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What is a doctor? What is a nurse?

February 21, 2013

Academic Medicine, journal of the American Association of Medical Colleges, has sent out a recent call for articles addressing the 2013 question of the year: “What is a doctor?  What is a nurse?”  Thirty years ago this would have been an absurd question.  Not only would it have been absurd for doctors and nurses, but for patients too.  Roles were clearly delineated within the disciplines, and the white coat indicated a doctor and the white uniform and cap identified the nurse.

There are several reasons why we have to ask the question posed by Academic Medicine.  A big reason is the entry of women into the field of medicine.  Another is the development of advanced degrees for nurses.  The computerization of medical records has spurred increases the need for physician extenders to support practices.  A huge reason recently has been cost-containment considerations.  The erosion of the doctor as an ultimate authority figure and the rise of patient autonomy have leveled the field as well.  To some extent access to education is in the mix also.

Educational level is usually part of the definition of a doctor or nurse.  This is no longer a reliable indicator.  A doctor has an undergraduate degree and an MD.  But a doctor might be a DO also, a doctor of osteopathy.  A nurse has an undergraduate degree in nursing.  Except that a nurse might have an undergraduate degree in something other than nursing, and get the nursing training later in a master’s degree program.  Up until relatively recently you didn’t have to have a BSN to be a nurse, an associates degree was enough.  Now a nurse might have a master’s degree or a PhD.  A nurse practitioner has a master’s degree.  A physicians assistant might also.

Authority used to be used to separate doctors from nurses.  Doctors can prescribe medicines.  But now so can many advanced-practice nurses.   Doctors can write orders.  So can nurse practitioners.  Doctors can examine you and diagnose you.   So does your NP.

Nurses and doctors used to LOOK different.  The physical appearance and dress of nurses and doctors in hospitals today is actually emblematic of the blurring of the lines of identity that have characterized medicine in recent years.  A doctor might wear scrubs; a nurse practitioner might wear a white coat; in the operating room, everybody wears the same thing.  Clothing has long been a tangible symbol of turbulent times.  The casting off of corsets was a signal of relaxing social restrictions.  The shock of a woman wearing pants coincided with women entering the workforce.  Burning bras were a way of protesting gender inequality.  It is no accident that the shedding of the nurses cap happened around the same time nurses became college educated.

Lifestyle and money?  Nope.  A primary care doctor makes less than a nurse anesthetist.  Some doctors don’t take call anymore, and many nurses do, even those without advanced degrees.

Surely knowledge, skill, and ability separate nurses from doctors?  Of course not.  Your experienced floor nurse knows way more about medicine than your average intern.  Physicians assistants can sew up wounds and assist in surgery.  A person who becomes a nurse is just as smart as a person who becomes a doctor, which has always been true but not always acknowledged.  An MD is just a piece of paper that gives a person permission to start learning how to be an actual doctor.  An RN is much the same.  Clinical experience  and training are the only things that matter materially to patients.  Some argue that training level is also part of the definitional differences between doctors and nurses.  Doctor’s clinical training in a formal educational system is usually longer.  So you could equivocally say that a doctor has longer training.

I would suggest to my readers that the ONLY thing that truly separates doctors from nurses is ULTIMATE RESPONSIBILITY.  The editor of Academic Medicine says in his introductory remarks introducing the question that his daughter was trying to decide between medicine and nursing.  This is the decision she must make.  Does she want to live with the ultimate responsibility for every patient under her care?  Because of our investment of time and money, and presumably because of the economic and social standing granted to us, we doctors bear this ultimate burden.  This is not to say that nurses don’t also have a responsibility to their patients and their field, or that they haven’t invested just as much time and money.  I have been both a nurse and a doctor, and am a huge proponent of the expanded role of nurse practitioners.  But the law and society have laid the ultimate privilege and burden on the person that people call “doctor”.  That’s the difference.

