"I am a nurse but I am also a doctor": Conflicting Identities to the Patient?
Should a nurse with a doctorate degree in nursing identify herself as a doctor to a patient? Here are excerpts from the current New York Times article on this question:
"Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title “doctor,” but also the money, power and prestige that often comes with it. ...
As more nurses, pharmacists and physical therapists claim this honorific, physicians are fighting back. For nurses, getting doctorates can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients. ...
So physicians and their allies are pushing legislative efforts to restrict who gets to use the title of doctor. A bill proposed in the New York State Senate would bar nurses from advertising themselves as doctors, no matter their degree. A law proposed in Congress would bar people from misrepresenting their education or license to practice. And laws already in effect in Arizona, Delaware and other states forbid nurses, pharmacists and others to use the title “doctor” unless they immediately identify their profession."
What do you think? Should M.D.s be identified to the patients as "doctors" and nurses with a doctorate degree be indentified as "nurses"? ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:05:00 AM
20 comments
20 Comments:
In academia very few PhD's use the title doctor because too many people confuse them with physicians.
I'm against it being used where the purpose would be to mislead patients into thinking they are physicians. If not being used to mislead, then it's simply a matter of personal choice. Most nursing PhD's don't care for patients but have administrative or academic duties.
Joel, would you say, therefore, that from the physicians' and the states' point of view, this concern about such use of PhD title "doctor" in a medical environment is much ado about nothing?..Maurice.
Have only my experience to go on. Other institutions may have different experiences.
Hasn't been a problem in my areas.
I work in academia connected to a community hospital. Our PhDs are often referred to in our academic environment as "doctor" but are rather quick to clarify that they are not medical professionals once in a medical environment. There is a big difference between the title applying to one's education and applying to one's profession. I rarely hear PhDs called "doctor" outside academic halls for just this reason. Technically, lawyers could be called "doctor" as well, but you never hear that outside an academic teaching environment, and rarely in it.
So, from that standpoint, I don't feel it's appropriate for a PhD to refer to themselves as "doctor" in a clinical setting. While it may be technically accurate, it's professionally misleading in that environment. When someone says, "Page a doctor", they don't want a PhD in art history.
Does it need a law? Given that it doesn't seem to have become a huge problem, I think it would be best handled in hospital bylaws and policies. For instance, only allowing practicing physicians to use the title "doctor" while at the hospital.
- Onion
Readers here might be interested in also reading the comments of participants on Medpedia regarding the same question. ..Maurice.
Anyone can get a PhD in nursing and religion,keep them
at arms length when you need healthcare.
PT
PT, you have got to be a bit more descriptive regarding the basis for your statement. I presume "keep them at arms length" is the expression for "don't engage in professional relationships with them as a patient."
But, really, can "anyone" get a PhD in nursing, specifically? The individual must go to and graduate from nursing school as well as a lengthy post-graduate program that must cost quite a bit of money and the expense of precious time in ones life. That's not "anyone".
We need licensed nurses to perform their professional nursing duties and unless that PhD nurse is now performing only administrative work for 15 years and nothing clinical, of course I would not want her taking care of me in the critical care unit.
But, again PT, elaborate a bit more on your generalization. ..Maurice.
I'm not sure what the exact answer is, but I suspect that the motive for nurses with a doctorate using the title "Doctor" would often be to mislead the patient. Prestige, power, etc.
I have seen medical professionals, if not actually misrepresenting themselves, come pretty close.
Interns and residents do not introduce themselves as such, just come in saying "I'm the doctor". OK, technically true, but the patient is generally assuming the are the attending, not someone still in training.
The worst one I encountered was a person giving medical advice over the phone. When asked "Are you a nurse practitioner or PA?" she answered "Yes". When asked "Which?" she answered "I'm a medical assistant". Terrific.
I agree with the above - many people are entitled to the title "Doctor" by their education, but people expect, when they hear that in a medical environment, that it is referring to a physician.
If nurses are going to start using that title, I think the physicians will have to come up with a new/modified title, so that people know exactly who they are dealing with. I believe that is the patient's right.
TAM
Tam, I posted the following question on the Medpedia website regarding the Constitutional aspects of this issue. I thought it would be appropriate to ask it here too on my blog.
I started this Question with an excerpt from the New York Times article: " A bill proposed in the New York State Senate would bar nurses from advertising themselves as doctors, no matter their degree. A law proposed in Congress would bar people from misrepresenting their education or license to practice. And laws already in effect in Arizona, Delaware and other states forbid nurses, pharmacists and others to use the title “doctor” unless they immediately identify their profession."
...how [does one] look at these proposed laws or those which apparently are already in some states in terms of violation of the Constitutional direction regarding freedom of speech? For a nurse to identify herself (or himself) with a "doctor" prefix is a matter of free speech isn't it? It is not a designation which is delivered out of "whole cloth" (knowingly false) since it represents the nurse's valid educational title and a title that is commonly used by others and applied to others with a doctorate degree? Or is this an example of a Constitutional limitation of free speech when the word "fire" is yelled out in a crowded auditorium when there is no fire and the intent of a individual who yells is to cause panic? In this example, the potential is for harm. What argument could be given to support those state nurse laws Constitutionally: attempt to mislead?
