Nurse Allie and NPs

What has become increasingly clear to me is that I am less concerned with titles, and I am more concerned with who is actually best suited to do the job.

Donna, the nurse practitioner I worked with for a decade, and a good friend. She hates this picture, but it’s the only one I have.

Every now and again, someone will ask me what I think our two kids will be when they “grow up”. This is probably commonplace for most parents, and it’s hard to avoid prognostications. What we try to avoid is pushing them down a set path. As we look at our children, we can see certain patterns with each of them, and certain careers seem to be a more natural fit. Other careers would seem to be a stretch, at least at this point.

Colleagues and friends have asked me if I would encourage our children to go into medicine or become a doctor. This is always fraught with a bit of peril. I don’t want to say “no” and sound cynical and jaded. If I say “yes”, I certainly don’t want to project that specific of an expectation upon them. Sometimes, I’ll dance around the subject. Andrew seems unlikely to pursue a medical career. Intelligence is not the issue. He likes history and current events more than science, he loves to negotiate with people, and frankly, he faints at the sight of blood. The Boy seriously almost passed out on our spring New Mexico trip when I took a splinter out of his toe. He claims it was surgery; I am predicting a litany of “man colds” in his adult life. The future still can be altered, I hope.

Allison, on the other hand, might have better odds. She has the intelligence. She also has a ton of compassion. There was one occasion when she was 3 years old, and Andrew tore some skin on his toes.  (He had been on his scooter wearing flip-flops. I hate flip-flops for this reason, and MANY others). Andrew panicked, and Allison had to settle him down. She had him on our couch, lying on his back. Allison found a dusty, dirty rag, ran it under cold water, and started dabbing his toes. “Bubby will feel better.” We called her “Nurse Allie” for a while after that.

I have a TON of respect for nurses (see my last piece). Maybe I’m telegraphing this one. Would I want either of my children to be a physician? I’m not sure. I would encourage them, however, to be a nurse practitioner.

I have a very positive view of all the NPs I have worked with. I frequently taught NP students during my 10+ years in pediatrics. (Please, to the physician assistant students I had, don’t be offended, as I only had 2 or 3 of you during my career. I’m speaking to the career path of which I’m more acquainted.) I collaborated with several NPs during my career. Some dynamite neonatal NPs took me under their wing when I was a resident. I get my medical care from a NP (and this person, who requested to stay anonymous, is the BEST). That should say it all right there.

I should probably have one of my NP friends tackle this next part. What’s the difference between a physician and an advance practice nurse (NP)? In brief, it is training and educational background. To become a physician, you have four years of medical school after your undergraduate degree, plus a residency in your chosen field (at least 3 years, often more – especially if you are a specialist). One has 7+ years after college, at a minimum, before you can treat patients on your own. NPs have their undergraduate degree, and must be a registered nurse (4ish years total to accomplish both steps). Their advanced training is usually another 3 years, and then they can see patients. (I know this is a bit of an oversimplified, but I don’t want to bore you with DETAILS.)

With the longer training, it would seem at first glance that physicians have the better background for taking care of patients. I think this is too simplistic of a view; I firmly believe there’s more than one road to Rome here.

Even though it is theoretically possible to be a NP in a shorter time frame than a physician, it doesn’t often happen that way. Most nurses will work in a clinical environment for several years before pursuing their advanced degree. Whether it is in a hospital or outpatient setting, nurses have to work in their field before progressing to an advanced degree. They are learning as they working; in a manner of thinking, it’s almost like an apprenticeship. Even though physicians have more dedicated formal education, the NP career path requires one to be hands on as a part of the process.

This period of employment before continuing with their studies also has some advantages.

-Maturity. I almost shouldn’t have to explain this one. Before furthering their education, nurses are actually living in the patient care world. They have to learn on the job, develop confidence, and actually assess their own performance before considering taking another step in their education. They are talking to and delivering care for patients and families, entering orders, interpreting results, and relaying information to physicians. “Learning by osmosis” has to happen before taking the next educational step.

