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- v.119(4); Jul-Aug 2022
- PMC9462903
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Mo Med. 2022 Jul-Aug; 119(4): 314–320.
PMCID: PMC9462903
PMID: 36118817
Gary Gaddis, MD, PhD
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Introduction
Advanced Nurse Practitioners (ANPs) provide at least a portion of the clinical care received by some Missouri residents. A subset of these ANPs have earned a Doctorate of Nursing Practice (DNP) degree.
Patients generally value the care they receive from their ANP clinicians, be they a DNP, or not. ANPs are generally perceived to be likeable and competent. Of course, by law, ANPs’ clinical competence is enhanced by the requirement that all Missouri ANPs must practice in conjunction with a “collaborating physician.”1 Fully independent practice in Missouri is reserved exclusively for physicians, the only clinicians who have the training that makes them actual medical doctors.
Unfortunately, some ANPs who have achieved a DNP degree refer to themselves as “doctor” in clinical settings. This is problematic. Although it is true that DNPs have earned a doctoral degree from an accredited institution, they are not physicians. In an academic setting, they could appropriately ask to be called “Doctor.” But, to call themselves “Doctor” in a clinical setting misleads the patient and perpetrates a fraud which defies their patient’s trust.
The fraud exists because in claiming the title “Doctor” in a clinical setting, the DNP who is in essence impersonating a physician ignores the substantial knowledge and training gaps that exist between a physician and a non-physician. They also overlook the inherent and substantial limitations that these gaps convey. Ignoring those limitations can cost the trusting patient greatly.
Two recent cases of which I have become aware are illustrative:
Case #1
While working in the emergency department of a rural critical access hospital in April, I cared for a young diabetic patient who did not know if he was a Type I or Type II diabetic. He had an obvious cutaneous yeast infection in his groin fold. His Body Mass Index exceeded 40, and he reported his typical daily awakening blood glucose level was typically 200–250 mg/dL. He was unaware of his hemoglobin A1-C level and indicated he had never heard of that test. His only medication for diabetes was once-daily long-acting insulin, and he identified a DNP as his “Doctor.”
Within the Epic Electronic Health Record, this DNP did clearly designate that they had DNP degree, and made no written claim to be a physician. However, the patient said the DNP called herself his “Doctor” during his office visits. The patient told me he did not understand the difference between a physician and a DNP, so I explained that difference to him.
He reported that his DNP had never suggested referring him to an endocrinologist or adding any other medications to his once-daily insulin blood sugar control regimen. Further, she had never suggested that weight loss would benefit him.
I am neither an internist nor an endocrinologist. However, this patient clearly needed more than once-daily long-acting insulin to ameliorate his chronic hyperglycemia. He needed to be encouraged and enabled to lose weight. If he was truly a Type I diabetic, he needed a more effective insulin regimen. If he was actually a Type II diabetic, an addition of a Sodium Glucose co-Transporter 2 (SGLT-2) such as JardianceTM (empagliflozin) and/or a Glucagon-Like Peptide-1 agonist such as OzempicTM (semaglutide) could be useful not only toward better glucose control, but also toward facilitating weight loss.
I must wonder how many ANPs are aware of these recent additions to the diabetes armamentarium, their effects, indications, and contraindications. In Missouri, to function as an ANP, one must be licensed as an Registered Nurse (RN) and then obtain a Document of Recognition (DOR) from the state.2 RNs in Missouri are not required to obtain continuing education credits to renew their nursing license.3 However, to maintain a DOR, ANPs must provide documentation of completion of at least 60 hours of continuing education every two years.4
Case #2
Substandard care is not limited to nurse practitioners who may not be holders of a DNP degree. An ophthalmologist with whom I was discussing substandard, non physician-led care noted a case of a patient referred to his clinic. The patient was a young female with Type II diabetes, who identified her “Doctor” as a “CNP.” It is not known what the patient was trying to communicate via this nomenclature, but she clearly had been managed only by a nurse practitioner for a prolonged period of time, during which numerous opportunities for better care were missed.
The patient reported that she had not undergone a thorough eye exam in at least 10 years, and the one that she had undergone was performed at a commercial optical office. By the time an ophthalmologist saw her earlier this year, she had developed proliferative diabetic retinopathy in both eyes, along with bilateral vitreous hemorrhages of varying ages.
The patient reported her NP had never suggested an annual exam by an eye specialist such as an ophthalmologist. She reported that her last Hemoglobin A1C was about 11 or 12%, and that her nurse practitioner had not cited this to the patient as problematic or done anything to improve it.
