The medical model versus the nursing model: A difference in philosophy

I recently blogged about the question of what the difference is between a doctor and a nurse, now that advanced practice nurses can do so many of the same things physicians do.  As both a nurse and a doctor I thought maybe I could wade into that quagmire.  In that post I suggested that the real difference is one of ultimate responsibility.  A reader pointed out that this is actually not true: in some states NPs and others practice independently.  I also realized this statement of mine was a little insulting to nurses, somehow suggesting that they willingly abdicate responsibility for their patients.  So I’ve thought about it and I have a new opinion.

The difference is one of philosophy.  The medical model versus the nursing model.  Until recently I found this distinction annoying and reductive, diminishing the individual differences each of us have.  There is an actual definition for “the medical model”.  Here is what www.thefreedictionary.com says:

“The traditional approach to the diagnosis and treatment of illness as practiced by physicians in the Western world since the time of Koch and Pasteur. The physician focuses on the defect, or dysfunction, within the patient, using a problem-solving approach. The medical history, physical examination, and diagnostic tests provide the basis for the identification and treatment of a specific illness. The medical model is thus focused on the physical and biologic aspects of specific diseases and conditions.”

The term medical model has been used in both complimentary and derogatory ways, but it is generally the way doctors think.  There is no definition of the nursing model, but nursing has some practice models/theories that emphasize the more holistic approach to disease that is taken by nursing.  For example, three British nurses back in the ’90s came up with a model called “The Activities of Living” model.  It views a disease in the context of what the patient can and cannot do for themselves.  They list activities of living like so:

  • breathing
  • eating and drinking
  • eliminating
  • controlling body temperature
  • mobilizing
  • sleeping
  • maintaining a safe environment
  • communicating
  • personal care and dressing
  • working and playing
  • expressing sexuality
  • dying

No actual disease diagnosis there, right?  More of a life-systems overview than an organ-systems overview. Another famous nursing model is one by Dorthea Orem.  Similar to the Activities of Living model, this one defines areas of self-care deficits brought on by the disease process.  So you might have “deficit in urinary function” for an enlarged prostate, or “deficit in oxygenation” or “deficit in respiratory function” for someone with pneumonia.  In a way this is kind of silly, since the model sort of seems like it’s re-naming diseases with different names, but what it emphasizes is that although the nurse knows pathophysiologically what pneumonia is and how to treat it, she/he also sees the pneumonia in the larger context of the patient not being able to do something he could do before, that is: breathe normally.

You kind of need both viewpoints don’t you?  Say you broke your foot.  You need a doctor (or an advanced practice nurse experienced with orthopedics, or a physician assistant who reads x-rays every day) to confirm that your foot is broken.  You also need someone who is going to recognize that this foot injury causes you to lose the ability to do things in your life that you could do easily before.  The doctor might prescribe pain-killers, but the nurse might come along and also prescribe a visiting nurse, extra ace-wraps, the number of a good babysitter, etc.  The medical model might consider this “soft science” but which person is going to make your actual life better, not just your foot?  That’s the difference.

Shirie Leng is an anesthesiologist who blogs at medicine for real.

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