The attainment of a doctorate degree is the pinnacle of many vocations, such as academia, religion and law. In recent years, many healthcare disciplines, such as pharmacy and physical therapy, have realized the advantages of having members become doctorally prepared, requiring it to maintain licensure. Although not a condition of licensure, many nurses also have opted to pursue a doctorate degree. With the Institute of Medicine’s 2010 Report on Nursing recommending that the number of doctorally prepared nurses be doubled by the year 2020, the numbers are likely to rise. Many physicians believe the abundance of these “doctors” in the healthcare setting may be cause for concern. With the physical therapist, nurse and physician each introducing him- or herself as “Doctor,” patients may get confused.
According to the American Medical Association’s Advocacy Resource Center, a 2010 survey by Global Strategy Group found 90% of patients said a physician’s additional years of medical education and training are vital to optimal patient care, and 83% prefer a physician to have primary responsibility for their healthcare. That survey also suggested patients’ confusion, citing 69%, 68% and 54% of patients who believe dentists, podiatrists and optometrists, respectively, are medical doctors.
To combat that confusion, the American Medical Association’s Truth in Advertising campaign calls for healthcare providers to clearly and honestly state their level of training, education and licensing. According to AMA’s website, “Patients deserve to have this information when in face-to-face encounters as well as when they read healthcare practitioners’ advertising, marketing and other communications materials.”
The AMA’s concern is not isolated. In January 2011, two U.S. representatives introduced H.R. 451, the Healthcare Truth and Transparency Act of 2011, designed to empower patients by increasing transparency in healthcare provider-related advertisements and marketing. Although not a new concept, this particular legislation has received tremendous bipartisan support, boasting a hefty 50 cosponsors at press.
Many states also have taken steps to enact or introduce their own “Truth in Advertising” legislation. Taking it one step further, in January 2011 then-New York Sen. Carl Kruger (D-27) introduced consumer protection bill S02250. The bill seeks to restrict the use of the term “doctor” in advertisements to only those who hold a medical degree or a degree in dentistry, as defined by the State Education Department. The bill has been endorsed by state medical associations, including The Medical Society of the State of New York and New York County Medical Society. Delaware has similar legislation to S02550 already in place.
“We advocate for proactive enforcement of New York State regulation that gives patients the necessary information to make informed decisions about who is providing their healthcare and who is making statements in ads,” said Daniel W. Green, MD, president of the New York County Medical Society. “In fact, we believe all healthcare professionals … should wear identification tags that state their professional designation in large block letters.”
According to Green, the organizations are not against professional and educational advancement of other healthcare disciplines. The issue is patient advocacy.
“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,” Green said. “The situation is further complicated if those with restricted scopes of practice call themselves ‘doctor.'”
I’m a doctor, you’re a doctor
Dianne Cooney Miner, RN, PhD, dean and professor at Wegmans School of Nursing at St. John Fisher College in Rochester, N.Y., and member of the New York State Board of Nursing and New York Organization of Nurse Executives, doesn’t understand why physicians believe they have sole right to the title.
“The term ‘doctor’ is an academic term, not a medical term. It belongs to a multitude of disciplines signifying the completion of what is in most cases the terminal degree in the discipline: Doctor of Philosophy, Doctor of Jurisprudence, Doctor of Nursing Practice, Doctor of Medicine, Doctor of Theology,” she said. “Many people have the right to use this title.”
Harriet R. Feldman, RN, PhD, FAAN, interim provost and executive vice president for academic affairs at Pace University in Pleasantville, N.Y., agreed. “Healthcare belongs to a variety of professionals, many of whom have the title ‘doctor’ as a result of years of education and, for most, vast years of experience,” she said. “In these days of multi- and interdisciplinary practice and multiple points of entry to healthcare, such a concept is backwards and not in the best interests of patients.”
While she believes the legislation to be unnecessary, Miner said she realizes the intent to lessen patients’ and family members’ confusion about who is a physician and who is not. “What I do understand and value are the efforts that all healthcare professionals make to improve the science and practice in the interest of those we serve,” she said. “Part of this work must focus on creating high-quality healthcare environments that are patient- and family-centered and sensitive to customer satisfaction.”
