Wednesday, June 10, 2009

AMA makes me go AMA (aint got nothin' on me)

I posted this response on The AMA is pissed that the new nursing doctorate program exit exams are touted to be as challenging as the third level of USMLE. Seems MD's are worried that these fake doctor's will obtain REAL doctorates, then call themselves doctors and thus will give physicians a bad name by providing excellent care, actually listening to the patients, and actually giving a shit. Outrageous.

This is a long post- my posts always are- that's how I roll- but I'll end the argument right here.

This one is important. I think the DNP is waaaay ahead of itself. Certified nurse specialists are hardly recognized. I work on the floor with N.P.'s who are kicking themselves because the payoff for 20K to 40K in loans and two more years of time and effort has been NOTHING. Having a BSN's doesn't guarantee diddley squat professionally, either. I don't think R.N.'s need a doctorate to prove their worth. It's like an industry wide lack of self esteem. The ability and potential of a minority of educated and motivated nurses is like medicine's dirty little secret.

"Medicine decries nurse doctorate exam being touted as equal to physician". Uhhhh-so what if it is? There are many different kind of nurses. Many different kind of doctors. Lawyers. Sales people. Pool cleaners. Judges. Some people in their chosen profession choose to take it as far as they can. YOU WANT TO ENCOURAGE THESE PEOPLE. Some nurses I wouldn't even let take care of my pet turtle. Same goes for everything. So what if the exam is equal to the USMLE?

Whenever I talk about my job people ask me if I'm a doctor. I proudly tell them "no, I'm a R.N."- I usually get a quizzical look implying the person asking the question thinks that if I'm not a M.D. I must hang around slinging bed pans all day, their look clearly says: "Why is this guy talking about HIS patient like he makes decisions about their care?" So I politely explain that M.D.'s make disease diagnosis and are in charge of plotting a course of treatment for the patient. I explain that is is my job to not only understand the course chosen for treatment- but I am the one who institutes the treatment and I manage it's physical run. Yes, doctor's prescribe medications and order diagnostics. But in my I.C.U. they sure as heck don't give medication. I start the I.V. I give the medications, I assess the patient and if anything goes wrong I need to catch it before it happens and give the doc a heads up so they can re-plot the course of treatment. If this is not true then why do I need to have a license? Why am I held accountable for an adverse reaction to treatment or a change in patient status?

Last night- I admitted a patient from the E.R. with a primary diagnosis of pneumonia, c/o chest pain-with an extensive cardiac history. The cardiologist who ordered the admit had full privileges at my hospital as he was standing in for an intensivist who had a family emergency. The cardiologist was responsible for the admit and all other standing orders. Other than the insurance the patient had, the cardiac history, and the fact that the patient had received nitro and morphine in the E.R. the cardiologist didn't know anything abut the patient OR WHAT TO DO WITH HIM. He had no clue how to address the possible pneumonia and or sepsis. (Apparently he hadn't heard of Joint Commission)

So I walked the cardiologist though activity, diet, fluid type and rate, antibiotic regimen and all other diagnostic procedures to rule out sepsis. I wrote the "orders" as I gave them with his consent. Apparently the patient had thrown up in the E.R.- I asked for an anti-emetic-all I heard on the phone was,"uhhhhh" So I suggested a medication with rate and frequency. I asked him for cardiac parameters. The cardiologist asked me how the patient looked. I gave him my the results of my cardiac and pulmonary assessment. He thanked me profusely, gave parameters, and kept apologizing that he was just moonlighting, he hadn't done this in a while.

He asked me for my interpretation of the chest xray.

I told him "Sorry, out of my scope." But I had seen bilateral infiltrates in lower lobes when I read it. So I again encouraged that we follow the sepsis protocol. No problem. It was nice that he was pleasant. But when push comes to shove-yeah, M.D.'s don't find the R.N.s so incapable after all. And then I began the paperwork.

Later that night, the attending came by and said, "Wow! Dr.--- can still write ICU orders like he works here everyday." I'm not a doctor. I sure as heck don't know as much as one. But how much education combined with clinical experience do I need to know as much as one? No doubt, a lot. As a brand new nurse I got chewed out by the attending physician right along with the interns and residents for flubs that we all should have caught.

You see, it's role reversal, plain and simple-without the exchange of authority. I want to learn more about the disease and cures while many of those interns, now residents, want to develop their bedside manner. Seems the smart ones have figured out that it increases the odds of a better outcome to be able to communicate with one's patient. Nurses learn this immediately. Some doc's never get it, or care to. In my opinion, they are the ones who are doing the most damage to physician's. Not a DNP. It appears that the few nurses who choose to pursue advance training, pushing the envelope of our assigned role is clearly terrifying to M.D.s. Perhaps a bit of "man behind the curtain", huh?

They can call us dumb nurses, wanna-be doctors, whatever. MD's know very well that as treatment becomes more rapid, more complex, more demanding, nursing education is becoming a dynamic new modality in itself. If I don't understand or anticipate treatment then I am useless.

And as frightening as it is to the A.M.A., I am rather inclined to learn as much as I can about the science behind my work so I 1) don't hurt my patient 2) continue to bring enthusiasm to my career. That may include advanced degrees. And I'm gonna say it: In my area of specialty, it certainly appears that experienced and well educated R.N.s know absolutely as much as physicians do, in that specialty area, and physicians know it. Much in the same way a cardiologist doesn't know what to do with an admit. You want evidence to back that statement up? Ever watch a new intern ask an experienced nurse a question? Tell me who is giving "orders" to who. What doctor hasn't been shown the ropes by a R.N. at some point? From the basics "he needs a fluid challenge" to "write an order to start a levo drip at 20mcg/min and start a central!"

But to know as much as an expert, takes a combination OF YEARS and education. Expedited by education but you can't be an expert without some serious time laid out.

According the the A.M.A.-this is simply impossible.The A.M.A.'s argument is essentially,"If you didn't start your career with a M.D. then you can't ever be as capable as one." Look how they treat D.O.'s? Childish. The truth is that the A.M.A. is concerned with the bad publicity they will receive when advanced nurses start taking the equivalent of the USMLE. THEY WILL DO OUTSTANDING. Nothing like the motivation of those with something to prove.

Example: My old hospital was a teaching hospital affiliated with a major university. It has a C.R.N.A. program. The S.R.N.A.'s have to retake anatomy and physiology along with the med students. Scores were posted in doctor's break rooms. Most of the med students pulled C's and D's. The nurses all scored above 80%. The hospital promptly stopped posting scores in the break rooms.

This is a turf war, plain and simple. MD's can't operate without us. Let them waste their time fighting nurses. Nurses don't fight for turf with doctors. We fight for respect and autonomy. Meanwhile- insurance companies- the real turf monster, are wiping the floor with what used to be the physician's salary and medical authority.