When I was 8 years old, I had an emergency appendectomy in a small county hospital near the summer camp I attended. I have a vague memory of the camp doctor who examined me briefly and decided that I needed surgery, and no memory at all of the doctor who performed the operation.
I do remember, in detail, decades later, the camp nurse who sat by my bedside until the doctor arrived, and the nurses on the children’s ward who brought me 7-Up with a bendable straw, and checked my incision, and told me I would be OK.
I thought of that long ago summer just recently, after a session of the literature and medicine group at my hospital. Several RNs, nurse practitioners, MDs, and hospital administrators meet one evening a month as part of a program sponsored by Mass Humanities to discuss poems, memoirs, essays, stories, and plays related to our work. This particular night, we’d been discussing narratives by two nurses from very different eras — Louisa May Alcott’s “Hospital Sketches” (1863) and Mary Jane Nealon’s “Beautiful Unbroken” (2011). A question came up, as we considered Alcott’s account of caring for the Civil War wounded, and Nealon’s descriptions of treating the homeless and those infected with HIV in the 1980s and 1990s: What’s the difference between a nurse and a doctor?
Fifty years ago this question would have been easy to answer. With few exceptions, nurses were women and doctors men; doctors had many more years of education than nurses; nurses had a more physically intimate relationship with patients, providing enemas, baths, and backrubs, while doctors moved from bed to bed, touching patients only as necessary to make a diagnosis or to assess a patient’s progress.
Nowadays, while more than 90 percent of nurses in the US are women, more than half the entering class at some medical schools are also women; nurses are more likely than ever to earn bachelor’s degrees — or masters or PhDs; and enemas and baths are delegated to assistants. Today, that 7-Up would likely have been handed to me by a food service worker. And nobody gives backrubs anymore.
And yet, our group still felt that there is a fundamental difference between doctors and nurses, one as true today as it was when Alcott was dressing cannon wounds among Union soldiers, and that it has something to do with time — and even more to do with a clinician’s relationship with the patient.
In the hospital, this difference is easier to identify than in a clinic or office practice. Nurses work set shifts — 8, 10, or 12 hours — and are assigned specific patients whom they see frequently during that period. Doctors, on the other hand, visit the patient once, maybe twice a day, usually for a few minutes, often with a team of other doctors and medical students. Doctors also show up when something goes terribly wrong: respiratory distress, high fever, a drop in blood pressure. When a patient rings the call bell because they can’t sleep, or they’re in pain, or frightened, it’s the nurse who appears.
In the hospital, doctors make important, but relatively few decisions, including which medication a patient receives and when they’ll be discharged. Nurses make dozens of decisions that come up each shift about every possible aspect of a patient’s care: whether a patient’s condition is deteriorating, whether to administer an “as needed” medication, when to evict a disruptive visitor.
As I learned after my appendectomy, and relearned again years later when various family members were hospitalized, nurses spend more time with patients and address, much more closely than doctors do, a patient’s actual experience of illness. In the hospital, doctors deal in critical, but — for the patient — relatively abstract issues. The idea that a patient has a particular infection and needs a certain antibiotic is formulated by the doctor. But the nurse plunges the drug into the patient’s veins and monitors the breaking of the fever.
In an outpatient practice such as mine, the distinction between doctors’ and nurses’ roles can be more subtle. Nurse practitioners, who have both bachelors and masters degrees plus special certification, prescribe medication, perform physical exams, and act in many ways indistinguishable from doctors. Outpatient RNs, such as those with whom I work, may find themselves on the phone with patients all day doing “triage” — that is, deciding who needs to come in to the office, who needs to go to the emergency room, and who’s better off staying home — while doctors have more actual physical contact with the patients.
And yet, even when the traditional roles seem to be at least partially reversed, I see a clear distinction between the nurse and the doctor.
Not long ago, a patient of mine who takes anticoagulants saw blood in his urine. It’s an upsetting symptom, one that raised several disturbing questions for the patient: When would the bleeding stop? What did it mean? Did he really need to be on this potentially dangerous medication? Did anybody care that he was bleeding?
The nurse with whom I work talked him through these concerns and — any nurse will tell you this is part of the job — calmly listened to him express the fear and anger he wouldn’t reveal so readily to his doctor.
By the time I saw him, the patient still had questions, but he didn’t feel quite as upset as he had before speaking with the nurse. She had acted as the intermediary between his experience (bleeding, frustration) and my agenda (his need for anticoagulation). Perhaps this is as good a definition as any for what a nurse does.
One of the nurse practitioners in our literature group offered a slightly different one: She was struck, years ago, while working in the emergency room, that when a foul smell wafted from one of the patient rooms, the doctors scurried past it, while the nurses threw aside the curtain and rushed in.Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. Read her blog on Boston.com/Health. She can be reached at inpracticemd@gmail .com.