Up with nurses! Down with doctorates!

By Razib Khan | October 1, 2011 1:48 pm

In light of growing health care costs and the demographic reality of an aging profession stories like this one in The New York Times are both depressing and hopeful. Calling the Nurse ‘Doctor,’ a Title Physicians Oppose:

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.

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.

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.

I applaud the wider distribution of medical services outside of the licensing monopoly of M.D.s. As an empirical matter I think there was a practical reason for the professionalization of medicine in the 20th century and the emergence of degree holding as necessary. To be frank about it for most of human history doctors were frauds or butchers. Modern medicine in the 20th century was a major revolution in that sense (though doctors are only part of it, the rise of an effective pharmaceutical industry is probably just as important if not more so). But the arrow of history does not always move in one direction, and we live in an “information age.” Doctors are human, and therefore fallible. They need the aid of both their patients and various other medical professionals to optimize health outcomes. The paternalistic model is just not viable in the long run, especially as the median educational qualifications of their patients keeps rising.

But notice that in this case we’re seeing greater and greater credentialism in fields which were traditionally perceived to be auxiliary to medical doctors. This is not a good sign. Instead of challenging the unquestioned prominence of medical doctors in domains where nurses are sufficient and more cost effective, the nursing profession is “fighting fire with fire.” This is not going to end well. Having to pile on education removes productive years in the work force. This is justifiable when education results in gains in productivity, but just as in education, I suspect that all the extra years for physical therapists and nurses is not doing anything but signalling, and further tightening up labor supply as the number of patients keeps on increasing because of the aging of the population.

MORE ABOUT: Medicine
  • Ian

    Speaking of “signalling” and “credentialism”, I always thought that of American lawyers (JD, versus LL.B. in the British system) and doctors (M.D. versus M.B.B.S. – bachelor of medicine, bachelor of surgery).

  • John Emerson

    Dean Baker uses the medical profession, specifically MDs, as a prime example of restraint of trade in the US. It is one of the factors making American medical care more expensive than anywhere else, and the cost of medical care is a major cause of the long-term deficit (medicare is vastly more important than Social Security in that regard).

    Restraint of trade includes barriers to the licensing of immigrant MDs (a restriction on “free trade”) and restrictions on the number of doctors graduated.

    This is one of the rare areas where libertarians and liberals could agree, though many liberals are too New Class and too attached to credentialization to do that.

    Meanwhile medical education has become so hard to finance that most doctors start their careers $100,000 or more in debt, which puts them under the control of insurance compoanies and HMOs that take their own big cut.

    The normal response to this is to say that American medical care is twice as expensive because it’s twice as good, but there’s not a lot of non-anecdotal evidence for that.

  • Ariston

    They aren’t “fighting fire with fire” to get respect any more than pharmacists were in 2004. It’s about raising the barriers to entry and also justifying salaries to end–users. This is a sudden across–the–board credentialism creep in nursing, too, as master’s were standard for most instructors at BSN programs, but now doctorates will be more generally expected.

    (That this is primarily about barriers to entry is especially notable in the pharmaceutical case, by the way, where a PharmD is overeducated for retail pharmacy and the bachelor’s–holders from pre–2004 are just as capable in the vast majority of cases.)

  • Dwight E. Howell

    The quick clinic works for most things. We need to move away from the more costly methods of delivery.

  • Baramos

    It’s just about paying them less even though they are as qualified as they were before.

    Our country should look at the medical systems of other first-world countries. There is far less emphasis on doctorates with better results (of course, we can’t even attempt to adopt a single-payer health system, so good luck on that…).

  • Mike in Maine

    Up here in Maine I have used both a FNP and a P.A. and am perfectly satisfied with them. What is almost amazingly disgusting is the resistance that these professional’s encounter simply because of a M.D.s ego ! There was a movie made not to long ago that had Alec Baldwin playing a doctor under investigation for malpractice. His response to the question concerning his ability as far as skill was concerned is a perfect example of this resistance; “I’m a doctor. I am God’. And medical insurace carrier’s wonder why they are losing cases left and right ?

    I’ve used P.A.’s in the Army (God love you ‘Doc’ Russell ! ) and in civillian life. A vast majority of them have seen, and are very aware of, the ‘God’ complex. And that’s why I always trust them long before I even think about seeing a MD.

