2015 DNP

ccso962 · Mar 4, 2011

This is pretty limited view of the Nurse Practitioner role. Primary care is one of the roles of an NP (and a very common one)...but there are many other NP roles. The first examples that come to mind are adult acute care NP's working in ICU's, or NP's who work in ED's around the country.

This was not intended to be a limited view of the role of NPs in the health care arena. I chose to focus on primary care specifically because the number one reason that most medical students give for NOT pursuing a residency in primary care is the cost of student loans versus the expected income of a physician in primary care especially in a medically underserved area. This was chosen specifically to illustrate my concern that rising costs of attendance to NP programs (which will no doubt happen when all programs shift from MSN to DNP) could be a limiting factor for these NPs to practice primary care in an area that is already experiencing a shortage of medical providers. To be sure there are NPs in many other practice areas, but there are not a shortage of medical doctors in most of those areas like there are in primary care in medically underserved areas. This is not meant to imply that NPs are not needed in these areas (in fact I think NPs are probably needed in areas they don't practice in now also), but rather to say that if an NP does not choose to pursue a career in an ER, for instance, there will not be a hole left unfilled without a provider, since there are plenty of PAs and MDs willing to practice in an ER. In primary care that hole could be all too real if NPs that might otherwise pursue primary care in these areas are unable to do so because of an increase in student loans without an appreciable increase in compensation. There is only so much that people who live in poverty stricken areas can afford to pay for health care no matter what the provider might think they are, or even actually are, worth. That means the only alternative might be to abandon these patients as many physicians have been forced to do in order to keep afloat. For all the good in the world and debate on health care reform the cost of health care education does play a limiting factor on where practitioners choose to practice.

I guess the primary point being that if you take mid-level providers and charge them as much for schooling as you do the medical doctor but pay them far less what is the incentive to enter the medical profession at this level. Sure feeling strongly about the nursing process or having a calling to work in this area are great, BUT these feelings don't pay the bills.

As always just my two cents worth.

CuriousMe · Mar 4, 2011

This was not intended to be a limited view of the role of NPs in the health care arena. I chose to focus on primary care specifically because the number one reason that most medical students give for NOT pursuing a residency in primary care is the cost of student loans versus the expected income of a physician in primary care especially in a medically underserved area. This was chosen specifically to illustrate my concern that rising costs of attendance to NP programs (which will no doubt happen when all programs shift from MSN to DNP) could be a limiting factor for these NPs to practice primary care in an area that is already experiencing a shortage of medical providers. To be sure there are NPs in many other practice areas, but there are not a shortage of medical doctors in most of those areas like there are in primary care in medically underserved areas. This is not meant to imply that NPs are not needed in these areas (in fact I think NPs are probably needed in areas they don't practice in now also), but rather to say that if an NP does not choose to pursue a career in an ER, for instance, there will not be a hole left unfilled without a provider, since there are plenty of PAs and MDs willing to practice in an ER. In primary care that hole could be all too real if NPs that might otherwise pursue primary care in these areas are unable to do so because of an increase in student loans without an appreciable increase in compensation. There is only so much that people who live in poverty stricken areas can afford to pay for health care no matter what the provider might think they are, or even actually are, worth. That means the only alternative might be to abandon these patients as many physicians have been forced to do in order to keep afloat. For all the good in the world and debate on health care reform the cost of health care education does play a limiting factor on where practitioners choose to practice.
I guess the primary point being that if you take mid-level providers and charge them as much for schooling as you do the medical doctor but pay them far less what is the incentive to enter the medical profession at this level. Sure feeling strongly about the nursing process or having a calling to work in this area are great, BUT these feelings don't pay the bills.
As always just my two cents worth.

I guess I don't see it as anywhere near the expense of medical school. There are already BSN --DNP programs that are three years long as opposed to the BSN to MSN programs which are two years.

ccso962 · Mar 4, 2011

Uh...this is where you are incorrect. If you read the position statement for the 2015 plan, this very issue is addressed. It is about an 85 page document, but well worth reading.
Physicians ARE NOT SOLELY ENTITLED by any law, legal maneuver, or even hospital policy, to be the only healthcare professionals to use the title "doctor" and the national associations that certify NP's talk about this very issue and how DNP's will COMPLETELY earn the right to be called "Dr _____" in a clinical setting.
That is one of the reasons for the change, believe it or not and they have ever intention of pushing DNP's to use the title.
Your typical PharmD program is 3 years in most states past the Bachelor level...that is a Doctor of Pharmacy degree...all of the PharmD's at my facility are referred to "Dr so-and-so".

