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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  • Guest

    I feel this piece is condescending in suggesting doctors cannot recognize that illness can cause social issues while a nurse can. My child’s pediatrician diagnosed my PPD, and my obstetrician gave me a great babysitting reference.

    However, after I was the parent of a patient I realized just how much nurses offer to the healing patient. My child’s physicians and surgeons were wonderful clinically. But the nurses took my hand and comforted me after her diagnosis. They goo goo ga ga’d with my daughter in the early post operative period. One of the nurses brought my healing daughter a dolly and sang songs with her. As a physician myself, I never imagined how much these little “non medical” touches could have meant.

    • http://www.stephaniefrederick.com Stephanie Frederick, RN, M.Ed.

      I wonder how varied the clinical skills were for these “nurses” that took your hand, goo goo ga’d with your daughter, sang songs and brought her a dolly. These days you might have encountered a med tech, nurse’s aide, or receptionist that stepped away from the desk. Experienced, highly skilled RN’s have been increasingly abused as the “healthcare” $ has gotten tighter, and the mentality of “a nurse is a nurse is a nurse” has become obviously quite pervasive.

      • Guest

        You missed the line where I mentioned I was a physician. That’s ok, I can state it again. I assure you, I knew who the aides, nurses, and everyone who entered that room were. Perhaps because of my own skills I was able to take for granted the presence/absence of clinical abilities in the nurses who tended to us and appreciate their sensitive touches.

        I was troubled by the fact that our nurses had 4 patients on their shift. My chid was one of 2 fresh infant post-ops, and the nurses each had 2 other children to care for. I was quite certain to call every 2 hours so that my infant could have her pain meds. Usually the nurse would be running to meet our demands, but to their great credit they were never late with pain meds. I envision they spent their entire shifts running for marginal compensation (my colleague told me the nurses at our children’s hospital were NOT well paid and turned over frequently).

        For all the disgruntled physicians in here, I will mention the surgeon never saw us again after he spoke to us after the actual procedure. He sent his fellow to round on us. And for a follow up visit he scheduled us with one of his colleagues. And my child is the daughter of a physician!

        I’m actually just starting to notice how much negativity there is in this forum. It’s quite depressing how bad we all must feel to be working in medicine.

  • Close Call

    Everything you described in the “nursing model” is taught in a modern family medicine residency program. It’s built into the curriculum.

    And they spend 3 years doing it.

    Clinical hours-wise, 4-5x as much as your typical NP before they’re let loose on the world.

    • Guest

      There is something different that nurses do. I’m not saying it’s well addressed in this piece. But while physicians treat medical illnesses nurses offer comfort and nurturing. I hope they still can as they’re stretched pathetically thin and expected to move mountains.

      • Close Call

        “But while physicians treat medical illnesses nurses offer comfort and nurturing.”

        I’m not sure where to even start with this…. So I won’t.

        • Guest

          Don’t bother. If you are ever a patient or have a child as a patient you WILL notice. I guarantee it. I’m a physician and I noticed it.

          • Close Call

            Nope, haven’t noticed a difference.

            Have witnessed many wonderful physicians offer comfort and nurturing… at the beginning of life and at the end.

            I can say the same for many wonderful nurses.

            Unless you’re a radiologist or a pathologist… try giving your patients a hug sometime… or call a parent on your day off to check in on their sick child… or take time after clinic to check up on one of your patients in the hospital, even if you stopped doing inpatient years ago… or attend the funeral of longstanding patient… or volunteer time in a free clinic… It’s good for the soul. It’s good for your patient. There’s still hope :-)

            “To cure sometimes, to relieve often, to comfort always.”

          • Guest

            Nice post, Close Call. It’s been a long time since I’ve see much humanity in medicine. Private practice in my saturated, competitive area has really removed much of the joy I used to find in medicine.
            Your patients are lucky to have you :)

  • Mark Hourany

    Nice post

  • tuframnedox

    I find ludicrous the implication that “the nursing model” – in effect, a list of cultural buzzwords and meandering rhetoric, including utterly subjective and intangible standards of living, including “maintaining a safe environment” and “expressing sexuality” – is in any way a replacement for science-based diagnostics. (Don’t pretend that you touted the two models as supplementary when you make it an either-or question in the final paragraph: “Which person is going to make your actual life better?”)

    I don’t mean to speak pejoratively about a reasonable holism. Like Close Call and others describe below, taking a learned diagnostic approach and a holistic approach is something that trained doctors have been doing for eons. And they’re not mutually exclusive. Having made that determination, let’s look at the actual doctor-nurse paradigm: you have a physician who is sensitive to holistic modalities and has the appropriate training versus a nurse who approaches medicine holistically but does not have nearly the same amount of training. It’s absurd to equivocate the two.