  • mknghorn

    more power to the nurses.they have always treated me like a human being.the same can not be said for the majority of doctors i have met.i am tired of hearing how in debt they are upon leaving med school.they know what they signed the numbers are right in front of them.if it is too much of a burden,don’t do it.

  • MikeP

    Really? A physical therepist needs a doctorate?

  • Harry Erwin

    I have an American PhD in neuroscience and am called ‘Doctor’. Medical doctors in the UK have done a five-year course, followed by training, which makes them fine practitioners, but I have more academic training in their field, more neuroscience–and in most cases, more neurology–than they have. That sometimes leads to an interesting conversation when I see a new member of the practice.

  • scott

    We also need to eliminate the bad doctors. I got sick with a simple parasitic gut infection (worms) and went to the doctor. He ran a few tests and then proceeded to tell my family I was going crazy and needed psychiatric help, but that there was nothing physically wrong with me. At that time I hadn’t seen any worms, I was just very sick and had lost a ton of weight in 12 day period of time. Fever…chills… loss of appetite.

    His explanation must have stuck. I stayed sick for months, my insurance company wouldn’t pay for any more testing because I was deemed crazy, and so I got worse.

    About 18 months later I started throwing up worms.

    A nurse practitioner at another hospital prescribed me a $30 medication that is stopped it all.

    Some doctors are fail. This one got his degree in the antilles most likely because he was unable to make it in an American institution.

    I don’t care who gets to be called “doctor” as long as we eliminate the ones that are ineffective.

    Never trust anybody that gets their degree from a country that has no research institutions… that has no actual history of “developing” medicines.

  • OneMedStudent

    Eventually, I believe, Nurse Practitioners and PAs will take over family medicine. Physicians should be reserved for difficult cases with worse prognoses. There’s no reason to have an MD for the vast majority of cases that these patients come in with, and it’s doubtful that an NP is even necessary for them. This is an odd way that they have gone around becoming a “Doctor” that I don’t believe should have ever been invented. If you want to treat patients, in upper level care, you should go through medical school. If you want to treat patients with simple dermatological diseases that are easy to diagnose etc… You don’t need more than a PA’s training, and the ability to say “I need help on this diagnosis”. Schooling for the sake of schooling needs to be retired. This “credentialism” as it is called has become absurd and useless, rising, profligate costs are burdening our system. I’ve never met the MDs you’ve claimed horror stories of, but it is disappointing that the opinion of those of us in the profession has dropped so much.

  • http://blogs.discovermagazine.com/gnxp Razib Khan

    This one got his degree in the antilles most likely because he was unable to make it in an American institution.

    do you think the NP was more intelligent than this doctor? i think the emphasis on medical school itself is a problem for a lot of the basic care, and you should be cautious about blaming doctors without the right credentials. the issue isn’t the nature of the credentials, but that you don’t need to super-intelligent to do a lot of basic medical diagnosis, and they should make it cheaper by distributing it across more professionals. this includes those who get educated abroad.

  • http://proteneer.com/blog/ Devin

    You’re a doctor in an academic setting if you have a PhD in a research discipline, or an MD. You’re a doctor in a medical setting if you have an MD. End of story.

  • ID

    I agree with Devin. The nurses are simply trying to confuse patients by calling themselves doctors. For simple illnesses, I have no doubt nurses are just as good as doctors. But when you have to get a quadruple heart bypass, you need a doctor, not a nurse. Nurses need to use their own names instead of trying to steal from other professions.

  • Inigo Montoya

    The US is certainly in a very particular situation because it awards professional doctorates to a large number of what effectively are bachelor-level degrees, including lawyers, vets, dentists, optometrists, now nurses, etc. etc. And this situation is not only getting worse, but copied by other countries such as Australia.

    In the end, in a 10 or 20 years, the Dr title will be meaningless as half of university bachelor-level graduates will be using it. Then they will have to figure out something else, like Super Dr, for those people with actual terminal degrees such as PhDs.

  • Craig

    As a new MD in residency, I can tell you everyone, both patients and MD’s frustrated with the current state of healthcare. We are mostly in debt because as Americans we have the wrong attitude toward healthcare, “More, more, more”, when there needs to be more emphasis on personal responsibility. Each and everyone of us has the power to help, the solution does not rest with politicians and doctors, it rests with the general public. Obesity is an epidemic and the solution is not a magic pill or surgery, but personal responsibility. Even more so, as a country we need to accept our own mortality and find a better way to grieve than spending >$ 100,000 on the last few weeks of a family member’s life, when it ultimately only increases suffering. These are all worsening trends that did not exist exist back in the “good ‘ol days of medicine”. The general public will force care to be rationed once the system goes bankrupt and physicians will be put in an even more difficult position.

