Friday, April 18, 2008

A doctor who acts like a nurse...

I've known from the start that I wanted to be a physician...but I've also known for a long time that I want to be able to spend time with my patients/clients, that I want to be able to encounter them as whole human beings with minds and spirits rather than just as inert bodies, not to see them mechanistically as solely automatons with pieces that sometimes break or get out of alignment and have to be set back into place. I've been doing a lot of CINAHL and MedLine crawling lately and it appears that this sort of holistic approach is much more in line with nursing than it is with doctoring; it would appear that for the most part (at least theoretically) nurses are concerned with the whole human being, while doctors are wham bam thank you ma'am, your heart isn't pumping right/your serotonin is low/you need this drug to lower your blood pressure.

Yesterday I came upon a handful of articles about the idea of 'caring presence,' which is apparently a philosophical construct that addresses the interaction between clinician (generally nurse) and patient; caring presence is part of what makes space in the patient's universe for healing. In a way, it's the 'being there' that the clinician offers, the gift of time and self that allows her to act as a conduit for hope and improvement. As the doctor/philosopher/crazy Germanic guy Paracelsus said, "The main reason for healing is love." (Germans? Talking about love? In a sentence that isn't "I love invading Poland" or "While the French are distracted by their wine and cheese and love, we will take Paris"?) To put it in a slightly less threatening way (a lot of people get skeeved out by the idea that anyone would have 'love' as part of her job description), I'll quote Madeline Leininger, a nurse-researcher who said, "There is no curing without caring."

In short, nursing (and by extension, a certain kind of doctoring) can be seen as a creation of safe space for the sick person. It's a process that involves not just trying to make the person feel better, which can be classified as 'being there' for the patient if you're really and truly present--it's 'being with' the patient, sitting with her in suffering, bearing witness to what she's feeling and sharing it, to whatever extent the patient will allow. Being there addresses the problem; being with addresses the person. And, of course, it involves a certain amount of vulnerability--because connection is built on shared experience and authenticity, which means not only does a clinician risk rejection by moving slightly into the patient's sphere; she also has to let a few of her walls down, and show a flash of her common humanity (I think this may be why doctors sometimes shy away from it--they're 'supposed' to be invulnerable, superhuman. They're supposed to fix things, address the problem, not sit with the parts of the experience that are beyond human control. Additionally, they aren't the ones changing dressings, and helping people to the commode, and encouraging people to eat. They aren't as involved in the patient's lived experience, in part due to the constraints the US' current healthcare system has imposed on physician-patient interaction).

I know it'll never happen, but can you imagine the sort of paradigm shift that might occur if there were a billing code in plain ol' medicine for 'therapeutic listening' or 'caring presence' (and not just psychiatry--although, hell, it's even falling out of favor there, too, to be replaced by "If you're not suicidal or homicidal or hearing voices, take this sample of Celexa or Zoloft or whatever the drug reps left this week.")? If clinician-patient interaction were seen not solely as an economic exchange, negotiated behind the scenes by third-party payors and tweaky administrators, but as, you know, a human exchange based on a certain mutuality and trust? Obviously this is a long-shot, a big dream, right up there with my dream "What if I woke up tomorrow and suddenly had seven million dollars in my bank account? And a pony instead of a crappy old car? And the clouds were made of cotton candy?" But a girl can dream, can't she? And I can still go to medical school, and keep my 'nurse-ish' tendencies to myself...(Yes, I know there are doctors who are this way. I don't mean to bag on doctors. If I thought the profession was that cynical, mechanistic and craptastic I wouldn't be trying to get into it. But I have met a lot of MDs and a lot of RNs/NPs in my time, and let me say that if someone told me I had to settle a moon colony with one or the other, I'd be loading the nurses into the space shuttle).

1 comment:

Denise G., RN, MSNc, CCRN said...

Speaking as a nurse who spent many years explaining why I didn't want to be a doctor (basically what you said above)...have you actually considered being a nurse? It is a paradigm shift, but as you have observed yourself, the "caring presence" and caring for the whole patient falls in the realm of nursing. I have never regretted my choice.