The Nurse-Crusader

 
December 8, 2009 -- Today the New York Observer published a generally good profile of "controversial" Columbia nursing dean Mary Mundinger, who is retiring after a quarter century at the forefront of the fight to help advanced practice nurses (APRNs) win the respect and resources they need to provide high-quality, cost-effective care. Dana Rubinstein's piece even cites the research, too often missing from press reports on APRNs, demonstrating that APRN care is at least as effective as physician care. The article also provides a short but relatively insightful look at the lack of respect nurses have historically suffered, and suggests that the nurse-focused television shows that appeared in 2009 represent a step forward for public understanding of the profession. The piece does at times paint a bit too rosy of a picture--some advances for APRNs and the appearance of the new nurse shows do not necessarily mean the public has grasped that nurses generally deserve more authority and respect. And there are a few unfortunate elements, like the reporter's apparent belief that "doctor nurse" is an appropriate term to describe APRNs. But on the whole the article is a helpful look at a nursing leader and the advanced practice nursing she has championed. We thank Ms. Rubinstein and the Observer.

"The Nurse-Crusader Goes to Washington" is a generally strong profile of a pioneering figure in nursing. It portrays Mundinger as a kind of genteel rabble-rouser and a master tactician, maneuvering to push APRNs ever closer to physicians in terms of respect, credentials, and reimbursement. Unfortunately, like too many pieces on nursing that are aimed at elite readers, this one is accompanied not by a current nursing image (like, uh, a photo of Mundinger) but by an old stock photo from Getty Images of a white-capped nurse jabbing a patient's arm with a huge syringe-type thing. Why must articles in such publications, like this or Business Week, so often portray nurses in this way, as if they were some odd throwback to another era? Oh, look how quaint--an old-timey female job! Remember when able women became nurses, back before women could join real professions? We've come a long way!

Fortunately, the actual text is much better. Rubinstein includes quotes from Mundinger, as well as her supporters and detractors, all of whom address Mundinger's central point that APRNs should be regarded as a full-fledged alternative to physicians in most substantive health care areas. The basic story:

For nearly a quarter century, Ms. Mundinger has served as dean of Columbia University's School of Nursing, during which time she has waged a single-minded and often contentious campaign to put nurses on a more equal footing with doctors, in part by creating a new class of nurse practitioners with doctorates, sometimes called "doctor nurses."

Ms. Mundinger is retiring from the deanship next year, but not so she can settle into the lazy senescence of old age. Rather, Ms. Mundinger plans to lobby Congress to fund nurse doctorate education so as to bolster the supply of primary care physicians come the eventual enactment of health care reform.

This is generally good, giving a quick sense of the scope of Mundinger's work and future plans, and particularly the need for more funding for nursing education. So what's with "sometimes called 'doctor nurses'"? The reporter goes on to use the term herself, without quotation marks. This term is generally used to mock doctorally-prepared nurses, to stress that they are not "real" doctors. But APRNs are not trying to be physicians, who do not, in fact, possess the only effective advanced practitioner care model. This is the answer to critics like anthropology professor and university senator Ralph Holloway, who, according to the Observer piece, asked the New York Sun in 2002: "If they are supposed to be doing all that doctors do, why don't they go and get their degree?" They don't because they don't need a degree from a school of medicine in order to provide high quality health care. Of course, the term "doctor" itself should be scrapped, since it exalts one type of professional above all others, with no basis for doing so.

The piece describes Mundinger's background, noting that she got a "nursing degree" from the University of Michigan in 1959, shortly before the Medicare and Medicaid programs laid the groundwork for the first nurse practitioner program at the University of Colorado. The article notes that those reforms led to a shortage of primary care physicians, just as reforms currently being considered might exacerbate primary care shortages by introducing many new patients into the U.S. health system. Mundinger later got a "nurse practitioner certificate" and "an MA in teaching and a doctorate in public health from Columbia." She published books, including Autonomy in Nursing (1980), and became Columbia's nursing dean in 1986. The piece reports:

In 1994, she founded the first primary care practice run entirely by nurse practitioners, in Washington Heights. Three years later, she founded Columbia Advanced Practice Nurse Associates on East 60th Street, the first nursing school practice where nurse practitioners were compensated at the same rate as primary care doctors.

Supporters explain how Mundinger gets things done. Her husband, Queens College biology professor Paul Mundinger, notes that "if she's thwarted, she'll try to figure out a way to get there through another route." Myron Weisfeldt, "chairman of medicine at Johns Hopkins, and from 1991 to 2001, chairman of medicine at Columbia," says that Mundinger "was very expert at appealing to what she believed to be the prejudices of the person she was talking to, while in fact continuing to advance her agenda beyond the grasp of the vision of the person she was talking to. I found that to be very attractive."