This is a patient at high risk of premature and avoidable blindness due to the retinopathy, and renal insufficiency due to diabetes-associated renal microvascular changes. Her quality of life and life expectancy will surely both be negatively impacted due to the poor quality of care she has received The patient was unable to identify the physician supervising her nurse practitioner, and reported that she had never seen that physician. Of course, under Missouri statutes, an ANP’s collaborating physician is not obligated to ever see the patient, whose care can be supervised from afar.1 The required degree of physician collaboration can be provided by review of a subset of the ANP’s clinic notes. One must wonder how much collaborating was going on between the doctor and the ANP in this case, and whether the fault for this was mostly due the ANP, the physician, or both. This case also clearly illustrates that a better definition of “collaborating physician” may be indicated.
Quality of Care is Important
Kianmehr et al. have recently demonstrated that diabetic patients with poor control of their Hemoglobin A1C, hypertension, low density lipoprotein levels, and body mass index suffer demonstrable harm via a shorter life expectancy.5 The poor control of these patients’ medical problems is likely to cost them years from their lives.
Physicians versus ANPs: A Huge Contrast in Outcomes
Many nurse practitioners can give good care, if they stay within their appropriate scope of practice. And, that scope should include the careful and regular oversight of a collaborating physician, as provided by Missouri law.1
In my experience, ANPs can be willfully blind to the inevitable shortcomings arising from their truncated clinical training, when compared to that obtained by a physician. These deficits can easily perpetrate outcomes such as those illustrated above.
Unfortunately, clinically unsupportable statements demonstrating willful blindness exist from nurse practitioner organizations, regarding their alleged high quality of their care. Here is an example: “… it is well established that patient outcomes for NPs are comparable or better than that of physicians. NPs provide high-quality and cost-effective care.”6
This statement is demonstrably false. Consider the recent data from a clinic in Hattiesburg, Miss., published earlier this year in the Journal of the Mississippi Medical Association7 and publicized by the Physicians for Patient Protection8 (PPP). This study documented that care provided by Advanced Nurse Practitioners (ANP) was markedly more costly than the care provided by physicians.
To quote a PPP news release: “The Hattiesburg Clinic in Mississippi—a large, multi-specialty facility with over 300 physicians—spent 15 years hiring more physician assistants, nurse practitioners, and other advanced practice providers (APPs). The clinic’s goal was to provide the best care to patients at the best value. After analyzing years’ worth of data, they reached an important conclusion: Replacing physicians with PAs and NPs resulted in higher costs, not lower.”8
The cost difference was enormous, estimated at more than $28 million annually.7 The bulk of the higher cost came from increased test ordering, increased specialist referrals, and more patients being sent to emergency medicine departments. Nurse practitioners, in particular, stood out as high-cost outliers.7,8
The authors “…disclosed that, based on “a wealth of internal data, the results are consistent and clear: by allowing APPs to function with independent panels under physician supervision, we failed to meet our goals in the primary care setting of providing patients
Physicians Alone Have the Expertise and Training to Lead Clinical Care Teams and Lead They Must
Physician organizations have long justifiably advocated for physician-led care. For instance, the American College of Emergency Physicians adopted a policy on the matter in 2014 and updated it in 2020 (Figure 1).9 That policy clearly asserts that physicians should lead clinical care teams.
Figure 1
American College of Emergency Physicians Position Statement Regarding the Use of the Title “Doctor” in a Clinical Setting.
Some nurses’ organizations opine differently. An author of an item published by “registered nursing.org” has stated: “Those who support using the title of “doctor” for DNP or PhD nurses have a few reasons why it should be allowed. First, it’s a recognition of the level of expertise and clinical skills of a nurse. It represents that the nurse has achieved the highest degrees possible in nursing and should be considered an expert in his or her field. Second, it also can help build trust between the nurse and patient as the patient can be reassured of the nurse’s competency. This is especially true for nurse practitioners who practice similarly to physicians. Additionally, if other professionals can refer to themselves as “doctor,” why shouldn’t someone who earned a Doctor of Nursing Practice?”10
There can be no way that just saying something is so makes it true. Use of the term “doctor” by a DNP in a clinical setting does not help the patient be “… reassured of the nurse’s competency.” Such a statement is misleading and conveys an illusion that overlooks several important facts:
Master’s level ANP programs exist which have admitted 100% of their applicants in 2019.11 This group of admitted students has included substantial numbers of nurses with scant previous clinical experience. No medical or osteopathic school has ever admitted 100% of those who apply. This contrast speaks for itself.
