Saturday, October 21, 2006

Doctors vs Nurses: Medicine's Oldest Battle Reaches The Blogosphere

One of the most ancient battles in the medical profession has been that between doctors and nurses. Each wants the other to just hunker down and do their damn jobs, but inevitably doctors develop a superiority complex and start lording their superior selves all over the hospital whilst still running whimpering to the nearest nurse whenever anything goes wrong, whilst nurses tire of the superiority (and the arse-wiping and the bedpan-cleaning) and try to tell doctors what to do. Then people get pissed off, the kid gloves come off and things can sometimes get nasty. (Especially when you're an inexperienced medic in the maternity ward's delivery room doing your best not to rip a newborn baby's head off, and the only help available is from huge bitchy nurses long on experience but short on temper. Not that I'd know anything about that, of course.)

Well today, the floodgates did indeed open, and the Doctor vs Nurse debate broke out in the blogosphere. It all started with an angry nurse who posted a rather inflammatory comment about a patient being unnecessarily sent to A&E. She diagnosed the patient as having Quinsy, but showed little sympathy for him hollering for the paramedics after a little inflammation:
"Excuse me sir - could I have a look at your throat? What's that I see? Inflammation? Things with pus in clinging to other red swollen things?Ever had tonsillitis? Oh you have ? And it was just like this except this is worse?"
Quinsy is indeed an emergency, but to be unable to have even done the most basic of examinations before getting all excited and calling the blue light boys....well.
(this Nurse Ratchet is not to be confused with the nice Nurse Ratched in my links, who thankfully keeps her diagnoses to herself.)

Not only that, but in a previous post she makes very clear her opinion of doctors:
For too long now Nurse Ratchet has been reading blogs by erstwhile members of the Medical profession; and while the views and observations on the whole are to be commended, there runs a theme throughout of "Nurseism", or "Nurseogynism" - or even "Nurse-o-phobia". These self-satisfied, pompous, narcissistic fellows (I assume they are fellows?) take great pleasure in patronising nurses who have the temerity, nay the bare faced cheek to aspire to something greater than lovingly wiping an arse, mopping a piss soaked floor…
Now, anyone who knows me (and watches enough Russell Peters) will know that I have a theory that once in a while, just for the fun of it, God looks down upon the Earth from His throne in High Heaven, and in all His infinite wisdom picks a random person on the street, and BOOM. All hell breaks loose, with hilarious results. Now usually that person is me, but today as luck (or rather, God) would have it, this little nurse gets lucky. And along comes none other than Dr John Crippen of NHS Blog Doctor, who reads the post, and decides to add a doctorly riposte:
Oh dear me, nursey, you have, to coin a phrase, just crapped all over yourself by demonstrating the classic nursey intellectual inability to have a "DIFFERENTIAL" diagnosis. You do not have the mental card-index of diseases that all experienced doctors flip through their mind as they are assessing a patient. You can think of two diagnoses. A doctor can think of twenty.
Now usually Dr Crippen is quite civil in his lambasting of the NHS, but in this one he seems to have gone over the top a little. Unfortunately for poor Nurse Ratchet (but very fortunately for God's amusement) his is the first post, and sets the tone for about 50 other commenters who promptly materialise and proceed to take turns gang-raping the nurse and making very clear their opinions of her intellect:
Was he ill? Yep.
Was it serious? Yep.
Did he need to be in hospital? Yep.
Quickly as possible? Yep.
Could I have harmed him by delaying? Yep.
Let me guess, Nursey. You haven't been on the course yet.
Render under Caesar that which is Caesar and leave to the physician that which he knows namely the art of differential diagnosis which passeth the understanding of the ignorant.
Nurse Ratchet - we don't interfere in your job, why don't you lot stop interfering in ours and stop all the nay-saying and bitching from the side lines. If you want to diagnose, manage and treat patients - go to medical school. In the meantime, stick to the bedpans.
Then Dr Crippen decides this shows a dangerous lack of medical knowledge and respect on the part of nurses, and decides to make Nurse Ratchet the focus of a whole post on his blog.

(This is also about the time when God decides to go into Ultra-Gag-Mode.)