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6 Comments
  1. Hummingbird permalink

    Your assessment is accurate, and probably will be true for a while; however it is changing. Advanced Practice Nurses with Doctorate degree in Nursing Practice (DNP) are trained to function as independent clinicians. They are just as important and reliable as physicians and other care providers in patient care. The line between physicians and APN-DNP is getting blurred as the APN-DNP are becoming more and more recognized by the patients and our society as independent clinicians. Frankly, who is the ultimate boss is not important, the most important is what can we do for our patients and society.

  2. Lauraine Kanders permalink

    I echo the above except there are 18 states plus DC that allow independent NP practice…no DNP required (as of yet). So, “ultimate responsibility” is no longer an issue as stated in this article. Things are rapidly changing.

  3. Nina permalink

    It’s easy for me to be dismissive when a writer begins a thought with “an M.D. is just a piece a paper…” Really? But in fact, this is where we must unreavel your argument. The difference between a doctor and a nurse was always a legal matter. Both are professional caretakers, with independent histories and cultures, and they of course shared many responsibilities. But the delineation of roles and the difference in duty to the patient were always fairly clear. Now, sadly, the lines are blurred, whether in prescribing authority, or autonomy, or in matters of extent of responsibility to the patient . Patients are confused, and tensions are high. And it was a totally avoidable mess. There are plenty of ambitious, dedicated people who began life doing one thing, and decided to train for another. An accelerated track for nurses interested in becoming doctors to retrain should have been created and made widely available years ago. Now, we have an “evolution” of ultimate healthcare authority to include nurses which is neither “evolved” nor inevitable, much less practicable. Is it quaint to say that “if a nurse wants to practice medicine, he should become a doctor?” Perhaps, but such a course would have saved both honorable professions, and the vulnerable patients, from a lot of heartache and turmoil.

    • Yes! It’s a legal definition that generates the rules and policies of hospitals and governments. If something bad happens in any given situation the nurse might get sued but you can bet the doctor will. That’s what I mean. Legal responsibility. This is changing, as I have been informed by other readers. I refer you to a subsequent post called Dr. Nurse, nurse doctor. You might like that one better.

  4. “The only thing that truly separates doctors from nurses is Ultimate Responsibility.” I think that’s a little off. The distinction between doctors and nurses is that the doctor has the responsibility to make medical decisions on behalf of his patient. But that’s all the distinction in the world. Let me give you an example. On a college basketball team there’s a head coach, a trainor, a team doc, a player, and the player’s mom. Each has an Ultimate Responsibility. The player to himself, the trainor to the player’s fitness, the doc to his health, the mom to get the kid to practice on time, etc. And the coach wants to win. But they all do different things. Your argument about doctors and nurses misses this point. Doctors and nurses are two different animals. That’s why a list of each’s responsibilities is different. Their job descriptions are different. And in those increasing number of cases where NPs and CRNAs are taking independent responsibility for patient’s medical care (for which they are apparently well qualified), their job looks more like the doctor’s than a nurse’s. So an M.D. means you began professional life as a doc; an R.N. means you began it as a nurse. What’s all this business about who’s smarter than whom? The vast majority of nurses (and I know a lot) do NOT view their training as a stepping stone to medicine, or an incomplete medical training process, or see themselves as unfulfilled because they do nursing and not medicine. And while your assertion that patients care about experience and training, they know something that you resist acknowledging, that medical and nursing training are simply different, and can’t stand in for the other. Medical training is not just longer (that’s insulting), it’s different. No resentment or bitterness. It’s a different line of work.

    • Ed: Thanks for your comments. There’s alot there. I refer you to a later post of mine called Dr. Nurse, nurse doctor which I think you will agree with more. I agree with most of what you say. You and I know that AP nurses come from a different point of view than doctors, but I don’t think patients necessarily do, and that’s why the issue is out there. I get more email on this subject than on any other that I write about. To a couple of your points: perhaps I shouldn’t have brought up the subject of smarter vs not as smart, for it’s a non-issue. Nurses do NOT, as you say, feel somehow inferior because they are not doctors, I don’t think I suggested that. Finally, there are many people who have commented on this topic who resentfully point out that their training is LONGER and more painful than NPs. This is not my suggestion. It’s out there.

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