ANP programs provide their students with much less in-depth instruction in both the pre-clinical medical sciences such as anatomy and physiology, and the clinical medical sciences such as pharmacology or clinical pathology, than do schools of medicine or osteopathy. It is easy to discern the superficial levels of basic and clinical science understanding by many nurses, who are strong as regards caring and “pattern recognition,” but woefully weak in their understanding of the underlying science that explains the patterns they observe. All physicians, myself included, have gained highly valued lessons from the nurses with whom we have worked. Those lessons generally don’t involve deep dives into the sciences that underpin the medical decisions we make as physicians. Rather, they are vignettes passed from a teacher to a learner in the manner by which a master instructs an apprentice, passing along valued lessons learned via experience.
Many ANP programs require their students to arrange their own site for their supervised clinical experience. This would be unthinkable for physician training in the United States, both for undergraduate and graduate medical education.
ANP programs do not require those providing the evaluation of the ANP’s supervised clinical training (which need exceed only 500 hours) to be faculty members of the degree-granting institution. This strikes me as a form of academic fraud.
ANPs do not begin or complete any residency program to sharpen their clinical skills after they obtain their advanced nursing degree. Therefore, no organization equivalent to each medical specialty’s Residency Review Committee (RRC) exists to provide third-party oversight of ANPs’ postgraduate clinical training processes, because no such post-graduate training processes exist!
Upon completion of their clinical experience while enrolled in an ANP program, the sum of the ANP’s clinical training is markedly less extensive and less well-supervised than medical school clerkships. When totaled, an ANP’s supervised clinical formation can include as few as 500 hours of such training. No state allows medical students to perform unsupervised medical practice after 500 hours of well-organized medical clerkships. No states allow residents who have logged at least 500 hours of well-organized, clinically-supervised care to become fully licensed physicians, either.
The education of physicians is a much more extensive and carefully regulated process, on a number of levels. The Liaison Committee for Medical Education (LCME) accredits medical schools and the various specialties’ RRCs provide exacting accreditation and third-party oversight of residency training.
Clinical formation supervision by medical school and residency faculty is a task that requires 5,000 to 15,000 hours of preparation on the part of the learner, depending on the specialty. This supervision is provided by educators who are members of the degree-granting institution’s faculty.
In contrast, the model that best describes ANP training is an apprenticeship, because the student finds the site and preceptor under which they are exposed to the clinical realm. Schools of medicine abandoned such an apprenticeship-type approach to education at the time of the Flexner report in 1910.12
ANPs Who Assert Being a “Doctor” in Clinical Spaces
Approaches in Selected Other States
Several states have statutes that consider the facts about the shortcomings of ANP training, and specifically limit ANPs from using the term “doctor” or “physician” to describe themselves in a clinical setting.
Texas
Texas nurse practitioners have recently been cautioned by the Texas Nurse Practitioners’ Office not to mislead their patients (Figure 2). The cautions included, “The Texas Medical Board very-well may and often does open investigations into the practice of medicine without a license on nurse practitioners. To date, as long as the advanced nurse practitioner with a doctorate abides by the above law and it is extremely clear that one is not a physician but rather an advanced nurse practitioner with a doctorate, such cases eventually have been dismissed, but after the expense of a defense.13
Figure 2
Advice from the Texas Nurse Practitioners Office13
Minnesota
Minnesota law also specifies that an ANP should clearly identify themselves as a non-physician. Advanced practice registered nurses (APRN) who have doctoral education often contact the Board regarding the appropriate and permitted use of the title “Doctor.”
Information offered to Minnesota ANPs by the nursing board is contained in Figure 3.14
Figure 3
Minnesota Statutes Regarding Use of the Title “Doctor” in Clinical Settings14
Summary
Medical education is more selective than ANP education. Some ANP programs exist which admit 100% of their applicants, whether or not they have previous and extensive nursing experience. Data comparing ANPs against physicians, when considering their pre-clinical exposure to the medical sciences and their depth and length of supervised clinical formation, show that ANPs fall far short not only in the hours of preparation for their clinical roles, but also in the depth of instruction provided by the degree-granting institution, compared to allopathic and osteopathic physicians.
No school of medicine or osteopathy confers clinical degrees with the substantial lack of institutional oversight that characterizes many nurse practitioner programs, which typically allow their students to secure their own clinical formation training site, with supervision and evaluation by a non-faculty member of the degree-granting institution, at a clinical site that may not have been visited by a member of that institution’s faculty. ANPs obtain clinical training in a model best described as an apprenticeship, an approach abandoned by medical schools since the Flexner Report of 1910.12
A physician’s scientific and clinical training far exceeds that of any ANPs both in length and depth, whether the ANP is a holder of a DNP degree or not.
Data from the Hattiesburg Clinic clearly show that although ANPs earn a lower wage than physicians, they provide much more expensive care because they order more tests, they refer more patients to the emergency department, and they obtain more consults. This belies their general difficulty at efficiently reaching a clinical decision, a handicap that may derive from their being less extensively educated regarding scientific and other crucial clinical matters than are physicians.
