Nurses move to doctorate in primary care
■ Nurses are aiming to fill the gap created as fewer physicians opt for a primary care career; doctors are skeptical.
By Myrle Croasdale — Posted June 6, 2005
The nursing profession is creating a career path it considers on par with primary care physicians, a move that physicians are not convinced will be in patients' best interest.
Columbia University School of Nursing in New York is the first to roll out a clinical doctorate in nursing and is in the process of admitting its first applicants for the fall. Another 63 schools are planning similar programs, said Mary O'Neil Mundinger, DrPH, RN, dean of Columbia's nursing school.
The two-year Columbia degree will equip nurses to become a legitimate primary care choice for patients, she said. "With more physicians going into subspecialties, there's a wonderful opportunity to fill in the gap in what physicians have conventionally done."
Nurses not necessarily the answer
Mary E. Frank, MD, president of the American Academy of Family Physicians, isn't so sure it's a wonderful idea. "There's been a drop-off in students choosing all of the primary care disciplines, but it seems to have bottomed out now. I don't think the answer is to have nurses take that place."
More than half of AAFP member physicians work with nurse practitioners or physician assistants and find the team approach to patient care effective, Dr. Frank said. Allowing a nurse to practice independently from a physician, especially when it comes to treating chronic diseases like hypertension or diabetes, raises concerns about patient safety and quality of care, she said.
To address the primary care shortage, the AAFP has been investigating what it will take to attract medical students into family medicine through its "Future of Family Medicine" project. Developing team care models that include nurses as well as other health professionals has been part of the effort.
"We need to fix the problems in the health care system, not produce another layer of health care providers," Dr. Frank said.
The American Medical Association does not have policy specifically addressing primary care nursing doctorates, but it does oppose advanced practice nurses giving medical care without physician supervision.
Dr. Mundinger is aware that changing nurses' educational backgrounds won't change their scopes of practice. That would take a state-by-state legislative initiative.
"This degree will not change regulations but will influence regulations," she said.
Advanced degrees have effectively influenced regulators in the past.
Dr. Mundinger cited the Balanced Budget Act of 1997 as an example. It acknowledged the advanced education of nurse practitioners by granting direct reimbursement for their services at every site.
To apply for the clinical doctorate program at Columbia, nurses need to have completed four years of undergraduate education, two years of nursing school and have a two-year master's of nursing degree. To earn the doctorate, nurses need to complete 30 science credits, one year of full-time residency in a hospital or office setting approved by Columbia, and a scholarly portfolio of complex case studies.
"So in the final outcome it will take one more year to become a primary care physician than it will take to become a primary care nurse," Dr. Mundinger said.
Other schools may differ
Degree requirements have yet to be standardized, and the length of study and curriculum of the other programs may vary from Columbia's program.
Demand for Columbia's program has been beyond expectations. The school had 800 applicants for its first class of 20. In 2006 the incoming class expands to 40, with plans to expand it to 100 in 2007.
Dr. Mundinger envisions that nurses who complete the doctorate program will have practices similar to physicians. They would see patients every 15 minutes, hold hospital admitting privileges and prescribe medications. In New York, nurse practitioners already have prescribing authority.
Dr. Mundinger said research she conducted, published in the Jan. 5, 2000, Journal of the American Medical Association, backs nurses' efforts to fill the primary care gap. The study compared outcomes for patients assigned to nurse practitioners with those assigned to physicians for primary care follow-up and ongoing care after an emergency department visit. She found no significant difference in patients' health outcomes.
Dr. Frank wasn't convinced such data justified nurses working independently from physicians. Again, she emphasized the effectiveness of collaborative care. "We have good research that nurse practitioners working with physicians is the perfect team and that patients appreciate the team approach."