And so the shit truly hitteth the fan. DOCTORS.NET picks up the article and has their say, while visitors to Dr Crippen's well-known blog take potshots at Nurse Ratchet on both her blog and Dr Crippen's. Even Singapore's Angry Doctor picks up a pitchfork and joins the fray. At this time, of course, I (having a perpetual death wish) try calling for diplomacy. Strangely enough, I do not get fragged, and instead Dr Crippen backtracks and agrees with me that the debate has descended into vulgarity:
I tend to agree with you, Angry Medic. It is getting a bit vulgar and out of hand over on Nurse Ratchet's site.

Her article has been picked up by DOCTORS.NET and battalions of angry doctors have mobilised and are on the attack.

I suspect Nurse Ratchet is writing with a little bit of tongue in cheek. As was I in the first comment I made under her article.
He then very cleverly diverts the argument to the real problem, that of what he calls the "dumbing down of the NHS", including (as I mentioned in a previous post) the endless reorganisations, the target-setting, and general nonsense that the NHS has taken from prophet of doom Patricia Hewitt. And thus the real villains of the story are revealed.

The midwives.

*dum dum DUMMM*

Okay maybe not. But Dr Crippen, in his reply to me, pointed out that the line between doctor and nurse is a fine one, particularly nowadays that Patricia Dimwitt is trying to replace doctors in A&E with nurse-practitioners and community matrons.
It is fascinating to look at the job requirements to be a "community matron"
• take a comprehensive patient history

• carry out physical examinations

• use their expert knowledge and clinical judgement to identify the potential diagnosis
• refer patients for investigations where appropriate

• make a final diagnosis

• decide on and carry out treatment, including the prescribing medicines, or
refer patients to an appropriate specialist

As far as I can see, that is EXACTLY what I achieved after 5 years at medical school and three or four years as a junior hospital doctor.
Spot on. The NHS is messed up, but that's not what I'm getting at here. Nurses take a lot of crap, sometimes more than doctors do, and I've worked with enough nurses to know that they can make or break a doctor, especially in his junior years. They also have a far greater impact than doctors do on the quality of a patients' stay in hospital, and the work they do cannot be undervalued. However, the hospital is sometimes a jungle, and as I saw on a National Geographic documentary so long ago, the "key to survival is respect". If we all just respect each other, let each other do their jobs, and stay the hell out of each others' way, the hospital will be a much better place.

Thank God I'm still in med school.

29 comments:

Sarah said...

Selamat menyambut deepavali(is it too late??:-P)

Anonymous said...

Hurrah! Voice of sanity!
We need to slag off rubbish policies, not each other.

Dr John Crippen said...

Great stuff, Angry Medic

A good but lengthy summary; only disagree with one point, which is a factual inaccuracy; it was NOT me who launched the gratruitous (though very funny) attack on the the madwives.

****

Finally, you say:

"Nurses take a lot of crap, sometimes more than doctors do, and I've worked with enough nurses to know that they can make or break a doctor, especially in his junior years."

[We all take a lot of crap in the NHS - just you wait - and nurses get their fair share. Nurses cannot "break" a junior doctor, though they may try; the only person who can break a junior doctor is the doctor him/herself.]

"They also have a far greater impact than doctors do on the quality of a patients' stay in hospital"

[That is complete crap. Touchey feely well meaning codswallop. Yes, bad nursing care can make a patients stay in hospital awful; bad surgery kills; bad medicine kills; the only way that nursing care kills is when there isn't any (and there isn't much now as half the nurses have bogged off to try to be doctors]

"and the work they do cannot be undervalued."

[too many negatives there - but I think you mean, and I agree, that good nursing care is an essential ingredient to hospital care, and good nurses are scarce, underpaid and undervalued.]

"However, the hospital is sometimes a jungle, and as I saw on a National Geographic documentary so long ago, the "key to survival is respect". If we all just respect each other, let each other do their jobs, and stay the hell out of each others' way, the hospital will be a much better place."

[Absolutely agree with you. 100%. Particularly the "let each other do their jobs" - that is the whole problem with the "Project 2000" twerps who are destroying the nurising profession by pretending they are doctors when they are not.]

Yes, I did give Nurse Ratchet a bit of a going over, but that is her fault. She posted a (probably)a badly written attack on GPs and had not got her facts right. If you do that on the internet, you will get what you deserve.

And I did NOT have a change of heart; I think she probably was being a bit tongue in cheek, and the tirade from the batallions at Doctors.net went over the top.

I assume you have access to Doctors.net. Personally, I find the FORUMS a bit embarrassing; all well and good to let of steam but some of it is very third form. I think if you ahve something worth saying, it is worth saying in public so that the likes of Nurse Ratchet can reply.

And make no mistake, she will be very pleased with her vastly increased hit rate.


John

Mother Jones RN said...

I looked up my diagnosis in the DSM IV. Scary. I’m young, energetic, and I look just like Angelina Jolie. Hey! Rule number one, when dealing with delusional individuals, don’t challenge them unless you can replace their delusions with something else.

I’m sorry some nurses haven’t learned that most doctors are very nice people who got into medicine because they want to help people. Sure, I’ve run into a few pin-head doctors with a superiority complex, but that shouldn’t detract from the rest of you who are decent human beings.

Why can’t we all just get along?

heather said...

I liked your comments on the nurse's blog and the stuff you write here is interesting but I'm finding it difficult to read against your background - I find your background gets in the way, which is a shame because it looks really good.

Anonymous said...

...the work they do cannot be undervalued

Perhaps you meant overvalued?

Anonymous said...

Brilliant!

Just the sort of thing I'd like to know more about.

Great Job and please keep the site up and running.

p.s: the background makes it difficult to read your articles.

Anonymous said...

For what it's worth, I like the background - I don't find it makes the entries hard to read.

PaedsRN said...

Yep, the hazards of using background images on a site whose content is text-based (and most of 'em are.)

As a 'blogwarming' present, I have used my limited nursing intelligence to fade the image slightly for you. This should make reading over the top somewhat easier. PNG version. Also, this JPEG version will load faster without sacrificing much quality.

I recommend you upload these images to Blogger when you get the chance, as Flickr tends to be a bit slow.

No protocols were harmed in the making of these images. Any resemblance to noctors either living or dead is purely coincidental.

Shiny Happy Person said...

Bless. I hate to sound patronising, but, well, I'm still going to be.

Being a doctor is incomparable to being a medical student. The things you think you know will go up in smoke when you qualify. I understand - I thought doctors exaggerated their difficulties when I was a stude too.

You were able to be the voice of reason on that thread because you simply do not yet understand where all of these doctors are coming from.

Doctors do NOT "inevitably develop a superiority complex". You still believe what they tell you in medical school - that everything nurses do is wonderful and they know more than junior doctors and we must be touchy-feely and not forget how many doctors turn into shits. All that stuff about nurses "making or breaking a doctor" is bollocks, frankly. When I qualified I spent a year wondering where the hell all these nurses were who knew so much more than me. I worked with some great nurses and some terrible nurses - the great ones knew a lot about NURSING (ie, not doctoring, the job I was doing) and did it well. The rubbish ones didn't seem to know anything much. And yes, there are crap doctors, too. We always have to add THAT disclaimer, don't we?

Most doctors and nurses get along and work together well. We DO respect each other. There is always the occasional nurse who hates all doctors. The world is full of people with chips on their shoulders. The thread on Nurse R's blog was never about undervaluing nurses' work, but about the danger of nurses trying to practise medicine without a medical degree.

Staying out of each other's way isn't a particularly good idea either, is it? That would be a pretty disastrous arrangement.

It's nice to be idealistic. But you'll learn.

Mary said...

Anyone having trouble reading against the background - the content is still accessible, you just have to highlight the text. Or, if you can't read white on a blue background either, copy/paste it into word and then make it whatever size/font/colour is easiest for you.

My Own Woman said...

Things that make you go ..........hmmmmmmmm. The doctor vs. nurse debate continues. The struggle for power (in one's own mind) prevails once again over patient needs. I became a nurse because my focus on patient care is different than say my daughter's focus who is in her last year of residency. My focus is to carry out the treatments prescribed by the physician and care for the needs of the patient who otherwise could not do for him/herself.

Now, having said that; I also think it IS my job to point out various problems to the doctor to make sure he/she is AWARE of them (ie: fever, redness around incision sites, decreased urinary output, episodes of chest discomfort..etc.). While I never diagnosis a patient's condition, I do lay out the symptoms expressed to me by the patient; who often times is too intimidated by the 'white coat' to tell the whole story.

I see myself more as a mediator between God and man.....just call me (oh my goodness, I can't believe I'm about to say this) ..... Just call me Jesus! Ok, ok... don't all of you get your panties in a bunch...it was honestly said with tongue in check.

Spirit of 1976 said...

Cheers, The Angry Medic

I enjoyed your attempts to inject a dose of sanity into that particular debate, even if it was ultimately unsuccessful in the face of a barrage of sixth form behaviour.

I posted my own thoughts on this particular blogfight here: http://spiritof1976.livejournal.com/276638.html

I'll be continuing to read your blog with interest.

The Angry Medic said...

my own woman: heh. I like how you referred to the doctor as God. (and the way you've practically put yourself in the line of fire with that Jesus thing, but that's just me.) I agree with your description of your job; nurses ARE meant to back the doctor up and cover things he may have missed, because junior doctors DO make mistakes (many, sometimes. not that I'd know anything about that, of course). And I absolutely agree--oftentimes a nurse can get out of a patient what a doctor can't. Though I always assumed that was because junior doctors sometimes looked too incompetent. (again, not that I'd know anything about that).
sh

shiny happy person: "The thread on Nurse R's blog was never about undervaluing nurses' work, but about the danger of nurses trying to practise medicine without a medical degree."

agreed. but the venom spewed on her blog didn't exactly stick to the topic, did it? now those were some vehement pitchfork-brandishers, and many of them talked down to nurses, even going so far as to insult their intelligences. That was uncalled for, which is why I stepped in. I admit to sometimes being a wide-eyed idealistic medical student, but my arse has been saved by nurses more times than I care to admit, and whilst some of them WERE the bitchy walking slabs of meat we hear about in the horror stories, they were also surprisingly sympathetic. You're right, though; they might turn back into their usual cold PMSing selves when I earn my white coat, but I like to think I'll never become the sort of doctor who doesn't bother looking at nurses' faces when talking to them.

and I've faded the background! (using paedsrn's generous gift above.) Hope no one's having trouble anymore, else I could take it down. Pity though, I rather liked the gun in the top.

Shiny Happy Person said...

No, of course it wasn't ALL called for, but I can well understand the frustration behind it. This is not a simple matter of internet flaming; it is about people whose despair with the system in which they work is at breaking point. I very much doubt that all the doctors who spewed venom at Nurse R are the sort of people who act like that at work. They wouldn't get very far if they did. Yes, the doctors were insulting, but Nurse R was insulting too. It was a pathetic "ner ner" post intended to get her own back on people like Dr Crippen who are endlessly frustrated with the dumbing down of the NHS, which misses the point rather. "Up yours, doctors - you're crap too!" It just happened that her blog was picked up on doctors.net, which led to a lot more comments than if it hadn't.

I'd be interested to know how you end up with nurses "saving your arse". How much responsibility do you have as a medical student that you need nurses to save your arse?

One final comment: "Usual cold PMSing selves"? PMSing? And you considered the comments towards Nurse R patronising and insulting? Bugger me, but you've got a lot to learn.

Anonymous said...

I'm a med student and I hate the whole doctors vs nurses debate. Nurses do a valuable job but they are not doctors I'm sure some nurses would make good doctors and if they want to they should go to med school and train like they rest of us. Yes there are some doctors with a superiority complex but there are also nurses that treat medical students (and I'm sure other members of staff)like crap as well. But in any line of work there are going to be people you don't get on with suck it up people and get on with your own job thats whats ultimately best for the patients.

Anonymous said...

i'm a medical student applying to cambridge. can you give me hints?

Jenny Tew
xxxxxx

Nighteyes said...

