NHS BlogDoctor

"But you will not convince the nurse-specialists of this; they still
churn out their vacuous botty-wipe when they would be better occupied wiping
bottoms. "

Thus writes "Dr. Crippen" of the NHSDoctor blog. He is a British GP who is deeply, deeply unhappy with the state of the NHS. His attitude seems to be that the NHS would be in fine form if doctors were paid the kind of salaries that US private physicians made, and if it were managed by the CEOs of major industry.


This does seem somewhat contradictory to the original aim of the NHS, which was to provide every British citizen with a high level of free health care, but I can see the allure of it. My own experience of the NHS, in, admittedly, a somewhat ideal situation and over 30 years ago, gave me a lot to think about.


ANY national health service, introduced at a time when the country was bankrupt [as the UK was after two ruinous World Wars, a Depression, and the loss of its Empire] is going to have hard going living up to its promises. Especially at a time when it still had food rationing, for heaven's sake. Moreover, there wasn't then--and there isn't now--any way to adequately budget such an all-encompassing health service for the simple reason that inevitably it will uncover vast amounts of hidden health problems. You don't go to a doctor when you're feeling a bit off-color if it's going to cost you an arm and a leg. But if it's free, you run to him with every ache and pain (real or imaginary) and some turn out to be serious, unsuspected illness. Further, there's no way of knowing what advances there will be in medical science. Heavens, when I was a child, there were hardly any antibiotics besides penicillin, and when I was a newly-graduated obstetric nurse, neither ultrasound nor fetal monitors had yet been invented.


And lastly, the NHS was brought into being by politicians. And every change of government--and sometimes even more often than that--added "reform" which is politician-speak for another layer of bureaucracy. And bureaucracy = inefficiency nearly 100% of the time.


But my year in Cambridge was vastly instructive. The level of care a pregnant woman/newly-delivered British mother and her baby got was immensely better than her American cousin who did everything privately and at great expense (let's not even compare our British patient to those millions of American women who have no antenatal care at all because they haven't got insurance or ready cash). Even in the mid-70s there was moaning and teeth-gnashing by the consultants about the "14 signatures" needed to order a new scalpel, but I couldn't help feeling that some of this was overreaction when I made home visits (home visits!!) to every woman after discharge from the postpartum ward to check her and her baby. American women have no such service at all.


But that's not what I really wanted to address when I began this. "Dr. Crippen" doesn't like nurses who don't stay in "their place". He doesn't like nurse practitioners, calling them "nurse quacktitioners". He obviously feels very threatened by them and wants to maintain his medical superiority at all costs. I noticed this back in the 70s in Cambridge. Doctors did not breathe the same air as us on a social level. Nurses were expected to associate with hospital auxiliary staff, such as ambulance drivers. Our lounge in the hospital had a black and white TV and several tabloids and the Daily Telegraph while the doctors' lounge had a color TV and The Times. (As a Yank who didn't know any better, and since the doctors' lounge was in the part of the nurses' residence in which I lived, I blithely used the doctors' lounge all the time and none of the doctors--the British are so polite--quite had the nerve to ask me to leave it) This was rather odd, because the relationship between the obstetricians and the midwives was actually quite good, on a professional level. The Central Midwives Board's code of practice made us the complement of the doctors, not subordinate to them. As long as our patients were within certain parameters, we were not even obliged to notify a doctor of their existence. But once those parameters were crossed, and we called a doctor, he knew that it was not a trivial call.


What "Dr. Crippen" is actually protesting is not that nurses are too stupid to work in conjunction with, instead of for doctors. What he is protesting is the level of their education, which, for all I know, may be inadequate nowadays. If this is true, then get the nurses' education upgraded! But don't be paranoid about nurses being used as "doctors on the cheap". Nurse practitioners can be an immense asset.

I currently work in the Israeli version of an HMO. Every day I get women who come into my room seeking amplifications and explanations that their doctors either didn't think necessary to give or which they didn't understand. It is part of my job to make sure these women do understand, as well as to screen those patients prior to seeing the doctor. Sometimes they don't need to. Sometimes they need to see the doctor immediately and must jump the queue. The doctors rely on me to be sufficiently able to discern this. That's what I mean by "complement".


I could do more. There really isn't any reason to make a woman wait an hour to get a prescription for prenatal vitamins, but in Israel nurses cannot write any prescriptions at all. As a midwife, in hospital I can do a vaginal exam to determine if a woman is in labor, but I can't do that in a sick fund clinic, although we tell women that they should come to us rather than go directly to the labor unit if they suspect they are in labor, in order to prevent unnecessary trips to the hospital (which charges the sick fund). So when a woman arrives, in obvious labor, I have to have her wait until a doctor is free (and to the great annoyance of the other women, who have to wait even longer to get into the doctor).


When I was a student nurse, I remember being told by a nurse nearly ready to retire of her excitement when, in 1938, a doctor had actually allowed her to take a blood pressure. Now of course, even nurses' aides do it. As doctors get new toys, they generally find that--amazing!--the nurse who was too stupid or uneducated to use the old ones has suddenly had a brain transplant and can cope with the technology. I think it took about 3 years before we were allowed to do anything more than wrestle the tank-sized first models of fetal monitors into patients' rooms. Placing the sensors on the woman's abdomen was obviously beyond our capabilities (although dragging the heavy machine around wasn't) until ultrasound arrived and then the doctors had something new to entrance them and fetal monitoring became a time-consuming burden best left to their "inferiors".


Because I spent some time in medical school, I understand the difference in the mental disciplines of doctors and nurses. Our goal is the same: to return the patient to health; our methods are different. It is truly sad when one group feels threatened by the other, and the other is made to feel inferior to the "superiority" of the medicos. I'm not a "diluted doctor" nor do I want a string of initials after my name for the snob appeal in order to feel less "exploited". I think doctors--some of them, at any rate--actually resent that it is good nursing care which can actually be the determining factor in a patient's recovery. (And let me state that the quality of British nursing care which I saw in Cambridge was truly excellent). So yes, "Dr. Crippen", wiping bottoms is important. But it's not the only thing. When my mother was dying, good nursing care was all that eased her suffering, once the doctors had thrown up their hands. But the kind of care she received could not have been done by stupid, uneducated, indifferent health care workers. It was done by highly intelligent, well-educated nurses, who saw aspects of her situation the doctors never noticed. Without the care and the observations of the nurses, doctors wouldn't have almost any data on which to base their plans of treatments. Lab results and tests only tell you so much.


As part of his blog, "Dr. Crippen" includes a weekly diary of some of the patients he sees. Nearly every week he describes at least one patient who could have been assisted by a nurse, at least partially, and would have helped him spend more time with the sicker ones. He finds this almost frightening, and I really can't understand it. I'm not there to replace him, heaven forbid.