The only thing that truly separates doctors from nurses

The only thing that truly separates doctors from nurses

Academic Medicine, journal of the American Association of Medical Colleges, has sent out a recent call for articles addressing the 2013 question of the year: “What is a doctor?  What is a nurse?”  Thirty years ago this would have been an absurd question.  Not only would it have been absurd for doctors and nurses, but for patients too.  Roles were clearly delineated within the disciplines, and the white coat indicated a doctor and the white uniform and cap identified the nurse.

There are several reasons why we have to ask the question posed by Academic Medicine.  A big reason is the entry of women into the field of medicine.  Another is the development of advanced degrees for nurses.  The computerization of medical records has spurred increases the need for physician extenders to support practices.  A huge reason recently has been cost-containment considerations.  The erosion of the doctor as an ultimate authority figure and the rise of patient autonomy have leveled the field as well.  To some extent access to education is in the mix also.

Educational level is usually part of the definition of a doctor or nurse.  This is no longer a reliable indicator.  A doctor has an undergraduate degree and an MD.  But a doctor might be a DO also, a doctor of osteopathic medicine.  A nurse has an undergraduate degree in nursing.  Except that a nurse might have an undergraduate degree in something other than nursing, and get the nursing training later in a master’s degree program.  Up until relatively recently you didn’t have to have a BSN to be a nurse, an associates degree was enough.  Now a nurse might have a master’s degree or a PhD.  A nurse practitioner has a master’s degree.  A physicians assistant might also.

Authority used to be used to separate doctors from nurses.  Doctors can prescribe medicines.  But now so can many advanced-practice nurses.   Doctors can write orders.  So can nurse practitioners.  Doctors can examine you and diagnose you.   So does your NP.

Nurses and doctors used to look different.  The physical appearance and dress of nurses and doctors in hospitals today is actually emblematic of the blurring of the lines of identity that have characterized medicine in recent years.  A doctor might wear scrubs; a nurse practitioner might wear a white coat; in the operating room, everybody wears the same thing.  Clothing has long been a tangible symbol of turbulent times.  The casting off of corsets was a signal of relaxing social restrictions.  The shock of a woman wearing pants coincided with women entering the workforce.  Burning bras were a way of protesting gender inequality.  It is no accident that the shedding of the nurses cap happened around the same time nurses became college educated.

Lifestyle and money?  Nope.  A primary care doctor makes less than a nurse anesthetist.  Some doctors don’t take call anymore, and many nurses do, even those without advanced degrees.

Surely knowledge, skill, and ability separate nurses from doctors?  Of course not.  Your experienced floor nurse knows way more about medicine than your average intern.  Physicians assistants can sew up wounds and assist in surgery.  A person who becomes a nurse is just as smart as a person who becomes a doctor, which has always been true but not always acknowledged.  An MD is just a piece of paper that gives a person permission to start learning how to be an actual doctor.  An RN is much the same.  Clinical experience  and training are the only things that matter materially to patients.  Some argue that training level is also part of the definitional differences between doctors and nurses.  Doctor’s clinical training in a formal educational system is usually longer.  So you could equivocally say that a doctor has longer training.

I would suggest to my readers that the only thing that truly separates doctors from nurses is ultimate responsibility.  The editor of Academic Medicine says in his introductory remarks introducing the question that his daughter was trying to decide between medicine and nursing.  This is the decision she must make.  Does she want to live with the ultimate responsibility for every patient under her care?  Because of our investment of time and money, and presumably because of the economic and social standing granted to us, we doctors bear this ultimate burden.  This is not to say that nurses don’t also have a responsibility to their patients and their field, or that they haven’t invested just as much time and money.

I have been both a nurse and a doctor, and am a huge proponent of the expanded role of nurse practitioners.  But the law and society have laid the ultimate privilege and burden on the person that people call “doctor.”  That’s the difference.

Shirie Leng, a former nurse, is an anesthesiologist who blogs at medicine for real.

Image credit: Shutterstock.com

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  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Well written piece. Physicians in training probably get more clinically supervised hours of providing care before they can go out and practice independently than nurses. Yes the ultimate responsibility is the difference

    • http://twitter.com/RNLibrarian AsktheLibraryRN

      With greater responsibility comes greater accountability, which translates into higher malpractice insurance rates for doctors. It will be interesting to see how such shifts influence malpractice rates for clinical “doctors” of nursing (DNPs).

      • Noni

        I, for one, cannot wait! The NPs and PAs want to be treated like docs. Sounds great! You can pay 30% of your income towards malpractice and start being hounded by the lawyers. Let’s see how much they enjoy that part!

  • Close Call

    “Clinical experience and training are the only things that matter materially to patients.”

