“Scope of Practice” Minefields

“. . . my clinical practice as a women’s health NP began in the mid-1970s.  My colleagues who had gone on to academic careers questioned my commitment to nursing and to nursing values.  A common question was ‘Are you a nurse, or are you a mini-doc?’  My answer was, is, and will always be:  ‘I am a nurse with primary care skills.  I take care of my patients within a nursing framework. . . . my values lie in nursing, not in the medical model.  I care for my patients as a fully prepared, primary care provider of women.” – Judith A. Berg & Mary Ellen Roberts, “Recognition, Regulation, Scope of Practice:  Nurse Practitioners’ Growing Pains” (2012)[1]

“We agree certified nurse practitioners can provide many core primary care services, but it is important that this not be misunderstood as suggesting that nurses are interchangeable with physicians in providing the full depth and breadth of services that primary care physicians provide.  The two professions are complementary but not equivalent.  For diagnostic evaluation of clinical presentations that are not straightforward and for the ongoing management of complex or interacting medical problems, the most appropriate clinician is the physician.” – J. F. Ralston & S. E. Weinberger, “Nurses’ Scope of Practice” (2011)[2]

Entering the debate on the “scope of practice” between nurse practitioners (NPs) and physicians is like parachuting onto a battlefield strewn with semantic landmines and decaying verbiage, while overhead the whistle of incoming word-tipped artillery fire grows louder.  For the opposing forces, the NPs and the MDs, negotiation about the scope of NPs’ provider activities has given way to incendiary propaganda and explosive metaphors.  It is all a matter of logistics, planning, grand strategy, tactical advance and retreat.

When the nursing historian Julie Fairman and her colleagues argue that “physicians’ additional training has not been shown to result in a measurable difference from that of nurse practitioners in the quality of basic primary care services,”[3]  they leave unexamined the meaning of basic.  Someone, after all, has to do the defining, and in so doing, to differentiate basic services from services that, in given circumstances, are not so basic.  Someone also has to stipulate how exactly “quality” is being assessed, qualitatively and quantitatively, in both the short- and long-term.

It is fine to make the commonsensical point that nurse practitioners should be permitted to practice “to the fullest extent of their skills and knowledge,” as recommended by the authors of the Institute of Medicine report of 2010, The Future of Nursing.[4]  But who decides what “fullest extent” actually means in relation to specific clinical contingencies and management challenges?  Is there even consensus on the meaning of NP “knowledge and competence” in contradistinction to the “knowledge and competence” of those who receive medical training?  Literally, then, what are Fairman and her colleagues talking about?

NP advocates make tactical use of the word “partnership” in framing debates about NP expansion.  And yes, certainly we need NPs and physicians to be collaborative partners in providing quality health care.  But the notion of “partnership,” as used by NPs, also subserves polemics.  Partnership, after all, does not entail parity among partners.  In law and business, for example, there are senior partners and junior partners, name partners and equity partners, voting partners and nonvoting partners.  In medicine, there are any number of  procedures (e.g., colposcopy, sigmoidoscopy, nasopharyngoscopy) that fall within the domain of adult primary care, but that many primary care physicians no longer perform, even if they are competent to do so, owing to issues of liability and lack of third party coverage.  This does not mean that primary care physicians, gynecologists, gastroenterologists, and ENTs are not “partners” in care, but rather that “partnership” does not abrogate the need for a division of labor, with the differing responsibilities, obligations, and entitlements that such  division entails.

Physician groups threatened by the legislative incursions of nonmedical providers like NPs are no better and even worse.  The Physicians Foundation is a nonprofit organization of medical groups formed to push back the nonmedical invaders, especially nurse practitioners.  Their report of November, 2012, Accept No Substitute: A Report on Scope of Practice, brims with military metaphors.  The authors, Stephen Isaacs and Paul Jellinek, write of “holding the line” on “expansionary forays” and summarize bulletins “fresh from the front lines.”  “What is the score so far?” they ask.  “Who is winning these scope of practice battles?”  And the military metaphors segue into sports metaphors, with the authors’ dour acknowledgment that physicians “are usually playing defense on scope of practice” brightened by occasional successes in eliminating nonphysician licensing.  In the latter cases, they exult, physicians “are in fact able to move the ball up the field.”[5]