The APRN advances in the 1990's led to a "blowback" from critics who doubted nurses were able to provide comprehensive primary care, so Mundinger "proposed a randomized study," which impressed Weisfeldt greatly. Commendably, the piece gives the specifics on this:

The randomized study, conducted between 1995 and 1997, compared the outcomes at her clinic in Washington Heights with three clinics in the same neighborhood run by physicians. The resulting paper, published in the January 5, 2000 edition of the prestigious Journal of American Medicine, proved her point: "In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable."

The piece, which portrays Mundinger as a wily "scrapper" confounding critics, goes on to describe her later work to "develop[] the country's first doctoral program in nursing." That's incorrect, though, since the first doctoral program in nursing was established at New York University in 1934. The reporter means that Mundinger started the first doctoral program for APRNs, as opposed to the research-focused PhD's that tens of thousands of nurses have earned in recent decades. This points up a tendency of this piece and many others to assume that advanced nursing is all about APRNs, when in fact all registered nurses have rigorous health training, and doctorally-prepared nurses have been the profession's intellectual leaders for many decades. Nursing did not suddenly become a respectable health science because of APRNs.

In any case, the piece notes that Mundinger's nurse practitioner doctoral program started in 2005, with predictable opposition from organized medicine about the supposed "dangers to patients." The piece quotes George Thibault, president of the Josiah Macy, Jr. Foundation, who says that "[a]ll pioneers run the risk of being sometimes too far out ahead or sometimes misunderstood," and that Mundinger has had detractors, even inside the nursing profession. It might have been interesting to hear from one of those, but the piece does rightly offer significant space to Lori Heim, the North Carolina-based president of the American Academy of Family Physicians. Heim argues that physicians still get more post-graduate training than APRNs do. The piece says APRNs typically get roughly five years of academic and clinical post-graduate training, compared to the seven years most physicians get. Heim states:

We as an Academy still continue to think that even with the doctorate, there is a very substantial and real difference in training and the ability to broaden the differential diagnosis, and provide broader and better treatment plans.

When I've worked with advanced nurse practitioners, they are very, very good at working as part of a team and being able to manage certain conditions, but those are usually conditions with which the patient has already been diagnosed, and at following protocols. I think they are very effective at being what we call in the military a force multiplier.

The reporter asks Heim what she thinks of "Mary Mundinger's argument that nurses, by nature, and by education, have better communication skills and are more empathetic and compassionate than their primary care physician colleagues." Heim responds that it's "kind of a slap in a face. It's almost like saying that people that go into nursing are women." The piece was right to include these views, but it doesn't provide direct responses. So we'll give it a shot!

We appreciate Heim's suggestion that NPs are good at managing chronic conditions, but we are aware of no research suggesting that physicians can "provide broader and better treatment plans" than APRNs can, nor that physicians' ability to diagnose is superior. The research all suggests the reverse, and that's why physician critics like Heim never mention it. In particular, the suggestion that physicians are better at "broader" treatment plans is silly, since it is nurses who receive years of training under a broad, holistic practice model that takes account of all relevant factors and potential measures to promote well-being. Moreover, despite Heim's comments about the limits of what NPs can do, there is plenty of anecdotal evidence going the other way. Many APRNs have diagnosed things physicians have missed, because nurses do have advanced interpersonal skills, they do take the time to listen to patients, and they are not afraid to seek input from others. And with regard to those interpersonal skills, we hope that Mundinger has not said that nurses are better "by nature"  or because they're women, particularly since many APRNs are men. But it is fair to note that the nursing care model emphasizes psychosocial skills that are well-suited to primary care, and this is one key reason that APRNs can provide such excellent care even with less formal education. Of course, APRNs do not necessarily have less health care education, since nurses have at least two years of rigorous health care education as undergraduates that physicians do not get, thus leading to a total (using this article's numbers) of seven years of health training--the same as physicians, even counting residencies the same as formal university training. In addition, health care is not just about "broadening the differential diagnosis," though it may be tempting for some to embrace a House-like fantasyland in which the sole measure of a clinician is her ability to identify rare conditions, rather than to improve outcomes generally. Finally, Heim's comments about "following protocols" and the "force multiplier" are insults reminiscent of the term "physician extender," which some physicians use to denigrate APRNs, implying that graduate-prepared, autonomous APRNs are like inanimate objects that help physicians reach things on high shelves.

