Doctor Nurses

The shortage of primary care physicians is apparent to everyone. Most primary care physicians have little flexibility in their schedule for new patients and virtually no room in their schedule for walk-ins. Many of their patients with urgent care needs are diverted to the emergency room. The nursing profession is offering possible solution: the PhD Registered Nurse. More than 200 nursing schools have established or plan to establish doctoral nursing practice programs to equip graduates with skills the schools say are equivalent to primary care physicians. The two-year program includes a one-year residency and allegedly produces a "provider" with more training and skills than a Nurse Practitioner. To establish a national standard for doctoral nursing practice, the National Board of Medical Examiners (NBME) developed a doctoral nursing certification examination based on the same test physicians take to qualify for a medical license. The NBME was to begin administering this examination in the fall of 2008.

Physician groups, including the American Medical Association, are concerned that blurring the line between doctors and nurses will confuse patients and jeopardize the quality of patient care. Ted Epperly, MD, president of the American Academy of Family Practice, warns that the NBME exam will "give an implicit legitimacy that PhD nurses are subject to the same eyes of the medical board that credentials doctors" despite differences in education. Nurses with PhDs after their names can use the term "doctor" as a title designation. It is obvious to many physician advocates that four years of medical school training and three years of residency training are not equal to a two year of doctoral nursing degree. Currently nurse practitioners are allowed to write prescriptions in some states and also receive Medicare and Medicaid reimbursement. The doctors of nursing practice will, it is hoped, also be able to receive reimbursement by commercial health insurers, as well as convince hospital medical boards to allow them to admit patients.

There is information that specially trained nurse health care professionals provide standard quality in areas such as general patient care. A study led by Columbia Medical School''s Dr. Lumdindger published in the Journal of the American Medical Association in 2000 showed comparable patient outcomes in patients randomly assigned to nurse practitioners and primary care trained physicians.

The problems surrounding healthcare cost and personnel remain complex. With an already severe shortage of registered nurses will high prestige "doctoral programs in nursing" lure more nurses away from bedside care? What does it mean for specialties such as radiation oncology? Although evaluation and management services can be provided by a nurse practitioner or physician assistant, the highly specialized services surrounding radiation treatment delivery can only be provided by a properly trained specialist. Should we develop a strategy for radiation oncologists to interact with this new class of primary care "providers" to be certain they understand the role of the radiation oncologist and to determine how we might best interact for the benefit of cancer patients?

Paul J. Schilling, MD, FACRO
Community Cancer Center of North Florida, Gainesville Florida