Ever since my presentation to the American College of Surgeons earlier this month on personal resilience in a medical career, I cannot shake the feeling that we need to do more of this work. Physicians from different fields need to talk more to one another, share experiences, and reconnect. We also need to include other members of the care team as equals, and let go the hierarchical thinking that has far outlived its usefulness.
I do not suggest that physicians, nurses, therapists, pharmacists and others should play interchangeable roles in the care of patients. Rather, similar to the central tenet of gender equality, the unique contributions of each team member need to be respected equally for their own merits and importance. As a primary care internist, I must admit that I have seen my professional world through a rather narrow lens until now. I confess that I live at Stage 3, according to David Logan and colleagues’ definition of Tribal Leadership and culture. The mantra for this stage of tribal culture, according to Logan et al, is “I’m great, and you’re not.” Or in my words, “I’m great; you suck.”
“I’m a primary care doctor and I am awesome. I am the true caregiver. I sit with my patients through their hardest life trials, and I know them better than anyone. I am on the front line, I deal with everything! And yet, nobody values me because ‘all’ I do is sit around and think. My work generates only enough money to keep the lights on (what is up with that, anyway?); it’s the surgeons and interventionalists who bring in the big bucks—they are the darlings of the hospital, even though they don’t really know my patients as people…” It’s a bizarre mixture of pride and whining, and any person or group can manifest it.
Earlier this fall, Joy Behar of TV’s “The View” made an offhand comment about Miss Colorado, Kelley Johnson, a nurse, wearing ‘a doctor’s stethoscope,’ during her monologue at the Miss America pageant. We all watched as the media shredded the show and its hosts for apparently degrading nurses. What distressed me most was the nurses vs. doctors war that ensued on social media. Nurses started posting how they, not doctors, are who really care for patients and save lives. Doctors, mostly privately, fumed at the grandiosity and perceived arrogance of these posts. It all boiled down to, “We’re great, they suck. We’re more important, look at us, not them.” The whole situation only served to further fracture an already cracked relationship between doctors and nurses, all because of a few mindless words.
It’s worth considering for a moment, though. Why would nurses get so instantly and violently offended by what was obviously an unscripted, ignorant comment by a daytime talk show host? It cannot be the first time one of them has said something thoughtlessly. What makes any of us react in rage to someone’s unintentional words? It’s usually when the words chafe a raw emotional nerve. “A doctor’s stethoscope.” The implicit accusation here is that nurses are not worthy of using doctors’ instruments. And it triggered such ferocious wrath because so many nurses feel that they are treated this way, that they are seen as inferior, subordinate, unworthy. Internists feel it as compared to surgeons. None would likely ever admit to feeling this way, consciously, at least. But if we are honest with ourselves, we know that we all have that secret gremlin deep inside, who continually questions, no matter how outwardly successful or inwardly confident we may be, whether we are truly worthy to be here. And when someone speaks directly to it, like Joy Behar did, watch out, because that little gremlin will rage, Incredible Hulk-style.
I see so many similarities to the gender debate here. As women, in our conscious minds, we know our worth and our contribution. We know we have an equal right to our roles in civilization. And, at this point in our collective human history, we feel the need to defend those roles, to fight for their visibility and validity. More and more people now recognize that women need men to speak up for gender equality, that it’s not ‘just a women’s issue,’ but rather a human issue, and that all of us will live better, more wholly, when all of us are treated with equal respect and opportunity. The UN’s He for She initiative embodies this ideal.
It’s no different in medicine. At this point in our collective professional history, physician-nurse and other hierarchies still define many of our relationships and operational structures. It’s not all bad, and we have made great progress toward interdisciplinary team care. But the stethoscope firestorm shows that we still have a long way to go. At the CENTILE conference I attended last week, I hate to admit that I was a little surprised and incredulous to see inspiring and groundbreaking research presented by nurses. I have always thought of myself as having the utmost respect for nurses—my mom, my hero, is a nurse. The ICU and inpatient nurses saved me time and again during my intern year, when I had no idea what I was doing. And I depended on them to watch over my patients when I became an attending. But I still harbored an insidious bias that nurses are not scholarly, that they do not (or cannot?) participate in the ‘higher’ academic pursuits of medicine. I stand profoundly humbled, and I am grateful. From now on I will advocate for nurses to participate in academic medicine’s highest activities, seek their contributions in the literature, and voice my support out loud for their important roles in our healthcare system.
