The world outside the cave

Physician writers salute nurses in the elite media

March 3, 2014 -- The last few months have seen a striking range of elite media items in which physician writers have recognized the importance and expertise of nurses, from famous figures of the past to unnamed nurses in current practice. On December 16, 2013, Richard Gunderman had a piece in The Atlantic, "Midwives for the Dying," in which he argued that death has a lot in common with birth. To illustrate this theme he offered an extensive, thoughtful interview with Michigan palliative care nurse Peg Nelson. Ten days later, Barron Lerner posted a review on the New York Times Well blog of a book by Yale historian Naomi Rogers about Elizabeth Kenny, an Australian nurse who played a prominent role in early polio care and emphasized patient mobility and "keen clinical observation." On February 10, 2014, Lawrence K. Altman wrote a Well blog post about an "eminent" medical professor's belated realization, after a hospitalization at age 90, that nurses were important to his care. The piece shows genuine appreciation for nurses' knowledge and their role in catching deadly errors, but it does not show an understanding that they are autonomous professionals who save lives following their own practice model, not just valuable physician assistants. And today, Victoria Sweet penned an essay, "Far More Than a Lady With a Lamp," about the radical change in her opinion of Florence Nightingale when she actually began to learn about the British nurse's pioneering work on hospital design, data-driven health research, and other public health matters. We thank those responsible for all of these items. It's not that nurses need physicians to approve their work, of course. But the pieces signal openness to a serious consideration of nurses' health care skills, and physician-created media about nursing may be more persuasive to the public than media by nurses themselves would be.

People have always been dying: Richard Gunderman and Peg Nelson

Lecturing a group of physicians: Barron Lerner on Sister Kenny

Tender, loving care and the culture of medical education: Lawrence Altman on a key discovery

Our beautiful hospitals: Victoria Sweet on Florence Nightingale

People have always been dying

Richard Gunderman, a physician and writer at Indiana University, begins his Atlantic piece "Midwives for the Dying," by arguing that the process of death resembles that of natural birth, with the ups, downs, and waiting. And just as midwives have long assisted in births, there are comparable health professionals who aid in the dying process.

One person who regularly plays this role is Peg Nelson, nurse practitioner and director of pain and palliative services as St Joseph's Mercy Oakland Hospital in Pontiac Michigan. Peg has been a nurse for thirty-three years and brings fifteen years of experience in palliative care to her patients. She is the recipient of numerous awards for her work, which she now regards as her life's calling.

He asks Nelson some open-ended questions, and she responds, as he says, with "helpful insights from which everyone contemplating death or caring for a dying person can benefit." Nelson does not feel helpless in confronting death, because she has accepted that she can't control it, which "frees you up to use your compassion to help people." She does so by easing pain, fear, and lack of understanding of the illness; by helping patients make the most of the time remaining; and by really listening to them. Nelson notes that "there is no one right way to die," and every patient and family is different in their preferences. Gunderman asks what she says to those who are dying, and she gives examples, like "I wish things were different." She stresses: "It is not only pointless but harmful to pretend that dying is not happening." When Gunderman asks about the heartbreaking situations Nelson encounters, she says she focuses on doing what she can. One young widower came to terms with his wife not having said goodbye after Nelson helped him see that "for her, doing so would have seemed like giving up, and her way of loving was never to give up." And when Gunderman presses the midwife comparison, Nelson observes that "just as women have been giving birth forever, so people have always been dying, and our mission is to help them do it as comfortably, naturally, and meaningfully as possible. Just as we need help coming into the world, we need support and love going out of it." 

This piece does not include a lot of technical information, but it allows Nelson to display her psychosocial expertise and even wisdom. Her comments, together with the credential-rich introductory profile quoted above, convey both authority and humility. And although she is dealing with very emotional issues, there is really nothing here to reinforce the angel stereotype, no easy platitudes, but instead honest, practical nursing insights. And one impressive intervention:  helping the young widower reach a better place.

