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Dr and Nurse

Because I’m currently in school and expected to think about things I’ll be too busy to think about once I’m working in the field, I do. That’s not always a bad thing. I’ve started to envision a revised healthcare system in my spare time. I have no idea how to figure out the financing or laws governing such a thing. I just know I’m noticing stuff that could be different or better than it currently is. Over the last couple of weeks, this vision has been occupying my spare thoughts more and more. Some of the initial images in my vision are below.

Nurses are not doctors. They don’t go to medical school, they don’t get the income, respect, or ability to diagnose medical conditions (except for specific circumstances as a Nurse Practitioner). Doctor’s treat conditions. They decide someone has an infection and they prescribe various medicines to treat the cause of the infection. A surgeon may opt to remove or modify a body part to treat some disease. In every case, the medical doctor is concentrating his or her skill on combating a particular problem which is affecting the patient.

A nurse, on the other hand, doesn’t care what the central cause of the person’s illness is. This is contrary to expectations, but true. In some ways it’s much simpler than expected, and in others it’s much more complicated. We don’t treat a broken leg exactly. We treat the patient suffering from a broken leg. They need help moving. They need something to do. They have to switch positions. They have to learn how to use to the toilet. They have to be checked for proper circulation, signs of infection, skin breakdown, and a host of other things that go on (or wrong) in a body kept immobile.

If you substitute another condition for “broken leg”—like “pneumonia”—many of the same things done by a nurse would still be the same. There would be other ones that might be added or subtracted, based on the specific illness, but the overall approach is the same: care for the person with something not normal for them in mind, body, or spirit.

With those primal differences made clear, it’s still perceived as nurses doing the doctor’s bidding in many cases. The doc decides on things, and even dictates what can be done by power of the prescription or written order. The nurse might want to provide more pain relief to a patient, and have evidence to base the decision on. But the doc must be consulted to change or create a written order to allow the nurse to now administer the medication. Even if the nurse knows the medication intimately, and suggests to the doc exactly what to provide in the written order.

I can see a time in the future where that last step shouldn’t be necessary.

Doctor’s are a commodity which can be moved from the front lines and into specialties. Right now if a patient sees their primary care physician for a rash, the doc looks at it and might take a guess as to it’s cause. After some initial treatment—or sometimes immediately—the doc will refer the patient to a dermatologist or skin specialist. Same with some intestinal disorder. “Hmm, not sure, I’d like you to see the internist”.

Doctor’s don’t need to be in the role in the more heavily populated areas. Plug a Nurse Practitioner (NP) into the position, as is being done in many places, and you have happy patients and cheaper healthcare. The NP, through additional schooling and licensure, is able to write furnishings (the same thing as a prescription) for many of the more common medications needed. If the NP has any doubts or suspicions, the patient is referred to a specialist. Just like is happening now.

So, if we pull many of the docs off the front lines and instead place nurses there, we’ll have effectively the same situation at reduced cost. And this allows the more intensely schooled docs to go where that investment is better used.

There’s still a gap though. Back in that example above where the nurse has to wait for a written order for exactly what is known. What if, in addition to the change with the docs as the gatekeepers to additional healthcare specialists we also endow nurses with the ability to write written orders? I don’t think we’re being prepared for this currently in school. It might be granted to those at the Nurse Practitioner level. Or perhaps the Doctorate of Nursing Practice (DNP) which is just now becoming a reality.

Doesn’t it make sense to streamline the system to allow people to do things better and more effectively than they already do? As long as the safety of the patient is kept central to the process in moving forward, I don’t see how a modified system couldn’t be more useful for everyone.

Change of Shift banner

Have a peek!

The program I’m enrolled in is part of a new idea from AACN to promote a better prepared nurse that remains at the bedside instead of moving into management. This seems like a good plan: nurses have some exposure to the finances and administration needs in a healthcare facility, they get some team and leadership training, along with a lot of opportunity to hone critical thinking skills.

All of this is not a replacement for experience however. We are counseled repeatedly that while these skills are necessary for the future of nursing, we have to pair them with very solid experience. Don’t come out of the gate trying to boss everyone around because of your high-falootin degree. Luckily, no one in my class is of the predilection to do something like that. We mostly ask a lot of questions, and are being taught to look for the “why” behind the scenes. Being handed a drug and knowing it’s name and side-effects are the beginning of understanding: WHY is that patient being given a steroid? To reduce the post-operative swelling from the craniotomy, that’s why.

I know our program is met with horror shock disbelief cocked eyebrows from established nurses. How can you get a Masters degree if you don’t have a Bachelor’s in nursing already? The answer is because you have to have a Bachelor’s already. It sounds trite, but it just means all the General Education stuff is taken care of, and they can concentrate on nursing specific curriculum.