Communicating with patients and families regarding the different roles is a better option than alienating clinicians who do not hold an MD, Miner said.
“I believe what is of utmost importance is that as many healthcare disciplines seek to improve the science and practice by preparing people with advanced terminal degrees that lead to the title ‘doctor,’ every healthcare professional must provide patients and families with the information they need to understand each professional’s roles and responsibilities within the therapeutic relationship,” she said.
Abby Kurtz, RN-BC, EdD, director of nursing education and research at Bronx-Lebanon Hospital Center, believes there is merit to the claim that to take care of patients, the entry to practice may need to be at a doctorate level. But that doesn’t mean only MDs.
Letting patients know who is caring for them is a simple solution. “It behooves those who have ‘doctor’ titles, including physicians, to identify themselves with their specialties as appropriate,” Kurtz said. “An introduction such as ‘Hi, I am Dr. Joe Smith, your physician,’ or ‘I am Dr. Jane Doe, your nurse practitioner,’ would be appropriate.”
Chances of enactment
With the recent resignation of the legislation’s sponsor and no companion bill in the assembly, New York’s S02250 is inactive and will not be up for vote this term.
“The New York bill was sponsored in the Senate by Carl Kruger, who resigned from his post in December and has since pleaded guilty to federal corruption charges,” said Barbara Zittel, RN, PhD, international nursing consultant and immediate past executive secretary to the New York State Board of Nursing. “The bill will likely have its enacting clause stricken without the presence of the former senator.”
The New York Organization of Nurse Executives’ Committee on Public Policy developed a draft position statement in opposition to the proposed legislation that will be acted on shortly, said Marie Ankner, RN, MS, NEA-BC, assistant professor of nursing at Long Island University, Brooklyn, and past president of NYONE.
Despite his organization’s support of the bill, Green also believes its passage is unlikely. “As far as S02250’s chances of passing soon, it is a one-house bill introduced by a minority member who is no longer there,” he said.
Sally Dreslin, RN, MA, MS, associate director of governmental affairs for the New York State Nurses Association, said the association didn’t take any specific action. “If the bill had gained additional sponsors or an assembly companion bill had been introduced, the nurses’ association would have actively opposed it,” she said.
Dreslin said the bill is redundant because state law already addresses its concerns. “Nurses are professionally and ethically responsible for identifying their profession to their patients,” she said. “The New York Board of Regents indicates that using the word ‘doctor’ in offering to perform professional services without also indicating the licensed profession in which the individual holds the doctoral degree, constitutes unprofessional conduct.”
Zittel agreed. “The [Board of Regents] have anticipated such a situation and provided a penalty for individuals who abuse the title,” she said.
The American Association of Colleges of Nursing does not take positions on state legislation. But the organization does recognize that the title “doctor” is common to many disciplines and is not the domain of any one group of health professionals or field of study, said Joan Stanley, PhD, CRNP, FAAN, FAANP, senior director of education policy for the AACN.
“Many APRNs currently hold doctoral degrees (PhD, DNP, EdD) and are addressed as ‘doctor,’ which is similar to how other expert practitioners in clinical areas are addressed,” Stanley said. “‘Doctor’ is not synonymous with physician and many healthcare providers, including nurses, rightly use this title, which speaks to their level of advanced preparation.”
Impact on practice
In New York, the legislation most likely will not affect nurses’ practice, Kurtz said. “The quality of care that is provided by nurses, including DNPs, is not sacrificed nor dependent on the title,” she said.
Nurses are patient advocates and enactment of S02250 would have little effect on the way they practice. “It is not enough to have your role and title in an advertisement or on a sign or on an ID badge that many patients cannot read due to the small print or to the fact that someone has taken away their glasses on the way to the operating room,” Miner said. “I have always introduced myself to my patients and their families as a registered nurse and, despite my academic degrees, I am committed to continuing this practice.”