    Average family medicine graduate gets about 18-20,000 clinical hours before they’re set free on the world. Average NP program is 1/5 of that.

    There are strict criteria about numbers of clinic visits, procedures done, didactic hours, community projects, patients managed on a service, etc. before a family medicine resident gets to graduate. I don’t know of similar criteria for NP graduates. For example, I’m still trying to find how many outpatient visits they need to conduct before they’re allowed to graduate, or how many hospital patients they’re expected to carry on a service. If anyone knows the requirement, would love to hear!

    And let’s not go down that road of “Many NPs have 30 years of ICU experience before they became NPs.” It’s simply not a significant portion of new graduates.

    Clinical training and experience do matter. Completely agree.

  • http://drpauldorio.com Paul Dorio

    This piece unbelievably minimizes the role of the doctor in today’s society. I am surprised that someone who has been both a nurse and a doctor would not realize the damage such sentiments are doing to doctors’ roles in the health care system. What is needed is an appropriate understanding and appreciation for the extensive and unique learning that occurs during four years of medical school, followed by three separate, grueling, multiple-hour long licensing examinations. Following that rite of passage, doctors are required to work as residents, i.e. indentured servants of sorts, for three or more years and then take another grueling, highly complex examination before becoming Board-certified and before being able to apply for licensure in each state in which we wish to practice. Sure, there are similarities between doctors and nurses, including the fact that both groups go through periods of education and testing. But I have yet to hear of the “advanced nurse” who has undergone similar lengths of time in schooling and training. But besides “ultimate responsibility,” the fund of knowledge that a doctor acquires cannot be approached without attending medical school, including disease processes ranging from the measles to Madura foot, immunology, microbiology, anatomy, pathology, biochemistry, histology, just to name some of the disciplines. Those areas are only learned in the first TWO years of medical school and are built upon through every subsequent year of training. I cherish my medical education and use the fullest extent of that hard-earned knowledge every day. Anyone with the wherewithal and necessary intelligence can attend and succeed at medical school. Not everyone has such ability, even if given the opportunity. But, as you correctly noted, when it comes down to it, being able to shoulder the “ultimate responsibility” is, at the very least, more than enough for all doctors to continue to be set apart from the rest of the world’s health care-givers. I applaud the advancement of nurses, and other caretakers who help care for people. But I am more than a bit apprehensive that society might begin to incorrectly feel, as you indicate, that there is such little difference between doctors and nurses. Perhaps you might consider, in your reply, what might happen if medical liability reform were truly enacted. Would doctors then equate to nurses in all respects? I wish I hadn’t gone through all of those years of training if such may become the case.

    • http://www.facebook.com/shirie.leng Shirie Leng

      Paul – yes we suffer more. We work more. We have more debt. Our lives suck more for longer. The result of all this work is that we know how to handle the hard stuff, the complicated stuff, the stuff that requires extensive basic science background, the unusual stuff. Yes we “pay” more. We also pay the malpractice.

      • http://drpauldorio.com Paul Dorio

        Clearly it is an interesting topic you have raised. It’s not that doctors’ lives “suck,” as you say, but that we are the major diagnosticians and “private detectives,” for our patients. It is more of a matter of differential expertise in areas that are complementary to nursing, as another person noted when she brought up Florence Nightingale. Doctors diagnose while nurses attend to the patients’ needs. Not that those rolese are exclusionary. Just that each group has essential roles in the care of our patients. Neither could be eliminated without irrevocable harm to patients. We all should recognize that fact.

        • nurseTTG

          I’m not confident that more public (and private) dollars and time spent in training translates seamlessly to better quality care. One could argue that nurse practitioners have demonstrated that Medicare doesn’t need to fund extensive residencies for physicians who are planning to practice primary care; the studies consistently show that quality of care by NPs with fewer years of training is the same as that of physicians. Physicians often rely upon the argument that they have more years of education, and of course this is true. The unanswered question is: what is the public getting for this?

  • N N

    “I have been both a nurse and a doctor, and am a huge proponent of the expanded role of nurse practitioners.” — I feel the same way about CRNAs expanded role in anesthesiology. Just like NPs who have shown to have just as good outcomes as primary care physicians in their self-funded studies, and believe they should have autonomous and independent practice without a physician, I think the same can be said for CRNAS when it comes to replacing anesthesiologists. I am sure you agree, right Sherie?

    • Noni

      Would you be ok with the no-pays and crappy insurance patients seeing midlevels leaving you with the patients who know and want better? Personally, as a physician, I’d be ok with that.

