Doctors and nurses have shared the common goal of patient
care for centuries. They selflessly give up their livelihoods to better the
health of the rest of us. So why would there ever be conflict in the work
environment when these two professionals attempt to share responsibility over
the sick and dying?
Every doctor has been there. Its 3:00 AM, and you’re just entering REM
sleep after somehow finding a comfortable position in the call room. Your body is in a heavenly state of paralysis,
and the only muscles doing any work are those in your eyes, busy making your
orbits dart up and down in synchrony. Then
comes the feared jolt of your pager’s vibrations followed by a screeching alarm
that signifies that someone, somewhere, needs you. You clumsily punch in the numbers on your cell
phone and await a human voice. A young
nurse picks up. She is taking care of
78-year-old Ms. Jackson, whom you admitted from the emergency department
earlier that evening for a urinary tract infection, and wants to know if she
can give the patient a stool softener since her thorough review of systems
picked up the fact that Ms. Jackson had not had a bowel movement in four days. Its 3:10 AM by now. There is no chance of enjoying another round
of REM sleep before your morning rounds start at 6:00 AM.
Every nurse has been there. You’re assigned to Mr. Stephens who is a
55-year-old man admitted last night to the hospital for a bout of chest pain. While you’re getting settled for the beginning
of your shift, he calls for his nurse and asks why he hasn’t had any meal trays
delivered today. You review his orders
and see the infamous “NPO” order (nil per
os, latin for “nothing by mouth”). You tell him that you’ll check with his
physician as there may be a good reason for this. You page the physician and await the callback.
Meanwhile, Mr. Stephens is growing more
and more restless and is threatening to leave the floor to buy his own food
from the cafeteria. You try to talk him
down, and simultaneously send a second page to the physician. Finally, there is nothing more you can do to
stop him and he goes off the floor to satisfy his cravings for the cafeteria
cheeseburger. How are you expected to know the plan of care
if no one has made any effort to keep you abreast of the details? The physician finally calls back, initially
with profuse apologies for his delay which quickly degenerate into scathing
remarks directed towards you for allowing his patient to eat since he was just
about to take him for his cardiac catheterization.
Before getting into the differences between doctoring and
nursing, it may help us to look back at the beginnings of both professions. Healthcare providers date back to as early as
3000 BC when Imhotep, advisor to the king of the 3rd dynasty of
Egypt, made detailed accounts of anatomical observations, various diseases, and
observed cures. Imhotep was also a
superhuman of antiquity, acting as an advisor to the King, inventor, architect,
engineer, philosopher, and priest. Physicians in other civilizations such as
India and Mesopotamia arose independently around 1000 BC. In 700 BC, the Greek formed the first medical
school, which soon led to the time of Hippocrates, considered to be the “father
of modern medicine.” He wrote the
Hippocratic Oath which continues to guide the practice of medicine and is still
recited at medical school graduations to this day. The original oath includes such promises as “to
do no harm”, “to not give a pessary to cause an abortion”, and “to keep confidential
all matters of the doctor-patient relationship”. The 19th century AD saw major
paradigm shifts in our understanding of disease with new ideas and discoveries
from Charles Darwin (evolution and natural selection), Gregor Mendel (genetics),
Ignaz Semmelweis (aseptic technique), and Louis Pasteur (germ theory). These legends of medicine revolutionized the
field and opened the door to new discoveries which advanced medical therapies
and extended life expectancies to what they are now.
During the Crimean War (1850’s AD) fought between the
Russian Empire and a few Western European kingdoms, Florence Nightingale was an
Englishwoman who rose to fame as she tended to wounded soldiers on the
battlefield. She had already displayed a
very independent nature when she went against the grain of the woman’s typical
housebound role in her day and entered nursing in 1844. On the battlefield, she gained the nickname
“The Lady with the Lamp” as she made her rounds late at night with a lamp among
the barrack’s many injured.[1]
Nightingale was best known for bringing
to attention the poor living conditions of the soldiers at war. Ninety percent of the casualties during her
first winter at war were from illnesses such as typhus, typhoid, cholera, and
dysentery as opposed to battle wounds.[2] After the war, in 1860, she founded the
first secular nursing school in the world at St. Thomas’ Hospital in London. Akin to the Hippocratic Oath, the Nightingale
Pledge was soon created by Lystra Gretter, an instructor of nursing in Detroit,
Michigan, in 1893 and is recited by new nurses upon entering the profession. The pledge includes promises such as “to never
administer harmful drugs,” “to maintain confidentiality,” and “to aid the
physician in his work”. Since then, we
have seen nursing take a more holistic and assertive approach in patient care
over the decades. Nurses are no longer
passive members of the medical team. They
now take a more proactive role in the care of their patients, anticipate needs
from both patients and physicians to facilitate efficient delivery of
healthcare by understanding the pathophysiology of disease, and serve as the
final checkpoint in the error-free world of medicine that we all hope to live
in.
