered NPs as a patient and not have realized it. NPs work in hospitals and clinics; some even have their own practice (I’ll get to that in a moment).

At my first visit, my NP spent over 45 minutes with me discussing my medical and family history, as well as my health concerns and goals. When she felt that a particular health issue was beyond her expertise, she referred me to a physician specialist. I think it’s great. I established a relationship with an NP, instead of being shuffled among various primary care physician residents—something that is common in a teaching hospital. So filling the gap with APRNs makes sense to me. It makes sense to Dr. Rowe, too.

But having APRNs filling the role of primary care physicians doesn’t make sense to others. Especially some physicians.

Why? Because it threatens everything that they have worked for. Four major medical association oppose these proposals, according to Rowe. It is not surprising. Medical associations have been fighting against APRN autonomy (“autonomy” meaning an APRN can do everything a primary care physician can do, including filling prescriptions without supervision) for years. While some states, such as California, allow complete APRN autonomy, other states don’t. In Illinois, where I am studying, APRNs lack full autonomy. According to Illinois Law (225 ILCS 65/65-40):

“A collaborating physician or podiatrist may, but is not required to, delegate prescriptive authority to an advanced practice nurse as part of a written collaborative agreement.”

A few of my professors speculate that this is because the AMA is headquartered in Chicago and has a lot of political clout in the state.

Everybody with me so far? Good.

To complicate the issue, the American Association of College of Nurses adopted a position which recognizes the Doctor of Nursing Practice (DNP) degree as the highest level of preparation for clinical practice. If physicians don’t like autonomy of APRNs, I am guessing they won’t like autonomy of DNPs, either. So now we have NPs that can be APRNs or DNPs. And they are both called nurse practitioners. And one is now a “Doctor”. Some physicians (probably the same physicians as above) don’t like the idea of someone without a medical degree being referred to as “Doctor”, and some are even trying to enact legislation to prevent that from happening. Shocked? Me, neither.

This leaves students like me wondering about the future of nursing and advanced practice nursing. There are so many levels of education in the nursing profession alone. In the US, nursing students are able to pursue four different educational pathways to become registered nurses (RNs): a diploma in nursing, the associate’s degree in nursing (ADN), the bachelor’s of science in nursing (BSN) and an accelerated RN program for students who possess a baccalaureate degree in another field (that would be me; I have a BA in biology and a Master in Public Health. As an aside, someone with a Doctor of Public Health is called “Doctor”, similar to a PhD). When you see a nurse, that nurse could have any level of education. Now, the IOM recommends that 80% of nurses should have a BSN by 2020 . Some hospitals will not even accept students like me, who will be an RN with more clinical hours and education than a BSN at my university, but will not actually have a BSN. (This program does not issue a BSN because we have degrees already, and a second bachelor’s degree makes it difficult for a student to qualify for federal financial aid.)

“One of these people is not like the other…one of these people is not the same.”

Other questions loom: As a nurse practitioner, will I be able to practice as an APRN, or should I work toward a DNP? Will DNPs have more autonomy than APRNs in their practice in states like Illinois? If I got a DNP, should I take the title of “Doctor”? Will I even be able to? Do patients recognize a difference between an APRN or a DNP? What about a PhD in nursing? Would patients recognize me as a knowledgable authority on health issues? And then throw physician assistants (PAs) into the mix (“Nurse practitioners are absolutely different from PAs, Erika!” my professor growled at me in class—it’s a touchy subject for some)…will the public understand? How does the nursing profession address these issues?

Confused? I don’t blame you. So am I. As a patient or a health care worker, what are your thoughts? How do we educate patients on the nursing profession’s various roles? The field of nursing and advanced practice nursing is ever evolving, and there is no consensus on where it is heading. But, it is most important that RNs, APRNs, NPs, DNPs, MDs and others put their egos aside and do what is best for the patients. After all, isn’t that what they are there for?

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About erika

nurse, certified nurse-midwifery student, public health fan, math & science geek, single malt scotch aficionado, klutz, goofball, scribbler, funny face & lover of all things nerdy.
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