I won't say that doctors deserve the superiority complex they have over nurses, but I guess everything society puts in and the long strenous course may contribute to why they think they're better. In the end though, you're right, respect is the first thing any institution needs. Hospitals would only function when the doctors and nurses stop worrying over who's better than who and actually get the work done.

I like that you're playing diplomat. Keep up the good work. ^^

Potentilla said...

Hey SHP, how old are you? If your tribal loyalties lead you in any way to support the garbage making up about 50% of that comment thread, you've got a lot learn.

Shiny Happy Person said...

Oh for god's sake, potentilla.

Tribal loyalties? Yes, I am loyal to my profession, and make no apology for it. What I was trying to say is that I understand where the depth of feeling came from. And I think I DO know something about the subject - you know, being a doctor and everything. My age has bugger-all to do with it - a cheap dig, if I may say so.

You assume too much. I acknowledged that not all of the vitriol was called for, a part of my post that you must have conveniently ignored. What you presumably fail to realise is that such vitriol and strength of opinion comes from somewhere other than a desire to insult people for fun. Misplaced it may be; uncalled for also. But I object to being labelled tribal and naive because I understand why a lot of doctors were angry about Nurse R's post.

At what point, exactly, did I show my support of any specific comments on Nurse R's blog?

It was a shame that many of the doctors' comments were so base because they did the rest of us no favours, and added fuel to the fire of "doctors are all so up themselves". The more reasonable comments (ie those that pointed out the idiocy of the post without making cheap and patronising jibes) went unnoticed. And whatever you may thin about doctors, the post was idiotic - it demonstrated an example of very dangerous nursing practice by someone crowing over what they had done.

This seems another example of deciding I'm one of the bad guys on the basis of what I do for a living. If I was a nurse and had written the above, would you have accused me of the same?

medstudentitis said...

I haven't read a lot of what was said, only your great summery, but I think a lot of the problems in Canada with the nurse vs. doctor vs. nurse acting as doctor debate centers around nurse practitioners. In this era of doctor shortages, a lot of northern communities that cannot recruit physicians now have nurse practitioners that act as GPs instead. I have been told that they take an extra 2 years of training after their nursing training and do a 1 year internship to qualify. They can prescribe and do everything that a GP can do. This leaves me wondering when all GPs will be replaced with NPs because they're the cheaper option. As someone who wants to practice rurally when i'm finished my training, I see working with NPs as a part of my future. I'm still not sure how I feel about the quality of care they provide and how it differs from that of a qualified physician.

The Angry Medic said...

shiny happy person: I'd be interested to know how you end up with nurses "saving your arse".

oh believe me. There are some doctors here who are so far up their own arses they view all medical students as being anal warts. Nurses' sympathy helps make this ride through hell a lot easier.

"Usual cold PMSing selves"? PMSing? And you considered the comments towards Nurse R patronising and insulting?

Yes, you see, I'm an Angry Medic, not an Idealistic Medic or a Cheerful Medic. I thought the big fat banner at the top of the site would have indicated that. As such, I tend to be cynical and insulting sometimes. I'm definitely not siding Nurse Ratchet. I'm just calling for some diplomacy (befitting our status as professionals) in the gang-rape we bloggers seem to have subjected her to.

It was a shame that many of the doctors' comments were so base because they did the rest of us no favours, and added fuel to the fire of "doctors are all so up themselves". The more reasonable comments (ie those that pointed out the idiocy of the post without making cheap and patronising jibes) went unnoticed. And whatever you may thin about doctors, the post was idiotic - it demonstrated an example of very dangerous nursing practice by someone crowing over what they had done.


Spot on. You're absolutely right. The minority of proper rational posts was submerged by the tidal wave of angry doctors. Nursey made a mistake--but then again, it IS her blog, and she has the right to spew whatever she wants on it. The overstepping of her boundaries was a mistake though. I hope her noticeable lack of response is a sign that she has realised this. Dr Crippen was right though--she WILL be enjoying her vastly increased hit count, as well as her newfound fame in bloggerdom.

spirit of 1976: thanks! I've added you to my blogroll. Your summary was succinct and to the point. I'm up for that round of drinks adam promised us in Nurse Ratchet's comments :)

anonymous (5.15pm) : Nurses do a valuable job but they are not doctors I'm sure some nurses would make good doctors and if they want to they should go to med school and train like they rest of us. Yes there are some doctors with a superiority complex but there are also nurses that treat medical students (and I'm sure other members of staff)like crap as well.

