Putting an End to the ‘Doctor-Nurse Game’

Libster is a psychiatric mental health clinical nurse specialist.

In 1967, Leonard Stein, MD, coined the term “doctor-nurse game,” which he described as clear agreement between doctors and nurses that their relationship was hierarchical and that physicians were superior. Nurses were to “be bold, have initiative, and be responsible for making important recommendations, while at the same time they had to seem passive.” A 1993 study of 100 years of the “game” by Adele Pillitteri, PhD, RN, PNP, and Michael Ackerman, PhD, RN, showed that in the late 19th century, there was more collaboration between physicians and nurses and recognition of teaching and learning relationships than in the 20th century.

In 2023, the doctor-nurse game is over. Advanced practice registered nurses (APRNs), and anyone else who graduated with a doctoral degree, may also be “doctors” — not physicians, but doctors. Patients’ needs are complex and there really is no more time for games.

A recent op-ed in MedPage Today titled, “Doctor or DNP: Who Is Really Providing Care?” by president of the California Society of Anesthesiologists, Antonio Hernandez Conte, MD, MBA, brings this issue to the forefront again. He argues that in the clinical setting, any “non-physician” who refers to themselves as a “doctor” to patients is misleading and putting patients at risk. This is inaccurate.

Nurse doctors do not need to engage in title debates and turf wars. Doctorally prepared nurses (DNPs and PhDs) have a right, if not an ethical responsibility, to identify themselves as “doctors.” Universities graduating these nurse doctors and the boards of education and national bodies accrediting them have deemed our expertise and training worthy of this respect. Unfortunately, several states have proposed legislation banning nurses and other healthcare professionals with doctoral degrees from using the “doctor” title. In fact, two states — California and Georgia — have been successful in passing such laws, but lawsuits have been filed to challenge these bans. It seems prudent that if physicians were successful in achieving title protection for the word “doctor,” that DNP and PhD nurses no longer permitted by the laws would be entitled to reparations from the educational institutions that told them they would be “doctors” without stipulation upon successful graduation.

Beyond fighting for physicians to be the only “doctor” in a healthcare clinic, some are going as far as to state they believe that they (physicians) are to lead all patient care teams. In his June 14, 2023 inaugural speech, president of the American Medical Association Jesse Ehrenfeld, MD, MPH, claimed that efforts to expand the scope of practice for “nonphysicians” is “putting patients at greater risk.” He believes the solution is “physician-led care teams.” But where is his evidence? In fact, some research suggests that nurse-led services compared to usual care can provide comparable or superior care, with high levels of patient satisfaction. Furthermore, the history of healthcare has numerous examples of successful collaborations between nurses and physicians both in practice and educational preparation. Physicians and nurses are aware of the evidence that collaboration ensures the best outcomes for patients.

When considering what is most important to advancing a healthcare system that supports public well-being and happiness, for me, debating title recognition takes a back seat to advancing precision science and person-centered care. Additionally, when that debate poses direct opposition to a nurse’s calling and a centuries-old history of autonomy as well as collaboration in practice, then nurses stop playing the game.

Anyone who has earned a doctorate degree should have the right to use the “doctor” title if they wish. PharmDs and JDs have chosen not to use the term “doctor” in practice — that is their professional decision. In the field of psychiatric mental health care, there are two professional groups who use the title “doctor,” psychiatrists and psychologists. Now the DNP has joined the group. Notably, nurses use the “doctor” title while simultaneously being transparent with patients about our experience and expertise.

Having worked in the mental health field for 25 years, I have never observed evidence for patient confusion about these roles. More often, professionals’ titles are just not the priority issue for people in distress. For decades, APRNs with doctoral degrees (PhDs and DNPs) have successfully and safely cared for patients. We too have earned and are entitled to be called “doctor.” We don’t lobby to be called “physician,” already a protected title for those with medical degrees. If we wanted the physician title and all that it represents to physicians and the public, we would have gone to medical school. Instead, we chose nursing.

Martha M. Libster, PhD, MSN, is a psychiatric mental health clinical nurse specialist, and an award-winning nurse historian.

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