We need more conferences like this, more forums in which to share openly all of our strengths and accomplishments. We need to Dream Big Together, to stop comparing and competing, and get in the mud together, to cultivate this vast garden of health and well-being for all. I’ll bring my shovel, you bring your hose, someone else has seeds, another, the soil, and still others, the fertilizer and everything else we will need for the garden to flourish. We all matter, and we all have a unique role to play. Nobody is more important than anyone else, and nobody can do it alone.
We need to take turns leading and following. That is how a cooperative tribe works best. It’s exhausting work, challenging social norms and moving a culture upward. And we simply have to; it’s the right thing to do.
Another great post! And I will be quoting you to a friend of mine because you’ve made some statements here that apply in terms of race and gender discrimination that he needs to hear. Thank you!
Thank you, Tim! I’m interested to read your thoughts on these applications, would you care to elaborate? 😊
Amen. SUCH a great post.
But can I just say (in a heated aside) that, even as a resident physician in [insert my fav non-primary care specialty] at [insert my non-Columbia Ivy League] I’m massively vexed at Columbia P&S at this moment?
Columbia did away with their FP residency and faculty a few weeks back (until appropriate social media outrage sparked reversal). The reason, from the Columbia P&S dean: [Although family medicine is] “an important part of the American medical scene, and we don’t discourage our students going into FM, our primary goal is not to train family physicians, which is the goal that some state schools have.”
Wow. WOW. To say that the education of primary care physicians is somehow beneath them as an institution – or rather, to state that the mission of an ivy league affiliated hospital/MS does not include PCP training, thereby implying that primary care is neither prestigious nor ambitious, and therefore that primary care itself is easy and unimportant – this is misguided asshattery. And downright dangerous.
Did you hear about this?! Ridiculous.
Also, sorry. I did clearly hear your lovely message of unification and collegiality and respect. Really I did! But my blood is still boiling over this….
Thank you so much. There are so many layers, and one can only write so much at one time.
I read the article you linked. It blows my mind. What must leaders experience to make such a decision? I’m sure I have no idea what goes on at the institution, but from the outside it certainly undermines any trust I might have had in it, and it makes me wonder whether other similar institutions also consider such action. It’s definitely enough to spark some serious catastrophization! And, it becomes a nice reminder to practice what I preach–withhold judgment, get curious, and see if I can take the other’s perspective. Meanwhile I am free to make up stories, as long as I maintain awareness that that is what I’m doing… “Fascinating,” as Ben and Rosamund Stone Zander would say! Please keep coming by! 😊
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Thanks for this post! I know so many great nurses, and I hope I will continue to respect them at least as much as I do now, even after finishing medical school and becoming a “real” doctor…
Thank you for stopping by and for your comment, and I hope so, too! I have a feeling you will, because you have set it as a goal. 😉
I don’t know how many ways I can say “Thank the Universe for You.” The system is a reflection of the culture, which is full of “misguided asshattery” (love that term beyond belief). Competition and health care do not belong in the same sentence, but we’re talking about human beings, so…
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Thank you, Sandy Sue! 😊 I love that phrase, too…
Sometimes I think all this chaos and “M.A.” must mean that humanity is moving toward some higher, enlightened state–that this is our awkward adolescence, and we are testing limits, struggling to reconcile impulse with judgment. It makes me feel at once compassionate and impatient. The leading cause of death in adolescence is accidents, after all, often caused by a false sense of invincibility and lack of insight and judgment…
Oh well, we are all here, each doing our best. If we could look up and really see one another as just that, with a little more love and empathy, even only part of the time, how much better could it all be??
So glad to have found you here, SS. 😊 Write on! 😁
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Cathy, one of your best posts. THANK YOU! As Donald Berwick said so many years ago (to paraphrase): The enemy is disease–not each other!
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Thanks, Larry, for reading and for your comment! Hopefully there is more where this came from, if it was one of my best! 😉 Tribes pull together when we recognize a common foe–it helps dissolve intra-tribal differences and conflict, at least temporarily. We need to figure out how to make that cohesion last!
Thoughtful post, eloquently stated! Could part of the problem be that providers grapple with the “gremlin” but don’t really have a judgement free space to discuss it, and possibly disarm it in the process?
Thoughtful post, eloquently stated! Could part of the problem be that there providers grapple with the “gremlin” but don’t really have a judgment-free space to discuss it, and disarm it in the process?
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Thank you for visiting and for leaving your thoughtful comment!
I think you have *nailed it*, sir! I look forward to reading your blog, as I have a feeling I will find a lot more insightful material therein. Please keep visiting and sharing your thoughts here!
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