Response to the 2013 Question of the Year
Dr. Nurse, Nurse Doctor: Blurring the Lines of Professional Identity Shirie Leng, MD
Thirty years ago, questioning what
it is to be a doctor or a nurse would have been viewed as absurd by doctors, nurses, and patients alike. Roles were clearly delineated within the disciplines and signaled by clothing, with the white coat indicating a doctor and the white uniform with cap identifying the nurse. There are several reasons why we now should ask this question. These include the entry of women into the field of medicine and the development of advanced degrees for nurses. The computerization of medical records has spurred increases in the need for so-called physician extenders, such as physician assistants (PAs) and nurse practitioners (NPs), to support practices and deal with the complicated and timeconsuming data entry responsibilities these computer systems require. Costcontainment considerations have led to the expansion of nurse and technician roles. The erosion of the perception of the doctor as an ultimate authority figure and the rise of patient autonomy have leveled the field as well. Educational degree levels have tradi tionally helped define “doctor” and “nurse,” but may no longer be a reliable indicator. Traditionally, a doctor who graduated from a U.S. medical school had an MD; today, a doctor may also have a DO if he or she attended an osteopathic medical school. In the past, nurses had an
Dr. Leng is an anesthesiologist, Beth Israel Deaconess Medical Center, Boston, Massachusetts. Correspondence should be addressed to Dr. Leng, 33 Florence St., Newton, MA 02459; telephone: (617) 990-4436; [email protected]. Acad Med. 2013;88:1613. doi: 10.1097/ACM.0b013e3182a7eeef
associate or bachelor’s degree in nursing. These days, a nurse may have a doctorallevel degree (e.g., PhD, doctor of nursing practice) or a master’s degree in addition to his or her undergraduate degree in nursing or another field. Prescriptive and diagnostic authority used to separate doctors from nurses. But now, many advanced practice nurses can prescribe medicines, write orders, and examine and diagnose patients. Nurses and doctors used to look different as well. In hospitals today, the ways that nurses and doctors dress are emblematic of the blurring of the lines of professional identity. A doctor may wear scrubs, and a nurse practitioner may wear a white coat. In the operating room, everybody wears the same thing. Clothing has long been a tangible symbol of change. For example, women started wearing pants around the time they started entering the workforce, especially during World War II. The nurse’s cap disappeared in the late 1980s, in part due to the entry of men into the field of nursing. Do differences in lifestyle and compen sation remain? Nope. A primary care doctor often makes less than a nurse anesthetist does. Some doctors no longer take call, whereas many nurses do, even those without advanced degrees. Knowledge and skill do continue to separate nurses from doctors. The doctor may have more book knowledge, but the experienced floor nurse knows more about treating patients than the average intern does. The ability to perform complex surgery or diagnose a complex medical problem is generally acquired by physicians. The ability to place that complex medical problem
Academic Medicine, Vol. 88, No. 11 / November 2013
within the larger context of the patient and environment is the nurse’s forte. This last distinction is where I believe the definitions of “nurse” and “doctor” can be found. I have been both a nurse and a physician. In my view, the difference is one of philosophy. Everybody takes anatomy and physiology, studies pharmacology, and accrues clinical experience. The approaches taken to these and other subjects differ, however. Medicine considers itself a branch of science. Doctors are trained to diagnose and treat disease processes as individual entities. The term “medical model” is defined in terms of pathology and signs and symptoms of specific disease.1 In contrast, the nursing model is more sociological and places greater emphasis on the larger environment in which the disease occurs. For instance, prominent models of nursing practice include the “activities of living” model,2 in which disease is evaluated in terms of how it affects daily life, and Dorothea Orem’s3 model, which focuses on how the disease process causes self-care deficits. I think even the remaining distinctions are becoming hazy. Doctors are becoming more holistic in their practice even as nurses are becoming more specialized. I am hopeful that eventually the questions will not be “What is a doctor? What is a nurse?” but, rather, “What does it matter?” References 1 Medical model. In: Marshall G, ed. A Dictionary of Sociology. New York, NY: Oxford University Press; 1998. http://www. encyclopedia.com/doc/1O88-medicalmodel. html. Accessed July 25, 2013. 2 Roper N, Logan WW, Tierney AJ. The Elements of Nursing. New York, NY: Churchill Livingstone; 1980. 3 Orem DE. Nursing: Concepts of Practice. 6th ed. St. Louis, Mo: Mosby-Year Book; 2001.