What is one to make of such sophomoric posturing in the face of a serious and growing shortage of primary care physicians?  Where will we find the 51,880 additional primary care physicians that, according to recent published projections, we will need by 2025?[6]  It is easy to appreciate the exasperation of primary care NPs who face such opposition in the face of well-established facts.  To wit:   Only 20% of today’s medical students will choose a primary care specialty; NPs provide more cost-effective care than their physician counterparts; patient surveys reveal satisfaction with the care provided by NPs; and half of all physicians in office practice already work with NPs, certified nurse midwives, and/or physician assistants.  All such facts, be it noted, are ceded by the authors of The Physicians Foundation report.[7]

It is time for physicians to accept not only the reality, but also the socioethical desirability of nonphysician providers.  By the same token, it is time for nurse practitioners to accept the reasonableness of practice limits.  An expanded scope of practice is not a limitless scope of practice.  And, yes, self-evidently, the limits to which NPs are subject will not be identical to the limits imposed on physicians. There are indications for which physician consultation and supervision should be mandatory; there will be procedures that only physicians, including primary care physicians, are trained and legally authorized to perform. Establishing boundaries will always be shaped by power politics and economic self-interest, but it need not be deformed by them.  The process can be elevated by concern for public safety and prudent good sense.  By way of identifying two areas in need of further dialogue informed by complementary needs for patient access and patient safety, consider the topics of chronic disease management and prescriptive authority.

Nurse practitioner advocates tout the important role of NPs in managing chronic disease, and type 2 diabetes is typically given as a case in point.[8]  Certainly NPs can manage diabetics whose glucose levels must be monitored and insulin dosages adjusted.  There is also evidence that specialized NPs are highly effective in collaborative practice with primary care physicians, where they serve as diabetic care coordinators.[9]  What then is the problem?  It arises from the fact that management of chronic disease, especially among the elderly, is rarely a matter of managing a  stable disease entity.  In later life, diabetes, however well monitored and managed, typically leads to neuropathy, retinopathy, and/or kidney disease.

Are NPs trained to manage chronic diseases as independent providers when management ipso facto entails a plethora of intersystemic complications?  Consider another example.  Perhaps an NP-nephrologist can manage end-stage renal disease (ESRD), a chronic disease that can be stabilized for long periods with dialysis.  But what happens when such management, and the prolongation of life it entails, leads to diabetes and heart disease, as it often does?  Is such management still within the “knowledge and competence” of NPs?  As I wrote in “The Costs of  Medical Progress”:

Chronic disease rarely runs its course in glorious pathophysiological isolation.  All but inevitably, it pulls other chronic diseases into the running.  Newly emergent chronic disease is collateral damage attendant to chronic disease long-established and well-managed.  Chronicities cluster; discrete treatment technologies leach together; medication needs multiply.

Well-trained NPs no doubt bring much-needed talent to managing intercurrent disease in certain respects.  I am no expert here, but I am open to the possibility that independent management of chronic disease, particularly among the elderly, may not be commensurate with the discrete “skill set” that NPs acquire, even as this “set” is enlarged by the medley of nonmedical skills inculcated by “nursing education and its particular ideology and professional identity.”[10]  Management of chronic disease, that is, often entails complexity of a distinctly medical sort.  Scope of practice debates should be informed by the fact that diabetes, to keep to the example, is no longer a disease with a stable natural history.[11]  The same can be said of kidney disease and heart disease and many types of cancer.  So the question of what NPs can and cannot do needs to be fleshed out in a more clinically realistic manner:  We need to know whether NP-generalists are as capable as primary care physicians of managing chronic illness in the context of life span issues and specific dimensions of patient care.  Are they as capable as primary care physicians, for example, of prioritizing interventions among older patients with multiple chronic diseases?[12]

