2009 AMA House of Delegates Meeting

AMA Testimony Reveals Subspecialists Don't Like DNP Equivalency Claims, Either

By Barbara Bein • Chicago
6/24/2009

The AAFP received a strong show of support from subspecialists and other physicians for its earlier objections to the way the National Board of Medical Examiners, or NBME, has been presenting its new certification examination for doctors of nursing practice, or DNPs. In fact, a resolution introduced during the 2009 annual meeting of the AMA House of Delegates, held here June 13-17, originally asked the AMA to withdraw its representatives to the NBME if the two organizations could not see eye-to-eye on what the resolution's sponsors termed "the integrity of the physician licensure process."

Photo of AAFP President Ted Epperly, M.D., testifying at the AMA annual meeting about doctors of nursing practice

AAFP President Ted Epperly, M.D., (at microphone) testifies to an AMA reference committee that the National Board of Medical Examiners has yet to make good on its assurances that it would clarify its doctor of nursing practice certification exam in no way confers equivalency between physicians and "doctor-nurses."

Listen to an audio statement (6:57-minute MP3 file; About Downloading) by AAFP President Ted Epperly, M.D., about his AMA testimony on a resolution addressing the doctor of nursing practice certification exam.

Although the resolution's sponsors later amended the measure to remove the withdrawal language, ultimately, the resolution was referred for further consideration in light of the many complexities associated with the DNP certification issue.

The resolution, "Preserving Physician Licensure Integrity and Fostering Competition in its Business Aspects," was introduced by the American Society of Anesthesiologists, the American College of Emergency Physicians, the American Society of Plastic Surgeons, the College of American Pathologists and the Indiana delegation to the AMA.

In the resolution, the groups took issue with several statements made in an NBME white paper (8-page PDF; About PDFs). Among the statements made in that paper, "NBME Development of a Certifying Examination for Doctors of Nursing Practice," are the following, shown here with the same emphasis that appeared in the groups' original resolution:

the DNP certification exam uses the "test blueprint developed for USMLE (United States Medical Licensing Exam) Step 3 as a basis for its design";
"the exam will utilize test items previously used in the USMLE Step 3 examination"; and
an NBME "review of the scientific literature does not support a contention that the clinical services provided by nurse practitioners are inferior to similar clinical services provided by physicians. Numerous studies demonstrate that when nurse practitioners are compared to physicians, NPs provide equivalent levels of safety and quality of care for acute and chronic medical problems."

The resolution went so far as to direct the AMA and its physician member organizations to "explore other physician licensure options to compete with the NBME." Moreover, the resolution said, "if the NBME is unwilling to preserve the integrity of the physician licensure process," the AMA should withdraw its representatives to the NBME.

In testimony before the AMA reference committee considering the resolution, several speakers made strong statements about any appearance of equivalency between physicians and DNPs.

AAFP President Ted Epperly, M.D., of Boise, Idaho, said the NBME has reneged on its promises that it would make clear that the DNP certification exam is not equivalent to the process involved in physician certification.

These equivalency claims "must be stopped," Epperly said.

DNP Advocate Addresses AMA Council

On June 12, a day before the AMA House of Delegates' opening session, Mary Mundinger, R.N., Dr.P.H., dean of the Columbia University School of Nursing in New York, spoke to members of the AMA Council on Medical Education. Mundinger is a major proponent of the doctor of nursing practice, or DNP, degree and the DNP certification exam administered by the National Board of Medical Examiners, or NBME.

Mundinger told council members that critics of the DNP program and certification claim that she and others want "inadequately trained people (to) replace physicians in primary care."

Not so, said Mundinger, emphasizing that DNPs are licensed first as registered nurses who later earn a master of science degree. After additional training and experience, she said, there is a small overlap in the clinical skills used in nursing and those used in medicine, and the NBME's DNP certification exam is intended to measure that overlap area.

Telling the reference committee that the "anger is real" regarding the NBME's portrayal of the DNP exam, William Hazel Jr., M.D., an orthopedic surgeon and a member of the AMA Board of Trustees, urged the NBME to use "clear and accurate language" to describe what the DNP certification exam does and does not do.

John Neeld Jr., M.D., an anesthesiologist, testified that the American Society of Anesthesiologists has been very concerned that such equivalency claims would arise, because the DNP certification exam uses the same questions as USMLE Step 3. "We want (the NBME) to address this claim of equivalency," he said.

The issue goes far beyond a disagreement about scope of practice or "turf," other speakers agreed, saying that nothing less than the quality of patient care is at stake.

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