1. Kennedy, Maureen Shawn MA, RN, news director
  2. Roush, Karen MSN, FNP, RN, clinical editor

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Physicians have long viewed nurses as subservient, second class citizens in their hierarchy of health care, and now they've assigned them an even more ludicrous role: public health threat. That's what the American Medical Association (AMA) wants the public to believe with its warnings of the "confusion, injury, and breakdown of quality medical care" that nurse doctoral programs are about to unleash.


At the AMA annual meeting in June, delegates adopted Resolu-tion 211-"Need to Expose and Counter Nurse Doctoral Programs Misrepresentation." (See AJN Reports on page 25 for details.) Why should the AMA see more education as a problem?


The AMA claims that nurses will misrepresent themselves as "doctors" and subsequently "create confusion, jeopardize patient safety, and erode the trust inherent in the true patient-physician relationship." Yet year after year, nurses are ranked in Gallup polls as the most trusted professionals. And a recent metaanalysis published in the Cochrane database showed that advanced practice nurses (APNs) provide safe, high-quality, cost-effective care, often receiving higher ratings in patient satisfaction than their physician counterparts.


The AMA resolution has nothing to do with protecting patients but is a thinly disguised effort on the part of physicians to safeguard their power and money.


As long as APNs provide care to populations largely neglected by MDs-the poor, immigrants, the uninsured-the AMA is quiet. When it sees nurses as climbing out of this niche, the AMA roars down from its perch at the top of the hierarchy. It did so in 1997 when Columbia Advanced Practice Nurse Associates opened its practice in an affluent neighborhood in Manhattan, gaining hospital-admitting privileges as well as insurance reimbursement equal to that of physicians. It did so again in 2000 with a petition to the Health Care Financing Administration, demanding oversight of, and limitations on, Medicare payments to APNs.


Yet there is no evidence, nor has there ever been, that APNs overstep the bounds imposed on them by law or misrepresent themselves to patients. Boards of examiners oversee licensed practitioners, investigate reports of possible practice violations, and handle charges of malpractice. In addition, certification boards require rigorous examinations for advanced or specialty practice. These safeguards have protected the public for years.

Figure. Kennedy and ... - Click to enlarge in new windowFigure. Kennedy and Roush.

It would be easy enough for the AMA to look at the standards and criteria our discipline uses to regulate its practice. Instead, at last year's annual meeting it passed Resolution 814, committing more than $171,000 to take on the spectrum of "limited licensure healthcare providers"-those who're not physicians or osteopaths.


These resolutions are a misguided attempt to hold onto an antiquated and dysfunctional model of medical imperialism. Instead of spreading apprehension among a public already unnerved by the too-real threat of medical error, the AMA could foster a partnership with nursing and other health professions, in which a variety of approaches to care are afforded respect.


The United States has the most expensive health care system in the world, and it's failing its citizenry. We spend twice what other developed nations spend per capita, and still our disability-adjusted life expectancy (the number of years a person can expect to live in full health) is one of the lowest among wealthy nations and our infant-mortality rate is the among the highest. Nursing and medicine should unite to address the flaws in the system: out-of-control costs, shameful disparities in illness and death rates in poor and minority populations, and for many, severely limited access to care.


Perhaps a better subject for the AMA to research is why more and more patients are choosing nurses over physicians. It's clear that the hierarchal system isn't serving anyone but physicians.