Another “fullest extent” problematic concerns prescribing privileges.  NPs and APRNs (advanced practice registered nurses) demand the same authorization to prescribe medications as physicians.  This insistence, globally formulated, masks the fact that prescriptive authority is always qualified in various ways. Perhaps physicians, NPs and APRNs, and legislatures should set the all-or-nothing rhetoric aside and wrestle with the real-world issue of “prescriptive authority of various levels” that gets codified in state law.[13]  Is it within the NP’s scope of practice, for example, to change antibiotics without physician consultation for a child who comes to the pediatrician with fever, sore throat, and pain, and whose symptoms have not abated with first-line antibiotics prescribed by the NP?[14]  To begin to get a handle on this kind of issue, one must at present read the law on NP “scope of practice” in a particular state, as NPs have in fact been enjoined to do.[15]

Here is the point: primary care NPs in all states deserve – and now have – “prescriptive authority,” but reasonable people may differ on the breadth of this authority.  Here is an issue that can be subject to empirical research and meaningful negotiation among all the stakeholders, including the public. To wit, what kinds of drugs are NPs trained to prescribe and, based on survey data, what kinds of drugs do they actually prescribe?  Several studies from the 1980s showed “that NPs prescribe a very limited number of relatively simple medications to predominantly healthy populations.”[16]  Perhaps these studies are badly dated and superseded by  recent studies attesting to the broadened range of drugs now prescribed by primary care NPs. Well and good.  Then the “prescriptive authority” granted to NPs by legislatures should be broader rather than narrower.

But, normatively speaking, should it be equivalent to the prescriptive authority of primary care physicians?  Should NPs be granted authority to prescribe controlled substances without collaborative arrangements with physicians and without limiting stipulations as to dosage and duration of use?  Here is another issue ripe for further negotiation informed by empirical research and considerations of patient safety.  I bring no special expertise to the table beyond noting that NPs, however great their knowledge and competence, do not receive the extensive training in physiology, pathophysiology, and pharmacology that physicians do. I do not find it unreasonable that NP-issued scripts should require some degree of physician involvement, as is now the case in 32 states.[17]

The power differential between organized medicine and organized nursing, including medical specialty societies and NP/ACRP societies, has made matters worse for highly trained nurse practitioners seeking to practice to the fullest extent of their knowledge and competence.  But it has also led some NP representatives to demonize medical groups that seek any drawing of lines, since the very act of drawing a line can only derive from the economic imperative to “hold the line” on NP rights.  Consider the reaction of the editor of Policy Politics Nursing Practice in 2006 to the insistence of medical groups that the difference between nurse practitioners with doctorates and physicians be clarified for the benefit of patients. “Does anyone,” he wrote, “seriously see it as part of a conspiracy to mislead patients by having APRNs refer to themselves as doctor? And are physical therapists (who are moving toward a requirement for doctoral-level education), psychologists, and pharmacists in on the conspiracy, too?”[18]

Well, no, hardly.  But the issue here, shorn of polarizing rhetoric, isn’t about willful misleading; it’s about the cultural valence of the title “doctor” and the everyday meanings people impute to it in connection with healthcare.  A patient who seeks treatment from a licensed primary care provider who is referred to and addressed as “doctor” will, absent some kind of a priori clarification, likely assume the “doctor” in question is a physician.  It is not unreasonable to suggest reasonable efforts at patient education to clarify the different roles and orientations of different kinds of providers.  And what prevents NP groups from adopting their own strategy of patient education?  What prevents them from developing and publicizing endorsements of the “doctor of nursing practice” degree that play to the latter’s  “doctoring” strengths in contradistinction to those of physicians?

If there is a conspiracy out there, it is one perpetrated on the public by both physicians and NPs.  It is a conspiracy of partial explanations.  It is the conspiracy among physicians who refuse to cede that nurse practitioners have arrived, that they are licensed clinical providers who are perfectly capable of providing a great deal of what has traditionally been the province of medicine, especially primary care medicine.  But it is also the conspiracy among NP advocates whose rhetoric masks important distinctions, viz., that “fullest extent” of NP/APRN practice is not coextensive with the typically full extent of care that primary care physicians are trained to provide.  This follows from various considerations, not least of which is that family physicians train a total of 21,000 hours whereas NPs train between 3,500 and 6,000 hours.[19]  There, I’ve done it again.  I’ve made a a series of claims that strike me as reasonable and will win me no friends in either warring camp.

