“Once she did that, once she said, it’s not just that I know what’s good, and I’m going to do it, but I’m going to prove that it works, and I’m going to have it peer reviewed and publishable… she had me,” he said. “I was her pawn as much as she wanted me to be her pawn.”
(Not everyone in the medical establishment was as easily won over. In 1997, Charles Aswad, then executive vice president of the New York Medical Society, told The New York Times, that, “We think the public has to be protected from the representation that a nurse clinician is equivalent in training to a physician.”)
The randomized study, conducted between 1995 and 1997, compared the outcomes at her clinic in Washington Heights with three clinics in the same neighborhood run by physicians. The resulting paper, published in the January 5, 2000 edition of the prestigious Journal of American Medicine, proved her point: ” In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients’ outcomes were comparable.”
But Ms. Mundinger had more in store for her critics. She began developing the country’s first doctoral program in nursing.
Anthropology professor and university senator Ralph Holloway offered a representative complaint to the New York Sun in 2002: “If they are supposed to be doing all that doctors do, why don’t they go and get their degree?”
Despite the brouhaha, the doctorate program was officially launched in 2005. On April 2, 2008, the Council for the Advancement of Comprehensive Care and the National Board of Medical Examiners announced that they would write and administer a certification exam for doctors of nursing, one that used similar questions to the third part of the medical boards. The move prompted more withering statements from medical organizations about the dangers to patients, inadequate training, and the like.
To be expected, say Ms. Mundinger’s supporters.
“ALL PIONEERS RUN the risk of being sometimes too far out ahead or sometimes misunderstood,” said George Thibault, president of the Josiah Macy, Jr. Foundation. “She certainly has had detractors within the nursing profession and outside of the profession.”
One of those detractors is Lori Heim, the North Carolina-based president of the American Academy of Family Physicians.
Ms. Heim points, among other things, to the disparities in education between nurse doctors and doctor doctors. The doctorate in nursing program takes only two years – one year of clinical practice and one academic. In order to qualify for the program, a nurse must already have a masters (typically 1.5 to 2 years) and be certified as a clinical practitioner. Total post-grad education: about five years. In contrast, doctors typically do four years of medical school, and then another three years of residency, totaling seven years.
“We as an Academy still continue to think that even with the doctorate, there is a very substantial and real difference in training and the ability to broaden the differential diagnosis, and provide broader and better treatment plans,” Ms. Heim said.
“When I’ve worked with advanced nurse practitioners, they are very, very good at working as part of a team and being able to manage certain conditions, but those are usually conditions with which the patient has already been diagnosed, and at following protocols. I think they are very effective at being what we call in the military a force multiplier.”
What, then, does she make of Mary Mundinger’s argument that nurses, by nature, and by education, have better communication skills and are more empathetic and compassionate than their primary care physician colleagues?
“It’s kind of a slap in a face,” Ms. Heim said. “It’s almost like saying that people that go into nursing are women.”
By 2009, there were about 125,000 nurse practitioners practicing in the United States, according to the American Academy of Nurse Practitioners; 8,000 were graduated in 2008. According to the 2009 Annual Report by the American Association of Colleges of Nursing, from 2007 to 2008, enrollees in doctorate in nursing programs “nearly doubled,” from 1,874 to 3,416 students, and the number of doctorate in nursing programs grew from 20 in 2006 to 92.
For her part, Ms. Mundinger readily concedes that there are some things nurses are not educationally equipped to do: oncology, surgery, things that call for medical specialists. But she argues that, if anything, primary care physicians are overeducated.
“I spoke to the Federation of State Medical Boards, the people who run all board certifications, and a primary care physician stood up and said, ‘Are you saying I wasted my time going to medical school?’” recalled Ms. Mundinger. “I wanted to say, yeah.”