How do so many journalists miss it? The Washington Post on nursing expertise

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How do so many journalists miss it?

bulls-eye rash
September 27, 2010 -- Today The Washington Post published a lengthy entry in its "Medical Mysteries" series headlined "Nurse solves mysterious ailment that puzzled orthopedists, oncologist." Sandra G. Boodman's piece describes a local man who spent more than a year consulting various specialist physicians, enduring "two unnecessary knee surgeries and dozens of physical therapy sessions, as well as acupuncture and other useless and sometimes painful treatments that cost thousands of dollars," before "a nurse" at an infectious disease specialist's office suggested that he might have Lyme disease. He did. You might think, then, that the article would be a tribute to nursing expertise, but instead the central fact of the story is overwhelmed by disrespect for nursing. It's not just that the piece repeatedly dismisses what the nurse did by calling it "simple" and "obvious," "a basic query by a nurse, not the acumen of five specialists." No, the most striking thing is that in this 1,300 word story describing all the erroneous thinking of the "specialists," the nurse who actually solved the problem is never named, quoted, or further described. It's true that none of the specialists are named or quoted directly either, which certainly protects them from embarrassment. And it seems that the approach of these pieces is to rely mainly on the patient's account; perhaps this patient never actually met the nurse, though he says he "remains grateful" to the nurse. But the piece does name and quote an infectious-disease expert the patient consulted after the diagnosis, so it might have done more with the nurse, even if could not give the nurse's real name. The net effect of what we do have here is to suggest that the nurse solved the problem by being so simple and limited, with a mind uncluttered by real expertise. Needless to say, there is no suggestion that maybe the nurse solved the problem because of her own expertise, or the nature of nursing, including the profession's holistic and flexible approach, which is no less "expert" for being broad. The piece pokes fun at the specialist physicians, but it still reinforces the idea that they are the main source of health knowledge--the same idea that seems to have gotten this patient in so much trouble.

This is the story of John Gordon, the 54-year-old president of a commercial real estate firm. Gordon thinks he might have been better off "had his office not been located in a Montgomery County high-rise that also houses many medical offices," which made it convenient for him to see all the specialists there. Gordon, "whose father and father-in-law were doctors," says he did not ask enough questions, and was "too good a patient," which must mean accepting whatever physicians say--hardly surprising for a person with that background. The result, apparently, was "two unnecessary knee surgeries and dozens of physical therapy sessions, as well as acupuncture and other useless and sometimes painful treatments that cost thousands of dollars." This part of the article hints that we should not be so trusting of specialist physicians. But then we get this:

In the end, it was a basic query by a nurse, not the acumen of five specialists, that led to the correct diagnosis of a common malady. "If you don't ask simple questions, you screw up," Gordon said. "I see that in my business all the time."

The piece traces the history of Gordon's problem, which appeared in 2007, when he first noticed that his knee was swollen. He consulted an orthopedist, who recommended physical therapy. That did not help. The orthopedist drained the knee and gave Gordon cortisone shots. That did not help for long. An MRI showed no torn ligaments or cartilage, so the orthopedist recommended exploratory surgery. A surgeon operated, "told Gordon he had a partially torn meniscus, a common injury involving cartilage," and then "repaired the cartilage." That did not help. Gordon consulted a physiatrist, who specializes in rehabilitation and pain management. This physician considered whether it might be an infection, but assumed that had been ruled out, and suggested acupuncture. That did not help. Gordon got a second MRI, and his orthopedist suggested surgery for "pigmented villonodular synovitis, which causes an overgrowth of tissue for no apparent reason." Gordon switched orthopedists but had the surgery. It did not help. The surgeon suggested that the abnormal tissue in the knee pointed to cancer, and referred Gordon to an orthopedic oncologist and an infectious-disease specialist. But the tissue biopsy was negative.

The infectious-disease specialist confidently suggested that Gordon had contracted "valley fever," a serious fungal infection, from a recent trip to the Southwest. Gordon took "the maximum dose of a potent antifungal drug" for two weeks. It did not help, but it did make Gordon "feel weak and very nauseated." The infectious disease specialist was stumped, though that did not stop him from prescribing an antibiotic.