    • http://www.facebook.com/shirie.leng Shirie Leng

      Totally agree, NN. Most of what anesthesiologists do can be done by CRNAs. As I said to Paul, medical school and residency gives you the ability to handle the complex cases, the emergencies, the unexpected and the unusual.

      • N N

        Wait, wait, you JUST SAID that the only thing that “truly separates doctors from nurses is ultimate responsibility”, and “Surely knowledge, skill, and ability separate nurses from doctors? Of course not.” This is in complete contradiction to what you just said about handling complex cases and emergencies. At least get your talking points straight.

        • Guest

          Ridiculous.

          • Guest

            Meaning she and her article are ridiculous!

      • http://www.facebook.com/sujana.pulivarti Sujana Pulivarti

        if nurses want to take over and play doctor–take the gd boards like doctors do. let’s see them pass that. and how much do nurses pay in medical malpractice???? if a see a psychiatric nurse being paid the same amount as a doctor, i swear to god, i’m going to throw a fit. as a jd/mse/llm ; my future as a lawyer is gone. all that money, all that hard work and sacrifice-gone. my brother has been denied a residency spot for the third time and he is on the brink of a nervous breakdown. he did all the right things and he is committed to being a rural psychiatrist. and the assumption that doctors get overpaid is untrue. the ones that do work damn hard and have good business skills. my dad, triple board certified is 65, 30 years of experience as a nephrologist makes 130,000. you nurses need to stick to your own duties and stop acting like you’re qualifeid to become a doctor!!!

  • Noni

    I am curious – have you ever seen an NP or midlevel as a patient? I have, and I’ve never had a good experience (mostly with recommended treatment). Sure, they’re nice and confident, but I’ve yet to see one who was really competent. I didn’t doubt their intelligence, but they simply did not have the clinical experience of expertise to even handle the simplest of issues. I think it’s great that they become a larger part of primary care. I just always hope I will have the option to see a physician. Because I know the difference.

    • SarahJ92

      I disagree. My NP diagnosed my condition after 25 years of misdiagnosis and mistreatment by MDs. She also dx’d melanoma in a co-worker the dermatologist said he would have missed. She is excellent.

      • Guest

        My child’s sailing instructor, no stranger to the damage the sun can cause, told me that a dark thingy on the top of my foot looked for all the world like skin cancer to him and that I should get it taken care of ASAP. And he was right, it was a skin cancer.

        Who needs doctors, amirite??!!

        • Mengles

          Well “studies” have shown that sailing instructors have similar if not better outcomes in melanoma detection in comparison to physicians. /sarc off

          • Mandy

            And the fact that those “studies” were funded by the American Sailing Instructors Association had nothing to do with it at all. AT ALL! ;-)

    • Suzi Q 38

      My neurologist dismissed my weakness and tingling in my legs (mainly) and arms (minimally) as a problem relating to my lumbar spine, easily corrected with physical therapy, he said.
      My physical therapist thought otherwise. He thought it was very serious, and that I needed more MRI scans (cervical and thoracic) plus nerve tests on my limbs to attempt to find out why I could not stand up straight and was weak when walking.
      The doctor refused to act because he thought that I was fine.
      A year later, i finally got those MRI’s and nerve tests. I had spinal stenosis with signal changes that were left alone to rot on my nerves for a year. Fast forward to now..it is almost the same as before my much needed spine surgery: I am barely weight bearing, and I can barely walk, let alone run. I can not sit for long periods. I wake up several times a night due to the tingling and pain. I have improved a little, but not much.

      I sometimes think about what my outcome would have been if the doctor had listened to the PT and me (telling him what the PT suggested).

      My message is this: I don’t care which health professional comes up with the correct diagnosis and treatment. No, you are not equal as far as education. I get it.

      On the other hand, good detective work and instincts can not be bought and paid for with a medical degree. You are born with it, or have the desire to be a detective of sorts.

      Clearly, my neurologist (UC graduate and assistant professor at a major teaching hospital) with his 14+ years of undergrad and medical training PLUS 8 years or more practicing neurology, did not have as much of a clue as my PT and gastroenterologist. The gastro was the one that figured it out.
      It wasn’t even his specialty.
      The neurologists pride and insistance that he was right, almost cost me my mobility.

      I hate it when egos get in the way of doing what is right for the patient.

    • http://www.facebook.com/kate.curry.3950 Kate Curry

      Totally agree. I’m a BSN, have seen NPs and MDs — as a patient and as a co-worker — sorry, no equivalency there AT ALL. In my experience, of course — haven’t seen every NP there is to see.

  • A. Bruce Janati, M.D.

