AMA Delegates Oppose DNPs as Medical Team Leaders

Delegates at the recent annual meeting of the AMA House of Delegates here left little room for doubt when it came to their views on the appropriate role of nurses in patients' medical care. Although nurses -- including those with a terminal degree in nursing -- are welcomed as part of the medical team, physicians still need to take the lead.

Despite strongly worded opposition from national nursing organization representatives who attended the meeting, the delegates adopted a resolution that called for new AMA policy stipulating that doctors of nursing practice, or DNPs, "must practice as part of a medical team under the supervision of a licensed physician who has final authority and responsibility for the patient."

The delegates further directed the AMA to oppose a recent move by the National Board of Medical Examiners, or NBME, which earlier this spring announced (6-page PDF; About PDFs) it would develop and administer a certification exam for graduates of DNP programs.

AAFP President-elect Ted Epperly, M.D., of Boise, Idaho, clearly voiced the Academy's support for the resolution during testimony to the AMA Reference Committee on Legislation on June 15, citing multiple concerns the AAFP has previously expressed (Members Only) about the DNP issue.

Perhaps chief among those concerns are the precise nature of the nursing practice doctorate and the vast differences in clinical training requirements between the DNP degree and a medical or osteopathic doctorate, Epperly noted.

"The current doctor of nursing practice refers to nurses who have a doctorate for reasons of education, research and scholarly work," he said. "It is not a clinical doctorate."

In fact, Epperly added, a DNP candidate completes only about 500 hours of additional training after receiving his or her master's degree. "That compares to about 9,000 to 15,000 hours of work that it takes a physician to become a primary care physician and a true doctor," he said.

In his testimony, Epperly also criticized the NBME's recent announcement that it would begin administering an assessment exam to graduates of DNP programs, saying the national board had "crossed the line" in making this decision. "This is not the National Board of Nursing Examiners, it's the National Board of Medical Examiners," he noted.

Following up on a June 11 letter (3-page PDF; About PDFs) from the American Nurses Association, or ANA, to the reference committee, Eileen Carlson, J.D., R.N., associate director of government affairs for the ANA and an official observer from that association to the AMA House, spoke against the resolution in the reference committee hearing. She urged that the measure be withdrawn or defeated, noting that the nursing community views this issue as one of expanding access to care and pointing out that some 22 states now permit some level of independent nurse practice.

Finally, Carlson questioned the AMA's attempt to intercede in what she said the nursing profession sees as an internal issue. "It is no more appropriate for the AMA to regulate nursing practice than it would be for the ANA to regulate medical practice," she told reference committee members.

Another point Epperly made in his reference committee testimony on the DNP resolution -- that use of the term "doctor" in a clinical care setting can mislead patients if it's not reserved solely for physicians -- also pertains to another measure AMA delegates adopted June 17. That resolution calls for the AMA to "advocate that professionals in the clinical setting clearly and accurately identify to patients their qualifications and degree(s) attained." The resolution also directs the AMA to develop model legislation to help states implement that action and to support state legislation that would make misrepresentation a felony.

AMA delegates also dealt with numerous other professional issues, adopting resolutions that call for the AMA to: