The deep professional rift between nursing and medicine

I recently attended Primary Care Progress’s Gregg Stracks Leadership Summit. The summit brought together chapter leaders from around the country to get coaching in how to lead our chapters to accomplish our individual goals.

I went to the summit knowing that PCP values teams – the team-based model of organizing to improve the primary care profession and the team-based model of primary care delivery.  In both cases, there would be a place for me, an RN and a nurse practitioner student.

But amidst the initial excitement and bustle of registering and sharing greetings with strangers, when I put on my name tag, I noted that it clearly identified me as part of an under-funded school of an under-respected profession: nursing. I recognized myself as part of a minority of non-medical students, and, despite what I knew about PCP, I wondered if I would be taken as seriously as my new weekend peers. Would medical students, residents, and doctors be as interested in networking or even just talking with a nurse?
I realized that I had internalized the historic tension between nurses and doctors and between nurses and nurses, and it occurred to me that this tension could be a possible barrier to PCP’s efforts to engage more nurses in its work.

I am more of an anthropologist than a nurse or nursing student in my comments here. And I am neither the first to make this observation nor am in any way qualified to unpack the many layers of history that have colluded to keep these two groups at odds. Still, these tensions are worth bringing out in the open if the efforts of those of us involved in PCP are going to include a space for those who are not doctors or doctors in training, and in so doing, bring different perspectives and a history of (dis)empowerment to navigating the problems in health care.

Before I decided to go into health care, an oncologist friend cautioned me against nursing. “Do you want an M.D. or an N.P. after your name?” she asked. She warned me both as a woman from another generation and also as a clinician who greatly valued the power she saw as intrinsic to becoming an M.D. I believe many who choose medicine share my friend’s value, but ultimately I entered nursing because as a non-traditional student, I wanted to gain clinical skills and experience as quickly as possible.

I was both haunted by and propelled towards health care by experiences I had while working as an English-Swahili interpreter for a group of American doctors and nurses in Tanzania. There, I saw the harm that can come from efforts “to do good” through the stasis of hierarchy and at the exclusion of others. In one typical clinic, a nurse stood before a long line of Masaai tribal members seeking care outside of the handmade community structure that they had built years ago, hand prints baked into the clay walls. The doctor and resident sat within the cool spacious building and saw one patient at a time, while the nurse worked outside, assessing vital signs and watching as people, weary from many miles of travel under the hot sun, grew frustrated with such a slow and inefficient use of space and personnel. The doctors had essentially recreated the design of their offices back in the U.S. and, like they may have done back home, greatly underutilized the expertise of the nurse.

In the end, the clinic ended abruptly, as the numbers of hot and tired patients kept growing and reached a crescendo when a doctor slammed a young man’s hand in the car door while trying to leave the site in haste.  Although the nurse commented throughout each and every clinic about other (perhaps better) ways to utilize space, provide care, or understand a given  problem, she rarely spoke up to express her views to the doctors. I can only assume she felt she would not be listened to or respected.  In part through this experience, I saw nursing as an opportunity to be of use to another human being in some of the most concrete ways possible. After all, the nurse was outside with the patients all day; few saw the doctor. We see in the U.S. health care system as well that nurses (and CNAs) are more often able to be at the bedside when it matters, addressing our most basic human needs. The work can be as humble as assessing a patient’s urinary or fecal output, or as profound as attending to someone in their final hours of life.

I knew little of the deep professional rift between nursing and medicine, and I knew even less about the complex way in which this legacy has impacted not only the way doctors and nurses work together, but also how nurses treat one another and undervalue themselves. Nurses are notorious for “eating their young,” and will not only often ignore their own needs but they also have an unfortunate legacy of hazing new nurses in ways that emphasize a culture of workaholism, co-dependency, and fear. In most clinical settings, doctors’ and nurses’ worlds are so deeply divided despite their interdependence. Even socially these divisions are maintained by many in choices as simple as with whom to sit at dinner.

You can imagine my relief at the summit when, during our first break-out group, I met a young med student who introduced himself by way of a story of meeting an RN at a homeless shelter and expressed his humility and respect for the clinical knowledge she had. This was one of many experiences during the weekend that opened me to the possibility that the hot buzzword of inter-professionalism is actually a living force and exists in genuine collaboration and creative exchange between diverse constituents.