    This is the most unscientific article have ever read. There may be some truth to what this writer says, but he neglects to discuss the issue deeply. The reason why doctors in America are compared to nurses is very simple. The quality of medical school training has drastically declined in the US , thanks to a dilapidated and demoralized health care system which has been ranked the worst among the industrialized nation

    • Suzi Q 38

      Sure it is, but that doesn’t mean it shouldn’t be posted.
      Dr. Leng was formerly a nurse, now an anesthesiologist.
      Good for her! She has “walked” in the nurse’s “shoes,” so to speak, so she provides us with a valuable and interesting perspective, albiet it controversial.

    • querywoman

      But medical training gets longer all the time! Please explain how the “quality” has declined. FYI, I currently have some excellent specialists and need them as I age, better than I used to have. But, 15 years ago, when I was not so lucky and saw umpteen specialists, I had my best luck with a non-board certified young GP. He had a gift for family medicine. He’s board certified now, of course.

  • A. Bruce Janati, M.D.

    I should add that the truly mediocre US health care system obviously cannot afford good physicians. It is parsimonious in providing quality care to its population, at the expense of the well-being of its citizens. Such a depraved disregard for humanity is not unexpected from a system with a notorious track record..

    • Suzi Q 38

      I agree with you, but the mediocrity comes from people that are health professionals in general. Some doctors don’t have good attitudes, so eventually, they become mediocre.

      The same could be said for any health professional in general.

      If our present system is so bad, why do people come from other parts of the world (especially Canada) to have their operations?

      • A. Bruce Janati, M.D.

        The Canadian health care services are wonderful but dilatory. The only reason that Canadians travel to the US to receive medical care is to hasten their therapy ,not because of quality care. In Canada ,due to the nationalized health care system , there is a long backlog for elective surgeries. Also, the negative attitude of health care professionals in the US is due to mismanagement of the health care system by incompetent leaders whose only agenda is self-actualization and self-promotion. Also, let me suggest that whenever you are about to see a doctor , please ask for his/her curriculum vitae. Please note that there are many incompetent doctors in the US who are volunteers for slavery , and who have no choice but to ingratiate the system to sustain themselves.

        • Suzi Q 38

          Thanks for your perspective, which provided some good insight into the Canadian system.
          I look up a doctor’s CV whenever I can.
          Most teaching hospitals have the CV easily available, for all to view. Other than medical schools, residency, fellowship, and actual hospitals worked, what am I looking for?

          What else would be good traits for a good physician or surgeon based on his or her CV?

          • A. Bruce Janati, M.D.

            You need to find out if they have published in peer-reviewed journals in the field that pertains to your condition. For example, a seizure patient should look for a doctor who is specially-trained in epilepsy, and who has published in neurology/epilepsy journals. Other good strategies to find a good doctor include ” word of mouth”and physicians’ ratings on-line.

          • Suzi Q 38

            Thank you.
            Usually the CV lists publications, right?

        • Suzi Q 38

          Dr. Janati,

          If I my legs and arms were getting weaker and causing me a weird walking gait, and partial paralysis, how soon would I get my much needed surgery in Canada? Remember that once the problem was fixed through cervical dissection and fusion, the problem stopped progressing and getting worse. The MRI showed the stenosis and narrow cord and the neruoradiologist verified problematic signal changes that could make my paralysis permanent.
          Yet, if you saw me, I was still walking tentatively.

          How long from your diagnosis would I be able to get my appointment with the surgeon, then get the surgery itself?
          Each day brought new, troubling symptoms.

          My surgeon graduated from a major teaching hospital in L.A., then did his residency and fellowship at the number one hospital for neurology in the U.S.

          Not that there aren’t other good surgeons with good skills, but that is not a bad start.

          • A. Bruce Janati, M.D.

            It seems that your symptoms are due to spinal cord compression, hence surgery is urgently needed. You need to make an appointment with your qualified neurosurgeon immediately. Good luck

          • Suzi Q 38

            Thank you for your help, doctor.
            You are a good “detective.”
            I wish my first neurologist was that good.
            I even asked him for further tests, but he claimed that I was improving. I told him yes, but my symptoms are still there, and I am getting new ones.
            Ater I had severe symptoms while exerting myself on a European vacation, the first neurologist finally gave in and got me the MRI of the upper spine and brain that I needed. He wouldn’t have done so if it wasn’t for my gastroenterologist, who did the same thing you did, be a good “detective.” He demanded the MRI and told the neurologist so.
            After I got the results of spinal stenosis with signal changes, I needed another opinion. You have to remember that I was there a whole year and a half, complaining all the while, and they did nothing.

            I went to another teaching hospital. One that specialized in neurology, rather than cancer.
            After the surgeon and MS Specialists gave their opinions which took 2 1/2 months to get an appointment, and a hospital that was closed during the last two weeks of December 2012, I emphatically asked for my surgery on January 9. I received it on January 18.

            Now both hospitals are pointing fingers at each other as to who postponed care too long.
            I guess after my sad ordeal with the medical profession, I shouldn’t be so scared about the Canadian-type of system.

          • A. Bruce Janati, M.D.

            It is not uncommon for compressive lesions of cervical spine(eg.spinal stenosis ,disk herniation) to be associated with abnormal MRI signals within the spinal cord, resembling MS. Your physicians may wish to do more studies including “evoked potentials” and MRI of the brain to rule out MS. A lumbar puncture would be risky due to the presence of spinal stenosis(spinal narrowing).

          • Suzi Q 38

            Thank you! I did not know that. No one suggested evoked potentials, although I have read about them.
            The first teaching hospital (famous for cancer) did a lumbar puncture in October. The results were negative. It hurt so much and I don’t want to take another one. Now I know how risky it is due to my cord.
            I did get the MRI of the brain, which showed two small flecks in areas that were not considered typical for MS. I am getting another MRI of my brain, cervical and thoracic spine tomorrow. This way, the MS neurologists can compare it with the ones taken in late September and mid October 2012. If the lesions havent increased or grown in size, especially in my brain, I am going to rejoice.
            I do not wish to take those harsh MS drugs at my age 56 unless I have MS.

          • Barry Nuechterlein

            My understanding, as an American-born and -trained physician (and patient) presently working in the Canadian system, is that high-quality emergency care is delivered pretty promptly in both systems.

            Yes, there are horror stories of delays in Canada. Just like the horror stories of unneeded procedures being performed by “patient mills” in the States. There was recently a kerfuffle in Elyria, Ohio, about a Cardiology practise “taken to task” around (allegedly) overly aggressive angioplasty/stenting. That’s a procedure that carries real risks, so it’s no small matter.

            By and large, for situations like the one you describe, both systems do a good job.

            The difference comes in terms of non-emergency care. That’s where the Canadian system tends to delay (view patients as “loss centres”) and the U.S. system tends to pile on additional activity with dubious benefit (viewing patients as “profit centres).

            I guess, in either system, you can always remember what they say at Scotland Yard:

            “Gentlemen, if you wish to solve the crime, you must first follow the money.”

          • Suzi Q 38

            Thanks for your explanation. It helps.

  • http://www.facebook.com/shirie.leng Shirie Leng

    I seem to be a catalyst for sturm und drag when it comes to this topic. I have been informed by a reader that, in fact, in some places NPs do work independently, so ultimate responsibility doesn’t really define the difference either. Maybe we should stop talking about who is who and who is better and just start working together.

    • Suzi Q 38

      I agree, Dr. Leng.
      I know that there is going to be plenty of work for both.
      The doctors are going to need a few good NP’s to help them build a practice.
      Our daughter is helping out two clinics. One is in a wealthy area of town. At this office, the doctor only allowed her to chart the information about patients for several weeks, until he figured out that she was very capable in helping him with his patients.
      She felt it took a long time to learn anything at that office, because he was so careful about not allowing her to do anything at first.
      Now he lets her see patients under his supervision.

      In the other clinic, she does almost anything that the doctor does.
      It is located in a poor area, and the patients are all over the place.
      She just tells the doctor what she has decided to do, and why.
      The doctors at this clinic like her, and teach her how to treat patients everyday.

      I know that it is tough to think about, but the NP’s are going to help you.

    • N N

      If you didn’t even know that basic fact about NPs working in quite a few states independently, then you probably shouldn’t write an entire diatribe, with no actual facts to back it up, on the differences between nurses and doctors.

  • Guest

    “The casting off of corsets was a signal of relaxing social restrictions.
    The shock of a woman wearing pants coincided with women entering the
    workforce. Burning bras were a way of protesting gender inequality.”

    What the WHAT?

    How did a trite and frothy thought-bubble from an undergraduate Women’s Studies essay find its way into an allegedly serious article on the issue of the relative roles of highly-trained doctors vs. lesser-trained nurses and other mid-level medicos vis-a-vis 21st century American healthcare?

    According to the OECD, women make up 54 percent of physicians below the age of 35 in Britain, 58 percent in France and almost 64 percent in Spain. Around half of med school grads in the USA are women. It’s not a /thing/ anymore.

    The issue of doctors versus nurses is an issue of professionalism, clinical training, education and experience. The average patient wants to see a real doctor for real medical issues, and not a nurse, not because of Ingrained Societal Sexist Patriarchal Hegemony, but for the same reason they want a real pilot flying their plane, not someone who’s reached Level 8 on Microsoft Flight Simulator. It’s the skillz, stupid.

  • A. Bruce Janati, M.D.

    It is noteworthy that the doctor vs nurse issue has been fueled by the AMA, the most inconsequential organization which has surreptitiously pursued an adversarial policy against doctors. One should never forget the collusion of AMA and Medicare aimed at capping the income of physicians, particularly the qualified ones.

    • Suzi Q 38

      I think what the AMA did was borderline “criminal.” i think that there needs to be new leadership, an “uprising”so to speak. The teachers would not have put up with this nonsense within their national group. The only reason why it has allowed to continue is that you have been the silent majority. You doctors have allowed it to happen. At times I have wondered why. You are smart, you have dazzling CV’s, your accomplishments are extraordinary, and you have some money. Most people would love to have what you have rightfully earned. Yet by not uniting and getting organized in some way (doesn’t have to be a union, but if that is the only model that works, so be it) you lose every time. It is almost as if you all have drunk the “Koolaid” that says that you can’t beat the system and you have to accept less than what a hairdresser gets paid to treat a medicare or medicaid patient. Also, the private insurances don’t pay that much either. They see what the government gets away with paying you, and they do the same. My PCP gets about $40.00 a visit from my PPO insurance company. My hairdresser gets about $40-$50.00 to cut and style my hair.
      With the new changes in Obamacare. you all have to careful this year. You don’t want this tone to continue this way.

      It needs to happen at the next conference meeting for the AMA.
      All concerned physicians should attend and pack the room.
      Chosen speakers from the new group should speak on behalf of all physicians calmly but directly and truthfully. Basically, tell them that they are weak excuses for physicians-leaders, and you all are tired of it.
      Get them to resign. Vote new people in. Have physicians line up outside, call the media. Call patients that care to come. Call nurses that know that this animosity is all hogwash. My daughter is a nurse, and no one has made her feel bad about being a nurse. most of her doctors work well with her, like her, and most importantly, teach her so much.
      Make the next AMA meeting look like a 1960′s protest and “sit in.’
      March on Washington D.C. Do something no doctors have ever done before. Correct a huge wrong.
      Elect people that are both charismatic and intelligent to represent you. No fatties, as you all are so critical of such people. Don’t you vote people in? If so, nominate others. Get rid of the old. Orchestrate a letter writing campaign to the president and anyone else of importance. Make this year different.

  • http://www.facebook.com/people/Natalie-Gonzalez/590578764 Natalie Gonzalez

    Herman Hesse once wrote, “it always amuses me and seems right that what is of wisdom and value to one man is nonsense to another.” Generally I have enjoyed this discussion for it is minus a lot of the usual vitriol and has presented some sound differences/similarities. What I most agree with is the point that what is needed is clinical skills.
    I work for the State of WA Dept of Health and I recruit primary health care practitioners (MD’s/DO’s/NP’s/PA’s) to rural areas and to work with underserved populations, including Tribal Clinics and state institutions. In our rural areas we need clinicians who are confident in their skills and who can basically “do everything”, within their scope of practice. We have several NP only clinics and a couple of PA only very remote sites. They all have MD’s/DO’s for back-up and know when to refer. Remember these are not idiots!!! Often times discussions portray NP’s, in particular, or PA’s as wanting to be physicians. No, they just want to be, and should be, recognized for their skills and to work to their full scope of practice.
    We do not have enough access to care. I liked the person who talked about the NP who works in two clinics and in the “poor” person clinic was trusted to do more than in the “rich” person clinic. From what I have seen or observed or read the quality of care in Rural Health Clinics and in Community/Migrant Health Centers (both seeing a lot of poor folks) meets any standard of care. Most participate in the various chronic disease collaboratives and are being “certified” as patient homes. Until we have adequate access to care for the un and under insured in our urban and rural areas “we” do not need to fight over who does what. Let’s just do it!!
    Last evening I went to a small town to meet with a solo 64 year old BC FM doc, in poor health, who wants to sell his practice and he will donate his not so new equipment to whoever will take over. His spouse is his office manager. They just want their patient’s (mostly a Medicare panel) and their employee’s to be taken care of by a new physician. Trouble is finding someone. We have more than enough patient’s we just need any and all primary care clinicians willing to help keep/increase access to care.

    • Elizabeth Rankin

      I’ve enjoyed the varied responses to the comparison of professionals and their status. These issues are not likely to be understood or resolved unless there is a model developed for joint study and practice that requires all prospective health care students, regardless of end chosen profession to enrol in programs where they learn not only the basics of the sciences but the basic of skills required including beside skills, learning how to talk to patients, encourage narrative comments of patients so they work and problem solve together so when they graduate there is at least some understanding and recognition of what each profession has to offer. Respect goes along way when helping patients which is what a health care professional is intended to do. If there is little or no trust, there is no respect, and what have we got in health care today…? Looks like the posted comments reflect the state of the art!

  • Homeless

    In my state, NPs can practice independently without a MDs supervision. They are responsible for their patients.

    Those NPs I have seen as a stand in for busy doctor often look for “band aid” solutions.

    And if more training is so important, wouldn’t it follow that for a specific problem, I should see a super specialist that is well versed in that problem instead of a general specialist or a generalist?

    • Mengles

      You get what you pay for. You pay less, then you should be satisfied with Band-Aid solutions.

      • Homeless

        If I go to “my doctor,” who never has time to see me, I get a NP who puts on that “band aid” and the price is the same as a doctor’s visit.

        If I go to an independent NP, I pay less and get solutions beyond the “band aid.”

        Of course, I could go a specialist for the same price as my PCP and I would get my money’s worth instead of that “band aid” solution at my PCPs office.

  • buzzkillersmith

    Why is Dr. Leng throwing around bombs like this? It reminds of the guy who goes up to two other guys, each in turn, and says that the other called him a bad name.
    Why is Dr. Leng trying to get docs and nurses at each other’s throats? Go after the corporate scumbags and I’ll be right there with you, but leave the nurses alone.

    • Mengles

      She’s done with almost all of her articles like “What doctors and teachers have in common”, “The only thing that truly separates doctors from nurses” and “Why your nurse practitioner is your friend” (essentially saying that most of what PCPs do can be replaced).

      • buzzkillersmith

        Good to know. I am now alert to what we’re dealing with here and will scrutinize and comment as needed.

  • jloos

    In states where NPs practice independantly the buck stops with the nurse.

  • mytwocents

    at this point in our economy and healthcare status, none of this is even relevant. point blank, most NPs are more willing to go out to rural areas and/or work for less money in a hospital setting whereas most MDs are not (and for good reason). that is the whole reason for the recent push for NPs and PAs.

  • traumadoc

    well, i see a difference. i went to Rome 6years to study medicine(after 4 of pre- med in the states). then 5 of general surgery, then 2 of pediatric surgery, then 3 of trauma-ER surgery. i have been a doc without borders for many years. i now in my golden years and i teach anatomy and physiology to nurses to be. i teach medical school also part time.
    now—what is all the fuss about? this should not even be an article!!! compassion makes the difference in medicine and the patient will react to that no matter who you are. but, the study load is much heavier to the doctor and so is the malpractice insurance.

  • http://www.facebook.com/thegypsynurse Gypsy Nurse RN

    I do not think that it ‘minimizes the role of the doctor’ as Paul states below. I LOVE it and think that it’s a great reminder that many of today’s nurses are just as well educated as physicians. Great job!!

    • Suzi Q 38

      I don’t agree. I have respect for nurses, as my daughter has her Master’s and is working on her NP. She has had about 4 years of undergrad and 3 years of nursing. Then two more years for her NP.
      The years have been long, but not as tough as the curriculum of a physician. the exams are not the same.
      They are educated in different ways, and they compliment each other.
      She knows that she is not a physician, she is a nurse and loves her work. The two jobs serve patients and medicine but are very different.
      She is going to be able to assist doctors in their clinics.

    • http://drpauldorio.com Paul Dorio

      I hope you are right and that most people reading these comments realize that nurses, doctors and other caregivers play complementary roles in the care of our patients. Unfortunately, it seems that some people see one type of caregiver, are told one thing, then get told something different by another person and end up taking home differing messages that makes them either confused or feeling like the first person (I.e. doctor usually) was wrong. They need to go back to that doctor and try to obtain a rational explanation for the differences.

  • Doctor Who

    This is ridiculous. “Surely knowledge, skill, and ability separate nurses from doctors? Of course not. Your experienced floor nurse knows way more about medicine than your average intern. ”

    Nobody is comparing a floor nurse with years of experience to a first year intern. The comparison that occurs is between inexperienced nurses and full-fledged physicians, where the nurses believe they have the experience and ability of the trained doctor.

    There is no comparison between a fully-trained, board certified physician and a graduate nurse. No matter how much other groups may buy studies and try to fool people into thinking otherwise.

    • Suzi Q 38

      I agree about the studies.
      My daughter is learning to be an NP, so I asked her for studies.
      You can find a lot of them, on almost any medical subject.
      For any side you wish, pro or con.

