This morning I was talking to my wife about her plans to become a nurse practitioner. She had been considering this for some time, as she wants to do something different than she is doing right now as a registered nurse. However, she is having second thoughts at the moment as she has heard that once again the "professional organizations" that claim to represent all nurses have started to push once more to require a doctorate in nursing before that individual can become a nurse practitioner. As my wife said, "if I put in that much time in school, I might as well become a doctor."

Of course, that is why I think this push will probably fail. Though the professional societies will, like all professional societies, claim that their licensing requirements are there to "promote professionalism" and "ensure the safety of consumers" and many other high sounding goals, the truth is, like all barriers to entry, these restrictions exist to keep labor scarce and increase the revenues of those already in the profession¹.

But in this case, the action may be a bit too ambitious. If the degree of education required to become a nurse practitioner is comparable to that required of a doctor, and nurse practitioners are required to carry malpractice insurance, then nurse practitioners will begin to charge rates comparable to doctors. If that is the case, which would you hire? A nurse practitioner who costs as much as a doctor, but who requires a doctor to sign off on all his orders and to prescribe, or a doctor who can do everything for himself²? However that is the logical outcome of requiring training for nurse practitioners comparable to that required of doctors.

You see, the quantity of education is not always the determinant of pay that someone will seek, but as the training for nurse practitioner and doctor is loosely comparable, as the same sorts of people go into both professions and the skill sets are similar, if the amount of education is close, then the salaries will likely be similar. Which means if they raise the training requirements for nurse practitioners, they will see a sudden drop in the demand for nurse practitioners. Even if the existing nurse practitioners accept slightly lower salaries to keep jobs, there will be a dearth of students for the training programs, as they can get a better salary by putting the same effort into becoming a doctor³. All of which makes this a foolish plan.

Then again, my readers aren't here to read about the specific woes of those hoping to become nurse practitioners. But fear not, this whole conversation reminded me of a topic I brought up a few times in the past⁴. And that is the modern tendency to over-educate and to make "professions" of jobs. In part this is the outcome of the student loan programs the government created, but even more significant are efforts such as the one I described, professional societies' efforts to restrict entry to keep salaries high.

At one time, many subjects we now think of as graduate studies were studied either through apprenticeships or at a level we would now call "undergraduate"⁵. Medicine, law, divinity, nursing, all were subjects which were being studied by people who were at a stage moderns would see as the beginning of undergraduate education.

Now, some will object that yes, in the past people could go apprentice themselves to a doctor, or to a lawyer, but thanks to our much more extensive knowledge, we need those extra four years to prepare us for the study of medicine or law. Except that such claims do not make sense. Does anyone today think that the lawyers of today are better educated than the founding fathers? How many modern lawyers can write conversationally in Latin and Greek or quote Ovid, Homer and Aristotle in their arguments? It seems in the case of law, at least, the past had it all over the moderns.

Of course, medicine is different, or so some argue. It is a technical field, and we know much more than in the past. Except that doctors are not required to study science before medical school. They can study anything, making a lie of the idea they spend those four years preparing. In fact, those who do go "pre-med" tend to complain the first year of medical school is just a rehash of what they spent four years studying, making it seem silly to argue that undergraduate education is somehow preparation.

To which some reply that the four years are not technical preparation, but intended to "mature" doctors. To broaden their horizons and give them a better understanding of life. And again, I ask if they really contend today's doctors are more broad minded and wiser than, say, Averroes, Avicenna, Paracelsus, Galen, Maimonides, or Hippocrates. Or to move into more recent times, say Benjamin Rush or William Harvey.

No, the fact is that our modern professions like to become graduate subjects for two reasons. First, the appeal to vanity implicit in being a "doctoral" study. When any teenager could begin studying medicine or the law, there was not as much prestige associated with being a medical student as when it became post graduate education. The quality of study may not have improved, but the status associated did.

Second, and the biggest incentive to push education later and later in life, is that it serves as a barrier to entry and thus improves the bottom line of existing practitioners. If law students must go through four years of undergraduate education and three years of law school before practicing, that removes them from competition for seven years, not to mention reducing the pool of competition to only those who could make it through such a course of study, and remain without a profession for 7 years after high school. If they could apprentice themselves right out of high school, they could be earning as they studied, and competing in a few years, which would certainly drive down salaries.

Many will scoff, thinking that I am placing too mercenary a reading on this fact, but I have one bit of proof that is incontrovertible.

The various professions tend to not just require education, but tests as well. For example, lawyers need to not just have passed a post-graduate law school, but also need to take the bar exam.  In some states, there was a strong resistance to the ABA"s insistence on requiring schools to be ABA certified, so students were allowed to take the bar without having completed law school, the only requirement was passing the bar.