    As for nurses, NPs and PAs, they are in a great position to help with end of life care, which is the major cost to our healthcare system. They are already in tune with patient needs and comfort and have more time to spend explaining palliative options in a sensitive manner. It would increase quality of life, patient satisfaction, while cutting costs.

  • Private Citzen

    DOs are “doctors” too in the USA. However, a good old-fashioned dentist told me years ago that his friends that couldn’t get through DDS school became Osteopaths and “now when I see them on the golf course, their pockets are full of money”.

    Chiropractors: Doctors
    Homeopaths: Doctors
    Veterinarians: Doctors

    So lots of people are called “Doctor” in the USA in the context of medical practice (physician). They’re not all competent, not all intelligent. Some fields, it seems to me anyway, are disproportionately highly represented by mountebanks. In every case a well-educated consumer practicing scientific rigor will have a better outcome. That even applies at Wal-Mart when buying plastic goods, I suppose.

  • John Emerson

    I don’t think that difference in quality between an MD and a Nurse with a doctorate is enough to make a big deal about. Some people need to have a “terminal degress” apex to the pyramid, and in many cases they need to be on the apex personally, but I don’t think there’s any good reason for anyone not invilved to care much.

    For quadruple bypass surgery what you need is a surgeon qualified in quarduple bypass surgery. Neither the average M.D. nor the average nurse is qualified, and most likely even the average surgeon isn’t.

    One theory is that psychoanalysis developed because some people and families needed an apex higher than the mere MD. At one time at least psychoanalysts were required to have a PhD or MD, plus additional training.

  • AG

    Title of `doctor’ should be preserved for PhD. A medical `doctor’ should be called physician.

  • John Emerson

    The primary meaning of “doctor” in the English language is “physician”. But who gives a fuck, really?

  • Ken Duncan

    I am a nurse practitioner, currently pursuing DNP. I have no intention of introducing myself as a “doctor” to my patients. I believe it is confusing to them.
    I understand the push for doctorate as a terminal degree for advanced practice and should offer an opportunity for best prepared NP’s.
    I believe that in the clinical setting, the title “doctor” should be reserved for the physician.

  • Mindy

    As a Nurse Practitioner with a PhD, I say shame on all of us for wasting so much energy on this topic. With the health care in this country in the state that it is in, rather than fight about titles, how about we all work together to make sure the best of care is provided. Every level of education is an amazing achievement and one that those achieving it should be proud of. And those that have achieved should exude pride in others regardless of level.
    As for being called Dr – I choose not to while I practice, and ask that I am referred to as “Dr. only when I speak or teach. Let’s stop comparing ourselves to other countries and be happy we are fortunate to be here in the U.S., and accept that the beauty of our level of freedom brings with it this vast variety in education.

    Patients have enough to contend with when they are not well and despite what each provider wants to call themselves, patients have a right to know who is providing care for them. A competent and compassionate provider, whether a physician, PA, NP, Pharmacologist, PT…. will make that obvious based solely on the care provided. Credibility is not achieved solely by the abbreviations behind the names, bur rather the quality of care we provide. Being called Mindy works for me!

  • NJB

    The demand for PhD entry level has been promoted by ancillary professions to influence insurance/ 3rd party payors to reimburse for direct access to service by these professions. It is financial and political having little to do with quality of care.
    It would be deceptive for a PhD to present as MD(“doctor”) and is important for such persons to be clear in defining their area of expertise , qualifications, limitations of practice to the client.

  • Douglas Knight

    As to the name, I have no sympathy for those who live by the sword. Physicians wanted the respectability of teachers, so they stole the name. They shouldn’t be surprised if nurses do the same to them.

  • Jill

    I am one of those Dr Nurses and when I introduce myself as “Dr” right behind it is “I am a Family Nurse Practitioner.” Dr is not a physician title and if you think it is, you need to educated yourself. Dr indicates you have a terminal degree in your professions. MD’s and anyone else that thinks those with a Doctorate, can not use that title, has an ego problem. There are plenty of patients out there for all of us to take care of and one of the things that NP’s do really well is educating their patients, including telling them that we are NPs with Doctorate degrees, I am very proud of being an NP!