I’ve even asked some of the nurses I’ve worked with in the hospital what their impression of the program is. The feedback has been very good so far. They appreciate that the students are bringing a different set of experiences to nursing. This isn’t likely to be their first career if they have a degree in something else. Consequently, the students are a bit older, and not quite as fragile. This is not to say there aren’t excellent nurses that are young, fresh, and full of enthusiasm. It’s just the reality of being able to sit and hold someone’s hand while they die instead of rushing to find someone to help “fix it”. This comes from having lived a few summers longer, nothing else.

Concierge

I’m conflicted about the growing trend for Concierge or Boutique medicine.

It’s clearly something that is valued by some, but how about all the rest of humanity that can’t even pay for bad health insurance? If you haven’t looked at the links, or haven’t heard of it before, the basic idea is you pay out of pocket (no insurance) for premiere healthcare. You have a physician or small group of physicians that you have 24/7 access to via phone, email, text, smoke signal, etc. You will have guaranteed response in minutes if not hours. The response may include a housecall if you’re so inclined.

We have thousands of people in the US without healthcare, and chronic conditions they can do nothing to address. No money to pay for insurance, or a co-pay assuming they did have it. Sure, there are free clinics that the working poor can go to.

Let’s have a quick look at the “free” part of that though: take a day off of work, so you lose a day’s wages (assuming you aren’t fired outright for not being there); spend hours and hours waiting; bring food or be forced to pay for something there; arrange for childcare before, after, or during the normal workday hours; if you’re not seen by the time the clinic closes, you have to return for another “free” visit.

Not looking so free anymore, and that’s just a very quick rundown of obvious costs.

On the other side of the equation, not everyone has running water either. Should those of us with that new-fangled “indoor plumbing” rip it out because our brethren don’t have it?

I keep switching sides on the Concierge approach. It both horrifies and excites me. Man, I wish I could afford it. No! Bad man! A housecall! No! Must. Not. Give. In….

I think they’re crazy
I’ve had this week off school, so I haven’t had to sit through any long lectures. Maybe that’s made me extra sensitive, or maybe I’ve just had the opportunity to read more non-school stuff due to the break.

But I swear people are losing it.

The state of Washington is looking to pass a law that will make it illegal for people to chant or boo at a college game. This seems to peg the needle on the “We need to be PC” scale. Protect people from racial slurs and dangerous behavior, yes. I absolutely think a college game is an inappropriate place to cast dispersions (or fecal matter) without thought. But I think someone getting their feelings hurt because the other team has a better rhyme is just a tad too much.

Then there’s another state, New Mexico, that’s decided to make Pluto a planet again. Since when do we get to ignore scientific definitions? Can I decide I don’t have to obey gravity? Do I “opt-in” on the whole Round Earth idea? How could it possibly make sense to purposely teach the wrong thing to the kids growing up in that area?

And let’s not stop there. No, state legislators can do more. They want to imprison a substitute teacher for not being able to stop a window popup attack on a computer that wasn’t hers in a classroom she was substituting in. Now, according to the article this woman likely won’t have a movie about her inspiring kids to tackle calculus in middle school, or win a state wrestling championship because of her inspiration. She might not even deserve to continue teaching because she’s been reprimanded about spending too much time not focused on the students prior to the event. But she isn’t promoting porn or trying to show it to the kids. Just an example of a posse of worked-up parents that can thrash the school administration into a lather and over-react.

And speaking of over-reacting — a jury has awarded a man 400K even though the nurse named in the lawsuit was found to not have caused any injury.

On the other side of the coin, there was a recent bruhaha in the medical blogosphere where Scalpel made a bad joke and Graham reacted. Now, I don’t know either of these people, but what looked like an innocent, albeit dumb, misstep (which I didn’t get the joke on by the way), turned into a long back and forth about compassion and appropriate behavior. From my point of view, Scalpel flubbed the joke. Graham and others on his blog called Scalpel on it, and told him exactly why it was a bad joke. This is where I was a bit surprised. Scalpel took the stance that it’s his blog, his opinion, and he doesn’t care what anyone else thinks. I can understand that — to an extent. Don’t read it if you don’t like it. But what it fails to recognize is the public-ness (I just made that word up) of the posting. While I may not have been offended by the joke, the fact that someone was and made it known why in a cogent and respectful manner seemed dismissed by Scalpel’s rebuffs. That just strikes me as wrong headed. Why not try to learn some compassion and sensitivity. The “Oh you can’t take a joke” mentality tends to allow for inappropriate behavior under the guise of “just funnin”, but it’s not fun for everyone.

Now I really need to get back to the real world.

OK, this is a departure from the typical posts revolving around nursing school, but it came as something of a personal epiphany, so I wanted to get it down before it slipped away into the ether which is consuming my brain.

Just Say No

In the past I’ve always been unable to address people’s arguments about downloading music, copying DVDs, or (insert digital drug of choice here) without paying for it. My position could be summed up by the title of this post, which is unacceptable to many people.