Any answers from those on my blog thread?
..Maurice.
Quick thoughts:
a. The "freedom of speech" isn't wrong because it's like shouting "Fire" in a crowded theater, it's because you can't make trade claims falsely. I'm sure a lawyer would be able to phrase this more eloquently and also know the precise legal principle, but the FDA and Federal Trade Commision constantly monitor claims made by manufacturers of drugs and anything else for false claims. RNs calling themselves "Doctor", the naysayers would argue, constitutes a similar false claim.
b. "Anonymous" above takes issue with housestaff who would call themselves "doctor", but this seems to me to be going too far. They're doctors! Perhaps there's a little room for confusion if they introduce themselves as the doctor (implying the attending), but the average Joe finds the terminology of housestaff rank (clerk, sub-I, intern, resident, senior resident, fellow, senior fellow, attending...and that of course leaves out the role of consultants) so confusing that "doctor" relays the basic message, that this person is in some meaningful way responsible for a patient's health.
c. What to do about PAs? They're much more like doctors than they are like nurses, with considerably more autonomy. Many of the PAs I work with are MDs in all but name only. Yet the title "physician's assistant" almost implies something clerical. Them I'd call "doctor".
d. My own personal policy: once I learn that a person has a PhD in whatever field, I call them "doctor" until they tell me otherwise. I do not call them "professor" unless they are full professors. It's as close to a by-the-book system I know of, and it ain't worth the trouble to offend someone who gets worked up over this stuff. (Maya Angelou, the great poet, had received honorary PhD's later in life, and insisted on being formally addressed as "doctor". If I were invited to tea with her, I'd respect her wishes even if I'd have to pucker my lips just a lil' bit before doing so.)
e. I don't really care what patients call me, although hate to say it I've gotten accustomed to being addressed as "doctor". If they call me by my first name, so be it. I do insist that the nurses with whom I work call me by my first name, since I don't call them "Nurse So-and-So".
f. I agree that there are some occasional moments when someone in the health profession might very seriously mislead a patient by referring to themselves as "doctor" when their claim to that title is tenuous, but is the problem really that serious that we need to put laws on the books against it? Wow. I'm in agreement that this could be a policy implemented by particular facilities that need to clarify things.
I think the law suggested above "And laws already in effect in Arizona, Delaware and other states forbid nurses, pharmacists and others to use the title “doctor” unless they immediately identify their profession." seems very practical.
OK, fine, everyone who got a doctorate degree of any kind worked hard for it, and thus earned the title of "doctor". However, in a clinical setting, they should immediately make it clear that they are not a physician. If they aren't trying to mislead anyone, that shouldn't be an issue for them.
As far as free speech - well, I guess in unfettered free speech, I could call myself "doctor" too. I don't have a doctorate degree, but I still could do so. Should I? Of course not. As said above, free speech has limits.
Re. the house staff - when someone tells me they are "The Doctor" I should be able to expect that they are fully trained, licensed, and entitled to work on their own, unsupervised. It doesn't take much to say "I'm Dr. so and so, I'm the resident/intern working with Dr. Attending", and many do. If the patient doesn't care, fine. Some, like me, do. I do not think this ommission is accidental. It can be very interesting trying to extricate what year a resident is in, from either the resident or staff - often, they really try to not say. Of course, this doesn't apply to everyone - I have met some very nice and brilliant medical students and residents also. Plus a few that were "too big for their britches".
TAM
That has nothing to do with free speech! I have no medical training whatsoever, and I could call myself a physician! An individual calling himself a doctor is misleading patients, possibly to inspire more trust, but it'll backfire. they're fooling patients anyway.
To me, there is a difference between using a title that is earned and misleading a patient. I am a psychologist and refer to myself as doctor (a degree I did earn). I also include the nature of my doctorate and my licensure in any correspondence and introduction. It should be illegal to imply I am an M.D., just as it is illegal where I practice psychology to claim to be a psychologist without being licensed by a licensing board.
I work in a medical setting. Physicians I am associated with always address me as doctor and I have never asked them to use the title. The nature of my work is such that the use of my given name would be inappropriate. I earned the title as much as any physician. It is simply a doctorate in a different field. I have no problem with insisting on clarity. Patients (and other professionals) should never be misled. I do have a problem with physicians deciding they are the only ones with the title "doctor" who are allowed to use a title they earned.
EA
EA,
Your role is different b/c you are a psychologist. Your patients know you won't tell them what to do about their blood pressure. In outpatient settings, NPs routinely are the PCP for patients. Some use "doctor" and some don't. In one practice, the NPs called themselves "Dr. first name" and the MDs called themselves "Dr. last name" as a way to distinguish between levels.