-Communication skills. I have yet to meet a NP student (or a NP) that is a poor communicator. I can’t say that about some physicians. Why are they better? See my first point. It’s the most fundamental job for nurses. They live and breathe communication; it is a prerequisite of being an effective nurse. Most NP students I have taught needed to learn about meditation dosing, selection of the correct medication, understanding the vaccination schedule, when to refer patients, and other similar things. But they know how to educate patients and families; they know how to make information more understandable to the public.

-Compassion. I’m going to hear it from some of my physician friends on this one. Whether it is forced upon doctors (due to training in medical school or the demands of needing to care for 20+ people per day just force a level of detachment), or different personalities are drawn to medicine and nursing, I think our nursing counterparts have us beat in the compassion category. Maybe different personalities tend to gravitate to each profession; maybe it is selection bias on my part. I don’t know if there is data on this (how does one quantify compassion?), but from my qualitative observations, this seems to be the case. This is not to say physicians lack compassion; I do believe that the nursing profession (and therefore NPs) do a better job of incorporating compassion into their care.

I fully believe that the medical system could be improved with one crazy idea. It is important to have a frame of reference that your co-workers have. I would personally like to see medical students train with or shadow nurses for 4 weeks in medical school. And nursing students should do something similar with physicians. Better understanding of the other group’s “tasks” would have to foster better healthcare. It’s a crazy idea, and there are probably logical reasons that it doesn’t happen, but I sure would like to see it. Maybe it would help bridge some of the philosophical differences between nurses/NPs and physicians.

Heading in to 2016, before it was general knowledge that I was leaving, I had decided that I wasn’t going to teach any students that year. I was toast and I just wanted to keep to myself as much as possible. An old friend called, and asked if I could take her on, as she needed A LOT of clinical hours to finish off her coursework. I jumped at this opportunity.

Leah is the name of the student. I overlapped with her while I was in training at Cardinal Glennon. Some of the best nurses I worked with at Cardinal Glennon worked in the pediatric ICU (PICU). And of those, Leah was in the conversation of the best. She worked hard, she worked quickly, and she knew her (expletive) cold. I told her on the first day that she knew most of what she needed to know; she had been a PICU nurse for 12+ years. This was just finishing school.

She confidently talked to families, was thorough in her examinations and assessments, and knew most of her medications cold. When we would talk to families, she would scoop up crying children and hold them. She identified social concerns, and was dynamite with making sure people understood instructions. I think our office functioned better when she was there. And none of it surprised me; given her intellect and gigantic heart, it would gave been foolish to think otherwise. “I would let her take care of my children” is what I wrote on her evaluation. I would take umbrage if you told me that she is not equal to a physician. In most cases, Leah is probably superior.

I worked with a NP in our office off and on for a decade. Donna is the consummate professional. She worried about “her kids” more than anyone I knew. She always was the best dermatologist in our office (I have a hard time with thinking in 3D). And she had the biggest collection of photos that families had given get of their children. I was there to work with her, but honestly, I never saw her as working under my direction. We were colleagues in the truest sense of the word. As a professional, I had the utmost respect for her work. I can’t fathom of thinking if being her superior just because of difference of titles on our degrees.

I am not trying to denigrate physicians at all. Most are wonderful, compassionate people. And yes, the extra years of training occasionally makes a difference. But I think that accounts for less than 1% (not scientific) of what a provider will need to address on a regular basis. I think medicine should be less hierarchical and less concerned with status of the “who is more important” game. What has become increasingly clear to me is that I am less concerned with titles, and I am more concerned with who is actually best suited to do the job. One mark of being a true professional is understanding that certain people have “it”, and “it” is not dependent on a title. The best leaders, the best healthcare professionals, the best people are all well equipped to get certain tasks done, and the specific arc of their training matters less than many people care to admit. It is time we give our NP friends the full respect that is due. I am honored to have worked with and help educate each NP during my career. You have my respect; and if my kids go in to healthcare, may they turn out like you.



Author: Jason Kesselring

I am a 40 year old pediatrician on sabbatical, happily married, and a father of two wonderful children. I fell out of the Ugly Tree, and hit every branch on the way down.

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