ANTIGONOS' BRAIN

Your Brain is Green
Of all the brain types, yours has the most balance. You are able to see all sides to most problems and are a good problem solver. You need time to work out your thoughts, but you don't get stuck in bad thinking patterns. You tend to spend a lot of time thinking about the future, philosophy, and relationships (both personal and intellectual).

Tuesday, January 16, 2007

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.

10 comments:

Dr Sniper said...

Dear Antigonos - I am a fan of Dr Crippen. His point, I think, about nurse practioners is a little more complex than feeling threatened by them.

The nurse practioners are being used as a political tool. Instead of seeing a gastroenterologist, you see an NP get a flexi-sig and then go back to the GP. The NP may well be more competent than the reg. But they are a lot cheaper to run than a doctor. Money saved, normal investigation done. It just did not go far enough, because the NP does not have the autonomy to go further. The patient is still anaemic with no answer. Then 4 years later the patient dies of their previously occult cancer. This time frame for death coincides with when the previous incumbent health minister/government has left office. Who do you blame for your parent's death? You can't blame the politician who changed the system. You can’t find them and only with sharp hindsight will you spot the error. Perhaps a highly autonomous NP is a doctor without a medical degree? They are cheap to train, cheap to run. It is a political win, less cost, shorter waiting lists and huge political spin. They are expected to do a doctor’s job on a nursing salary. I personally feel that NPs have a role and may have more experience within certain areas than some registrars but they sometimes lack the holisitic physiological overview of a doctor. Certainly, I learn from NPs. I believe in NPs - as part of a team. They should not be the whole team, which is the way things are turning out in the UK.

Dr C's other point about NPs is that, instead of being allowed to nurse. Nurses are expected to upskill and become NPs. Nurses do nearly all the care of patients and should be left alone, politically speaking, to do it. Dr C was being facetious when he talked about bottom wiping, it is important, but nurses can’t even perform this basic service because there are not enough of them employed. How can they give the support and care to dying patients/relatives when they are too busy for basic nursing care? We as docs ask for things to be done and then the nurses try to do it. The nurses deliver the actual care, not us. But we exist together as a highly symbiotic creature.

Dr Sniper

Anonymous said...

you look like an overweight drag queen.

Andria and Co. said...

are you kidding me??? you post on a GRIEVING mother's website, that her baby's death is her fault?
what's next? are my three miscarriages in the last year my fault as well?
shame, shame on you.

Antigonos said...

Anonymous thinks I look like an overweight drag queen. Overweight I definitely am, but how can I be a drag queen if I'm female?
Andria and co. wonders if I would blame her for her miscarriages. Of course not, there's no comparison, and no intelligent person would make one, unless of course she climbed Mt. Everest after her doctor told her exertion might cause her to lose the baby. The biggest cause of early miscarriage is a defective pregnancy or hormonal problems; later miscarriage (if after 20 weeks it is technically an intrauterine fetal death or stillborn) is due to a variety of factors, such as incompetent cervical os or insufficient amniotic fluid or the placenta not functioning well. Although the cause of some miscarriages is never determined, there are successful treatments and medical regimes for most.

Andria and Co. said...

I was just (trolling) around on blogs, and I saw that Erin's website was back up. I then, saw the situation that was going on with Dr. Amy.

When I posted the comment to you before, I must admit, that I didn't know all of the facts. Now, I apologize. You certainly had every right to say what you felt- afterall, isn't her blog public?

I blog with the thought in the back of my head, that not everyone is going to agree with my comments. My views. My choices. And, when I receive negative comments, I either let them roll off my back, or I try to understand the perspective that the commentor is presenting.

