A doctor is a doctor is a nurse

Jason Fodeman Physician
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A recent Institute of Medicine (IOM) report calls for expanding the authority of nurses to practice medicine and for increasing their pay. Besides helping a loyal unionized constituency, the report claims that allowing nurses to do more can alleviate the physician shortage. In reality this will likely have the exact opposite effect by disincentivizing individuals from becoming medical doctors in the first place. Thereby, rather than improving patient access to physicians, these recommendations will make the problem even worse.

While the newly-passed Patient Protection and Affordable Care Act will drown already overwhelmed physicians with new layers of regulations and mandates, it does contain some attractive carrots for nurses. It raises Medicare reimbursements for nurse midwives to equal that of obstetrician-gynecologists. The American Nurse Association hopes this is the first step towards pay parity for all nurses with advanced degrees.

The recent report must be music to their ears. It argues that Medicare and Medicaid should pay these nurses the same rate as physicians for the same treatment. Former Clinton Health and Human Services Secretary and chair of the IOM committee, Donna Shalala, said “When you do the same job you ought to be paid the same.”

Additionally, the new report urges state and federal governments to abolish barriers limiting the care that advanced practice nurses can provide. It also lobbies for nurses to be able to practice more independently. This past spring the Associated Press reported 28 states are already considering increasing the role of nurse practitioners.

Nurses deserve respect and a competitive wage. In fact according to a Merritt Hawkins & Associates survey, some nurses with advanced degrees already earn more money than some doctors. The survey concluded the average base salary for a certified nurse anesthetist was $189,000 compared to an average base salary of $173,000 for primary care physicians. Nurses are certainly an integral part of the health care team, but there is no substitute for the clinical skills physicians acquire during their education and training.

People make a tremendous investment in both time and money to become physicians. Doctors must sacrifice at least 11 years to education and rigorous training before being able to earn a living wage. Most devote significantly more time to advanced training. In addition, the average physician starts his or her career with $150,000 in education-related debt.

Yet, if one can walk like a doctor, talk like a doctor, act like a doctor, and get paid like a doctor without having a medical degree and without enduring the blood, sweat, and tears of medical school, it remains to be seen who would sacrifice so much to become a physician. Why work 80-hour weeks and 30-hour shifts at an hourly salary barely above minimum wage during all those residency training years?

Many people contemplating a medical career will instead logically choose nursing. If nurses can get paid the same and do the same work as physicians, why would anyone invest the time in training to become a doctor? Thus, the IOM’s recommendations will actually exacerbate the physician shortage. This short-sighted and misguided proposal will limit access to physicians and prevent patients from getting the care that they want and need.

Physicians have been browbeaten for years by regulators, bureaucrats, lawyers, insurance companies, and businessmen. For some this could easily be the final straw. With fewer physicians practicing, those still seeing patients will have to see more and more. Time constraints will be worsened by the new regulations, red tape, and price controls of Obamacare.

Ironically, these effects will be most pronounced in the primary care specialties of family medicine, internal medicine, and pediatrics. Primary care physicians will be the most threatened by expanding the authority of nurses because their more basic background and lack of specialization make them relatively expendable. If the IOM’s recommendations become law, it will make zero sense for a doctor to practice primary care. This will only further pressure those still pursuing or practicing medicine to specialize.

During the health care debate, many in the public were rightfully concerned about the impact Obamacare would have on physician access. President Obama repeatedly attempted to allay these fears with his “if you like your doctor” mantra. Despite polls showing strong disapproval amongst physicians and indications many doctors would stop practicing medicine altogether if the president’s radical prescription passed, the president ardently stuck to his talking points. Now that the dust has settled, the public is getting a glimpse of health care under an Obamacare system. To paraphrase Donna Shalala’s former boss, President Clinton, it seems to depend on what the definition of “doctor” is.

Jason D. Fodeman, M.D., is an internal medicine resident at UCONN and a Visiting Fellow at the Galen Institute.