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[1] J. A. Berg & M. E. Roberts, “Recognition, regulation, scope of practice:  nurse practitioners’ growing pains,” J. Amer. Acad. Nurse Pract., 24:121-123, 2012, at 121.

[2] J. F. Ralston & S. E. Weinberger, “Nurses’ scope of practice,” Correspondence, New Engl. J. Med., 364:281.

[3] J. A. Fairman, et al., “Broadening the scope of nursing practice,” New Engl. J. Med., 364:193-96, at 193.

[4] As quoted in J. A. Fairman & S. M. Okoye, “Nursing for the future, from the past: two reports on nursing from the Institute of Medicine,” J. Nurs. Ed., 50:305-311, 2011, at 309.

[5] S. Isaacs & P. Jellinek, Accept No Substitute:  A Report on Scope of Practice. White Paper for The Physicians Foundation, November, 2012 (http://www.khi.org/documents/2014/aug/26/accept-no-substitute-report-scope-practice/), pp. 1, 2, 3, 6.

[6] S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10:503-509, 2012.

[7] Issacs & Jellinek, Accept No Substitute, pp. 8-13.

[8] G. C. Richardson, et al., “Nurse practitioner management of type 2 diabetes,” Permanente Journal, 18:e134-140, 2014;  M. J. Goolsby, “2006 American Academy of Nurse Practitioners diabetes management survey,” J. Amer. Acad. Nurse Pract., 19:496-98, 2007; Fairman, et al.,  “Broadening the scope of nursing practice,” p. 193.

[9] Richardson, “Nurse practitioner management of type 2 diabetes,” op cit.; K. G. Shojania, et al., “Effects of quality improvement strategies for type 2 diabetes on glycemic control:  a meta-regression analysis,” JAMA, 296:427-40, 2006; S. Ingersoll, et al., Nurse care coordination for diabetes:  a literature review and synthesis,” J. Nurs. Care Qual., 20:208-14, 2005.

[10] On the notion of clinical competence as acquisition of a “skill set,” see, e.g., J. Fairman, “Delegated by default or negotiated by need?:  physicians, nurse practitioners, and the process of clinical thinking,” in E. D. Baer, et al., Enduring Issues in American Nursing (NY: Springer Pub., 2002),  pp. 311-12 and J. Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick: Rutgers, 2008), pp. 187, 190.

[11] Chris Feudtner terms it a “cyclical transmuted disease” in Bittersweet: Diabetes, Insulin, and the Transformation of Illness (Chapel Hill: North Carolina, 2003), p. 36.

[12] For exemplary instances of how clinical judgment – and not a clinical “skill set” – enters into the prioritizing of treatment interventions among concurrent chronic diseases, see K. C. Stange, et al., “The value of a family physician,” J. Fam. Pract., 46:363-69, 1998; K. C. Stange, “The generalist approach,” Ann. Fam. Med., 7:198-203, 2009, and E. J. Cassell, Doctoring: The Nature of Primary Care Medicine (NY: Oxford University Press, 1997).

[13] Of course, the issue of  levels of prescriptive authority pertains not only to physicians and NPs, but also to physician assistants, dentists, optometrists, osteopaths, and podiatrists. For the concrete manner in which the state of Florida spells out prescriptive levels for each of these professions, see http://www.thehealthlawfirm.com/resources/health-law-articles-and-documents/prescribing-in-florida.html).

[14] M. Crane, “Malpractice risks with NPs and PAs in your practice,” Medscape, Jan 3, 2013 (http://www.medscape.com/viewarticle/775746).

[15] E.g., C. Buppert, “Scope of practice,” J. Nurse Pract., 1:11-13, 2005.

