[NPInfo] Call me "Dr. Nurse"

Sun Apr 27 17:11:31 PDT 2008

A doctor and a nurse, all in one package

By CHEN MAY YEE, Star Tribune
April 26, 2008

Anne Boisclair-Fahey is used to patients doing a double take when she  
introduces herself.

She begins by carefully explaining she's a nurse practitioner, then  
adds "You can call me Dr. Anne."

Get ready to meet a new kind of hybrid at your local clinic: the  
doctor nurse. They sport name tags with the letters DNP for doctorate  
of nursing practice.

Seen as one answer to the looming shortage in physicians, doctor  
nurses take the nurse practitioner concept to yet another level.  
Doctor nurses are trained in finance, health policy and systems know- 
how in addition to core clinical expertise. They can do a lot of what  
many doctors no longer have time to do in an increasingly complex  
health care environment.

While doctor nurses are still a rare breed nationally, that's about  
to change dramatically. The first class of 24 doctor nurses graduated  
in December from the University of Minnesota's School of Nursing, one  
of a handful of schools at the forefront of this trend. All have  
returned to their jobs or new positions, some with expanded roles and  
pay.

Now more than 90 nursing schools have introduced DNP programs and 200  
more are about to start. Beginning next year, the University of  
Minnesota is converting its entire master's of nursing practice  
program into a doctoral course, meaning any nurse practitioner who  
passes board exams will be a doctor nurse.

"They are designed to work in collaboration with physicians," said  
Connie Delaney, dean of the School of Nursing, "so that very  
expensive physicians and specialists can spend their time on other  
things."

But some physician groups worry that the increasingly fuzzy  
demarcation between doctors and nurses may be confusing for patients  
at best, and unsafe at worst.

A looming void

Experts are forecasting a shortage of physicians in the country by  
2020 because the population has grown even as enrollments in medical  
schools have remained flat.

What's more, 36 percent of active physicians are older than 55 and  
most will retire by 2020, said Edward Salsberg, director of workforce  
studies for the Association of American Medical Colleges. A new  
generation of physicians is less willing to work the long hours  
usually associated with the profession.

The shortage is already showing up in primary care, which includes  
family medicine, pediatrics and internal medicine. This year, U.S.  
medical graduates filled just 1,156 of 2,387 residency positions  
nationally in family medicine; the rest were filled by foreign  
medical graduates. Primary care doctors are paid far less than  
specialists.

Against this backdrop, nurse practitioners are "a phenomenal  
alternative," Delaney said.

There is a parallel movement in dentistry. Dentists are in short  
supply in rural areas of Minnesota, and there is a proposal moving  
through the Legislature to allow dental hygienists to drill and  
extract teeth, and prescribe medication without a dentist on site.  
The Minnesota Dental Association opposes the proposal, saying it  
jeopardizes safety.

Some doctors object

For years, physicians have resisted the notion of a doctor nurse.

The American Academy of Family Physicians, for example, wants it made  
clear to patients that nurses with an advanced degree are not the  
same as doctors who have been to medical school.

"With four years of medical school and three years of residency  
training, physicians' understanding of complex medical issues and  
clinical expertise is unequalled," said the academy's president,  
James King.

Macaran Baird, head of the Department of Family Medicine and  
Community Health at the University of Minnesota, says he's not  
worried about that. He points out that turf battles are not uncommon  
in the hierarchical world of health care.

However, he noted, there's no guarantee that doctor nurses will go  
into primary care unless the gap between payments in primary care and  
specialty care narrows.

Otherwise, he said, "we have the same risk of them going where the  
money is."

Projects show potential

For some nurses, the new title is a validation of what they've been  
doing for years.

Registered nurses, or RNs, are those with a bachelor's degree in  
nursing. Nurse practitioners have a master's in nursing practice and  
can see patients and prescribe drugs, just like doctors.

According to Delaney, there is already an 80 percent overlap between  
what nurse practitioners do and what primary care physicians do. The  
remaining 20 percent includes minor surgeries such as appendectomies  
or vasectomies. Nurse practitioners may also specialize in fields  
such as family practice, psychiatry, pediatrics, gerontology or  
midwifery.

Doctor nurses extend that nurse practitioner role even further with  
training positioning them for leadership roles in health  
organizations or teaching.

The three-semester program costs $14,500 for Minnesota residents and  
$23,500 for nonresidents. Most of the work is Web-based, with  
students coming to campus for several intensive weekends of work. So  
many nurse practitioners in the first class were able to add the  
doctor nurse credential while continuing to work part time.

Their student projects showed the scope and promise of combining a  
nurse practitioner's clinical skills with a doctor nurse's new  
awareness of health care systems. One student developed and  
implemented a standard screening for asthma patients during clinic  
visits, to ensure proper follow-up care. Another devised a plan to  
institute regular bathroom breaks at school for kids who wet their  
pants because of medical problems.

Karalee LaBreche, a psychiatric nurse practitioner for Ramsey County  
who was in the first class of doctor nurses, looked for ways to get  
emergency medication to those who needed it, including going to their  
homes. As a result, fewer patients showed up at the emergency room, a  
very expensive option.

The project won her an award from the International Society of  
Psychiatric-Mental Health Nurses.

More pay, promotions

For some, the new doctor of nursing practice degree has opened doors.

Six graduates have since been offered new positions or promotions,  
and a few have gotten modest salary increases, said Sandra Edwardson,  
director of the U's DNP program.

For Nicole Lynch, a psychiatric nurse practitioner at Abbott  
Northwestern Hospital in Minneapolis, the added training as a doctor  
nurse brought expansion of her role beyond outpatient care to  
inpatient care, too. For Boisclair-Fahey, who specializes in  
pediatric urology, it meant a 3 percent raise and an invitation to  
sit on a major board.

The proliferation of titles has caused some confusion.

Lynch explained her title to a child patient, who quickly twisted it  
around to "Nurse Doctor Lynch."

Most of the time though, she said, they just stick to "Miss Nicole."

Chen May Yee • 612-673-7434