Speaking of training, the piece suggests that Mundinger concedes that nurses are "not educationally equipped" to do "oncology, surgery, things that call for medical specialists." We're not sure what this means. Of course if a particular field requires many years of additional technical training that nurses do not currently get, then presumably they would not be qualified to practice in it, but plenty of APRNs excel at oncology and other fields that "call for specialists." On the other hand, the piece says that Mundinger "argues that, if anything, primary care physicians are overeducated," and it concludes by relating a somewhat incendiary comment Mundinger made in describing what happened when she spoke to the Federation of State Medical Boards, who administer board certifications. Apparently a primary care physician asked if he had "wasted" his time going to medical school. Mundinger: "I wanted to say, yeah." Of course, one might say that medical school is not the only way to become a highly qualified practitioner, and that much depends on the care model in which one is trained.

The piece also includes significant description of the nursing image and how it has affected the way nurses have been treated through the years. Much of this is good, though some biases also peek through the reporter's somewhat breezy account. Since the time of Florence Nightingale, she notes, "nurses have occupied a hallowed, and distinctly feminine role on the sidelines of medical care and in the popular imagination (that is, when they're not depicted as sadists)." Well, that's basically right when it come to the "popular imagination," but certainly not in reality, in which nurses have long played a central role in saving patients' lives, and in which many (though not enough) nurses have been men. Rubinstein says that from Hemingway's Farewell to Arms to Michael Ondaatje's The English Patient, "writers have a tendency to portray nurses as surrogate mothers, in an Oedipal kind of way: nurturing, wise, gentle, sexy. Not, however, as practitioners who should be directing a patient's health care." Exactly right.

But now, Rubinstein suggests, "[t]hat's begun to change" with "current TV depictions like Showtime's Nurse Jackie and TNT's HawthoRNe." She notes that in these shows,

the protagonist nurses are wise and nurturing, with amazing interpersonal skills, but also worthy of more authority than they are given, constantly banging their figurative white caps against a figurative glass ceiling. In the first episode of Nurse Jackie, a 27-year old bike messenger dies from an acute subdural hematoma after a churlish young doctor ignores the hard-won wisdom of the protagonist played by Edie Falco. Ginia Bellafante, in the Times, attributes the prevalence of the long suffering, yet talented nurse on this year's television lineup to the economic crisis: "The portrayal is something else for which the class warfare brought on by the financial crisis arguably deserves credit: the enemy isn't any single Dr. Feelgood but the whole infectious culture of entitlement that has enabled his ascension." Perhaps the presence of Nurse Jackie and Hawthorne is also an acknowledgment of the heights to which nurses have risen, and the authority that the establishment still only begrudgingly cedes them.

There is truth in all this, including in the suggestion that one reason for the new nurse shows may be the difficult economic conditions, which may cause media that questions existing power structures to resonate more strongly. And nurses are worthy of a lot more authority than most of them now have. To varying degrees, the new nurse shows convey that, including NBC's Mercy, which Rubinstein fails to mention. But consider the language that Rubinstein uses to describe the new TV nurse characters:  they are "wise and nurturing, with amazing interpersonal skills," they have "hard-won wisdom," they are "long-suffering, yet talented." The focus is on intrinsic aptitude, inspiration and virtue, but not on education or physiological expertise. And there are those "figurative white caps" again! In any case, it's a stretch to say that the new nurse shows indicate that nurses have risen to "heights" in reality or in the public's estimation, particularly since two of them are cable shows with short seasons, and Mercy is struggling to find the audience required to survive as a broadcast network show, even on NBC. To the extent the piece is suggesting that television depictions have begun to change generally, it is sadly mistaken; the most popular hospital shows like House and Grey's Anatomy, as well as countless other shows that may occasionally include hospital scenes, continue to portray nurses as the peripheral subordinates of omniscient physicians who provide all the care that matters.

Even Mundinger seems, based on comments quoted here, to share a bit of this rosy vision of improvements in public understanding, though she may be simply thinking of the undeniable progress APRNs have made in recent years. Mundinger sums it up for the reporter this way:

I keep writing the same story. The story is, nurses are important people. They have the skills and knowledge way beyond what the public recognizes in them. And, I finally feel like I've got through. It's kind of like my life's goal is achieved.

Of course, this is exactly the story that must be told. We're sad to report, though, that it has not gotten through to most, as the general state of nursing today shows. However, pieces like this generally good profile are part of the solution, and we thank Rubinstein and the Observer.

See the article "The Nurse-Crusader Goes to Washington" by Dana Rubinstein in the December 8, 2009 issue of The Observer.

Contact The Observer.