My concern is less over these distinctions than in states where NPs can practice independently. It is in the independent practitioner's best interest to minimize the differences in experience/education. There a wildly different capabilities between NPs, and patients are not aware of this. Not that they are aware of the differences between MDs either.
SKB,
I agree no one should be misled to believe a NP or a PA is a doctor. I think that kind of deception should be as illegal as it is to claim to be a psychologist when a person is not properly educated and licensed by a licensing board. It also seems clearly unethical to me.
You are correct, of course, that people often do not know the differences among MDs. The patients I work with often don't know the difference between a psychologist and a psychiatrist. There is another layer to that when marginally trained people call themselves nurses.
It is not just in the interests of the people directly seeing patients to mislead. It is also in the interests of those companies who profit from this sort of deception. A NP or PA costs less, yielding more in profits. Similarly, a nursing assistant costs less than an RN.
While I appreciate that the greatest danger is with those who practice independently, I don't think deceptive practices should be allowed at any level. I don't think we have any totally independent NPs where I live, though they do work alone in the so-called clinics that are springing up affiliated with pharmacies.
My guess is those who are practicing independently are mostly seeing people who cannot afford to go to a regular clinic and are desparate, or are seeing people who think they have something very minor.
I do not believe claiming to be something you are not in professions that require specialized training and licensure has anything to do with freedom of speech. There are things we are not, and should not, be allowed to say. I have the right to protest. I do not have the right to threaten another's safety. Claiming to have medical expertise can be a life or death matter. I don't think it takes much of a leap of logic to say only people who are trained as physicians can call themselves (or imply they are) physicians.
EA
SKB,
I agree no one should be misled to believe a NP or a PA is a doctor. I think that kind of deception should be as illegal as it is to claim to be a psychologist when a person is not properly educated and licensed by a licensing board. It also seems clearly unethical to me.
You are correct, of course, that people often do not know the differences among MDs. The patients I work with often don't know the difference between a psychologist and a psychiatrist. There is another layer to that when marginally trained people call themselves nurses.
It is not just in the interests of the people directly seeing patients to mislead. It is also in the interests of those companies who profit from this sort of deception. A NP or PA costs less, yielding more in profits. Similarly, a nursing assistant costs less than an RN.
While I appreciate that the greatest danger is with those who practice independently, I don't think deceptive practices should be allowed at any level. I don't think we have any totally independent NPs where I live, though they do work alone in the so-called clinics that are springing up affiliated with pharmacies.
My guess is those who are practicing independently are mostly seeing people who cannot afford to go to a regular clinic and are desparate, or are seeing people who think they have something very minor.
I do not believe claiming to be something you are not in professions that require specialized training and licensure has anything to do with freedom of speech. There are things we are not, and should not, be allowed to say. I have the right to protest. I do not have the right to threaten another's safety. Claiming to have medical expertise can be a life or death matter. I don't think it takes much of a leap of logic to say only people who are trained as physicians can call themselves (or imply they are) physicians.
EA
The thing is, are patients being decieved directly?
The NP comes in and says "Hi, I am Doctor so-and-so, and I will be taking care of you today". Did he/she directly deceive the patient? Did he/she state she was a physician? No. But the patient, in that situation, reasonably assumed he/she was a physician.
I do believe something needs to be done to prevent that. It shouldn't be the patient's responsibility to as if "Doctor" is a physician, or a nurse, or an astroscientist.
I believe that in a situation where there could possibly be a misunderstanding, a responsible medical professional should speak up to clarify the situation. Unfortunately, I don't believe that all of them will, so I would support legislation that requires them to do so.
No one is taking their title away, just enforcing honesty with patients.
TAM
I don't see what the big issue is. It's about linguistics and how words mean. Within the medical context, within a hospital, within a clinic, in the OR, in the ICU, at a LTC facility -- the title Doctor means "medical doctor." Period. Do we need to do a "study" to confirm this? If you were to go to a clinic or hospital and ask 100 patients at random this question: "If someone here comes up to you and introduces themselves as Dr. So and So, and that someone is dressed professionally (wearing scrubs, a white coat, a suit/dress, what will you assume about their academic background?" Give them some choices: (a) a nurse with a Phd; (b) a Phd in French Literature; (c) an animal Vet; (d) a dentist. (e) a medical doctor. Anyone want to guess the results?
Anyone who is not a medical doctor who uses that title within a medical context where a patient will logically assume he/she means medical doctor -- needs to add that he/she is not a medical doctor but a Phd.
The fallacy here is that, linguistically, words without context have objective meaning. They don't. Their meaning is intimately connected to many elements, including context, tone, body language, etc.
Anonymous said...
Anyone can get a PhD in nursing and religion,keep them
at arms length when you need healthcare.
Sure Mr Anonymous PT, "anyone can get a PhD in nursing and religion". YOU GO RIGHT AHEAD AND TRY IT.
It might not matter for many if not most doctors. But I think it could be a potential game changer in anesthesia with nurse anesthetists (CRNAs) vs. anesthesiologists. In this respect, I think we need to support our fellow anesthesiologists as much as we can.
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