The weekend helped me to step outside the isolation of my education program and of my future career path. The patterns of division and reactivity that have kept students and practitioners of medicine and nursing separate seemed absolved for a few days. Learning of new generations of programs that truly foster collaboration between health care trainees was radical and nourishing.

There is no need to reiterate the fact that our current primary care system in the United States needs a thorough overhaul. We all have stories and evidence of this need. I was heartened, however, to see that PCP chapter members I met at the summit seem to value the inter-professional matrix that primary care requires to survive this difficult time. It is my hope that all PCP members reflect that value. And I hope they do so without becoming lost in a quest for power that is equivalent to their peers in sub-specialties, but rather begin to assert an entirely new value system. As we begin our work to recreate health care delivery in the United States, it is not only good practice to bring all health care professionals to this drawing board, it is essential if we are to catalyze a new story of primary care.

Alana Rose is a family nurse practitioner who blogs at Primary Care Progress

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  • Steven Reznick

    The current primary care system is broken for one reason and one reason only. Primary care doctors who perform cerebral evaluation and management services are poorly paid for the time spent coordinating care. As a consequence Primary care physicians have retired early, left medicine or become snake oil salespersons selling supplements, cosmetic procedures or whatever it takes to cover the costs of their practice and lifestyle. At the same time medical students and residents, saddled with high educational costs and loans are avoiding the primary care specialties because of the difficulty they will have paying back their loans and living. At the same time nursing made a paradigm shift from requiring two years of post high school training and being hands on care givers at the bedside to getting a 4 year education and then post graduate training. This moved them from being hands on caregivers to more of care managers leaving much of the physical work they once performed to lesser paid aides. Physicians with great influence on the field of medicine and future education of doctors such as Ezekiel Emanuel MD ( brother of the former White House Chief of Staff and current mayor of Chicago), Robert Wachter MD ( founder of hospitalist medicine), D Berwick MD ( former head of CMS) and Bruce Berenson MD ( professional consultant to beltway politicians), have decided that medical school and residency should be shorter and cheaper . Despite the increase in volume of knowledge and technology they think a few years less of training and experience will result in less cost to train doctors and consequently we can pay them less. They additionally want doctors trained as either in patient specialists or outpatient clinic doctors. Make them less well rounded and they cost less seems to be their selfish mantra.

    Nurse practitioners get an average of 4500 clinically supervised hours before they are allowed to open a practice independently . The first wave of NPS came from ERs , critical care units, military acute field units and were so experienced that the limited training with supervision didn’t matter. If you compare this to the NP coming straight out of college with only 4500 clinically supervised hours and then compare it to the average doctor with 145,000 clinically supervised hours you see where the rift comes in.

    Insurers who captured patients and destroyed the doctor patient relationship while selling the contracted patient back to the PCP’s at a discounted rate helped support the growth of less expensive NP’s and PA’s. They are supported now by the Dr Bob Wachter’s who want to see a division between inpatient and outpatient doctors. It remains to be seen whether the Accountable Care Organizations will be successful using many NP’s supervised by a few physicians. I suspect the shortening of the physicians training coupled with the push to use less experienced nurses will result in the aging baby boomers with multiple chronic problems getting more fragmented less complete care then they need.

  • Doctor K Says

    Cannot agree with Steven Reznick more. The payment of physicians for managing medical delivery and coordinating of care is lacking in the healthcare model. It is not only in primary care. Surgical specialists gravitate to more lucrative procedures and avoid the management of complex problems.

    • Steven Reznick

      I believe the general surgeon will disappear like the general internist and family practitioner for much the same reasons. It is a crime. The fund of knowledge, experience, time investment and commitment I see in our aging general surgeon population is unsurpassed . They will be economically credentialed out of performing procedures they have performed well for years by the E Emanuels, R Wachters, D Berwicks, Bruce Berensons and C Cassel’s of the world.

      • kjindal

        don’t forget about the heads of HHS and CMS (neither a physician; a TRIAL LAWYER and a NURSE respectively).

        • Steven Reznick

          The trial lawyers husband apparently owns the largest RUC seeking to reclaim Medicare funds from physicians and institutions that the RUC claims over billed Medicare.