    It looks like the author is going to have to revise her opinion yet another time – but that’s not going to make her initial conclusion any less wrong. There is a significant difference between an advanced practice registered nurse and a doctor, no matter how much logic one has to circumvent or many rhetorical leaps one has to make.

  • DrJKH

    What it ALL comes down to is science based didactic training. Nurses have almost none. Physicians have an immense amount. Physicians are trained to be practitioners, nurses, even NPs are not. Nurses: want to “practice?” Do it the right way: GO TO MEDICAL SCHOOL!

    • militarymedical

      Interesting assumption. Where I was trained, medical and nursing students attended many of the same basic science courses as part of their “science based didactic training”: A&P, microbiology, organic chem, inorganic chem, a few others. In other words, for both groups (one undergraduate, the other graduate) most of the first two semesters were almost identical. There were multiple times when nursing students out-performed medical students academically. This also served a (perhaps intentional, perhaps not) purpose of building bridges early in both sets of students’ careers.

      If you want to insult nurses, I suggest you find another route. This isn’t it.

      • James Biggerstaff

        When I was an undergraduate, I took the same courses many others took and many made better grades than me. That doesn’t mean they were trained or even qualified to be physicians.

        Your argument that you took some common courses with doctors and, in some cases, made better grades so you are qualified to be a doctor is absurd.

        No one is insulting nurses for pointing this out. No one said that nurses aren’t as smart as doctors, but if you want to operate as a doctor then train as one. What’s so difficult to understand about that?

  • Alcibíades Batista González

    This is not the vision of a 21st. century’s “medical model”. Physicians have to focus in persons, families and communities, to provide integral and integrated care with emphasis in promotion of health and prevention of diseases, and obviously in identification and treatment of specific illnesses, rehabilitation and palliative care, when they are needed. And the gold standard for health care is the multidisciplinary approach, in which every health professional has a role to accomplish…

    • James Biggerstaff

      Yes, and each knows their place, not attempting to usurp the role of another.

  • http://twitter.com/nursebiz NurseBiz

    To clarify, there are several “models of nursing” that are in use today. To name a few that are published:
    1. Levine’s Conservation Model for Nursing
    2. Roper–Logan–Tierney model of nursing
    3. Sister Callista Roy developed the Adaptation Model ofNursing
    4. AACN Synergy model of nursing
    5. Anne Casey – Casey’s model of nursing
    6. Moyra Allen – McGill model of nursing

    However, most larger hospitals created their own models of care supported by the physician staff.

    The nursing model primary focus is on the treatment of the human response to disease as well as prevention of disease. The nursing process is goal-oriented the involves specific steps of nursing care as a means to restore a patient to an optimal level of wellness. If in cases death is the acceptable outcome, our goal as nurses is to provide that patient a peaceful death.

    As care becomes more patient-centric I believe the medical and nursing models will work as one to care for the patient holistically. We should all be on the same team to reach the same goal. We are all in this together.

  • http://www.facebook.com/profile.php?id=1002557801 Allison Falin

    Interesting post. The bickering between the two professions needs to stop if the patient is ever going to get the care needed for illness/preventative care.

    While nurses have been trained in their undergrad from the nursing model, as I was, my graduate degree was training on Evidence Based Practice and a focus on disease management, assessment and knowing the normal presentation of the disease so one can recognize the deviation from normal.

    As a nurse, and soon to be FNP, I think that it is imperative that I continue to learn, train and add to my knowledge base. Anything less would be errant on my part.

    Staying on top of the latest science, guideline updates and continuing education is part of that, but so is working alongside a mentor physician. I would imagine that would be no different for a new physician.

    Do I provide care and compassion? Yes. Have I worked with physicians that do the same? Absolutely. What I did NOT run up against were arrogant MD’s who thought I was sub-par or incapable of handing the patients that I would encounter on my own. For that I am eternally grateful, as they see the value in what I do and how I do it.

    I am sure that will change at some point, thanks to misinformation being put out by AMA, AAFP and other medical lobbying organizations.

  • http://www.facebook.com/susie.elizabeth.73 Susie Kelly

    As an APRN, I explain to people the “medical model” is more focused on the disease itself whereas the “nursing model” approaches disease from the context of the whole person. Both are important. Doctors have a much greater depth of knowledge about the diseases while nurses have a greater breath of factors to take into consideration. Which is why doctors will never be replaced. I understand my limitations as an NP and I welcome the expertise of the doctors to whom I refer or with whom I discuss challenging patients. Doctors’ focus on the disease in conjunction with nurses’ view of the larger picture synergistically makes for a holistic model of care better than either one alone.

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