AMA Delegates Oppose DNPs as Medical Team Leaders
Midwifery, Medical Imaging Also Topics at Annual Meeting
By Cindy Borgmeyer
• Chicago
6/25/2008
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.
AAFP President-elect Ted Epperly, M.D., of Boise, Idaho, testifies before the AMA Reference Committee on Legislation about the Academy's views on the role of doctors of nursing practice in the medical care team.
Hear AAFP President-elect Ted Epperly, M.D., recap his June 15 testimony to the AMA Reference Committee on Legislation in a brief AAFP News Now interview (2:53-minute MP3 file; About Downloading).
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.
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.
Academy Testimony Focuses on DNP Scope, Clinical Training
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.
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.
NBME Lays Out Plans to Administer DNP Exam
In a recently published article in The National Board Examiner (6-page PDF; About PDFs), the National Board of Medical Examiners described its plans to administer the doctor of nursing practice, or DNP, exam.
"The DNP examination will assess the knowledge and cognitive skills necessary to support advanced clinical practice by DNP graduates. It will be comparable in content, similar in format and will measure similar competencies and apply similar performance standards as Step 3 of USMLE," the article reads, referring to the U.S. Medical Licensing Examination.
"Step 3, the last in the USMLE sequence of examinations, provides a final assessment of physicians assuming independent responsibility for delivering general medical care," the Examiner article continues. "The DNP examination will assess some of the competencies assessed by Step 3 and will be administered to DNP graduates for the first time in November 2008."
"The DNP examination will assess the knowledge and cognitive skills necessary to support advanced clinical practice by DNP graduates. It will be comparable in content, similar in format and will measure similar competencies and apply similar performance standards as Step 3 of USMLE," the article reads, referring to the U.S. Medical Licensing Examination.
"Step 3, the last in the USMLE sequence of examinations, provides a final assessment of physicians assuming independent responsibility for delivering general medical care," the Examiner article continues. "The DNP examination will assess some of the competencies assessed by Step 3 and will be administered to DNP graduates for the first time in November 2008."
Nurses Denounce AMA's DNP Measure
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.
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.
When Is a Doctor Not a Doctor?
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:
AMA delegates also dealt with numerous other professional issues, adopting resolutions that call for the AMA to:
- advocate for licensure only of those nurse-midwives who have been certified by the American College of Nurse-Midwives,
- support state legislation requiring appropriate physician and regulatory oversight of nurse-midwives,
- continue to monitor states' midwifery licensure and scope of practice activities,
- work with state medical societies and medical specialty organizations to safeguard maternal and neonatal health with regard to midwifery issues,
- support state legislation acknowledging that hospitals or appropriately regulated birthing centers are the safest settings for labor and delivery,
- oppose legislative and regulatory efforts to restrict the delivery of advanced imaging services provided by qualified physicians in accordance with established clinical guidelines and technical standards, and
- ensure that physicians of all specialties engaged in providing needed imaging services to their patients have an equal say in developing quality and efficiency measures for those services.
