Karalee LeBreche talked with her supervisor Brian Theine about staff training. LaBreche was one of the first doctor nurses, a new designation, to graduate from the University of Minnesota.

Kyndell Harkness, Star Tribune

A doctor and a nurse, all in one package

  • Article by: CHEN MAY YEE
  • Star Tribune
  • April 26, 2008 - 9:25 PM

Anne Boisclair-Fahey is used to patients doing a double take when she introduces herself.

She begins by carefully explaining she's a nurse practitioner, then adds "You can call me Dr. Anne."

Get ready to meet a new kind of hybrid at your local clinic: the doctor nurse. They sport name tags with the letters DNP for doctorate of nursing practice.

Seen as one answer to the looming shortage in physicians, doctor nurses take the nurse practitioner concept to yet another level. Doctor nurses are trained in finance, health policy and systems know-how in addition to core clinical expertise. They can do a lot of what many doctors no longer have time to do in an increasingly complex health care environment.

While doctor nurses are still a rare breed nationally, that's about to change dramatically. The first class of 24 doctor nurses graduated in December from the University of Minnesota's School of Nursing, one of a handful of schools at the forefront of this trend. All have returned to their jobs or new positions, some with expanded roles and pay.

Now more than 90 nursing schools have introduced DNP programs and 200 more are about to start. Beginning next year, the University of Minnesota is converting its entire master's of nursing practice program into a doctoral course, meaning any nurse practitioner who passes board exams will be a doctor nurse.

"They are designed to work in collaboration with physicians," said Connie Delaney, dean of the School of Nursing, "so that very expensive physicians and specialists can spend their time on other things."

But some physician groups worry that the increasingly fuzzy demarcation between doctors and nurses may be confusing for patients at best, and unsafe at worst.

A looming void

Experts are forecasting a shortage of physicians in the country by 2020 because the population has grown even as enrollments in medical schools have remained flat.

What's more, 36 percent of active physicians are older than 55 and most will retire by 2020, said Edward Salsberg, director of workforce studies for the Association of American Medical Colleges. A new generation of physicians is less willing to work the long hours usually associated with the profession.

The shortage is already showing up in primary care, which includes family medicine, pediatrics and internal medicine. This year, U.S. medical graduates filled just 1,156 of 2,387 residency positions nationally in family medicine; the rest were filled by foreign medical graduates. Primary care doctors are paid far less than specialists.

Against this backdrop, nurse practitioners are "a phenomenal alternative," Delaney said.

There is a parallel movement in dentistry. Dentists are in short supply in rural areas of Minnesota, and there is a proposal moving through the Legislature to allow dental hygienists to drill and extract teeth, and prescribe medication without a dentist on site. The Minnesota Dental Association opposes the proposal, saying it jeopardizes safety.

Some doctors object

For years, physicians have resisted the notion of a doctor nurse.

The American Academy of Family Physicians, for example, wants it made clear to patients that nurses with an advanced degree are not the same as doctors who have been to medical school.

"With four years of medical school and three years of residency training, physicians' understanding of complex medical issues and clinical expertise is unequalled," said the academy's president, James King.

Macaran Baird, head of the Department of Family Medicine and Community Health at the University of Minnesota, says he's not worried about that. He points out that turf battles are not uncommon in the hierarchical world of health care.

However, he noted, there's no guarantee that doctor nurses will go into primary care unless the gap between payments in primary care and specialty care narrows.

Otherwise, he said, "we have the same risk of them going where the money is."

Projects show potential

For some nurses, the new title is a validation of what they've been doing for years.

Registered nurses, or RNs, are those with a bachelor's degree in nursing. Nurse practitioners have a master's in nursing practice and can see patients and prescribe drugs, just like doctors.

According to Delaney, there is already an 80 percent overlap between what nurse practitioners do and what primary care physicians do. The remaining 20 percent includes minor surgeries such as appendectomies or vasectomies. Nurse practitioners may also specialize in fields such as family practice, psychiatry, pediatrics, gerontology or midwifery.

Doctor nurses extend that nurse practitioner role even further with training positioning them for leadership roles in health organizations or teaching.

The three-semester program costs $14,500 for Minnesota residents and $23,500 for nonresidents. Most of the work is Web-based, with students coming to campus for several intensive weekends of work. So many nurse practitioners in the first class were able to add the doctor nurse credential while continuing to work part time.

Their student projects showed the scope and promise of combining a nurse practitioner's clinical skills with a doctor nurse's new awareness of health care systems. One student developed and implemented a standard screening for asthma patients during clinic visits, to ensure proper follow-up care. Another devised a plan to institute regular bathroom breaks at school for kids who wet their pants because of medical problems.

Karalee LaBreche, a psychiatric nurse practitioner for Ramsey County who was in the first class of doctor nurses, looked for ways to get emergency medication to those who needed it, including going to their homes. As a result, fewer patients showed up at the emergency room, a very expensive option.

The project won her an award from the International Society of Psychiatric-Mental Health Nurses.

More pay, promotions

For some, the new doctor of nursing practice degree has opened doors.

Six graduates have since been offered new positions or promotions, and a few have gotten modest salary increases, said Sandra Edwardson, director of the U's DNP program.

For Nicole Lynch, a psychiatric nurse practitioner at Abbott Northwestern Hospital in Minneapolis, the added training as a doctor nurse brought expansion of her role beyond outpatient care to inpatient care, too. For Boisclair-Fahey, who specializes in pediatric urology, it meant a 3 percent raise and an invitation to sit on a major board.

The proliferation of titles has caused some confusion.

Lynch explained her title to a child patient, who quickly twisted it around to "Nurse Doctor Lynch."

Most of the time though, she said, they just stick to "Miss Nicole."

Chen May Yee • 612-673-7434

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