Romano, Carol A. PhD, RN; Pangaro, Louis N. MD
In January 2013, the Academic Medicine Question of the Year (QOTY)1 asked, “What is a doctor? What is a nurse?” Individually, these questions challenge us to examine professional identity and evolving roles on the health care team; together, they invite discussion of the dynamics of interprofessional teams and the future of health professions education and practice. We believe that all aspects of these questions must be carefully considered as we plan for the future of health care education and delivery. In this commentary, after analyzing the published responses to the 2013 QOTY, we offer an assessment of the evolution of the interprofessional interaction between physicians and nurses. Finally, we examine the role of health professions education in shaping the future professional roles and scopes of practice for physicians and nurses. We hope to carry the discussion from the present tense (What is a doctor? What is a nurse?) into the future (What will the future team of health care professionals require?) to provide a discussion of challenges to academic medicine and academic nursing in preparing the next generation of health professionals.
A Synthesis of Perspectives
Before adding to the discussion on this topic, we first wanted to analyze what had already been said. Our review of the responses to the QOTY2–8 published in the November 2013 issue of the journal revealed several perspectives in the voices represented and in the themes that emerged. Although the QOTY used the term “doctor,” we will use here the word “physician” to avoid confusion with the level of one’s academic degree. In summary the authors’ “voices” included views associated with academic health centers; an even gender mix; a professional mix of 3 physicians and 7 nurses (including 1 nursing student); and an education mix with 7 of the 10 authors holding a doctorate degree (MD or PhD) and all nurses having advanced nursing degrees.
Common themes reflected historical differentiators such as gender, education, income, dress, and prescriptive authority of roles in health care. Most authors, however, noted that these differences are blurring. While the simplistic descriptor of “physicians treating disease and nurses treating patients” (treatment versus care) was represented in some papers, there was also recognition that this differentiation is no longer adequate and ignores the interdependencies of the two roles. Other attempts at role separation described medicine as diagnosis of disease and orchestration of medical care, and nursing as management of patient responses to health or illness status. Typically the physician’s model was defined in terms of pathophysiology and the signs and symptoms of disease, which was contrasted with the nursing model as sociological in nature with concept of the “patient” including individual, family, and community.
These views, however, were not accepted by this group of authors as definitive. The need to work as a team was presented in several essays. Although many authors identified the physician as the team leader, several acknowledged that one type of professional cannot lead in every setting. The description of the physician as the gatekeeper to care and the nurse as the advocate and facilitator of care was also offered. Despite such differences between perceived roles, it was noted that both professions do share common values, have a commitment to quality and safety, practice in stressed environments, and at times experience lack of support and recognition. No author addressed social, economic, or political tensions between roles.
Most authors echoed the need for partnership and collaboration, and for less divisive dichotomies. There was acknowledgment that each team member is expected to be an expert in his or her respective field, regardless of how the roles are configured in a given health care setting. As a group, these essays reflect the growing awareness and acceptance that effective, safe, and efficient health care will require much more interprofessional collaboration than is reflected in prior stereotypes. The question itself—“What is a doctor? What is a nurse?”—reflects that there has been a separation between the two roles and begs for an approach to define these boundaries. It is interesting to consider whether the very attempt to narrow or circumscribe definitions of “nurse” and “doctor” actually promotes divisiveness. Given that concern, we think that a framework for addressing the distinction or differentiation between these roles should be articulated.
Reformulating the Question
Both nursing and medicine continue to evolve within the general society to which they are ultimately accountable. As a society re-determines what professional knowledge and skills it needs, institutions evolve to educate individuals to supply those needs. A health profession is the body of individuals whose work helps to maintain the health of their community, including cultivating what Pellegrino9 has called “the promise” of duty and expertise to those served. Questions about professional differentiation may be seen as questions about what different duties and professional proficiency are acquired by individuals within a health profession, and how and to what extent individuals practice within the full scope of their education.
The terminology used in the QOTY requires a closer look. “Doctor” derives from the Latin verb docēre (to teach), and signifies one who has been taught enough to teach others. It is typically used for a person who has obtained a research doctorate or professional doctorate degree. Many nonphysicians in clinical practice currently hold doctoral degrees and are addressed as “doctor”; confusion may result when the term “doctor” is applied beyond the field of medicine, where the term is used often interchangeably with “physician.” A more specific term for the medical profession, “physician,” is derived from Greek and implies someone that acts from an understanding of “nature” (“ϕυσισ,” the same root as physics or physiology). The term “nurse” is derived from the Latin “nutricia” for the “nurturing” nature of the act of nursing, and from the Anglo Saxon “nurice” for all things nourishing and good for the mind, body, and soul. It refers to the role of one that provides services essential to promote, maintain, or restore health and well-being, or in prevention of illness of others when for any reason they are unable to provide such services for themselves.
Both titles, physician and nurse, apply once the initial professional degree is conferred and do not change with further training. From these enduring titles we infer that our language has accepted that there are unique contributions that each profession offers to meet the needs of society. Further education allows for enhanced depth and breadth of the practice of a physician or of a nurse. And despite differences in levels of training within or across professions, health professionals are expected to practice within the scope of their education and licensure, and not beyond it.