  • nursereveal

    Interesting article and comments; I think MDs and RNs are both a vital part of the healthcare industry and should be valued and appreciated for what they each bring to the table as different professions. There are seasoned MDs and RNs with the knowledge, education, training, and clinical experiences that are very influential to the training, education, and clinical experiences of a new medical intern or new nurse grad. We, as healthcare professionals, have to be very careful that what we don’t display to our patients that one {MD vs. Nurse} is better than the other because depending on patient’s needs, one may be more of what they need at any given time and on any given day.

  • http://www.facebook.com/survivor.do Survivor DO

    “Your experienced floor nurse knows way more about medicine than your average intern.” I respectfully disagree with this. I would agree that the average floor nurse certainly knows more about hospital protocols and what is USUALLY done but this learning curve is quickly overcome by the intern. If the standard plan is varied from in even the slightest the difference between nurse and intern becomes apparent. The intern is quickly able to see how we are deviating from the standard plan and able to reason why. The nurse, in my experience, is typically “left in the dust”. Again, it is the higher level thinking that separates the MD/DO from the nurse.

    Survivor DO
    http://www.survivinggrays.com

  • Guest

    As always, a wonderful perspective from someone who’s been on both sides of the healthcare system. Additionally, I believe it’s important to recognize that doctors get their training in a structured environment through residency, while nurses learn on the job, so to speak. I would trust a 20-year veteran ICU nurse, over a novice Intensivist any day. And how wonderful that nurses are able to receive training in society today, which will enable more affordable healthcare for the masses. So until someone (from the medical field) carries out a study which proves that more harm is done to patients who receive care from nurses, rather than doctors, I believe the system is moving in the right direction.

  • Erica Berg

    As always, a wonderful perspective from someone who’s been on both sides of the healthcare system. Additionally, I believe it’s important to recognize that doctors get their training in a structured environment through residency, while nurses learn on the job, so to speak. I would trust a 20-year veteran ICU nurse, over a novice Intensivist any day. And how wonderful that nurses are able to receive training in society today, which will enable more affordable healthcare for the masses. So until someone carries out a study which proves that more harm is done to patients who receive care from nurses, rather than doctors, I believe the system is moving in the right direction.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Care to show us the studies (done by physicians in medical journals) that say that patients get just as good of care from Nurse Practicioners as they would from a doctor? Just because it may be cheaper to have a Nurse Practicioner caring for some of the patients does not necessarily mean that the care that the patient receives will be better than when getting it from a doctor. The majority of patients at least from what I can tell want their care to come from an MD/DO not a nurse when it comes to everyday medical care. The reason I ask for the studies is because I want to see if there are any done that got printed up in Medical journals just to see what the opinion of other doctors feel about this.

  • Erica Berg

    As always, a wonderful perspective from someone who’s been on both sides of the healthcare system. Additionally, I believe it’s important to recognize that doctors get their training in a structured environment through residency, while nurses learn on the job, so to speak. I would trust a 20-year veteran ICU nurse, over a novice Intensivist any day. And how wonderful that nurses are able to receive training in society today, which will enable more affordable healthcare for the masses. So until someone carries out a study which proves that more harm is done to patients who receive care from nurses, rather than doctors, I believe the system is moving in the right direction.

  • Suetonius

    Hahahahaha.. I’m not even going to justify this with a real response, other than: you can’t actually believe this.

  • http://www.facebook.com/Kymomof4 Brenda Smith

    Maybe the title of your article should be “Is the doctor or the nurse legally responsible for the outcome of a patient’s treatment?” I don’t believe there is only “one” thing which separates a doctor from a nurse. As Paul mentioned, doctors go through much more extensive education, residency, internships, and multiple exams than nurses do, none of which is a surprise to anyone planning on going into medical school. So along comes the responsibility with such rigorous preparation…. But we must not forget as medical professionals we need each other in order to provide the most “responsible” and best possible care to our patients. As I was taught in nursing school, the doctors had the greater complex medical knowledge and wrote orders for the nurses to carry out. We meaning “nurses” were the doctor’s “senses”, we spend more time with the patients and are able to pick up changes in the patient’s condition in which we report to the doctor before they become life threatening. Sometimes, more times than not, a nurse’s “gut” feeling has saved a patient’s life. But there are also a few doctors who think nurses are trying to make “something out of nothing” or doesn’t know what he or she is talking about when we call about those “gut” feelings. Unfortunately this happened to me with a young patient, who ended up cardiac arresting and didn’t pull through. I bring this up because we need to work as a team, it’s not really about who has more education, who has more debt from school loans, who took how many exams or who holds the burden of responsibility. If we ALL are true to our profession and follow the accepted major principles of health care ethics, then we really are not separate are we???

    Just my thoughts~

    A 24 year experienced diploma nurse soon to graduate with a BSN

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