Nancy handed the phone to the intensive care physician managing Marilyn's case while my curiosity mounted. Few patients are discharged from the ICU directly to home, so as home healthcare liaison I don't see critical care folks very often and am an anomaly when I appear in the unit. "We're getting ready to send her out," the doctor said, "She will need a nurse to see her at home. But what would a nurse do for a patient like this? I'm writing the discharge orders now, but, about the nurse, what should I write?"
It's a good and fair question, although I smiled at the realization that the doctor knew the patient needed a nurse, but he couldn't say why or what that nurse would do. It was perhaps the most honest and refreshing question I've been asked in a long time, but the fact is that none of us really know exactly what our colleagues in other professions know and do, at least not well enough to write orders or treatment plans for them.
From time to time I send patients to the doctor, or to the Emergency Department, or to a Physical Therapist or another provider. But I don't tell the doctor, ED, PT, or anyone else what to do once the patient arrives. I call ahead and explain why I'm sending the person, describe what I have observed and done, note how the patient responded, and sum up with a status report of how the patient is at the moment and any circumstances or special considerations I think the receiving provider should know.
But having done that I don't say, "And Doctor, I expect you to do a complete examination, order these blood tests, that scan, an EKG, and x-rays. Then when you have narrowed the differential diagnosis down to 'x' vs. 'y' vs. 'z' you should . . . " No. I provide my input as the treating nurse, and trust the doctor to practice medicine.
I will tell a Physical Therapist that I'm referring a patient because she or he was very weak when I visited, having difficulty rising from a chair, holding onto furniture for balance while walking, and complaining about back pain that made standing upright difficult. I don't say that I expect the therapist to do a comprehensive evaluation of the patient, assessing strength of all muscle groups, balance, endurance, gait, transfers, and the patient's ability to fling an empty beer bottle at the television when the referee makes a bad call. No. After I have described my observations and detailed my concerns, I trust the Physical Therapist to do his or her job.
I may call a counselor, a dietician, a speech pathologist, a pharmacist, a respiratory therapist, a member of the clergy, a chiropractor, a social worker, and/or any of a plethora of others, but I don't tell them what their jobs are or how to do them.
And that's a darned good thing, because no matter how capable a nurse I am, I'm not qualified to practice any profession other than my own. And neither is anyone else, including physicians.
The work of medicine is diagnosing and treating pathology. That's what doctors do. Along the way most have learned something about preventing some diseases, and so they counsel against smoking and in favor of "flu shots." But their focus is disease, and symptoms are the clues that tell doctors if they're proceeding well, that is, if patients are improving or deteriorating. Treat the disease, manage the symptoms and side effects of treatment along the way, and keep tweaking the plan until the patient is well, or as close to well as possible. Yes, that's what doctors do.
When healthcare is assumed to be synonymous with disease management, symptoms are a secondary focus, markers along the road that are an indication of the extent to which the pathology at hand is being well managed. This may be why doctors sometimes downplay symptoms that are important to patients: The doctors can see that the disease is improving and so the symptoms matter less, because in time, if all continues to go well, the pathology will be banished and the symptoms with it. In this line of thinking, some dizziness, discomfort, constipation, insomnia, nausea, whatever, are but relatively insignificant bumps on the road to health, and while a few pills can be tossed into the mix to lessen these, "really" the patient is "fine" and there's little cause for concern.
However, for patients the experiences that doctors call "signs and symptoms" are primary most of the time. While of course patients want their broken bones to heal, their hearts to recover from "attacks," their cancer to go away and never return, and their other diseases to be cured; in short, while in this way they and their doctors share a common goal, in the day after day dailiness of their lives what most affects patients is not that their ejection fraction is 30% but that just making a sandwich and washing the dishes wears them out. It's not that the x-ray looks "beautiful," but that the fracture site throbs at night and it's next to impossible to get dressed because the cast is in the way, nothing fits over it, and keeping one's balance while attempting the feat has become a gymnastic event. And while there's no better news than that the scan shows the tumors are smaller, what is in the forefront of patients' minds most of the time is the relentless fatigue that has taken over their lives since chemotherapy started, along with the sores in their mouths and and the backsides that have become almost unbearably tender from so many trips to the bathroom.