This might be the case that the powers that be in nursing want to be called "doctor" if they have a DNP, and that is all well and good I guess. However, I have several friends who have their PharmD (my cousin is currently in pharmacy school now), but NONE of these call themselves "doctor". In fact in most states people who refer to themselves as "doctor" in a health care setting (yes psychologists too) who are not medical doctors have to wear identification clearly showing what degree and career path they are. In other words a Physician Assistant who has an earned doctorate in health science would still have to have the phrase "Physician Assistant" on their ID or lab coat even if they referred to themselves as doctor. I am sure this will be the same with NPs who have the DNP.

One thing above that I KNOW is not truthful everywhere is the part about there being no hospital policies to limit who can be called doctor. The first hospital I worked at had EXACTLY such a policy. Even though DNPs would have been able to call themselves doctor under these policies those who did not have a specifically clinical doctorate (say for instance a PhD) were not allowed to refer to themselves as doctor unless they also had a clinically oriented doctorate (i.e. an MD/PhD or PharmD/PhD for example)when talking to a patient. Also at this facility ANY person who identified to a patient as "doctor" who was not an MD or DO had to follow their introduction to that patient by stating what they were. For example "Hi I'm Dr. Doe one of the Pharmacists here". For this reason NONE of the non-MD/DOs who practiced at this facility (and there were quite a few) that I am aware of referred to themselves as doctor to patients. Keep in mind also that in many states it is the responsibility of the non-medical doctor provider to make sure the patient understands they are not a medical doctor. This means that even if your ID tag says "John Doe, PhD Laboratory Science" and you identify yourself as Dr. Doe you have to make sure the patient knows you are not a medical doctor.

That said even if I was a medical doctor I would prefer my patients to call me by my first name. That's just the kind of person I am and I know there are many who won't feel this way. Thats ok too though because we are all different.

ccso962 · Mar 4, 2011

I guess I don't see it as anywhere near the expense of medical school. There are already BSN --DNP programs that are three years long as opposed to the BSN to MSN programs which are two years.

I understand and not saying that it WILL become that expensive, but I think one thing to consider on that front right now is that the three year BSN to DNP programs now still have to compete with BSN to MSN programs for students. If a BSN to DNP program shot the cost way up they would most likely loose some students to the BSN to MSN programs since they still exist. After the MSN programs go away (and I understand this might be significantly after 2015) then the only way to be an NP will be the DNP route meaning that all the schools can increase costs. Keep in mind that medical school tuition rises steadily every year. School One offering an MD of 4 years in length doesn't have to worry about competing with School Two whose MD program is 3 years in length and $50,000 cheaper since all MD programs (in the US at least) are 4 years in length. One thing that might help keep costs of DNP programs low is the shear number of NP programs versus MD programs. Meaning more competition between schools might help keep those costs lower, and lets really hope this is the case. If, however, some programs decide to close instead of offering the DNP (which might be the case for any number of reasons including not having accreditation to offer doctorate level programs) then that could increase the cost.

That said I think that medical school costs are skyrocketing, and we may very well see more would be medical students attending nursing school and ultimately DNP programs. This might also help to keep costs down. At any rate my concern is more IF the costs increase substantially not that they WILL increase substantially.

Hope that all makes sense, and being new to the forum I have really enjoyed the discussion on my post. :)

CuriousMe · Mar 4, 2011

I don't think that anyone is supporting that those with non-clinical doctorates use the title Doctor in a clinical setting, but any healthcare professional that has earned a clinical doctorate should be able to use the title they earned.

Physician = MD....not Doctor as is evidenced by dentists, PharmD's, psychologists, etc all using the title Doctor. Of course a Physician Assistant won't call themselves Doctor....are there even any clinical doctoral programs for PA's?

I find it amusing that it's only when DNP educated nurses use the term Doctor that folks get themselves into a tizzy.