And that made sense. If the bar exam tested one's ability, then presumably if one passed it, he knew what was necessary. So who cared if he had completed school if he had the requisite knowledge? In fact, I would argue that for any profession, if a person can pass the certifying exam, why should he have to have completed a school to practice? If he has the knowledge, does it matter where he acquired it?

Apparently it does, as the ABA fought tooth and nail to close that loophole. And, as far as I can tell, has succeeded. Nowhere int he country can you "read for the law", that is, take the bar without attending law school. Many states allow you to take the test after attending a non-ABA certified law school, but you still must have spent 3 years in some law school. And other professions are the same. The qualifying test is secondary, the long schooling is the primary requirement.

Why is that?

Because, school keep competitors off the market, tests don't do it half as well. Granted, having to pass a test keeps out some competitors, and allows salaries to rise somewhat, but not half as much as the burden of schooling and a test does. And so, in every profession, professional societies claim to have total faith in their certifying test, and then show that to be a lie by requiring an education before one can even take the test.

Of course I am sure some will doubt my argument, buying into the claims of various professional societies that they do it only to protect consumers or preserve the dignity of their profession. But their acts belie their claims. If they truly wanted to ensure the quality of the practitioners, wouldn't they rely on some manner of testing, rather than the arbitrary requirement such as X years of schooling? And more importantly, in many professions relying on a test that even current practitioners could not pass, that is a test which is clearly just an arbitrary barrier⁶?

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1. I admit some may believe they are encouraging professionalism and so on, but their actions belie their claims. For instance, why can't someone who passes the bar exam be a lawyer unless he also completes three years of law school? Because schooling keeps him off the market for three more years (and the ABA makes money licensing schools). Why must a barber know the names of bones in the skull? Because it is arcane knowledge that forces all barbers to go to classes and thus limits the number of barbers. All actions that are sold as "promoting professionalism" and "protecting consumers" make much more sense when reviewed in light of the motive "maximizing profit for practitioners".

2. I have tried to use the masculine pronoun for both nurses and doctors at all time, as the masculine is the pronoun to use when sex is unknown. But I have noticed I have a tendency to refer to nurses as "she. This is not because of any stereotypes, or because I think all nurses are women, but simply because my wife is a nurse, and when I write of nurses I think of her. So, please forgive me of some "she"s or "her"s slip through. I am trying my best, but mistakes happen.

3. Before any doctor complains that getting a doctorate in nursing is not comparable to getting  medical degree, I realize they are not precisely the same. The classroom time is about equal, with three years being the bare minimum, and most taking longer. On the other hand, a doctorate in nursing requires publication, which an MD does not, while an MD requires residence and internships that a doctorate in nursing does not.  But, as we are discussing a nurse practitioner, not only does the candidate need a doctorate, but an internship with an existing nurse practitioner, which makes the two much more equivalent. If anything the nurse practitioner may be more of a burden thanks to the research and publication requirements. But, whatever the relative difficulties, looking at the two, it is evident that the two are not so different in difficulty that one would happily pick the nurse practitioner route if the benefits of the MD are much greater.

4. See "When Help Hurts" and "The State Versus Universities". In each I am focusing on one aspect alone, but that does not mean that I thought that was the only cause.

5. Some titles cause confusion, as the names of degrees was often not uniform (and still is not in many nations), so many studying medicine were given a doctorate, which meant no more than they had qualified to teach (doceo, docere, to teach in Latin). But if you examine when they started and the length of study, often it was nothing more than the equivalent of a modern four year degree. It was very unusual historically for one to study one topic and then change at a later stage to study medicine or law. Today's pattern is quite an aberration when compared to the bulk of history.

6. The bar exam is the best example, a test most practicing lawyers could not pass, and which law school does not qualify you to take. Instead, law students complete school, THEN they take a cram class to pass a test which real lawyers could not pass either. An even better example may be the test some states require of beauticians and barbers, asking questions such as the name of the bones making up the skull. Does anyone really think a man can't cut hair unless he can tell you where the maxilla or hyoid is? This is clearly nothing but a barrier to entry to increase salaries. (And to earn the state a nice little licensing fee.)

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POSTSCRIPT

After I wrote this I realized I wrote only on the second reason and ignored the increase in demand for education due to student loans. For those interested, you can read the two essays I mentioned in footnote 4 above.

POSTSCRIPT II

I do not mean to suggest that I have no respect for the wonderful things doctors do. Far form it. My purpose is to ask if we could not get just as well trained doctors by allowing them to enter medical school at 18 rather than 22. And the same for pharmacists, lawyers and so on. We allow nurses and engineers to do so, and they do things just as crucial to saving lives, and their mistakes carry just as much risk of death, yet we think them mature enough to study at 18. So why not doctors and lawyers and pharmacists and dentists? Except to keep them off the market for a longer time, I cannot find a good argument for doing so.