[16] C. D. DeAngelis, “Nurse practitioner redux,” JAMA, 271:868-71, 1994.  The studies  DeAngelis cites are:  P. Repicky, et al., “Professional activities of nurse practitioners in adult ambulatory care settings,” Nurse Pract., 4:27-40, 1980; D. Munroe, et al., “Prescribing patterns of nurse practitioners,” Am. J. Nurs., 82:1538-40, 1982; J. Resenaur, “Prescribing behavior of primary care nurse practitioners,” Am. J. Public Health., 74:10-13, 1984.

[17] “Nurse Practitioner Prescribing Authority and Physician Supervision Requirements for Diagnosis and Treatment” (http://kff.org/other/state-indicator/nurse-practitioner-autonomy/).

[18] D. M. Keepnews, “Scope of practice redux?,” Policy, Politics & Nurs. Prac., 7:84-86, 2006, at 84.

[19] D. Marbury, “Scope of practice debate,” Med. Econ., September 10, 2013, 26-30, at 27 (http://medicaleconomics.modernmedicine.com/medical-economics/news/scope-practice-debate?page=full).

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

What Do Nurse Practitioners Practice?

What should the nurse practitioner’s “scope of practice” be  and how autonomously should she or he be allowed to practice within that scope?  A half century after the first advanced training programs brought nurses into the ranks of clinical providers, these two questions continue to bedevil nursing, medicine, insurance companies, and state legislatures.  The crucial role of nurse practitioners in modern health care delivery, their ability to provide primary care, and the satisfaction of patients who receive this care – these facts are well-established and, for me at least, beyond dispute.

But questions of scope of practice and practice prerogatives (including prescribing privileges) remain contentious, and different state legislatures have codified different answers.   I have no desire to enter debates that will likely continue at medical, nursing, and legislative levels for some time to come.  But let me offer one historian’s perspective on a few aspects of these knotty issues.

The expansion of nursing’s role in the direction of specialized clinical expertise occurred in an amazingly brief stretch of time.  In 1955, The American Nurses Association (ANA) approved a legal definition of nursing practice that prohibited “acts of diagnosis and prescription of therapeutic or corrective measures,” and it was only seven years later, in 1962, that it held its first clinical sessions at its annual convention.[1]  Even then, until 1968, the ANA’s Code for Professional Nurses framed the nurse’s professional responsibilities in terms of the nurse’s relationship to physicians.[2]  Yet, by the mid-60s, spearheaded by reforms in nursing education then underway, the term “nurse practitioner” came into use.  It conveyed a nurse with “specialized expertise,” often in hospital settings, that grew out of additional training beyond the three years of hospital-based training that led to state licensure as a Registered Nurse.

“Specialized expertise” is an evocative but imprecise term.  In nursing, it initially conveyed expertise in one or another aspect of hospital-based care.  In the early 1900s, nurses acquired expertise as x-ray technicians and microscopists, and then again in the 1930s, they “specialized” in monitoring polio patients in their iron lungs.  During World War II, nurses both on the front lines and in stateside hospitals began to perform venipunctures to administer fluids intravenously; after the war, they continued to do so, and some  became specialized IV  therapists, performing and monitoring  IVs all along their units.

But in postwar America it was especially the new technologies brought to bear in treating acutely ill patients that elicited nurse specialization.  Self-evidently, we needed critical care nurses, obstetrical nurses, and dialysis nurses able to exercise independent judgment and initiate (or discontinue) treatments in exigent circumstances, in what the historian Margaret Sandelowski terms “emergent life-threatening conditions.”  By the 1960s, as Sandelowski observes, the new “machinery of care” had fostered a more collegial and collaborative relationship between physicians and nurses.[3]  But this machinery  – vital function monitors, cardiac monitors, electronic fetal monitors, and the like – was integral to medical care in the hospital.  These monitors were not invented by nursing scientists as extensions of nursing care; they were instruments of improved hospital care whose design, manufacture, and intended use fell within the domain of physicians and the medical model.