Lecturing a group of physicians

New York University's Barron Lerner is another physician and writer. His New York Times piece, "A Nurse Gains Fame in the Days of Polio," discusses Naomi Rogers's biography Polio Wars:  Sister Kenny and the Golden Age of American Medicine. Lerner says that in the years after World War II, nurse Elizabeth Kenny was among the women Americans most admired because of her apparently successful polio treatment methods. "Sister Kenny" began as a rural "bush nurse" in Australia and served as a British Army nurse on troop ships. She began acting on her observations of polio, which was then a dreaded disease, often causing paralysis and even death. Kenny saw that exercise seemed to relieve symptoms, but that was contrary to conventional treatment, which emphasized immobilizing paralyzed limbs. She became famous, enjoyed strong support from believers, and opened a clinic in Minneapolis. Some physicians objected, and not just because there seemed to be no scientific basis for her theories (and some of her beliefs about the disease were proved wrong). Physicians also had problems with Kenny because "she was a nurse questioning the authority of physicians," she was an outspoken woman "challenging the overwhelmingly male medical profession," and "as Dr. Rogers admits, Ms. Kenny was prone to embellish both her own story and those of her patients." A polio vaccine was developed in the 1950s. But Lerner emphasizes Kenny's continuing relevance in the current era of evidence-based health care because of her "fierce adherence to what she observed at the bedside." He also notes that her "emphasis on early mobilization has come to be a mainstay of not only polio treatment but of physical therapy more broadly."

Lerner's piece is valuable because it presents a nurse as a fierce pioneer of clinical practice and nursing empowerment, defying the male physician establishment with some success, even if not all of her theories and practices turned out to be correct. And Kenny evidently was correct about some things, as Lerner explains. The review shows respect for Kenny's work and a sense of the nurse-physician dynamics. The piece also includes a striking photograph with Kenny, as the caption says, "lecturing a group of [male] physicians in a corridor of the Minneapolis General Hospital in 1942." We do have to note that, despite the changes in gender relations, it's not clear how different things would be today if a nurse were to defy the physician establishment as Kenny did. For a hint, consider how some physicians have reacted to the growth in advanced practice nursing.

Tender, loving care and the culture of medical education

Lawrence K. Altman's "Doctors" piece in the Times, "A Patient's-Eye View of Nurses," describes the experience of "the eminent former medical educator and editor" Arnold S. Relman after he fell at home and suffered severe injuries. Relman spent 10 weeks in the hospital and months in rehabilitation. He later wrote a "riveting account of the medical adventure" for the New York Review of Books that, Altman notes, "betrays a surprising lack of awareness of some critical aspects of the medical profession and the nation's fragmented health care system." Among other things, Relman "confesses that he 'had never before understood how much good nursing care contributes to patients' safety and comfort, especially when they are very sick or disabled.'" How could such an eminent medical leader "not have known about the value of modern-day Florence Nightingales?" Altman suggests it may be the "culture of medical education," in which young physicians follow and revere "august" medical professors who are often "supremely confident in their observations and opinions." That tradition has not involved much attention to those who are not senior physicians. Relman refers to the junior physicians at Massachusetts General--who Altman says "provided the round-the-clock attention that kept [Relman] alive"--only as "a team." Altman critiques the practice of medical professors holding forth about tests and plans in the hallway just outside patients' rooms, forgoing patient interactions, which the professors may see as an inefficient use of their time. Instead, they "rely on nurses" to provide personal care. Altman says modern health technology kept Relman alive, but "tender, loving care from family and nurses is priceless, as is the bedside manner of a sympathetic doctor." Relman noticed that his physicians' progress notes were full of technical data but had nothing about his appearance or feelings, and that his conversations with those physicians were rare. He wrote: "What personal care hospitalized patients now get is mostly from nurses. When nursing is not optimal, patient care is never good." Altman notes with regret that hospitals have cut nursing staffs, ostensibly to "make ends meet," but "many doctors say it is usually to increase the bottom line."

Nurses' observations and suggestions have saved many doctors from making fatal mistakes in caring for patients. Though most physicians are grateful for such aid, a few dismiss it -- out of arrogance and a mistaken belief that a nurse cannot know more than a doctor.

Altman suggests that Relman's piece reflects changes in how the health professions are trained, traditionally in "separate silos." But "as health care financing changes and doctors spend more time training in outpatient settings, a growing movement demands coordinating the education of health professionals to prepare them to work more smoothly in teams. If these efforts succeed, perhaps the next generation of doctors will no longer be surprised at the importance of nurses and other allied professionals."

