The Way I See It: We aren't all equals!

May 5, 2006

This author worries that midlevel medical personnel are usurpingthe role of doctors. And no one seems to care.

As physicians, we see the world of medicine from the inside every day. So we don't always realize the full impact of incremental changes unless we step outside our accustomed role.

So, it wasn't until my brother-in-law was hospitalized last year that I understood how far the use of ancillary medical personnel has eroded medical authority, and the danger to patients posed by that erosion. That experience served as a wake-up call for me, and a warning about the future of medicine.

My wife's brother, Timmy, was a healthy, active 47-year-old who played basketball and golf and never missed a business meeting. So I knew something was really wrong when his wife called me one morning to say he was too sick to go to work. My wife and I agreed to meet them at the emergency room.

When he arrived at the emergency room, Timmy was short of breath, and his oxygen saturation was 93 percent, where it stayed, even after two hours of 100 percent oxygen. He also had a rash and pulmonary infiltrates. By the time my wife and I left that night, Timmy had been admitted to the intensive care unit and was intubated.

The medical team treating Timmy never did deliver a formal diagnosis, though in retrospect the consensus seemed to be viral pneumonia. He spent three weeks intubated, underwent a tracheotomy, and after suffering a pneumothorax, was also given a laparoscopic thoracotomy. Eventually he was able to breathe on his own, and he's now back at work, although his exercise is still limited to walking.

Throughout his illness Timmy received thoughtful, attentive care from everyone, both at the acute care facility and in the rehabilitation unit. But I was surprised at the actions and attitudes of the ancillary personnel.

I've been a doctor for several decades, and I try to avoid making judgments of my colleagues. When physicians criticize one another, it seems to me that it undermines us all. But during my brother-in-law's hospitalization I was shocked by the thoughtlessness and ease with which nonphysicians challenged the medical management of Timmy's case.

The intensive care nurses all seemed to have strongly held opinions about Timmy's diagnosis. Worse, they shared these possibilities with Timmy's wife. The nurses wanted more diagnostic testing, and conveyed the impression that his doctors' failure to order these tests constituted negligence.

Some also held the opinion that the orthopedist who'd repaired Timmy's rotator cuff four weeks earlier must be to blame for his current condition-although they had less to say about what mechanism might lead from shoulder surgery to pulmonary distress.

The nurses also pressed for the tracheotomy in the first week of Timmy's hospitalization, although his doctors were more conservative.

The pulmonary therapists second-guessed the doctors on everything from oxygen pressure and volume to how much sedation Timmy should receive. The nurses disagreed with the pulmonary therapists, sometimes to the point of arguing at Timmy's bedside.

Needless to say, all of this made an already difficult situation much harder for Timmy's wife. She phoned me countless times for advice, hoping to make sense of the conflicting opinions. One day she walked into Timmy's room to find a priest giving him last rites-the result of a nurse's "hunch" about his prognosis.

At first I thought maybe I was observing the product of ethnic prejudice-the nurses and other ICU staff were largely American-born; the physicians were not. But in talking the situation over with others, I believe it's something else.

I think the confusion I saw at my brother-in-law's bedside is the logical consequence of the increased use of physician extenders. Physician assistants, nurse practitioners, and advanced-practice nurses have narrowed the gap between doctors and other caregivers. Once the line between doctors and everyone else became less distinct, other ancillary personnel also have started taking themselves more seriously-and deferring to physicians less.