The nomenclatural challenge proved even greater when advanced nursing practice left the hospital setting and became office-based, especially in the realm of primary care.  Historians of nursing such as Julie Fairman tend to collapse the distinction between hospital-based specialty nursing and independent “nursing practice” in a global narrative of nursing’s coming-of-age in the four decades following the end of World War II.  The storyline of professional self-becoming involves new forms of collegial collaboration between individual nurses and physicians, which, over time, empowered the nursing profession to liberate itself from the bondage of organized medicine, with its long-held belief in the subordinate role of nurses as physician extenders.  What tends to be glossed over is the phenomenology of “expertise” in relation to different professional activities.  Expertise in the implementation of technologically driven, hospital-based monitoring – with the diagnostic and treatment prerogatives associated with it – is not the same as the expertise that inheres in being a “practitioner” of medicine.

Or is it the expertise that inheres in being a “practitioner” of nursing?  In her illuminating history of the nurse practitioner movement in America, Fairman delineates the inter-professional tensions congealed in this question.  Even  Loretta Ford and Henry Silver, she points out, who collaboratively developed the first (pediatric) nurse practitioner training program at the University of Colorado in the mid-1960s, used different, politically laden terminology to describe exactly what kind of nonmedical practitioner they were training.  For the pediatrician Silver, the new provider would be a “nurse associate”; for the nurse educator Ford, she or he would be a “nurse practitioner.”[4]

And the linguistic-cum-political tension was played out in different pairs of descriptors.  Nurse practitioners saw themselves as “taking on” diagnostic and treatment activities traditionally reserved for physicians, whereas physicians saw themselves as “delegating” certain medical tasks to nurses.[5]  The need to define the nurse specialist’s prerogative to diagnose and treat illness as  something other than “medical”  was at the heart of the American Nurses Association’s need to distance itself from another nonmedically trained practitioner who emerged at this same moment in  American history:  the Physician Assistant.  PAs were precisely what newly empowered clinical care nurses, at least in the eyes of their professional organization, did not want to be: a Physician Assistant rather than an autonomous Nurse Practitioner.[6]

In the realm of independent practice, this claim is highly problematic, since diagnosis and treatment of illness is not nursing “practice” in any historically meaningful sense of the term; rather, diagnosis and treatment have always fallen to the physician, as the word “physician” has been understood since the beginning of the thirteenth century, when Anglo-Normans gathered the Latin “physicus” and the French “physic” into the English “physic,” from which the word  “physician” as a medical practitioner came in to use later in the century.  It is easy to see how nursing practice can envelop sophisticated technological skills that are teachable and learnable.  But the art of diagnosis and treatment – and the qualities of learned judgment[7] that fall to this task – have always been the province of medicine.

The historical claim enfolds an epistemic claim, a claim about the nature of different kinds of knowledge.  Nursing knowledge, as codified in Florence Nightingale’s Notes on Nursing: What It Is and What It is Not (1859) and the British and American training programs that adopted her model in the 1870s and thereafter, has never been coextensive with medical knowledge.  For  Nightingale and her cohort of nursing educators, it remained a “gendered” (read: womanly) knowledge of comfort care; such care drew on sanitary science and scientifically informed  bedside observation, both infused with a maternalistic sensibility.[8]  Whether or not the knowledge base that subtends such patient-centered caring is something other than medical knowledge (as Nightingale believed) or a neglected subset of medical knowledge, is beside the point. And the point is this:  The kind of “knowledge and skills”[9] that enter into independent clinical practice – “knowledge and skills” that, to be sure, nurse practitioners and other nonmedical providers can acquire to some extent  – are by their nature medical.  This is why the struggle of nurse practitioners to obtain state licensure that permits them to “practice” without medical supervision has been halting and may never succeed entirely.

It is not simply a matter of power in the sense of Foucault, of organized medicine’s ability to withhold, control, and/or regulate entry into the world of practice.  It is because the science of clinical evaluation, diagnosis, and treatment that emerged in postbellum America was vested in the medical profession, not in the nascent nursing profession.  In the final three decades of the nineteenth century, we behold the paradigm shift in medicine that historians endlessly write about:  Medicine became scientific medicine, and this shift, with its associated educational and organizational changes, coincided with the emergence of a “profession” in the modern sense of the term.  The physician, not his (then) helpmate nurse, was part of the profession vested with the scientific understanding of illness and the cultural authorization to act on this understanding by diagnosing and treating it.[10]