Yes, perhaps. Altman's piece has valuable insights about why physicians have not traditionally appreciated the value of nursing, as well as some good statements about what nurses do for patients, notably catching potentially deadly physician errors. And we really liked the reference to the "mistaken belief that a nurse cannot know more than a doctor." Yet the piece subtly reflects some of the same type of regressive assumptions. For instance, what's with the reference to the junior physicians keeping Relman alive with round the clock care? No doubt some physicians were around at all hours, but it's the nurses who provide the round-the-clock bedside care that keeps patients alive. Also, the notion that physicians "rely" on nurses for the personal care makes it sound like the nurses are just helping physicians, rather than following their own practice model to help patients. Nurses save lives in ways that have little to do with physicians, such as through patient education. And the reference to "tender, loving care from family and nurses" places nurses in the same category as unskilled family members. By contrast, the physicians have have a "sympathetic" "bedside manner," which sounds more like the good psychosocial skills of a modern professional. The piece reflects real appreciation for nurses' roles and skills. But nurses are not physician assistants who focus mainly on "tender, loving care."

Our beautiful hospitals

Today San Francisco physician and historian Victoria Sweet published a strong piece, "Far More Than a Lady With a Lamp," about how her views on Florence Nightingale changed. In medical school she had ignored Nightingale, assuming that the nurse represented the roles of "obedient wife, caring sister, modest daughter." But when later practicing medicine at an old hospital, Sweet learned why "its comfortable open wards were 'Nightingale wards.'" After the Crimean War, Nightingale had studied almost all of the hospitals in Europe and published Notes on Hospitals, "which became the guide to hospital architecture for the next century." Sweet was impressed by the "acerbic, witty and clear" analysis in this book and Nightingale's use of mortality statistics, including her invention of the polar pie chart, "a visual way of understanding data we still use." The appendix "gave [Sweet] the first inkling that this was a brilliant woman." Sweet read more by and about Nightingale, learning about her wealthy family background and her long struggle to get her family to allow her to be a nurse for the poor. Apparently using family money, Nightingale took over a hospital, but it was her work to reform the filthy and ill-equipped military hospitals in the Crimea that really caught the public's attention--and set her future path.

She wrote "Notes on Nursing," which became a best seller and made her financially independent. She reorganized Britain's army hospitals and reformed the nursing in workhouses. She founded the first real school for nurses, and its graduates -- "Nightingales"-- carried her reformation throughout the world. She wrote on public health, sanitation, India and prostitution, and for 50 years she was behind most of the health-related legislation in England. All this even though she was bedridden from chronic brucellosis, an infection she'd contracted in Crimea. ... So much of what she fought for we take for granted today -- our beautiful hospitals, the honored nursing profession, data-driven research.

Sweet closes with commentary on what Nightingale would have thought of the Affordable Care Act. She suggests Nightingale would have liked Obamacare's focus on public health, data, and better access to care, but not its complex regulatory structure, which "gives too much power to the telling of economists and lawyers and too little to the calling of doctors and nurses." But as an optimist and a fighter, Sweet writes, in the end Nightingale would likely have seen the legislative reform as a "work in progress."

This piece is very helpful because it charts the same journey we wish everyone would take regarding Nightingale and nursing in general --from the still-powerful sense of nurses as angels and handmaidens to an understanding that nursing is a profession for highly-skilled health innovators and advocates. Many readers may see themselves in Sweet's description of her early impressions of Nightingale, especially readers who can relate to being a highly-educated female entering an esteemed profession traditionally dominated by males. We might wish for a more evident link between nursing and Nightingale's public health innovations and patient advocacy. As it is, readers might not fully understand that this is all part of nursing, and modern nurses also do these things. At least the nurses trained at Nightingale's school could "carr[y] her reformation" forward, but beyond that, they seem to be simply "honored." Still, this tribute has real value.

See Richard Gunderman's "Midwives for the Dying," published December 16, 2013 in The Atlantic online.

See Barron Lerner's "A Nurse Gains Fame in the Days of Polio," published on December 26, 2013 in the New York Times online. A version of this article appeared in print on December 31, 2013, with the headline: A Forgotten Warrior Against Polio.

See Lawrence K. Altman's "A Patient's-Eye-View of Nurses," posted February 10, 2014 on the New York Times Well blog.