        • militarymedical

          At that level, the exact educational background of a CEO is not as important as his/her ability to manage a large organization – to fulfill its mission and (unfortunately) to make money. To use the military model, once one reaches flag rank (i.e., the ranks of generals and admirals), one’s basic branch (specialty) is immaterial. A general who has spent his/her career in Aviation may be made the Commanding General of the Recruiting Command. The current Surgeon General of the US Army is a nurse – one with years of critical care experience and two masters degrees, neither one in nursing. With respect, kjindal, but your comment serves only as a red herring.

          • kjindal

            I respectfully disagree. The HHS head is in a position to interpret & form policy on the basis of national expert panel recommendations e.g. the USPSTF and mammography recs. She has neither the clinical experience nor the educational background to do so. Same goes for the head of CMS- understanding and reforming the many forces that influence medicare & medicaid payment policy is GREATLY aided by having treated patients, especially in a variety of different settings (hospital, SNF, outpatient office, homecare, etc.) such as is done by a typical Internist of Family Practice MD. Also, referring patients to specialists is a quick lesson in where payment incentives lie, where money can be saved, and where more money should be put. This administration has paid lots of lip service to primary care, but the solutions are clearly from those who haven’t actually treated patients (rah rah electronic records and NPs will save the day!)
            ANY practicing primary care physician would be a better choice than either of these, but what is good for care always takes a back seat to cronyism in this administration.

  • kjindal

    Dr. Reznick you are so right. Primary care is in an accelerating death spiral, with a few of us hanging on because we can’t afford to retire.

    “The first wave of NPS came from ERs , critical care units, military acute field units and were so experienced that the limited training with supervision didn’t matter. If you compare this to the NP coming straight out of college with only 4500 clinically supervised hours…”
    So true. Where I work (large nursing home) there are HMO NPs and their students, who write long “medical student” type notes with “PERRLA” and long-winded neuro exams that I know never took place (most don’t even have a penlight). They are right out of nursing school, maybe 23 yrs old, and certainly don’t bring any real nursing experience to the table. When society tells board-certified Internists & FPs that these NP students are just about as qualified as us, it begs the question: Why not just shut down all medical schools tomorrow?

  • Samir Qamar

    The primary care shortage can be easily reversed – address the reimbursements. Primary care models such as Direct Primary Care and concierge medicine are growing quickly because their doctors can earn as much as 500K annually, sometimes twice that if successful. Several years ago in the UK the NHS dramatically increased pay to GPs and the shortage was reversed practically overnight. Unless we get innovative with new models of practice or reimbursement, physicians in primary care will soon become a minority.

    • Steven Reznick

      The question of autonomy is a big one not just reimbursement levels. As hospital and corporate systems hire physicians away from private practice and control their decision making and choices the patient’s lose advocates.

      • Samir Qamar

        Absolutely. Upcoming trends like Direct Primary Care, when involving private practice, also allow greater autonomy by minimizing dependence on third party payers.

  • Brett

    So, I am an Acute Care NP, and if I am to read Dr. Reznick’s comments correctly, I deserve at least some respect. I spent thousands of hours a year in ICU’s assessing and delivering necessary information (diagnosing without diagnosing) to doctors who were rounding for only 5 minutes a day. I understand the need for the short rounding, believe me. However, how is it that you 1) think NPs are not still studying and learning as their career advances?, and 2) that all NPs are idiots without clinical care experience anymore? Now, I would agree that floor nurses going to NP school is not the type of NP that I want to see. However, for the rest of us with thousands of hours in the ED/ICU, I think we deserve a little bit of respect.

    • Steven Reznick

      I think you deserve the ultimate respect and it is always a pleasure to work with an experienced care giver. The problem is in many states there is no distinction made between individuals entering unsupervised private practice or running clinics with little or no supervision who have only 4500 clinically supervised hours and practitioners who bring tons of experience to the table. It is no different than not wanting to go to a new surgeon who is performing a new procedure and has not performed it 200 or more times. I am not saying that any new NP is an idiot due to lack of experience. I am saying that there are powerful leaders in the field of physician education who are trying to reduce the length of training of physicians and the depth of their pre certification and licensing clinical experience solely to save money. If this physician workforce is blended with NP’s with little or no clinical experience it bodes poorly for elderly and complicated patients with multisystem disease blending multiple chronic issues with acute problems.