Doctor Nurse Redux

Way back in 2008 we riddled "When is a Doctor not a Doctor?". The answer: when they are a nurse.

It seems the more things change the more they stay the same.

Now the N. Y. Time is asking "When does a nurse want to be called Doctor?"

When Sue Cassidy went to a clinic because of pain in her ear, a woman with a white coat and stethoscope entered the exam room and said "I am Dr. Patti McCarver and I am your nurse."

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.

Let's face it. Calling someone Doctor has much more prestige than calling someone nurse, therapist, or even attorney. There is a certain "cachet" about the title . . . Doctor.

Unless of course the title is preceded by the word witch.

It seems that doctors, the REAL doctors, are taking exception to the use of the word doctor by anyone that isn't a REAL doctor.

This battle is not new.

Medical doctors have often sought to differentiate themselves from osteopathic doctors and chiropractic doctors and fought to exclude these medical practitioners from their inner circle. In some states only a medical doctor has authority to write a pharmaceutical prescription but those lines have blurred in recent years.

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 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 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.

As the demand for primary care increases the medical community responds by finding ways of accommodating the demand by creating a new level of primary care provider.

Meanwhile those entering medical school that are looking at four years of intense training followed by an additional three to five years of residency and internship before they can fly solo are abdicating the role of primary care in favor of a specialty. They are asking themselves why they should spend 7 - 10 years in school plus accumulating a ton of debt only to earn a little more than a school teacher when they are finally ready to fly solo.

A primary care nurse practitioner or physician's assistant can perform many of the same duties of a primary care doctor. The minimum training for a nurse is two years. According to the Bureau of Labor Statistics nurses earn an average of $65,000.

A nurse practitioner usually has 2 years of additional training beyond a nursing degree and earns an average of $85,000 per year.

Roughly the same amount of time is required to become a physicians assistant and a similar pay scale applies.

Nurse practitioners and physicians assistants earn about half of what a primary care physician earns, but this goes beyond earning power.

There is a real need for primary care providers and that need will only increase over the next few years. This is especially true in light of our aging population and the advancing wave of baby boomers.

If medical students opt for specialty practice over primary care the doctor shortage will only get worse.

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.

It is time to rethink our view of primary care. More education does not equate to better care.