  • planetnurse

    “Doctor” is a title. “Physician”, “Nurse Practitioner”, “Pharmacist”, etc., are roles. I think we are conflating the issue. Advanced practice nurses seek the doctorate (PhD or DNP) for further education, knowledge, professional growth, often at significant cost of money and time. There is an impetus to provide better care at a reduced cost.

    Most physicians that I work with want to be consulted – they don’t want to direct the ins- and outs- of daily patient care, set up diabetic teaching, home health, social work, etc. Nurse practitioners excel at coordination of care efforts and are excellent at primary care. I know of no NPs, CNS, CNAs or midwives who are attempting open heart surgery, neurosurgery, complex nephrology management, or other sophisticated medical specialty. It’s not what they were educated to do nor WANT to do.

    Perhaps we should view the hierarchy of medical care (with physicians at the apex) as more of a web or network – cooperative, collaborative and interdependent. Like the living beings that we are.

  • http://washparkprophet.blogspot.com ohwilleke

    While we are at it, it is worth mentioning another group of professionals, sometimes with PhDs, sometimes with M.D.s, sometimes with various master’s degrees or professional bachelor’s degrees who could be disentangled: mental health professionals.

    Psychiatrists use a very modest share of their medical training in their practice, often de facto delegate responsibility for insuring that prescribed drugs don’t interfere with each other to pharmacists, and the cost of care is greatly increased by having the authority to prescribed mental health drugs limited to physicians. Why should we as a society spend hundreds of thousands of dollars more than we need to in order to educate to tier mental health professionals?

    The essence of the problem is figuring out where to draw lines between professionals and to insure that the person at the top of the pyramid is competent enough. The burden of requiring a more or less autonomous professional to work under an M.D. is far more onerous and expensive than a lot of people in legislative roles, regulatory roles and in the ranks of physicians understand – and some of the costs are subtle because allowing professionals to practice not under the supervision of someone else changes the way you organize that subfield of the health care industry.

    We need to be authorizing the lowest level person who is competent to act autonomously to do so if we want to control costs.

    We also need to greatly increase the number of medical school slots that have become about twice as selective over the last thirty years.

  • Douglas Knight

    For those who talk of “terminal degrees,” there is only one: the habilitation.

  • John Emerson

    “The demand for PhD entry level has been promoted by ancillary professions to influence insurance/ 3rd party payors to reimburse for direct access to service by these professions. It is financial and political having little to do with quality of care.”

    There’s a good reason for it, though. Being able to go directly to a NP or PA for routine care would do a lot to make medical care more affordable, and there wouldn’t have to be any decrease in quality whatsoever. If the insurance companies demand a PhD for that, fine. In the present situation NPs and NP usually, often, or almost always (not sure exactly) have to be formally under an MD’s supervision, which basically adds a layer of rent-seeking bureaucracy.

    The need of some people to be at the top of a pyramid, and the accompanying demand that everything be organized into pyramids with tops, is a distorting factor throughout American life. Some hierarchy is necessary, some more may be desirable, some more may be inevitable, but there’s such a thing as too much hierarchy, and people with big egoes can’t accept that. Screw ’em.

  • Aurora Borealis

    add me to the chorus of people who really like NPs and PAs and CNMs and the rest of the non-“doctor” alphabet soup.

    Most of my recent medical care has been obstetric, and I much prefer the local certified nurse midwife to any of the OBs. She has a sort of a weird personality but is always on the ball and remembers details from one visit to the next.

    Doctors always seem too bored and important to really pay attention, which is understandable because healthy people are probably actually pretty boring, but I say why not open the field up to people who are actually interested? Let the very important MDs do things that are more exciting than decide whether the baby has thrush.

    My second pregnancy was actually attended to by a lay midwife and that was excellent, too. If my insurance had been willing to pay for it, I’d have gotten her again for subsequent pregnancies.


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About Razib Khan

I have degrees in biology and biochemistry, a passion for genetics, history, and philosophy, and shrimp is my favorite food. In relation to nationality I'm a American Northwesterner, in politics I'm a reactionary, and as for religion I have none (I'm an atheist). If you want to know more, see the links at http://www.razib.com


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