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Dr. Nurse, Nurse Doctor: Blurring the Lines of Professional Identity Shirie Leng, MD
Thirty years ago, questioning what
it is to be a doctor or a nurse would have been viewed as absurd by doctors, nurses, and patients alike. Roles were clearly delineated within the disciplines and signaled by clothing, with the white coat indicating a doctor and the white uniform with cap identifying the nurse. There are several reasons why we now should ask this question. These include the entry of women into the field of medicine and the development of advanced degrees for nurses. The computerization of medical records has spurred increases in the need for so-called physician extenders, such as physician assistants (PAs) and nurse practitioners (NPs), to support practices and deal with the complicated and timeconsuming data entry responsibilities these computer systems require. Costcontainment considerations have led to the expansion of nurse and technician roles. The erosion of the perception of the doctor as an ultimate authority figure and the rise of patient autonomy have leveled the field as well. Educational degree levels have tradi tionally helped define “doctor” and “nurse,” but may no longer be a reliable indicator. Traditionally, a doctor who graduated from a U.S. medical school had an MD; today, a doctor may also have a DO if he or she attended an osteopathic medical school. In the past, nurses had an
Dr. Leng is an anesthesiologist, Beth Israel Deaconess Medical Center, Boston, Massachusetts. Correspondence should be addressed to Dr. Leng, 33 Florence St., Newton, MA 02459; telephone: (617) 990-4436; [email protected]. Acad Med. 2013;88:1613. doi: 10.1097/ACM.0b013e3182a7eeef
associate or bachelor’s degree in nursing. These days, a nurse may have a doctorallevel degree (e.g., PhD, doctor of nursing practice) or a master’s degree in addition to his or her undergraduate degree in nursing or another field. Prescriptive and diagnostic authority used to separate doctors from nurses. But now, many advanced practice nurses can prescribe medicines, write orders, and examine and diagnose patients. Nurses and doctors used to look different as well. In hospitals today, the ways that nurses and doctors dress are emblematic of the blurring of the lines of professional identity. A doctor may wear scrubs, and a nurse practitioner may wear a white coat. In the operating room, everybody wears the same thing. Clothing has long been a tangible symbol of change. For example, women started wearing pants around the time they started entering the workforce, especially during World War II. The nurse’s cap disappeared in the late 1980s, in part due to the entry of men into the field of nursing. Do differences in lifestyle and compen sation remain? Nope. A primary care doctor often makes less than a nurse anesthetist does. Some doctors no longer take call, whereas many nurses do, even those without advanced degrees. Knowledge and skill do continue to separate nurses from doctors. The doctor may have more book knowledge, but the experienced floor nurse knows more about treating patients than the average intern does. The ability to perform complex surgery or diagnose a complex medical problem is generally acquired by physicians. The ability to place that complex medical problem
Academic Medicine, Vol. 88, No. 11 / November 2013
within the larger context of the patient and environment is the nurse’s forte. This last distinction is where I believe the definitions of “nurse” and “doctor” can be found. I have been both a nurse and a physician. In my view, the difference is one of philosophy. Everybody takes anatomy and physiology, studies pharmacology, and accrues clinical experience. The approaches taken to these and other subjects differ, however. Medicine considers itself a branch of science. Doctors are trained to diagnose and treat disease processes as individual entities. The term “medical model” is defined in terms of pathology and signs and symptoms of specific disease.1 In contrast, the nursing model is more sociological and places greater emphasis on the larger environment in which the disease occurs. For instance, prominent models of nursing practice include the “activities of living” model,2 in which disease is evaluated in terms of how it affects daily life, and Dorothea Orem’s3 model, which focuses on how the disease process causes self-care deficits. I think even the remaining distinctions are becoming hazy. Doctors are becoming more holistic in their practice even as nurses are becoming more specialized. I am hopeful that eventually the questions will not be “What is a doctor? What is a nurse?” but, rather, “What does it matter?” References 1 Medical model. In: Marshall G, ed. A Dictionary of Sociology. New York, NY: Oxford University Press; 1998. http://www. encyclopedia.com/doc/1O88-medicalmodel. html. Accessed July 25, 2013. 2 Roper N, Logan WW, Tierney AJ. The Elements of Nursing. New York, NY: Churchill Livingstone; 1980. 3 Orem DE. Nursing: Concepts of Practice. 6th ed. St. Louis, Mo: Mosby-Year Book; 2001.
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