"I can't even say I made my own mistakes. Really--one has to ask oneself--what dignity is there in that?"
-- Stevens the butler, The Remains of the Day (1989), Kazuo Ishiguro
June 20, 2004 -- Three recent New York Times pieces reinforce the false impression that physicians bear the primary responsibility for modern health care and for any significant problem in care delivery. They are Bob Herbert's June 18 op-ed "Not So Frivolous," M. Gregg Bloche's June 10 op-ed "After Abu Ghraib; Physician, Turn Thyself In," and today's article "Why Did They Die in Cosmetic Surgery?" by Alex Kuczinski and Warren St. John. While such pieces may seem unfair to physicians, they also perpetuate widespread misconceptions that nurses are marginal players who report to physicians, and obscure the fact that nursing is an autonomous profession with its own sphere of practice and its own legal and ethical duties.
In "Not So Frivolous," regular Times op-ed contributor Bob Herbert discusses two malpractice claims against an Ohio OB/GYN whom President Bush introduced at a recent campaign event to underscore the Administration's argument that high malpractice premiums caused by frivolous lawsuits are driving good physicians from practice. In the first case, the piece suggests that a critical problem for a baby born with "severe brain damage" was improper checking of a fetal monitoring strip while the physician was absent. Herbert quotes the mother saying she had "what they call a casual part-time nurse, who was not very well trained in reading fetal monitoring strips." The piece does not name this nurse. By the time the physician was "called back" from dinner, it was apparently too late to prevent permanent injury. Herbert states, with unmistakable contempt, that the physician "blamed the ensuing tragedy on the nurse." In fact, though we obviously do not have all the facts, the apparent error described here is just the kind of thing that would generally be a nurse's responsibility. Nurses are the ones responsible for monitoring a patient's condition at all times. Nurses are trained for this constant assessment; physicians generally are not. If the nurse on duty was not qualified for this task, that is the responsibility of nursing managers, since they--not physicians--hire and manage other nurses.
The other case Herbert describes involved serious intestinal damage caused to a patient who had a sponge left inside her during a Caesarian section. Certainly, the OB/GYN--who monitored the patient's worsening pain for four months of outpatient visits and failed to identify the cause of the pain--would appear to be partly responsible for the patient's ensuing injuries. However, a nurse would certainly have been present during the C-section itself, and nurses have an independent responsibility to account for the number of sponges used in surgery and to protect patients from mistakes just like this one.
In all, Herbert mentions the physician in question by name a dozen times in the piece. No nurse is identified by name.
Similarly, on June 10, the Times published a physician-centric op-ed by M. Gregg Bloche, a law and public health professor with an M.D. and a J.D., entitled "After Abu Ghraib; Physician, Turn Thyself In." Dr. Bloche's argument is that the U.S. military "medical professionals" who examined those tortured at Abu Ghraib prison in Iraq failed to discharge their legal and moral duties "to tell those in power what they saw." To his credit, Dr. Bloche's piece mentions "doctors and nurses" three times--though always in that order--and once refers to "doctors, nurses and medics." Unfortunately, he also states that the "duty of doctors in such circumstances is clear," and proceeds to explain physicians' responsibilities for treatment, record-keeping, testing and reporting--as if nurses had none, or were merely physician appendages. He refers to the pattern in recent decades of "rogue regimes" that were proud because their "doctors both contained and abetted torture." Dr. Bloche argues that "[i]ndependent doctors" should examine U.S. detainees who say they were abused at Abu Ghraib, Guantanamo and elsewhere. He asserts that if "[m]ilitary doctors had come forward with [evidence of patterns of abuse], brutal practices that have shamed us all could have been stopped at the outset." And he claims that "[w]hen guards and interrogators become torturers, doctors are first responders."
The overall impression left by this piece, especially the witless title, is that physicians are primarily responsible for all care, and ultimately responsible for advocating for patients. In fact, while we are not experts on military prison care, surely nurses would be "first responders" in in many contexts, as suggested by a reference to a nurse visiting a detainee in a Washington Post article reporting on the Abu Ghraib scandal. No doubt physicians treat and examine prisoners held in such facilities, but surely nurses would handle a good deal of testing and record-keeping, and nurses would typically spend more time with prisoners who were cared for at any length. Perhaps most ironically, readers of this piece would never dream that it is nurses whose professional responsibility is to be patient advocates, to protect their patients from anything that threatens them, and that nurses do this every day--often despite physician resistance. Of course physicians have more power and their views may (unjustifiably) carry more weight, especially in societies where nursing is less developed. But registered nurses are officers in the United States military. On the whole, this op-ed presents a vision of health care that suggests physicians run the whole show. They do not, and they should not.
Finally, in today's "Why Did They Die in Cosmetic Surgery?" Alex Kuczynski and Warren St. John discuss two recent plastic surgery deaths at the elite Manhattan Eye, Ear and Throat Hospital. In January, well-known novelist Olivia Goldsmith died, apparently of cardiac arrest related to anesthesia administered while she was receiving a "chin tuck" at the Hospital. The piece states that a nurse practitioner gave Ms. Goldsmith anesthesia, carefully noting that this is a common practice--perhaps lest anyone wonder whether this in itself was a safety issue, a realistic concern given the low public awareness of the work of these advanced practice nurses, despite research showing that their care is at least as good as that of anesthesiologists. But the nurse practitioner is not named, nor is there any further discussion of his or her role--even though the piece goes on to describe the alleged failure to monitor respiration and cardiac activity, for which he or she would presumably have been directly responsible. This is especially striking since the anesthesiologist involved in the other death is named a number of times, as are the surgeons in both cases. Less surprising is the failure to mention the roles of registered nurses, who would presumably have been involved in both surgeries, and whose professional responsibility is to monitor patient conditions and protect patients from all threats, including those that may arise from the acts of other health care providers.
By sending the inaccurate message that physicians are ultimately responsible for all health care problems, and that nurses are at most peripheral subordinates, influential pieces like these do far more harm to nursing than medicine. Nursing will advance only if it is seen as an integral and autonomous part of the health care picture. That means that it must receive due credit when things go well, and due responsibility when things do not.
See Bob Herbert's June 18 op-ed "Not So Frivolous," M. Gregg Bloche's June 10 op-ed "After Abu Ghraib; Physician, Turn Thyself In," and Alex Kuczynski and Warren St. John's June 20 article "Why Did They Die in Cosmetic Surgery?" in the New York Times.
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