What are we really interested in knowing when we ask the question “What is a doctor? What is a nurse?” More nuanced attempts to differentiate physician and nurse might also query what kind of physician and what kind of nurse are being compared, and in what settings. General practice physicians and physician specialists have different depths and breadth of knowledge. For nursing, while there is one perspective of practice shared by all nurses,10 advanced practice nurses (nurse practitioners, clinical specialists, midwives, and anesthetists) have had advanced graduate education, demonstrate a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy. In addition, the environment in which care is delivered influences the roles and scope of practice of nurses and physicians, and also the interdependencies of the partnership between them. For example, the interaction between a primary care physician and a nurse or nurse practitioner in an underserved, rural community is very different from the interaction of a critical care physician specialist and a nurse or acute care nurse practitioner in a hospital.
Although differentiation of clinical practice is a regulatory concern from a licensing, credentialing, and privileging perspective for both medicine and nursing, a framework for localizing each profession’s multiple and sometimes varying roles, as well as the interdependencies of the professions, may be useful. We offer one such perspective that can place practice within both the internal and external environments of human beings:
The health professional’s focus may range on a continuum that encompasses the molecular level, individual organs and systems, the whole person, the home and community environments in which a patient lives and works, and the organizations and delivery systems of care. Physicians and nurses both are educated to some degree in all aspects of this continuum. However, the depth and breadth of focus may vary, both across and also within each profession.
Therefore, attempts to define one pro fession within the context of an isolated part of this framework are probably incomplete and ignore the complexity of the health care environment, as well as the necessity for both nursing and medicine to act with an awareness of the micro “100-foot view” as well as the macro “10,000-foot view.”
For example, all physicians must be educated with in-depth knowledge related to the diagnosis and treatment of diseases, which requires a strong focus on the molecular and body-organ level of our paradigm. However, many physicians also move quickly from the “internal” focus on disease mechanisms to the external setting of care delivery in order to give good medical care. The defining characteristic of nursing is its focus on human responses to illness and on the promotion of health within the physical and social environments.10 Human responses are the phenomena to which science is applied, to which interventions are directed, and against which outcomes are evaluated. All nurses are educated in this perspective.
On the continuum from molecules to macro environments, nursing serves as a bridge between the individual’s health/illness status (at the molecular and body-organ level) and the response to it physically, emotionally, mentally, and socially. While some advanced practice nurses focus additionally on the diagnosis of disease and on other activities that overlap with medicine, all of nursing practice focuses on the human responses, the alleviation of suffering, and advocacy for patients. Physicians, too, address social responses, but typically as a consequence, and not as the starting point, of their practice. Most important, in our paradigm there cannot be exclusive ownership of any aspect or level of focus. In fact, a growing trend is for both medicine and nursing to play increasing roles at the macro policy levels of health. We would like to emphasize that it is the need for both physicians and nurses to shift their focus from inside to outside the patient’s body—and back, as needed—that makes us reluctant to accept the stereotypes of exclusively “treating disease” and “caring for patients” as an adequate differentiation or representation of our professions.
Both nursing and medicine accept society’s expectations that providers are educated, qualified professionals who work together for the good of others. Patients and families expect seamless care. Do we meet these expectations in actual practice? How are health professionals prepared for such interprofessional collaboration and orchestration? How do we educate future health professionals to meet this expectation?
The Challenge to Academic Medicine and Academic Nursing
Educational preparation of the physicians and nurses of the future is the responsibility of academic institutions. This includes the responsibility to address not only the knowledge, skills, and activities unique to each profession but also the role differentiation between professions, the dimensions in which they interact, and the collaborative requirements now demanded by evolving health and health care-delivery systems. One may ask, what should be learning objectives for nurses about the roles of physicians, and for physicians about the roles of nurses? Several national dialogues provide some guidance. The Interprofessional Education Collaborative Expert Panel11 references Barr’s12 framework of three dimensions of interprofessional competencies: common competencies that overlap in roles consistent with one’s individual scope of practice; complementary competencies that reflect individual expertise and which do not require close collaboration, only awareness across boundaries; and collaborative competencies that are needed to work together with other specialists, other professions, patients, families, nonprofessionals, and volunteers. In 2013, the publication Transforming Patient Care: Aligning Interprofessional Education with Clinical Practice Redesign13 addressed the gap in connecting practice redesign with education reform. These conference proceedings proposed elements of a new vision for collaborative learning and practice needed by health professionals. The challenge echoed in each of these sources is how to integrate interprofessional collaborative practice competencies into curricula to prepare future clinicians to work in collaborative, interdependent, redesigned care systems, in partnership with the people served, to create better outcomes and a healthier society.
Because most curricula are already filled with requirements, adding more material could be a stress for both faculty and students. However, our real challenge is not of “adding more” but, rather, of integrating a different approach into our reform of the existing, siloed curriculum. In reviewing our current educational approaches we may ask several questions. Do clinical experiences incorporate the common, complementary, and collaborative aspects of caring for individuals, families, and communities, and the interdependencies of health professionals? Are we focused on collaboratively addressing the triple aim of better care, lower cost, and better health? Does the need of professions to differentiate themselves (for economic, social, professional, or political agendas) overshadow the opportunities to learn together about, from, and with each other in the many different settings in which we deliver health and health care?
We believe it is possible through interpro fessional learning to clarify our current roles and responsibilities and, more impor tant, to direct the evolving roles of physicians and nurses in the future. We can work to align education with new models of health and health care delivery. Can academic medicine and academic nursing accept this challenge? Can they partner with clinical practitioners to provide an enduring answer to the questions “What is a physician?” and “What is a nurse?” We think that the 2013 QOTY provokes the challenges for us to work together to prepare physicians and nurses for the interprofessional practice environments of the future. Our collaborative efforts hold the promise for creating a healthier nation.