It’s difficult to nail down, because digital stuff is so easy to dismiss. One lost sale of a song, one additional person listening that hasn’t paid, nothing is “lost” in the process…. All of these contribute to the illusion that copying the information doesn’t hurt anyone.

I finally thought of a good analogy, which I’ve been lacking in describing the situation: Suppose you’re writing a paper for school, or submitting a proposal for your job, and someone copies it when you’re done but haven’t handed it off yet. This unscrupulous person then hands over the copied item as their own property. You still have it, don’t you? You could also turn in a copy of the same thing, right? Nothing has been “stolen” in the sense that you now lack the property. Yet the opportunity has been taken from you as surely as a physical object. Your grade or your job is now in jeopardy because of this action which leaves you lacking nothing.

The exact same thing happens when you burn a copy of a CD for your friend. The opportunity for the artist or recording company to recoup some investment is now gone. Multiply that by the tens (hundreds?) of thousands of people copying and trading software, and you have a good reason why it is hurting someone.

So if the reasoning behind the title isn’t enough, just think about the analogy next time you want to copy something without paying for it.

Change of Shift banner

Kim over at Emergiblog is hosting, and it’s a great roundup (but I’m biased, because I got in).

1. People on cell phones irk me.

They talk while buying their gas. They talk when cashing a check. They talk while taking a dump pooping having a BM (Hello? Acoustics!?). They talk while buying a coffee, ignoring the person actually serving them. They talk while walking, within arms-reach of another person walking with them. They talk while driving. Both people in the car are on the phone at the same time. I can only assume they’re not talking to each other.

And most of all they talk while at the theater. While everyone else is trying to watch and listen to the movie they paid to see.

Please, if you’re so important you have to take that call, just save everyone the frustration and stay home to make sure you get it.

2. Text messaging on a phone

If you have something to say, just call. If it’s not urgent, send an email. I want my phone to make phone calls, not play the latest offering of Youtube. If I want to see boobies research a paper, I’ll use my computer with a real screen, thank you.

I’ve had people tell me it’s rude to take a call when you’re in a meeting or otherwise supposed to be engaged (also known as “working”). But it’s not rude to respond to a text message.

I don’t get that. Either you’re focusing on what you’re doing, or you’re not, right?

3. Facebook

I have no experience with it. I’ve gotten so many suggestions to check it out that I finally signed up so I could see it, and I still must be missing the point. What do you do? Is it to chat? I admit it as only a cursory scan, but I don’t see how it adds to a blog or other information repository. I expect it will be a big “Ah-ha!” when someone bops me on the forehead and explains it to me.

Facebook

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I really should be studying. I’m avoiding it, and now I have no excuse since I’ve gotten these small things off my small mind.

Man coughing

There’s an interesting article about a guy incarcerated (in truth, although he hasn’t been charged) because he broke his agreement to take his antibiotics and wear a mask in public.

He didn’t, so they basically put him in a hole in Arizona until he either dies or his body clears the infection.

Now, I’m not a fan of stomping people’s rights, but the treatment he’s undergoing seems appropriate for the most part. Not being allowed a shower, TV, or computer seems overkill — but locking him up because he was posing a threat to all the people he was coughing around at the Circle K sounds like a good idea to this nursing student. This behavior is a big no-no according to the CDC guidelines for travelers.

The guy claims he was never told the extent of his illness, or not following the prescribed treatment. I find this difficult to believe. I know in the real world not every single thing is always communicated to a patient in terms of side effects, possible complications, or interactions. But I’d bet dollars to doughnuts that since he was sporting a case of extremely resistant TB, sticking to his antibiotics came up on a couple of occasions. Also, the wearing of the mask looking like a robber? How many robbers go around with a surgical mask on? Even accounting for his dual-citizenship and possible cultural bias, it’s a hard sell that he didn’t “get it”.

I’m thinking he deserves to be kept behind doors for so cavalierly risking everyone around him. What if it had been Ebola instead of TB? I’m okay with losing some civil liberties when images of Typhoid Mary keep popping into my head.

The Jetsons

I remember watching the Jetson’s as a puppy, and actually believing that we’d have flying cars by the year 2000.

Look at us now: seven years into the 21st century and we still haven’t figured out how to wean ourselves off fossil fuel.

In the hospital I work in we use a pneumatic tube system that was probably installed forty plus years ago. It looks like the one if the movie Brazil.

Pneumatic tube system

My question is this: we’ve figured out how to get to the moon, made an invisibility cloak, Superman has come back after a five year absence, and people are living longer than ever before in history.

Yet we’re still using a technology which apparently dates back to the 1st century BC. I get that we can’t attach a physical object as an email attachment, and I don’t really know the right way to solve the transport problem. It just seems to me that we have people making vaccines for killing diseases, as well as growing seedless watermelons. It just feels like we should have a better solution by now.