Well said. I agree completely. Especially this part: suck it up people and get on with your own job thats whats ultimately best for the patients. Goodness knows I need to get back to those books.

Jenny Tew: I do indeed have some advice; this post should help. If you have any other questions do drop me a line.

Potentilla said...

But SHP, I didn't actually accuse you of anything - I just said IF....... in fact, I found your self-confessedly patronising post a bit smug, so I thought I'd patronise you a little in return from the dizzy heights of 43. If you were a nurse and had written the above, would I have made the same comment? yes, definitely. I am not a subscriber to the all-nurses-are-put-upon-saints theory.

I agree with you that the original Ratchet (surely she means Ratched?) post was silly (even without having the medical expertise to make any judgment about the specifics, I think it was a silly post). Also that there were a number of sensible rational responses from doctors and medical students.

However, I don't believe that all of the "base" (good word) comments were driven by understandable frustration with the current politics of the NHS. I think some of them were driven by childish tribal knee-jerk reactions. My (fairly extensive) experience of the medical profession leads me to observe that doctors are MORE prone than other professionals to close ranks behind the actions of any of their number, however indefensible the actions may be to an outsider. This may be in part for understandable reasons to do with the drastic consequences of being struck off, I don't know. But I still think it's a shame, because it does tend to perpetuate the outside view of doctors being up themselves, such that the 99.9% of professional competent caring doctors get tarred with the brush of the 0.1% of incompetents and/or fuckwits (to borrow a tehcnical term form Dr Crippen) of the ilk of some of the Ratchet commenters.

IMHO, being loyal to a profession as opposed to being loyal to admirable individuals practicing that profession is a dangerous thing.

Sorry, Angry Medic, I seem to have gone on a bit.

justcallmejo said...

Thank you for your courtesy and sanity, Angry Medic.

There are tensions between nurses and doctors in the states, but it almost sounds as though the UK health care system throws these tensions into a pressure cooker. (Not to imply that the American health care system is anything other than deplorable and embarrassing.)

I read the argument/pissing contest over yonder and I found it baffling. I gave up a lucrative life in the computer world to be a nurse. I have had eight years of private (public, I guess to the UK) higher education. I struggle with this "But I AM smart!" thing that nurses seem to have, when it never occurred to me to say, "But I AM a smart computer programmer/database administrator/consultant/trainer!"

I hadn't been in a field where it ever dawned on me to not be treated as a professional before. Usually, when you're presenting to boardrooms, you just don't have to say, "No, really! I went to school and learned! Other people find me smart!"

Health care seems utterly weird this way.

Typically, when a patient says to me, "Wow, you should be a doctor!" I reply: "Would you like a stupid nurse?" I really don't want to be a doctor. I want to be a nurse. I don't want to waste my brain cells as an automaton/secretary to doctors. You do your thing (diagnose, prescribe, educate), I will do mine (provide cares, monitor, support, avoid complications and educate), we work together, the patient gets better.

Just seems like we can all be civil.
/jo, rn, bsn

Anonymous said...

doctor verus nurses
i respect doctors who respect me and my work. respond to my bleeps and review patients. no i not a doctor just a junior staff nurse trying to do the best for my patients.
sometimes the healthcare system we work in makes the work we all want to do harder.

Dragonfly said...

1. Russell is a legend.
2. @ justcallmejo "Typically, when a patient says to me, "Wow, you should be a doctor!" I reply: "Would you like a stupid nurse?" So true! And an awesome comback.

Paul M. Peterson said...

excellent article. In the debate of doctors v. nurses, I choose...both. They are both necessary for the health care system to work. A quick reminder...no doctor is God, no nurse is a saint.

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Anonymous said...

I'm a nurse and in the workplace i like to treat everyone as equal, and let them do their job. I personally don't see any rivarly between doctors and nurses, everyone gets along just fine.Don't forget the "Patient" is the center of the health care team, and that should be the main focus.