Physicians' special knowledge lets us "land the plane"

Commentary. By Eric Anderson, MD, amednews contributor. Feb. 14, 2000.

COMMENTARY

Observations on the state of medical practice and medical life

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As a primary care physician, I'm expecting any day now to get an invitation to join the BDA -- you know, the Barefoot Doctors of America. Their name distinguishes them from the BDC, a most worthwhile group of physicians who endeavor to deliver simple health care at low cost to the peasants of China.

Our barefoots are different. The BDA makes up a motley group: as the A team, psychologists who want to prescribe, pharmacists who want to treat, optometrists who want to operate and nurses and physician assistants who want to play doctor -- and following up, as the B team, assorted naturopaths, chiropractors, faith healers, nonmedical homeopaths, non-RN midwives, herbalists, drug counselors, telenurses, nutritionists, hypnotists, healing touch practitioners, astrologers, reflexologists, massage therapists and, though I'm not sure about this, possibly horoscope, zodiac and psychic readers. In other words, my equals.

What do they want in this great country that's so generous with newcomers?

They want my job.

They believe that, as reported in the Jan. 5 Journal of the American Medical Association -- because some nurse practitioners scored equally well with primary care doctors (in a few problems that lent themselves particularly well to cookbook-style medicine, such as hypertension) -- nonphysicians are capable of practicing, unsupervised, as doctors.

They believe the Health Care Financing Administration is on the right track when it announces its intention to recognize certain nonphysician providers as independent practitioners under Medicare.

They believe that a nation now welcoming alternative medicine is ready to go back to all the unsophisticated beliefs of the Middle Ages. They believe that everything in medicine is up for grabs. And they believe anything goes.

Well, as Richard Nixon was wont to declare: "Let me say this about that."

First, some concessions.

I think nurses are the most marvelous part of the health care institution. They "are ourselves with the barbarian left out."

Good hospital nurses know their patients so well that their insight and advice to the doctors is invaluable. Most of the nurses in intensive care units are godlike in the quality of their work. They note, suggest and advise, catch mistakes before they happen and constantly improve doctors' care.

And they're smart. I know this. Every time we took Advanced Cardiac Life Support classes and ran tests in our small New Hampshire hospital, there were always a couple of nurses who beat the scores of the doctors -- which was one of the reasons they'd always grin at me as we passed in the corridor.

And I delivered more than 500 babies in that hospital with only a nurse-anesthetist as anesthesia backup. She was superb. I couldn't have wanted anyone better. So with 40 years as a doctor, I don't have to be told the value of nurses.

And I know physician assistants, too. I've worked with three well-trained ones in the past, and they helped me greatly.

They were particularly good at listening and writing histories and even better at physical examinations.

They were always discovering modestly enlarged spleens or slightly diminished pulses, however, and they would not quite realize these were within the bounds of normal variation. Their weakness was therapeutics; they would use one medication, then add another rather than push the first one to maximum dose.

This was something we could work on. It comes with experience and maybe, to a certain extent, with a physician's comprehensive training.

No old heads on young shoulders

My Scottish grandfather used to say to my mother, usually after I'd done something stupid as a child, "You can't put old heads on young shoulders." Similarly, you can't put a doctor's head on a paramedic's shoulders and expect the same contemplative, attentive thoughts -- although this would come as a surprise to a public that today believes in magnets and copper bracelets, that rates things and does not value knowledge.

Medical columnists don't have an exclusive on knowledge, of course, and if I ever talk endlessly on a subject at dinner parties, my wife -- anxious to get the subject closed -- has been known to murmur, "Land the plane, Eric."

But that brings us to the difference between physicians and all those who think they can do our job without the years, expense and pain of going to medical school.

Maybe at times we are cruising along, following simple protocols for the treatment of some chronic conditions, just as pilots flying the Pacific in fine weather feel all is well with the world.

But at the back of our minds, we are waiting for that once-in-a-lifetime case where the patient tells us it's the worst headache in his life in time for us to catch a subarachnoid before it blows.

Or we're waiting to see the woman with the temple that throbs and the chewing muscles that ache so we can fill her full of steroids before her vision goes.

Maybe we're waiting for the child born with a patent ductus and a machinery murmur; or for the young woman from South Africa whose urine goes the color of port wine if it stands; and or for the old man with Paget's who says he's having to buy a larger size in hats.

In situations like that, we are not cruising, we are landing the plane. And we manage because we're doing the job we were trained for. That's why they call us doctors.

Dr. Anderson is a semiretired family physician in San Diego.