Walking into a hospital can be a bewildering experience for patients and their families. Although, as residents, we become accustomed to the routines and structures of the hospital, it can be a profoundly disorienting experience for our patients. When patients try to seek information from the medical professionals around them, the sea of often nearly identically dressed personnel can present a significant challenge to even hospital-savvy patients. As one of the many faces of various professions behind the white coats, we may add to this overwhelming feeling of confusion. Just trying to get an answer for a question as simple as “why can’t I eat?” will likely need to be asked to a multitude of people. Often, this is the case because patients don’t know to whom they are directing their questions.
Every time I approach a patient’s bedside, I introduce myself and explain my role as the anesthesiology resident. The function of this introduction and identification of the role we play as a part of the health care team will come to take on greater importance as we progress to building larger teams – teams with an increasing number of mid-level providers with varying educational backgrounds. This is especially true within the field of anesthesiology as we continue to shift the delivery of services toward a care team model.
A newly emerging trend that will not only add to patient confusion but also challenge the current model of health care delivery is the development of a new breed of providers under the umbrella degree “Doctor of Nursing Practice” (DNP). According to the American Association of Colleges of Nursing (AACN), there are now 257 institutions offering a DNP degree, which is up from 153 in 2010, and four in 2004. The stated purpose of the degree is to prepare nurses for independent primary care roles. Additionally, by 2015, the AACN has recommended a DPN be the standard for entry into positions such as nurse practitioners, nurse anesthetists and clinical nurse specialists.
The development of the DNP degree has many implications for the perception and delivery of health care. One of the key issues that has emerged is use of the title “doctor,” as many DNPs are now introducing themselves to patients as such. Although the term “doctor” is not synonymous with “physician”, every pharmacist and many physical therapists have long held doctoral degrees, yet they are not addressed as “doctor” because the term has traditionally been reserved for physicians in the clinical setting. The public typically associates the title “doctor” with those who provide medical advice and prescribe treatment. Identifying non-physician doctorates by the title “doctor” may lead to misconceptions from patients that such individuals, when working in a clinical setting, are able to offer medical advice and prescribe treatment. Daniel W. Green, M.D., president of the New York County Medical Society, summed up the issue as one of patient advocacy by saying, “scopes of practice are used for patient protection, as a means of limiting what a practitioner can do based on education and training, or based on what the supervising or collaborating physician believes they are capable of doing safely ... the situation is complicated if those with restricted scopes of practice call themselves ‘doctor.’”
In 2011, the American Medical Association started its “Truth in Advertising” campaign, which calls for health care providers to clearly and honestly state their level of training, education and licensing. Since then, many states have responded by introducing comprehensive legislation concerning this issue. Most recently, for example, the Florida state senate is currently debating Bill 612, which requires “certain health care practitioners make specified disclosures when introducing themselves as ‘doctor.’” More specifically, the bill would require nurses with doctoral degrees to explain to patients the nature of their degree or face legal penalties. Thus far, 25 states have introduced legislation that will require health care providers to clearly and honestly state their level of training, education and licensing. In my opinion, these measures are necessary to ensure that patients receive the requisite information to make informed decisions about who is providing their health care.
Put into larger perspective, perhaps the battle for the title “doctor” is a proxy in the larger struggle over who gets to treat patients. Pharmacists, physical therapists and nurses – with or without doctoral degrees – usually require supervision from physicians, and in this respect, largely play secondary roles to physicians. However, as of last year, 23 states allowed nurses to practice without physician supervision, and the DNP degree is another step toward independent nursing practice. Many physician groups fear that the real reason behind the creation of the DNP is to persuade more state legislatures to grant nurses the right to treat patients without supervision from physicians. In our own profession, this has already become a very real issue; currently, there are 17 states that have “opted-out” of the federal requirement for physician supervision of nurse anesthetists. If by 2015, all nurse anesthetists are required to possess a DNP, not only will they be able to practice independently in some states, they will also be introducing themselves to their patients as “the doctor.” Furthermore, in this situation, patients will likely believe they are receiving their care from a licensed medical doctor.
I believe we should all pay close attention to how this will affect the care of our patients and the perceptions they have of their caregivers. Not only is it important for us to clearly identify ourselves and our roles, it is the patients’ right to know who is responsible for their care and what sort of training their caregivers have. Regardless of legislation, we should take it upon ourselves to protect our profession. Whether or not the law requires that nurses presenting themselves as doctors must then subsequently clarify that they are not medical doctors, perhaps we should take a more active role in clarifying to our patients that we are the physicians – the medical doctors in charge of their health care decisions.