“Doctor Nurses”: Cross-Training for Flexibility

Cross-training is a staple of lean manufacturing. Having workers able to do a variety of jobs increases flexibility, making it easier for a business to respond to changing market conditions that require shifts in production.

I don’t know whether you would consider this a good example of cross-training, but in healthcare, there is a movement to have some nurses do more by becoming “doctor nurses.” According to the Wall Street Journal,

More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degree, says Mary Mundinger, dean of New York's Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

Why is this being pushed? According to the article (written by Laura Landro), it is because there aren’t enough doctors.

Dr. Mundinger, of Columbia, says the primary aim of the DNP is not to usurp the role of the physician, but to deal with the fact that there simply won't be enough of them to care for patients with increasingly complex care needs. As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

But there are concerns:

Some physician groups warn that blurring the line between doctors and nurses will confuse patients and jeopardize care. Nurses with doctorates use DrNP after their name, and can also use the designation Dr. as a title. Physician groups want DNPs to be required to clearly state to patients and prospective students that they are not medical doctors. "Nurses with an advanced degree are not the same as doctors who have been to medical school," says Roger Moore, incoming president of the American Society of Anesthesiologists.

"With four years of medical school and three years of residency training, physicians' understanding of complex medical issues and clinical expertise is unequaled," adds James King, president of the American Academy of Family Physicians. While nurses with advanced degrees play an important role in delivering care, Dr. King says they should work as part of a physician-directed team.

The new push for doctor nurses is actually part of an ongoing trend toward increased flexibility.

Nurses have increasingly been moving into more specialized and advanced roles over the past few decades. Advanced-practice nurses include specialists in fields such as nurse midwives and nurse anesthetists, and there are now more than 125,000 nurse practitioners in the U.S. Nurse practitioners in some states are required to work with or be supervised by physicians, but often have independent practices in family medicine, adult care, pediatrics and oncology.

A study led by Columbia's Dr. Mundinger and published in the Journal of the American Medical Association in 2000 showed comparable patient outcomes in patients randomly assigned to nurse practitioners and primary-care physicians.

What do you think? Is this an example of lean cross-training? Is it a sign of significant change in how healthcare is delivered? Post your comments below.