The similarities between doctors and nurses are obvious from
their historical origins as recounted above. Both professions got their start from highly
dedicated and diligent people, and both professions are held to the highest
standard with oaths that pledge their commitment to a noble cause. But the most striking difference in their
stories is the millennia of ancestry that precedes physicians in their trade. Doctors have frankly been around for much
longer. Nursing is by far a much younger
profession and, thus, is still experiencing an evolution of its role in
healthcare. In the last few decades we
have seen nurses leave the hospital wards and enter the role of primary care provider
as nurse practitioners, helping to restore the growing lack of general practitioners
needed to treat our populous country. We
have seen other nurses leave the bedside altogether to join the ranks of
hospital administration or to manage large research projects that create some
of the biggest breakthrough discoveries that guide our new therapies. For young doctors, the legends from eras past
like Hippocrates and Semmelweis serve as a reminder of the nobility of their
profession and the timeless nature of which it has given to its patients. So much of what we do as physicians is based
on habits of the past because that is what we know. What we know comes from these legends who have
changed the way we deliver healthcare.
Nurses see things differently. Because of their origins and perspectives on
patient care, they have looked across disciplines as a means of strengthening
who they are and what they can provide. They integrate physical therapists,
nutritionists, social workers, substance abuse counselors, clergy, and
cafeteria workers to deliver a complete package of healthcare to the patient
along with the pills that doctors prescribe. They see success not in giving the right
steroid or the most proven form of chemotherapy, but instead in keeping a
patient mobile during their hospital stay to prevent blood clots in their legs;
in turning an immobile patient frequently enough to prevent pressure ulcers; in
helping a diabetic learn to pick healthy options from a cafeteria menu; in
spending more than the two minutes a doctor spends convincing a smoker to lay
off the cigarettes; in talking to patients about social support at home and why
this was their third time in the hospital this month; and in asking patients if
they’re sure they can’t do anything else for them. With the reduction in physician reimbursements
and the need for more detailed documentation given our current litigious
environment, doctors are spending more time behind a computer or in a chart
than they are at the bedside. Efficiency
is great, but a hospital’s drive to coordinate multiple tests on a single day
in order to speed up hospital discharges also has the effect of keeping
patients out of their rooms on morning rounds when medical students and
residents sometimes have their only chance to learn about the practice of
medicine at the bedside. With all of
these trends, nurses will soon find themselves as the only part of the medical
team delving into the lives of our patients in order to explore the intricacies
of the social world that blends with so much of their physical health. And with this comes more responsibility to effect
change in these realms for the betterment of patient care. It is well know that medical wards filled with
nurses who are good at what they do have documented improved patient outcomes.[3]
On my medical ward at the hospital, doctors and nurses had a
very collegial relationship. There was a
team approach to medicine that I seldom saw on other wards. But there was one thing I still observe that I
wish would change. I wish that nurses
would stop having to refer to doctors as “Doctor.” Most patients will refer to their physician
as “Doctor,” and I am no different. I
enjoy the peace and trust that is implied when referring to the person to whom
I am surrendering control of my health and well-being. But when I am on a team of individuals who are
not recipients of these gifts but instead help to deliver just the same to my
patients, this phrase has less relevance and instead creates a rift that I
believe is destructive to the team.
Let’s take a closer look at the word itself. The word “doctor” originated from the Latin
word doctoris which means teacher. It dates back to 1088 AD when Western
civilization’s first university in Italy, the University of Bologna, assigned
this prefix to refer to its graduates, specifically of law. The term was then extended to graduates of
other fields such as Philosophy and Medicine in the 13th century. Although graduates of law in some countries
such as Italy, Spain, or Portugal continue to refer to themselves as “doctors”,
this prefix was lost in England and America since the practice of law was
taught as an informal and undocumented apprenticeship until the 19th
century, when lawyers were once again required to have a formal university
degree. The phrase never caught on
though, and lawyers here are seldom referred to with the prefix “doctor”
outside of certain conferences or academic meetings. In its stead, many other degrees have had the
“doctor” prefix extended, such as optometry, pharmacy, chiropractic, and even
ayurvedic and homeopathic medicine. What
it means to be a “doctor” has become more vague and dispersed than its roots in
11th century Italy.
The doctor-nurse
relationship will continue to evolve through this era of medicine. We are sure to see new roles develop as
healthcare becomes more stream-lined with electronic medical records and
genetic predictions of disease. But one
thing is for sure – the 21st century-trained physician is more than
ever dependent on the nurse to supply top notch care to his patient. And the only way to do this is to work as
members of the team, with the patient as the leader.
Doc Veritas
[1] Cook, E. T. The Life of Florence Nightingale. (1913) Vol 1, p 237.
[2] Nightingale, Florence (1999-08). Florence
Nightingale: Measuring Hospital Care Outcomes. ISBN 0866885595.
[3] Blegen M, Goode C, Reed L. “Nurse
Staffing and Patient Outcomes.” Nursing
Research 1998;47(1):43-50.
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