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.