An April 2nd article in the Wall Street Journal, Making Room for Dr. Nurse, details the new Doctor of Nursing Practice (DNP) degree being standardized by the Council for the Advancement of Comprehensive Care (CACC). The program will require two post-graduate years and one year of residency. A DNP will have earned prescription, Medicare reimbursement and hospital admitting privileges. A major stated goal of the program is to fill the dearth of primary care physicians (PCPs). Though to be fair a primary care physician has completed at a minimum four years of post-graduate training and three years of residency. It seems misleading for those that complete the DNP program to call themselves a doctor.
I understand the need to fulfill the need for PCPs. With lowering Medicare payouts many of my colleagues are committed to practicing specialized medicine because of the higher reimbursement of medical procedures versus seeing patients in an office setting. However, I think it’s misleading for DNP’s to use the prefix Dr., which they will be allowed to do. There is no doubt that DNP’s will have the necessary training to take care of patients in their prescribed role (they will be expected to take exams similar but less comprehensive than doctor licensing exams. The issue is that a doctor with a M.D. has significantly more training and a larger knowledge base for therapeutic decision making than a DNP. However, if a DNP and a M.D. go by the same title their distinction will be blurred. Doctor’s (with a M.D.) are not the only ones worried though, with the nursing shortage as critical as the shortage of PCPs there is concern that nurses will turn to the DNP degree and increase the nursing shortage.
One solution I have been kicking around recently is for internists and family medicine physicians to fully adopt the model that is currently being used by Anesthesiologists. With the advent of the Certified Registered Nurse Anesthetist (CRNA) there was initial concern over the role a M.D. trained Anesthesiologist would continue to play. However, the two groups have created a model that exemplifies the skills of both the CRNA and M.D. The Anesthesiologist has become an operating room manager, where they are available for consultation when a CRNA is having difficulty with a case or if the type of anesthesia necessary is very complicated. This allows the Anesthesiologist to be in control of multiple operating rooms at once. A PCP could create a similar model, and I suspect many have, where they manage multiple patient rooms at once by having DNP’s, nurse practitioners or physician assistants see patients on a preliminary basis. When a patient’s case becomes complicated or requires unconventional treatment options the PCP will become increasingly involved. I like the CACC’s unique approach to eliminating the shortage of doctors but they are doing so in a way that alienates PCPs and only straining the already contentious doctor-nurse relationship. Fitting the CACC’s plan into my rudimentary thoughts, I think, will be a more encompassing solution.