January/February  2004

The Zen of Science

Nurses
By Marc Ringel, MD

      I'm married to a nurse. Isn't that cute? A doctor married to a nurse. Never mind that we didn't, as would happen in the movies, meet in the surgery suite, where, with masks covering our mouths and noses, we found ourselves entranced by each other's beautiful eyes; nor did we first encounter each other in the delivery room, tenderly crying together over the miracle of birth we'd just been privileged to attend.

      We met in the produce section of Shop-All (motto: Best Little Store On Highway 34), a supermarket in Yuma , Colorado . I was a general practitioner in the town on a two-year gig with the National Health Service Corps. She was a nursing student, born and raised there, who stocked shelves and carried out customers' grocery bags on weekends and vacations.

      We were married a couple of years after we met. By then, Kathleen had become an RN. She'd worked very hard, both in and out of school, having paid her own way. Then she took her first nursing job and discovered, almost instantly, that she'd chosen the wrong career. In those days, a hospital nurse's existence was defined by the task of carrying out doctors' orders. Talk about an unsuitable job description for the woman I love. Taking orders? No way! Her nursing career lasted less than two years.

      I wouldn't have made a very good nurse either. I did toy with the idea of getting an RN degree when I was halfway through medical school. It was during my first clinical rotation. Having spent two years of professional training in the traditional role of passive receiver of an endless stream of lecturer-delivered medical factoids, I now found myself, as a third-year medical student, on the lung ward of a Veterans Administration hospital dressed in a short white jacket (by tradition, only the rank of intern or higher could wear longer lab coats), standing around the beds of seriously ill veterans. I was still a passive listener, but now I was listening to learned discussions among interns, residents and godlike attending physicians about actual patients.

      Here's how rounds went. We'd have the patient's chart with us. The resident or attending would greet the patient, ask him how he was doing, then not listen to the answer. That was the last acknowledgement by the team that a living, breathing (it was a lung ward, after all) person lay in the bed around which we all stood in our white coats.

      Then a lower-ranking member of the medical team who had actually examined and talked to the patient, did a case presentation, using the biggest words possible so that his colleagues would be maximally impressed and the patient would understand as little as possible. The chart would be opened to the laboratory or radiology section and a technical discussion between the more senior medical team members would ensue, mostly about the patient's test results. They'd talk about the range of diseases that the numbers and images might indicate, the array of possible therapies, and all the ins and outs, from a scientific point of view, of this particular case. Then they'd say goodbye to the patient and we'd move on to the next bed.

      I might linger behind the team to explain to the patient the gist of the discussion that had just occurred, literally, over his head. Often I'd come back later in the day so I could get to know him and maybe make myself of some use in communicating his needs and questions to the medical team. At that stage in my training I certainly didn't have much to contribute medically.

      The role I had naturally gravitated to-making a conscious effort to relate to the patient as a person while trying to incorporate into my understanding all I could about the scientific aspects of his disease-was that of a nurse. Doctors seemed rarely to get beyond the scientific stuff to seeing and relating to the person who was their patient. So I thought about transferring to nursing school, especially after I was criticized by a senior resident for "acting like a nurse, not like a doctor." But I came up against the very thing that Kathleen had faced when she became a nurse: the need to take orders.

      Nurses did not accompany us MDs and AADs (Almost A Doctor) on rounds, unless one tagged along to carry charts and write down orders. Unlike laboratory and imaging results around which our discussions revolved, nursing notes were never mentioned and probably never read. Back in the nurses' station, nurses were expected to give up their seats to any doctor who came in, including a lowly intern who might be thirty years junior, in age and experience, to the capped, uniformed nurse seated at the desk.

      Time and again I watched a bright, seasoned nurse, who'd spent the whole day at a patient's bedside, present a well-aimed suggestion to a greenhorn physician in such a way that he would think it had been his idea and then she would wait, with fingers crossed, to see if her suggestion had been accepted. Nurses got things done by asking and, when necessary, manipulating doctors to order what their patients really needed. I could see that, by nature, I wouldn't be able to pull off a nurse's deferential, indirect way of communicating with doctors. So I gave up my thought of becoming, as they were called in those days, a "male nurse."

      Thanks most of all to the women's movement, nurses, the majority of whom still are women, are not nearly so powerless today as they were when I began my career. Nurses don't wear caps and uniforms anymore. They don't give up their seats to doctors. In most situations, however, nurses still must await doctors' orders to act. Public health nurses, nurse practitioners and a few other categories of nurses practice more independently. Some even order tests, suture wounds, deliver babies, and write prescriptions without consulting a physician.

      It's hard to attract and hold people to this demanding, frustrating, under-appreciated profession. The need to do night and weekend duty in so many nursing jobs doesn't help either. The average age of American nurses is 48. Today, healthcare institutions are closing whole wings for lack of nursing staff.

      The nursing shortage feeds on itself. The more understaffed a unit, the worse the working conditions; the worse the working conditions, the more nurses quit. Recruitment and retention of nurses has become a high priority, with improved wages, sign-on bonuses, subsidized training, generous benefits, etc. But there aren't nearly enough nursing students to fill the pipeline, nor nursing professors to train them. Everybody predicts that this personnel crisis will only worsen over the next decade.

      To plug the gaps and fill hospitals with less expensive workers, healthcare institutions move nurses into supervisory positions and train aides to perform the hands-on care. It's a losing proposition for everybody, especially for patients. Study after study has shown that a higher ratio of skilled nurses to patients means better patient care, as measured by the rate of avoidable complications, time to recovery, and patient satisfaction. There is simply no better way to care for a sick person than to put a smart, well trained, compassionate professional, such as a nurse, on the front line.

      Nurses will tell you that what they learn while giving a bed bath, not just about the health of patients' skin, but about their values, families and level of comfort, is irreplaceable. Something is lost when direct-care tasks are delegated to aides. It is the combination of physical and emotional human contact with intellectual challenge that makes nursing potentially one of the most rewarding and important careers there is.

      Given what I know today, would I choose to be a nurse? No. Damaged though I was by medical school, I have still managed to learn, mostly from nurses, something about how to connect with patients. And I'm glad that I'm the one who can write orders and make a doctor's wages.

      In an ideal world, the world we need to be heading for, nurses and doctors would be true equals. We would respect each other's strengths and special skills. Each of us would make the decisions we are in the best position to make. And my wife and I would still flirt shamelessly over the fruits and vegetables at Shop-All.