Lest there be any doubt that arrogance and fear still roil in the gut of organized medicine, the American Medical Association (AMA) House of Delegates' recent passage of a number of resolutions offers proof. The doctorate of nursing practice (DNP) gave the docs a distinct dyspepsia at their meeting in June. The AMA resolved that a nurse with a DNP "must practice as part of a medical team under the supervision of a licensed physician who has final authority and responsibility for the patient."
Why is the AMA acting as though it's under threat from nurses? Nurses have long served populations that physicians have abandoned—such as poor immigrants in New York City in the early 1900s; more recently, an NP told me about how she treated uninsured patients in New Orleans after Hurricane Katrina in 2005, when some physicians wouldn't provide free care. A law requiring physicians to supervise DNPs would only further limit the access some of the nation's most vulnerable people have to necessary care. NPs often work where the pay is too low to attract physicians. And what most physicians don't realize is that many NPs have little interest in solo practice—they prefer collaborative practices with physicians.
In another reflexively self-protective move, the AMA House of Delegates voted against the National Board of Medical Examiners (NBME), which had agreed to offer a certifying exam for DNPs based on part of the licensing examinations that physicians take so that the public will know which advanced practice nurses are qualified to provide comprehensive care. (The NBME has a history of preparing reliable examinations and other assessments for various health professions.) This agreement was struck with the Council for the Advancement of Comprehensive Care, formed by the Columbia University School of Nursing, to advance the DNP while ensuring high standards of practice. The AMA's resolution against this idea said that the NBME should not participate "in any examination for Doctors of Nursing Practitioners [sic]" and should "refrain from producing test questions to certify DrNP candidates." This test is controversial even among nurses, but organized medicine can't quite give up the idea that it should be "the decider" for all of health care.
There were, however, two bright lights at the meeting. First, the group rejected a resolution that would have restricted the use of the words doctor, resident, and residency to physicians, dentists, and podiatrists. Somehow, the group realized that the term doctor applies to anyone who has earned a doctoral degree. The resolution would have supported making it a felony for a nonphysician to represent her- or himself as a physician to a patient. Of course, patients have the right to know whether they're being cared for by physicians, NPs, physician assistants, or other types of providers. But physicians don't own the title of Doctor, only the name physician.
The second ray of light came in a resolution that called for physicians to take an active role in addressing the shortage of bedside nurses. I hope that they will do so in collaboration with nurses and not decide that the solution is to fill nursing vacancies with "registered care technicians" who would report to physicians—as they did in the 1990s.
Only about 40% of the nation's physicians belong to the AMA, according to the American Nurses Association (ANA), although that percentage is greater than the percentage of the nation's nurses who belong to the ANA (5%). But the AMA still has clout, and some of the policy issues raised in the resolutions will be addressed in state legislatures. I urge all physicians to recognize that collaboration with nurses and other providers is the only way to transform a failing system. We have to better meet the nation's health care needs. Perhaps we have to accept that the AMA will guard physicians' turf at all costs. But individual physicians don't have to follow suit.