This might be the case that the powers that be in nursing want to be called "doctor" if they have a DNP, and that is all well and good I guess. However, I have several friends who have their PharmD (my cousin is currently in pharmacy school now), but NONE of these call themselves "doctor". In fact in most states people who refer to themselves as "doctor" in a health care setting (yes psychologists too) who are not medical doctors have to wear identification clearly showing what degree and career path they are. In other words a Physician Assistant who has an earned doctorate in health science would still have to have the phrase "Physician Assistant" on their ID or lab coat even if they referred to themselves as doctor. I am sure this will be the same with NPs who have the DNP.
One thing above that I KNOW is not truthful everywhere is the part about there being no hospital policies to limit who can be called doctor. The first hospital I worked at had EXACTLY such a policy. Even though DNPs would have been able to call themselves doctor under these policies those who did not have a specifically clinical doctorate (say for instance a PhD) were not allowed to refer to themselves as doctor unless they also had a clinically oriented doctorate (i.e. an MD/PhD or PharmD/PhD for example)when talking to a patient. Also at this facility ANY person who identified to a patient as "doctor" who was not an MD or DO had to follow their introduction to that patient by stating what they were. For example "Hi I'm Dr. Doe one of the Pharmacists here". For this reason NONE of the non-MD/DOs who practiced at this facility (and there were quite a few) that I am aware of referred to themselves as doctor to patients. Keep in mind also that in many states it is the responsibility of the non-medical doctor provider to make sure the patient understands they are not a medical doctor. This means that even if your ID tag says "John Doe, PhD Laboratory Science" and you identify yourself as Dr. Doe you have to make sure the patient knows you are not a medical doctor.
That said even if I was a medical doctor I would prefer my patients to call me by my first name. That's just the kind of person I am and I know there are many who won't feel this way. Thats ok too though because we are all different.

CuriousMe · Mar 4, 2011

Yes, it's possible that tuition will increase....but I don't think there's evidence that supports that it will be likely for tuition to increase any more than it has been in the past.

I understand and not saying that it WILL become that expensive, but I think one thing to consider on that front right now is that the three year BSN to DNP programs now still have to compete with BSN to MSN programs for students. If a BSN to DNP program shot the cost way up they would most likely loose some students to the BSN to MSN programs since they still exist. After the MSN programs go away (and I understand this might be significantly after 2015) then the only way to be an NP will be the DNP route meaning that all the schools can increase costs. Keep in mind that medical school tuition rises steadily every year. School One offering an MD of 4 years in length doesn't have to worry about competing with School Two whose MD program is 3 years in length and $50,000 cheaper since all MD programs (in the US at least) are 4 years in length. One thing that might help keep costs of DNP programs low is the shear number of NP programs versus MD programs. Meaning more competition between schools might help keep those costs lower, and lets really hope this is the case. If, however, some programs decide to close instead of offering the DNP (which might be the case for any number of reasons including not having accreditation to offer doctorate level programs) then that could increase the cost.
That said I think that medical school costs are skyrocketing, and we may very well see more would be medical students attending nursing school and ultimately DNP programs. This might also help to keep costs down. At any rate my concern is more IF the costs increase substantially not that they WILL increase substantially.
Hope that all makes sense, and being new to the forum I have really enjoyed the discussion on my post. :)

linearthinker, DNP, RN · Mar 4, 2011

Straw Man. Tuition costs have increased an average of 10-13% a year long before the DNP was a factor.

ccso962 · Mar 4, 2011

I don't think that anyone is supporting that those with non-clinical doctorates use the title Doctor in a clinical setting, but any healthcare professional that has earned a clinical doctorate should be able to use the title they earned.
Physician = MD....not Doctor as is evidenced by dentists, PharmD's, psychologists, etc all using the title Doctor. Of course a Physician Assistant won't call themselves Doctor....are there even any clinical doctoral programs for PA's?
I find it amusing that it's only when DNP educated nurses use the term Doctor that folks get themselves into a tizzy.

Oh no I agree 100% that if you have earned a doctorate (clinical or otherwise) and you want to refer to yourself as doctor then that is great. I am simply saying that not everyone agrees with that. In fact if you look around on most of the other medically relevant forums there are plenty of people discussing the problem of confusion to patients by multiple people being called doctor in a health care setting not just NPs. I happen to know of more than one hospital where pharmacists are NOT allowed to refer to themselves as doctor period.

As for the PA calling themselves doctor I worked with two PAs (both working in the ER) who had earned doctorates (one in Health Science (DHSc) and the other a PhD in Health Related Studies). Neither of these PAs saw any reason to refer to themselves as doctor so I don't know how the hospital would have reacted if they had.

