25.08.2013 Backbone of medical care
While surfing around for a hospital for treatment of a complicated medical problem the more important question is what hospital has the best
nursing care available
By Syed Mansoor Hussain
Whenever we think of medical care we think mostly about doctors and what they do. If any one comes to me to ask for a recommendation for a surgical procedure, the one thing they want to know about is the reputation of the surgeon and his results. Of course most major medical centres in Pakistan as well as those in more advanced medical countries thrive on the reputations of specialist physicians on their staff.
Every so often, magazines in the US put out lists of the ‘best’ doctors in a particular state who are then parlayed into advertisements for the medical institutions where these doctors practice.
Physicians who develop a reputation for excellence more often than not deserve it. But then as the saying goes, behind every successful man there is a woman, and for successful doctors it is often not just one woman but many; these women are called nurses.
Medical care is no longer a one-man show. The days when Avicenna or Al Razi strode the earth as giants of medicine are long gone. Even in their times these great physicians needed apothecaries to compound the medicines, tinctures and elixirs they ordered; if the apothecary did something wrong, the great doctor’s attempts at healing could fail.
Modern medicine has advanced to the point where it has become a ‘team effort’. The doctor, or more often the senior doctor or surgeon, is still the person in overall charge of a patient’s care, but he or she needs a lot of help and support to take care of a sick patient. In most major multispecialty hospitals, especially teaching hospitals, there are many junior doctors besides the senior doctor who work under supervision to provide direct care.
Besides these junior doctors, perhaps the most important component of direct medical care is the nurses. Without good nursing care, patients cannot do well. In addition there are now other very important parts of the health care team: the pharmacy department that that fills out the prescriptions, the laboratory personnel that perform all the tests required for diagnosis and treatment, physiotherapists, social workers, dieticians and the entire maintenance crew that keeps the hospital working and the machines humming.
But it is about nurses I want to write about today. More than forty years ago when I started my house job in Mayo Hospital, out of curiosity I looked at the ‘note book’ one of the student nurses was carrying. On the first page, on the very top in bold letters she had written: “You will obey the doctor’s orders at all times”. That was the nursing paradigm then; the nurse’s primary function was to carry out the orders she received from the physician, even the lowly house physician. Even so, many basic medical activities like starting intravenous solutions, drawing blood for blood tests, giving injections, inserting feeding tubes etc. are things I learned from the nurses. And the experienced nurses, especially in the operating theatres, were really a major learning resource for junior doctors like me.
Within a year I was in the US, starting my training as an ‘intern’. There also nurses were still pretty low in the medical hierarchy but there was an important difference. In Pakistan most nurses were from the poor segments of society and often from minority classes. However, in the US, many nurses came from the well established middle class families and quite a few were daughters of physicians. So perhaps there was a cultural difference.
The major difference I noted, however, was that nurses were much better educated and trained in the US and their services were valued at a much higher level. Frankly, during my ‘internship’, it was the nurses who taught me about the basics of medical care in the US. Over the next couple of decades nursing developed rapidly and soon we were seeing nurse clinicians, specialist nurses and eventually nurse practitioners. The latter in the US today fulfil many of the ‘primary care’ functions that doctors used to provide just a few decades ago.
I remember a time during the 1980s when I was running an intensive care unit (ICU) for cardiac surgical patients, some of my training fellows, especially those from the Subcontinent and the Middle East would often complain to me about the ‘haughty’ behaviour of nurses towards them. I had to explain to them that it took the hospital at least a couple of years to train a specialist (ICU) nurse and then we expected her to work for us for five or more years so the hospital would very much like to retain them while the ‘fellows’ were there for only a year or two. So from the hospital’s perspective as far as patient care was concerned, a well-trained ICU nurse was more valuable than a trainee doctor! Frankly a well-trained nurse was hard to come by and trainee doctors were easy to find.
Fast forward a couple of decades and I am running the department of cardiac surgery at Mayo Hospital in Lahore. The first thing I noticed was that the nurses were no longer primarily from a minority community but a majority were Muslims from an emerging lower-middle class. Even so, most of them still suffered from considerable gender discrimination. Often the nurses complained to me that the doctors treated them badly.
As I compare nursing in the US with that in Pakistan today, two differences are obvious. First, the nurses are not as well-trained or educated as they are in the US and second, women whether they are nurses or not are still held to be of an ‘inferior’ position in our society. Some progress has been made in this regard but obviously not enough.
Going back to the beginning, medical care is a team effort in the modern world and nurses are one of the most important part of such care. When somebody asks me which hospital they should they go for treatment of a complicated medical problem, as far as I am concerned, most doctors are within a couple of percentile points as far as ability is concerned; so a patient will probably get a doctor who can diagnose and prescribe appropriate treatment in most well staffed hospitals. But for me the more important question is what hospital has the best nursing care available. That said, sadly nurses are not provided the educational opportunities or professional support that can make them feel confident enough to act like the important medical care-givers that they really are. Let us not forget that for a patient lying in a hospital bed the nurse is the person who provides direct and immediate bedside care.
So, if we really want to improve the quality of care in our hospitals, we must make sure that nurses are well-trained and above all get the respect they deserve as medical professionals.
The writer is former professor and Chairman Department of Cardiac Surgery, KEMU/Mayo Hospital, Lahore: smhmbbs70@yahoo.com