Despite their more extensive training, physicians nonetheless commit clinical errors. By extension, it defies logic to suggest that any level of ANP, be they a holder of a DNP degree or not, could deliver clinical care with equivalent safety and cost-effectiveness to that provided by physicians.
ANPs are important and highly valued members of clinical care teams when they function with an appropriate scope of practice and supervision. However, it is a lie to assert that ANPs, with or without DNP training, can independently provide high quality care to complex patients with anything approaching that which can be expected from physician-led care teams. Further, for an ANP to refer to themselves as a “doctor” in a clinical setting compounds the degree of misrepresentation that begins with a misrepresentation of an ANPs educational processes and culminates when an ANP with a doctoral degree refers to themselves as “doctor” to their patients.
Future Directions
The American Medical Association adopted Council on Medical Education (CME) Report Number 4, that spoke to this matter during its 2022 Annual meeting.15 That report stated, in part:
“Our AMA: (1) will advocate that all health professionals in a clinical health care setting clearly and accurately identify communicate to patients and relevant others their qualifications, and degree(s) attained, and current training status within their training program; (2) and develop model state legislation for implementation to this effect; and (3) supports state legislation that would make it a felony to misrepresent oneself as a physician (MD/DO); and (4) will expand efforts in educational campaigns that: a) address the differential education, training and licensure/certification requirements for non-physician health professionals versus physicians (MD/DO) and b) provide clarity regarding the role that physicians (MD/DO) play in providing patient care relative to other health professionals…”15
Given the information provided above, our Missouri State Medical Association would be wise to identify state senators and representatives sympathetic to our beliefs, and work to facilitate enactment of statutes patterned after those of Texas and Minnesota, and concordant with the American Medical Association’s CME Committee Report #4, so that confusion in clinical settings regarding just what “doctor” means can be avoided in the future.
Conclusion
Only physicians should call themselves “doctor” in a clinical setting where clinical care is being provided to trusting patients.
Footnotes
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Gary Gaddis, MD, PhD, FFIFEM, MAAEM, FAAEM, FACEP, is a Clinical Professor of Emergency Medicine at Washington University School of Medicine in St. Louis.
References
1. Board of Nursing. Nursing and Collaborative Practice. A Regulatory Perspective. Missouri Division of Professional Registration; [Accessed July 5, 2022]. https://pr.mo.gov/nursing-advanced-practice-nursing-collaborative.asp. [Google Scholar]
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3. Lippincott Nursing Center. Missouri CE Requirements for License Renewal. Copyright 2022 Wolters Kluwer Health Inc. and/or its subsidiaries. [Accessed July 14, 2022]. https://www.nursingcenter.com/continuing-education/license-renewal-requirements-by-state/missouri-ce-requirements#:~:text=As%20a%20nurse%20in%20theto%20renew%20your%20active%20license.
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5. Kianmehr H, Zhang P, Luo J, et al. Potential gains in life expectancy associated with achieving treatment goals in US Adults with Type II Diabetes. JAMA Network Open. 2022;5(4):e227705. doi:10.1001/jamanetworkopen.2022.7705. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
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9. American College of Emergency Physicians. Use of the title “Doctor” in a clinical setting. [Accessed May 12, 2022]. https://www.acep.org/patient-care/policy-statements/use-of-the-title-doctor-in-the-clinical-setting/
10. Androus AB. Can you be referred to as a doctor if you earn a DNP? Registerednursing.org. [Accessed May 12, 2022]. Updated January 10, 2022 https://www.registerednursing.org/articles/referred-as-doctor-if-dnp/
11. Kerr E. Nursing Master’s Programs with 100% Admit Rates. US News and World Reports. 2020. Jun 9, [Accessed May 12, 2022]. https://www.usnews.com/education/best-graduate-schools/the-short-list-grad-school/articles/nursing-masters-programs-with-the-highest-acceptance-rates.
12. Flexner A. D.B. Updike. The Merrymount Press; Boston: 1910. [Accessed June 12, 2022]. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching. http://www.carnegiefoundation.org/sites/default/files/elibrary/Carnegie_Flexner_Report.pdf. [Google Scholar]
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14. Minnesota Board of Nursing. Using the Title of Doctor as an Advanced Practice Registered Nurse. [Accessed May 14, 2022]. https://mn.gov/boards/nursing/advanced-practice/advanced-practice-topics/using-title-of-doctor-as-aprn.jsp.
15. Report #4 of the Council on Medical Education to the American Medical Association. House of Delegates Adopted. 2022 June 15; [Google Scholar]
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