Medicine decries nurse doctorate exam being touted as equal to physician testing

Nursing organizations are accused of not accurately portraying the exam.

By — Posted June 8, 2009

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Physician leaders say a new doctor of nursing practice certification exam is being wrongly compared with testing that physicians take. And they fear that patients may be misled into believing nurses who pass the exam share the same qualifications as physicians.

Last fall, the National Board of Medical Examiners began offering the voluntary DNP test, based in part on Step 3 of the U.S. Medical Licensing Examination. Step 3 is the final stage in the physician testing series. In January, the Council for the Advancement of Comprehensive Care -- a nonprofit nursing group that contracted with the NBME to develop the exam -- announced the results of the first DNP certification test, with 50% of candidates receiving passing scores.

In its announcement, the CACC said the exam "was comparable in content, similar in format and measured the same set of competencies and applied similar performance standards as Step 3 of the USMLE, which is administered to physicians as one component of qualifying for licensure." In past statements, the NBME stated that the scope of the DNP exam was "materially different" from physician testing, in addition to differences in underlying training.

Physician leaders are chastising nursing organizations for what they say is a failure to portray the certification exam accurately. They also want the NBME to step in and further clarify that the DNP exam and physician tests are not equivalent.

"Our concern prior to the first round of testing was that the meaning of this test would be deliberately misconstrued to imply there was equivalence between nurses and physicians. And indeed some of the first statements seem to go in the direction of making those comparisons, which we believe are totally invalid and misleading to the public," said American Medical Association Board of Trustees member William A. Hazel Jr., MD.

The AMA and dozens of state and specialty medical organizations are asking the NBME to mandate that nursing groups clearly spell out the differences between the DNP and physician exams. At this article's deadline, the AMA House of Delegates was expected to consider, at its mid-June Annual Meeting, a resolution proposing to explore alternative physician licensing testing options. The resolution calls for the AMA to withdraw representation from the NBME if the testing organization fails to act to safeguard the integrity of the physician licensure process.

Doctors said they support advances in nursing education, which can contribute to a physician-led care team. But there are significant differences in testing and training that should not be minimized, Dr. Hazel said.

"For patients to make an informed decision, they need to know who is caring for them, what their level of training is and in what field. To the extent those lines are blurred, that [decision-making] becomes even harder," he said.

A push for scope expansions

The CACC in prior statements said the test was intended to set a uniform credentialing standard "to provide further evidence to the public that DNP certificants are qualified to provide comprehensive patient care" and help fill primary care shortages.

The test comes at a time when DNP programs are growing. In 2008, more than 90 DNP programs were offered at nursing schools nationwide, up from 53 in 2007, according to the American Assn. of Colleges of Nursing. It wants more than 200 nursing schools to offer DNP programs by 2015.

Physicians are concerned that nurses will leverage such DNP programs and the NBME test to seek scope-of-practice expansions.

The AMA, the American Academy of Family Physicians and other physician organizations, in letters to the NBME, pointed to an article in the Jan. 16 Chronicle of Higher Education. Mary O'Neil Mundinger, DrPH, RN, dean of Columbia University School of Nursing in New York, was quoted as saying: "If nurses can show they can pass the same test at the same level of competency, there's no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients." Mundinger, CACC president, declined comment for this article.

Physician organizations say that a lack of response from the NBME will only add credibility to such statements as Mundinger's and compromise patient care.

"It's very important the delineation between nursing degrees and physician degrees is not obscured and patients aren't misled," said Roger A. Moore, MD, president of the American Society of Anesthesiologists. He cited examples of DNPs referring to themselves as "doctor" in the clinical setting. Nursing schools also have adopted terms such as "residency" and "fellowship" as part of their doctoral programs.

Use of the USMLE Step 3 "appeared to be one more step in that direction for nurses to be able to claim they have the same credentials as physicians ... and that's a misrepresentation," Dr. Moore said.

American Assn. of Colleges of Nursing President C. Fay Raines, PhD, RN, said the DNP degree does not change nurses' scope of practice, which would be up to state legislatures.

However, such programs "are similar [to obtaining a medical degree] in that they involve advanced preparation ... and certainly there are some things that are common across disciplines," said Raines, dean of the University of Alabama in Huntsville College of Nursing.

Many states, for example, recognize advanced practice nurses' ability to independently treat and diagnose patients, as well as prescribe medications. Other health professions are moving toward practice doctorates to respond to primary care shortages and an aging population, Raines said.

The NBME's certification exam for DNPs is an additional, voluntary credential, Raines added. "But it's always important for people to be recognized in areas in which they are experts." Transparency is important, but the term "doctor" is not exclusive to physicians, she said.

NBME's role questioned

The NBME declined comment for this article. In a position paper posted on its Web site, the organization said it had not received any substantiated reports that DNPs misrepresented their training abilities.

AAFP President Ted Epperly, MD, questioned the NBME's endorsement of the test. "This is the National Board of Medical Examiners. These are nurses, not physicians ... and it only confuses the public."

According to the NBME, the DNP certification exam draws on portions of the USMLE Step 3 that test skills and knowledge related to patient management. It does not include assessments of fundamental science, clinical diagnosis or clinical skills included in the other two portions of the physician test.

Dr. Epperly said the DNP test uses defunct USMLE questions -- not current ones -- and applies a different performance standard, one set by a CACC-appointed committee.

Delegates at the AMA's 2008 Annual Meeting voted to oppose the NBME's participation in the DNP test, and supported legislative and other efforts to ensure health professionals' clearly identify their qualifications to patients.

The NBME defended its decision to offer the test as consistent with its mission. "Current and future patients of these nurse clinicians deserve a system that assures them that the clinician providing services meets appropriate quality standards. Our support for the DNP assessment process helps provide that assurance," stated the NBME position paper released, in part, in response to physicians' concerns.

Now that the test is out there, however, the NBME has an obligation to clear up the confusion to protect patients and physicians, Dr. Epperly said.

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Growing program

More than 200 nursing schools nationwide may offer the Doctor of Nursing Practice degree by 2015.

90 DNP programs were offered in 2008.

102 DNP programs are in the planning stages.

34 states and the District of Columbia offer DNP programs. States with the most programs include Florida, Minnesota, New York, Pennsylvania and Texas.

3,415 students enrolled in DNP programs in 2008, an 82% jump from 2007 enrollment. The number of graduates nearly tripled, from 122 in 2007 to 361 in 2008.

Source: American Assn. of Colleges of Nursing

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