When as a teen I announced my interest in a career in nursing teachers and many others often encouraged me to reconsider and choose medicine instead. I was too smart, too quick, too capable for mere nursing, they said, and really should be a brain surgeon or neurophysiologist instead. Or something else. But certainly not "just a nurse." And somewhere past the halfway point of my first undergraduate year the full crisis hit, and I sat sobbing in my dorm questioning whether I should change my major to pre-med after all and transfer to the "better" university that also had accepted me, in order to be as well positioned as possible for a slot in a top medical school three years later.
I stayed where I was, in one of the best undergraduate nursing programs in the country, but it was years before I could articulate why.
If one is fascinated by the human body as a biological organism and by pathophysiology and all that can be done, down to the sub-cellular level, to confound it, and if one feels a yen to serve by curing diseases and eliminating the suffering they cause, then a career in medicine is the way to go.
But if one is fascinated less by the disease, less by the biological science, less by the body as an organism, and more by persons, the choices they make, and life in all its richness and messiness that unfolds in so many different ways for different people, then the world of medicine is far too confining. Similarly, when patients want to be vibrant and healthy; comfortable, strong, and free; and able to envision the lives they want and to go about making those lives happen, regardless of age or of the specifics of their dreams or heartsongs, then "healthcare" that reduces to "sick care" simply isn't enough.
Nursing is the profession that is about helping people position themselves to live their best lives, whatever that means for them, whatever is possible for any given human being. We start where the patient is and move forward. We don't and can't do it all by any means, but we may be the best at knowing who can help, which referrals are in order, what other expertise to tap, and how to coordinate all the pieces.
Although I couldn't explain it at the time or for years to come, at fifteen, with a year as a "Candystriper" (hospital volunteer) under my belt, I knew better than my teachers and mentors where I belonged. And today I shake my head and try not to roll my eyes every time someone mentions "doctor's orders," because apart from the rather small slice of the healthcare pie that is medicine doctors really don't "order" anything at all, or know what to order in the first place.
"Well," I said to the intensive care doctor on the phone, "I'm hearing about Marilyn for the first time right now. I haven't met her or reviewed her chart. But based on what Nancy just told me I'd say that this patient is at high risk for pulmonary complications, so a nurse visiting her at home will assess and evaluate her respiratory status carefully, looking for any indication of infection, decreased pulmonary function, or other problems. I imagine you have tweaked Marilyn's medication regimen while she's been in the hospital; the nurse seeing her at home will evaluate the use and effectiveness of those drugs. The nurse also will assess the learning needs that Marilyn and her husband have and provide needed education based on those findings. Infection prevention and control are likely to be important, and the nurse will address those and also will address nutrition, both to promote strength and healing and to support the goal of weight reduction. I don't imagine Marilyn is moving around very much, so the nurse will be looking for complications of poor mobility and teaching ways to prevent these. And I'd suggest a Physical Therapy referral for a safety evaluation and to get this patient moving in whatever ways are possible."
"That's awesome!" the doctor exclaimed, with a tone that sounded truly awed, as opposed to the commonly overused, hackneyed invocation of the word to refer to anything positive or good, "That's perfect; thank you . . . " And I heard him muttering as he typed, " . . . evaluate respiratory status . . . nutrition . . . refer to Physical Therapy . . . "
"Really, just give me a jumping off point," I said, "'Evaluate and treat' or 'Home health to consult' almost always is sufficient. From there we'll evaluate the patient, flesh out the treatment plan, and send it to the patient's doctor. I'll be down shortly to start that process for Marilyn, once I meet her and read her chart."
All of us in healthcare professions bring something different to the table. In my state and many others a physician cannot even testify in court about the practice of a nurse or other non-physician; they are different professions, all highly educated, individually licensed, and uniquely experienced. It is a disservice to patients to implicitly or explicitly limit their healthcare to things falling under the umbrella of "doctor's orders," and everyone is best served when complementary disciplines work together. There was a time when physicians circled the wagons and fought to maintain control of healthcare, arguing that this was in patients' best interests, although that it served the financial and political self-interest of doctors was glaringly apparent. In the practice setting that is easing somewhat now, with day-to-day posturing of this sort mostly focused on squabbles about the actual diagnosis and treatment of pathology that has been doctors' forte all along (to what extent should Nurse Practitioners be able to make medical diagnoses and prescribe drugs, for example).
Be this as it may, and while yes, we yet have a ways to go, it is mightily encouraging when, instead of strapping on the traditional blinders of medicine and assuming that a correct diagnosis of pathology and a proper medical treatment plan is the sum total of 21st century healthcare, a doctor treating a patient, even a patient in a critical care setting, calls a nurse about the work of nursing to ask,
"What Should I Write?"
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