But a week later, in June 2008, the doctor called back. Gordon said he reported that during a staff meeting at which his case was being discussed, a nurse asked whether Gordon had ever been tested for Lyme disease.

nurse-physician discussion Gordon said he had not, and that "no one had mentioned it." We're actually impressed that the physician admitted that this was the nurse's idea. Physicians often receive credit for life-saving nursing ideas and observations, whether because physicians present the ideas to patients as their own, patients assume they must have been the physician's idea, or nurses hide their own role. Of course, it's also impressive that this specialist's office had meetings in which a nurse's professional opinion was considered. Physicians routinely leave nurses out of discussions of diagnosis and treatment, even though nurses' input can mean the difference between life and death. Nurses must often use complicated social dances to have their views considered. Naturally, the Post article explores none of this, though it certainly would be worth discussion in a major newspaper.

In any case, the infectious-disease physician faxed an "order" for the test, which was positive. The disease was responsible for Gordon's knee problems. The piece gives some basic information about Lyme disease, which is "a bacterial infection caused by a deer tick bite." Lyme arthritis is "sometimes permanent." Gordon was "stunned," and wondered how this could have been "missed by so many specialists."

For some answers, the piece turns to "Adriana Marques, an infectious-disease expert at the National Institute of Allergy and Infectious Diseases who is studying the natural course of Lyme disease," a physician Gordon consulted a few weeks later. She suggested he might have gotten the disease while walking his dog in a "park thick with deer" near his home. But the nagging question remained:

How did so many doctors miss it? "I think they just didn't think about it and went down a different road," Marques said. A simple blood test or an analysis of the knee fluid would have revealed the infection, but apparently neither was performed. Gordon said both orthopedists were skeptical that Lyme disease was the culprit even after he told them that tests had confirmed that diagnosis. "They said it didn't make sense to them," he said. Marques disagrees. "In his case there is no evidence he had anything other than Lyme disease," she said.

Gordon received doxycycline and his knee is now much better, but he "still has some residual stiffness and impaired range of motion, which is probably permanent." Looking back, Gordon would do things differently.

Early on, he now believes, he should have consulted an internist "and gotten an ally to deal with the experts." But, he said, after having a serious medical problem several years ago, it was his habit to go directly to specialists. "I blame myself" for not being more skeptical, he said, adding that he remains grateful to the nurse who asked the obvious question that led to his diagnosis. "All that was needed," Gordon said, "was a simple blood test. What was amazing is that so many doctors couldn't see what was right in front of them."

Deer tick The piece does at least hint, of course, that we should not be so trusting of "specialists," who may see only what they have been specifically trained to see. A generalist might have brought a broader perspective immediately and helped Gordon avoid all or much of what he went through. Unfortunately, the piece does not even quite convey that, as Gordon suggests only that the internist would have been an "ally to deal with the experts"--implying only that the internist would have been useful to negotiate among the specialists with real knowledge, rather than as an independent source of expertise. In fact, general practitioners, including nurse practitioners, are experts--they specialize in taking a broad view of health and wellbeing. Believe it or not, general practitioners are capable of diagnosing Lyme disease all by themselves.

This problem extends to the piece's treatment of nursing. Even though the nurse was the one who solved the problem--without even seeing the patient--what she did is relentlessly dismissed as "simple," "basic," and "obvious," in stark contrast to the "acumen" of the physician specialists. There is no suggestion that perhaps our views of "acumen"--that it resides only in physician specialists--might be wrong. There is no suggestion that maybe the nurse found the answer because he or she was a serious professional who thinks broadly. We hear nothing more about the nurse--training, experience, what the nurse was thinking in suggesting Lyme disease. Of course, we're not suggesting that the nurse lacked special expertise in infectious disease either; presumably the opposite is true, given where the nurse works. Nurses develop specialized knowledge in their areas of practice, just as physicians do.

But rather than explore how and why the nurse actually solved the mystery, the reporter consults another physician specialist to explain why the first group of physicians missed the disease. So apparently the solution here is just to keep searching until you find the right physician expert; sometimes the experts are just so expert that they can't see what's right in front of them! Marques functions here as the clever detective who explains everything in the end, even though it was the, um, nurse who actually identified the culprit. And the headline, at least, conveys that: "Nurse solves mysterious ailment that puzzled orthopedists, oncologist." In fact, it might have been better for nursing if Post readers had simply absorbed that headline and moved on, without reading the 1,300 words that followed.

Maybe the Twitter approach is better than the silly old mainstream media after all!

See the article "Medical Mysteries: Nurse solves mysterious ailment that puzzled orthopedists, oncologist," by Sandra G. Boodman, posted September 27, 2010 on The Washington Post site.

Please send author Sandra Boodman your thoughts on her piece at boodmans@washpost.com. (and please copy us at letters@truthaboutnursing.org). Thank you!

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