MD vs NP: Principles for a civil online discourse

For busy and opinionated physicians, online comments are both catharsis and a form of self-expression. After all, doctors are in the thick of it. We see how policies affect our patients. We know how politics affect our profession. While traditional editorials require time, editing, and an editor’s decision to publish the piece, online comments provide an easy and instantaneous way for even the most overworked and harried physicians to vent publicly. Seeing one’s opinion stream smoothly from brain to fingertips to computer screen feels good.

It is miraculously simple, but it can be problematic. Amid the stresses of patient care in an increasingly complex health care system, the temptation to unleash anger online can be hard to resist. Making sure our voices resonate with equanimity, with professionalism, with decorum, respect, and tolerance takes work.

In some online discussions, the voices have become ugly.

The highly charged scope-of-practice debate. Consider the debate about whether nurse practitioners should be able to practice independently. Kevin Pho regularly features posts by and about NPs. Like bees to nectar, a post on the topic is sure to draw dozens of anonymous, hate-filled comments. As Pauline Chen related recently in the New York Times, there’s a sizeable gulf between doctors’ and nurses’ assessments of the training, skills and abilities of NPs.

That’s putting it mildly.

When one of us wrote an article advocating independence for nurse practitioners, a reader (a doctoral-trained nurse practitioner) responded via email — an articulate, smart, knowledgeable, and witty response that not only illuminated one nurse practitioner’s perspective, but offered a glimpse into the nurse practitioner alternative universe that physicians know so little about. The correspondence inspired the reader to add to the public conversation by writing his own advocacy piece.

Within hours of his posting, there was so much hate speech directed at him — including a complaint sent directly to the president of the university where he works — that he feared for his safety. He had the piece taken down, effectively silencing himself.

It’s not hard to understand that some doctors feel directly threatened by nurse practitioners seeking to practice to the full extent of their education. “How,” some primary care doctors ask, “can someone with significantly less training, and very different training, do the same work as well as we do?” Many commenters (both physicians and other readers) cite anecdotes, perhaps unwittingly overlooking the canon of research demonstrating equal or better patient outcomes between physicians and nurse practitioners. Anecdotes can be a reasonable springboard for meaningful dialogue but they cannot be the only source of data. An angry anecdote is the lowest form of evidence; not surprisingly, responses may be divisive and escalating.

Change is occurring so quickly in American health care that many physicians feel that they are drowning. Disabused of their hopes for higher social status and struggling to keep their practices afloat, primary care physicians labor to adapt to each transformation of health care delivery. Even medical organizations like the American Medical Association and the American Academy of Family Practice that preach collaboration among specialties draw a line at welcoming nurse practitioners as partners rather than subordinates.

If nothing else, doctors and nurse practitioners can surely agree that sniping about characteristics inherent in different professions – professions that share end goals – is counterproductive. Progress can’t happen in a context of disheartening, rude, and sometimes appalling comments. Such vitriol empowers and encourages similar animus in comments from non-physicians. This can legitimize public misperceptions of nurse practitioners and validate physicians’ claims.

Both professions are held to the highest ethical standards in society. If professionalism is truly a core value and competency of physicians and nurses, then we need to practice what we preach. Act professionally. Appreciate other viewpoints as an opportunity to learn. Invite nurse practitioners to the table. Welcome their efforts to improve the health of the nation. And, most importantly, work together for the good of our patients.

Physicians and nurse practitioners can agree to disagree while keeping it civil. The art of listening, after all, is a cornerstone of both medicine and nursing.

Bullying is never the answer.

Principles for a civil online discourse 

The etiquette of online commenting is unusual in that much of the time people add to the conversation and do not return. Occasionally, of course, voluminous dialogue ensues. Here are a few suggestions for keeping online comments civil:

  • Anecdotes are fine, but avoid drawing generalizations from one story. (“We had that dumb NP once. She didn’t know where the gallbladder is located. So NPs must all be dumb.”)
  • Identify the underlying emotion of a comment that irks you, and name it when you respond. (“Doctor Strangelove, it sounds like you’re frustrated that NPs have fewer hours of training and are asking for the same salary as MDs. Here’s my take: ….”)
  • Name-calling is out. Polite, respectful comments are more likely to be taken seriously, and to stimulate a productive conversation. ( “SJ, I appreciate hearing your viewpoint. Here is WHY I disagree with you.”)
  • Own your comments. Instead of making broad generalizations, make it clear that you are offering your opinion. (Rather than saying, “NPs simply should not be practicing without some sort of physician supervision,” say “I don’t think NPs should practice without any physician supervision.”)
  • Consider phrasing your comment in the form of a question. (“I’m troubled by the thought of NPs working in a rural area with no access to collaborating physicians. Does anyone have experience with that?”)
  • Go for the win-win. (“The demographics, economics and politics of health care reform suggest there’s enough pie for all of us in the primary care world. We are all undervalued and overworked. By uniting in cause and working with each other, both groups stand to gain in terms of creativity, relationships, and (dare we say) income.”)
  • Find the best alternative to a negotiated agreement (known as “BATNA” — taken from the classic tome, Getting to Yes). (“NPs are here to stay, with increasing autonomy across more and more states. Let’s find a way to work together — whether you’re a doctor or NP, our end goals are the same.”)

John Schumann is an internal medicine physician who blogs at GlassHospitalAnna Reisman is an internal medicine physician who contributes to Slate. She can be reached on Twitter @annareisman. Matthew Freeman is a nurse practitioner.  This article was originally published in Health Affairs.

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