Sue Shirato is a nurse.
And a doctor.
But probably not the kind of doctor you think, which makes her introduction to patients at the Jefferson Heart Institute more complicated.
"I'm Dr. Shirato, but feel free to call me Sue," she tells patients. "I am Dr. Duffy's advanced-practice nurse."
Shirato, a nurse practitioner, just got her doctor of nursing practice degree at Thomas Jefferson University. Most nurse practitioners still have master's degrees, but nursing schools want the DNP to be the entry-level degree for advanced-practice nurses by 2015. Enrollment in DNP programs nationally jumped from 70 in 2002 to more than 5,000 last year.
Most newly graduating physical therapists now have doctorates, too. Pharmacists and psychologists already made that move. Audiologists, physician assistants, and occupational therapists can also get doctorates.
As nonphysicians with doctorates proliferate, the potential for confusion has grown, and physicians aren't happy about it. A 2008 survey by the American Medical Association found that 38 percent of patients believed that DNPs were medical doctors.
The AMA has produced model "truth in advertising" legislation that requires health professionals, including physicians, to wear badges that clearly spell out their credentials. Similar laws have passed in Oklahoma, Arizona, Florida, and Illinois and are under consideration in California and Pennsylvania.
James Goodyear, a Lansdale general surgeon and president of the Pennsylvania Medical Society, said health-care workers who are not physicians should immediately tell patients what they do.
"I am a physician. They are not," he said. "They trained for hundreds of hours. We trained for thousands of hours."
And, he said, physicians should still be in charge. "We think that those in the allied health fields that get a doctorate such as in nursing are a very, very important component of a physician-directed . . . team," he said.
People with doctorates in other fields said they generally don't want to call themselves doctors around patients, but they reserve the right to do so.
"There are some physicians who look at their title - doctor - as a protected title when it really isn't," said Kathleen Potempa, president of the American Association of Colleges of Nursing (AACN). "There are lots of people who have the entitlement to doctor now."
To make things more complicated, these new health-care doctorates are what are known as practice, professional, or applied doctorates - degrees meant to be put to work in the real world or used to climb a career ladder. They're not what most professors have: a Ph.D. Those are research-focused and tend to take longer - at least four years after the bachelor's degree - and require a dissertation. Academic snobs see a practice doctorate, which takes three years, as "Ph.D. light."
Medical doctors have a kind of practice doctorate, too. After college, they spend four years in medical school, and at least three years in residency to get them. In nursing and physical therapy, three-year doctoral programs are supplanting master's programs that took about 21/2 years.
Health-care leaders say the higher degrees address the growing complexity of care as the population ages and medicine moves to more scientifically proven treatments. It's getting impossible to cram everything that advanced-practice nurses and physical therapists need to know into a master's degree. There's also clearly a desire for greater respect.
"From a nursing perspective, I think that we should be on par education-wise, knowledge-wise and information-wise with our colleagues," said Beth Ann Swan, senior associate dean of academic affairs at Jefferson's School of Nursing. Its DNP program began in 2007.
Training programs for advanced-practice nurses - nurse practitioners, nurse midwives, and anesthetists, and for clinical specialists - have quickly embraced the DNP. Seventy-two percent of schools that train such nurses, who can safely perform many functions of physicians, either already offer DNPs or plan to do so. Widener University welcomed its first class in 2009. According to the AACN, Drexel University and the University of Medicine and Dentistry of New Jersey also have programs.
Not everyone is a fan of the trend, which some critics call "degree creep." Some vocal naysayers, including Afaf Meleis, dean of the University of Pennsylvania's nursing school, worry that it's a bad time to demand more training of the nurses best equipped to provide primary care. Health reform will soon flood the market with newly insured patients, and some believe there won't be enough primary-care doctors to tend to them. Fewer nurses may become nurse practitioners if they have to spend more time and money on school. So far, the doctorates have not translated to higher pay, but there is also a concern they could drive up costs when there will be intense downward pressure on spending.
Meleis and Kathleen Dracup, dean of nursing at the University of California, San Francisco, said the evidence showed that advanced-practice nurses already provide high-quality care.
"There is no proof that more than a master's degree is required to be an excellent practitioner," Dracup said.
Meleis also questioned why other schools had let their master's programs get so long. Penn nurses complete the material in 11/2 to 2 years, she said.
She worries that DNP programs will siphon off nurses who might have gotten Ph.D.s, a group that is much needed for teaching and research. Nurses have worked hard to prove to fellow professors that they can hold their own scientifically, she said, and DNPs will be "second-class citizens" in academia.
Nurses "finally gained a place at the table and equity at the table," Meleis said. "We finally have gotten it together and then we are rocking the boat and then not rocking it in a healthy way by creating the DNP."
AACN says Ph.D. enrollment is still growing slightly.
Nurses who completed Jefferson's DNP program said they specifically wanted to focus on patient care.
"If I'm taking care of you, you don't want me to have a Ph.D.," said Dolores Grosso, who got her DNP a year ago and who works with blood and bone-marrow transplant patients at Jefferson.
She said her coursework improved her problem-solving skills and taught her about statistics. She plans to do research driven by her experiences with patients.
She doesn't believe every nurse practitioner should have to get a doctorate, or that nurses should be able to go straight from college to doctoral programs.
She doesn't plan to call herself "doctor" around patients. "I'm happy with who I am," she said. "I don't feel the need to walk around and have people think I'm either a Ph.D. or a doctor."
Barbara Todd, who just got a DNP from Jefferson and is director of advanced-practice providers at the Hospital of the University of Pennsylvania, said she believed some confusion was inevitable. First of all, patients don't really understand what a nurse practitioner does. "Are you practicing to be a nurse?" they ask. And they assume nurse practitioners are doctors even when they don't have doctorates.
Though she worries about how the trend toward a nursing doctorate will affect the thousands of master's-level nurses already in practice, she believes the extra training boosted her credibility with other professionals.
Shirato also said she was being taken more seriously. "I think I have a lot more autonomy now than I did before," she said, "and I think the physicians look at me differently than they did before."