Erin, certainly, has my sympathy. My empathy. I have had three miscarriages, but cannot compare that to losing a child at birth. I worked as a Respiratory Therapist for 6 years, before deciding to stay home last year. The majority of full-term babies that came into the NICU were home-births gone wrong. And, those were the babies that actually made it into the NICU.
I am not disputing that babies die in the hospital. And, I am not attacking Erin. However, sometimes ignorance is bliss. I don't think she wants to accept the fact that this tragic death could have been prevented. That, or maybe she is not ready to accept it. There are five stages of death- maybe she is still in the anger part, and will eventually move into the accepting and understanding. I did not know that she had went into labor on Thursday, and by Saturday, was still laboring. And, refusing to have diabetic testing because "it doesn't run in her family", and then saying that she is adopted? How would you know?? I simply, did not research the blog and see the facts. I understand that Erin wants to use her blog as an outlet for grief. But, by choosing to make it public, she should understand that she is going to receive negative comments. And, not just meanspirited comments, but well-informed views, other than her own. And, I am not saying that your comments were meanspirited. If anything, you proved on Dr. Amy's site that you were actually concerced about Erin. When I saw Erin's entry on the "bitch who made a mean comment" (or something along those lines) I jumped to her defense. Afterall, she is a mother who lost her child. But it comes down to this...if she is going to attack every person who doesn't pat her on the back, and then publish their personal information, then she needs make her blog private.

Anyway, sorry for the rambling, I just wanted to apologize for attacking you before, without looking at the facts.

Andria

Antigonos said...

I was harsh with Erin because I think she is in danger of repeating the tragedy, not because I want to lumber her with excess guilt (frankly, I think she knows just how culpable she is). If she tries for a homebirth VBAC with her next baby, she is in real danger of dying herself. A "short, sharp shock", if you will.

My feelings about homebirth aren't as strident as Dr. Amy's. I think there is always potential risk in birth, not "inherent" risk, as she claims. But when one is in a situation where (1) one is in the hands of nonprofessional staff, and (2) there is no real backup capable of dealing with every kind of emergency, the risk in homebirth is an unacceptable one. Sure, the vast majority of homebirths will be uneventful--but when the axe falls in obstetrics, it falls VERY fast.

I think Amy has a point about "empowerment". Labor is something that the mother is simply not in control of, and as a result, is very frightening. In that sense, it is a kind of "rape" in that, by definition, rape is outside a woman's control. Any technique that promises a return of control over one's physiologically natural processes is very attractive (even if it doesn't work). And hospitals, and doctors, aren't always the nicest places to be. But I don't think that being at home is the answer.

Anyone reading these comments will wonder what the heck is going on. I promise, promise, promise, to bring the blog up to date soon!

Anonymous said...

Why did you have to be "harsh"? Why couldn't you just say what you said but in a better, nicer way? You didn't have to be so rude about it and say she is "more than a little responsible" for her daughter's death, If a child of yours was stillborn and somebody told you it was all your fault, how would that make you feel? huh? I'm just curious

Antigonos said...

You seem to have missed the point. There ISN'T any "nice" way to tell someone that they deliberately made really bad choices through ego and ignorance. Moreover, in order to try and avoid another tragedy--this time which could be fatal to her, or possibly end her reproductive career, mincing words would actually be a kind of fraud. Erin, who is still milking the situation for all it is worth, three months after the baby's death (she's created a shrine in her home, for heaven's sake, and she defines herself by her baby's non-existence, which is way over the top for normal grieving) likes to portray the baby's death as an act of God. It wasn't. It was an act of Erin. Time to face up, make new and better-informed choices, get on with life.

I deal with bereaved mothers frequently. Erin's behavior borders on the pathologic, sorry.

Anonymous said...

What is wrong with making a "shrine" for your child? Of course they are going to put pictures up of their daughter! You still have not answered my question either. What would you do if somebody blamed YOU for the death of your child? I lost my son two years ago in a hospital. I had regular check ups, I was told he was healthy, I ate the healthiest foods, took great care of myself, and he still died, IN A HOSPITAL, for "unknown" reasons. Is it all MY fault that he died? Is there something I could have done differently to prevent it? please share....

Anon said...

quote from your post: "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."

Actually, we do. Although most of us will have to pay out of pocket for our midwives. I had 2 home visits from my midwife, one at 2 days pp (went home the day after) and one at 1 week.

Then, I went in to their office for my 2, 4 & 6 week pp visits.