I am not aware of ANY entry level PA programs at the doctorate level...YET. There seems to be quite a bit of discussion out there on the internet about some PAs wanting to have a clinical doctorate option especially in light of the move to DNP. I don't know that the AMA would back this move, or the AAPA for that matter either. Keep in mind there are still PA programs that award the Bachelor's and a couple in California that still award Associate's degrees although the curriculum is all standardized for the most part and it all depends on pre-reqs etc. at the various schools.

As far as people getting in a tizzy when DNPs want to be known as a doctor and not other providers I think this, again, may depend on the region of the country you are in. There is still plenty of discussion on the forums out there about whether a pharmacist should be called doctor for instance, and even within the pharmacy profession there is division on this issue. I think maybe it seems more like its all DNPs on this site, because this site is geared toward nurses. I can assure you though that on sites geared toward medical students, residents, etc. there is plenty of dissent for anyone other than an MD or DO to be called doctor.

linearthinker, DNP, RN · Mar 4, 2011

ITA that there is endless dissension on the subject among our MD colleagues. That neither surprises or upsets me. I don't like to see a lack of support from nurses, and I'm happy to see this tide turning.

ccso962 · Mar 4, 2011

Straw Man. Tuition costs have increased an average of 10-13% a year long before the DNP was a factor.

Not a Straw-man at all. Or at least not an attempt to be one. There is serious discussion out there over the costs of health care education and its effects on bringing in practitioners, practitioner practice settings, etc. This is even more true with less access to financial aid which, although I am sure many will disagree, is a very REAL problem for certain students. The simple fact of the matter is the more I have to spend to produce a product or service the more I will ultimately have to charge the consumer of that product or service. In fact there is plenty of discussion out there about educational costs in this country already being too high without the 10 - 13% increase as you say a year. Keep in mind also that 10% is not a lot when you are referring to say maybe $100 dollars, but is a quite bit more substantial when you are referring to the tens of thousands of dollars. Maybe an increase from $20,000 a year to $22,000 a year is not a big increase to some, but I don't happen to have an extra $2,000 laying around in pocket change and with an increase in pay of 1.5% from last year to this my income didn't compensate for that 10% change in tuition either.

CuriousMe · Mar 4, 2011

As for the PA calling themselves doctor I worked with two PAs (both working in the ER) who had earned doctorates (one in Health Science (DHSc) and the other a PhD in Health Related Studies). Neither of these PAs saw any reason to refer to themselves as doctor so I don't know how the hospital would have reacted if they had.

Neither of those are clinical Doctorates (I'm not sure what the DHSc is....Doctorate of Health Science, I know, but I don't think it's tied to a clinical role at all) so neither should use the title Doctor in a clinical setting.

As far as people getting in a tizzy when DNPs want to be known as a doctor and not other providers I think this, again, may depend on the region of the country you are in. There is still plenty of discussion on the forums out there about whether a pharmacist should be called doctor for instance, and even within the pharmacy profession there is division on this issue. I think maybe it seems more like its all DNPs on this site, because this site is geared toward nurses. I can assure you though that on sites geared toward medical students, residents, etc. there is plenty of dissent for anyone other than an MD or DO to be called doctor.

Of course there will be discussion on a nursing board about this....I'm not talking about that. I've seen story's about this issue on mainstream news sites....and have yet to see any protests there about other professionals using their earned title.

And yes, I've read forums geared to med students and residents. I understand that many feel they own the term Doctor....but their opinions don't trouble me....they're hardly main stream.

ccso962 · Mar 4, 2011

ITA that there is endless dissension on the subject among our MD colleagues. That neither surprises or upsets me. I don't like to see a lack of support from nurses, and I'm happy to see this tide turning.

I agree that nurses should be more recognized, and, as I have said in other posts, I completely agree with a nurses right to earn a DNP. I guess the ultimate question is what will you be able to do with a DNP that you weren't able to do with an MSN (other than call yourself doctor)? As countless others, and not just me, have pointed out there is, in most programs, no increase in the medical science curriculum within these programs. Most of the "hate speech" I personally have heard lobbed at the DNP or doctoral prepared nurse in general from the medical profession is the fact that adding the DNP does not add additional clinical or medical competency since in most places it will only increase non-medical science areas. If it makes you feel any better there are many MDs that feel the same way about the change from BS to MS for most PAs.

If having the DNP makes you feel better about yourself and your profession that is great, in my opinion. However, if it adds nothing substantial to the patient care and scientific practice of medicine aspects of the job then I am not sure the DNP as an entry level program will garner any more respect from the MD community.