The foregoing helps explain why, in retrospect, the ANA’s insistence that pediatric nurse practitioners retain the prerogative to delineate their own scope of practice was foredoomed.  ANA leaders sought to contest a notion of “practice” that, by the early 1970s, was incontestable.  And the pediatric nurse practitioners knew as much.  Like their nurse anesthetist forebears, who formed the National Association of Nurse Anesthetists in 1932,[11] they walked away from the ANA and formed their own professional association, the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP) in 1973.  And the NAPNAP, without further ado, accepted affiliation with the American Academy of Pediatrics, realizing that the ANA’s insistence on complete autonomy for nursing was self-defeating.  The pediatric nurses, if not the ANA leaders, realized that such insistence militated against the idea of team practice, of a pediatrician, pediatric nurse practitioner, and nurse working together, and it contravened the reality that, in all such cases, the pediatrician would be the leader of the team.[12]

The dilemma for nurse practitioners is that they have spent  over a half century trying to define themselves by what they are not.  They are not physicians.  They are not physician assistants or associates.  They are not general nurses who lack advanced postgraduate training and specialty licensure.  So what exactly are they?

In the late 1950s and 1960s, nurse educators like Esther Brown and Hildegard Peplau sought to fill in the lacuna by articulating a new basis for nurse practitioner expertise.  In so doing, they adopted the same orientation as the founders of the “family practice” specialty movement during the same time.  That is, they sought to equate the nurse practitioner’s “expert clinical practice”  with a psychosocial sensibility and an ability to provide holistic psychotherapeutic care.  Social science course work and psychodynamic training, they hoped, would move the nursing practitioner away from medicine and toward this new kind of nursing expertise.

That Brown and Peplau spearheaded this effort in nurse education is hardly surprising, given their respective backgrounds.  Brown, a social anthropologist on the staff of the Russell Sage Foundation, authored Nursing for the Future (1948), a Foundation report that advocated university-based nurse training schools in the service of a vague psychosocial vision of nursing care.  The nurse of the future, she wrote, would “complement the patient by supplying what he needs in knowledge, will, or strength to perform his daily activities and also to carry out the treatment prescribed for him by the physician.”  Peplau, the founder of psychiatric nursing, followed an M.A. at Columbia’s Teachers College, where she completed the first course in advanced psychiatric nursing, with psychoanalytic training at New York’s William Alanson White Institute.[13]  She believed that psychiatric nurses should function as psychotherapists, and, implicitly, that all nurses should bring a broad psychosocial, really a psychotherapeutic, orientation to their work.  Were Brown, Peplau, and their associates successful in reforming nursing training in a manner that subserved a new kind of nursing identity?   No, certainly not in the manner they envisioned.  And further, at the time their educational reforms were introduced in the nursing schools of large public universities, there were serious problems: Graduates overfed with the new social science curriculum were simply unprepared to assume the responsibilities of nursing practice.[14]

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 My father, William Stepansky, whose remarkable postwar career in family medicine has been woven into many of these essays, was a pharmacist before he was a physician.  He entered Philadelphia College of Pharmacy and Science in 1940, but his education was interrupted by induction into the army in March, 1943, several months before he completed his junior year.  He had not begun pharmacy college with the intention of attending medical school – this seemed an utterly far-fetched dream for the son of poor Russian émigrés who fled the Pogroms in 1921 and struggled to raise a family in the Jewish enclave of South Philadelphia.  His own mother thought him foolish for entering college and crazy (meshuga) when he mentioned his interest in medicine.  In 1946, after two years of service as a surgical technician on the battlefields of France, Belgium and Germany and an additional six months as a laboratory technician in Pilzen, Czechoslovakia, he returned to Philadelphia, where he completed his pharmacy training in 1947.  Only then, with the G.I. Bill in place, did he allow himself to envision a career in medicine, and following an inventive series of initiatives, he gained admittance to Jefferson Medical College, where he joined the freshman class in the fall of 1948.[15]

My father not only retained an active pharmacy license throughout his career, but actually “practiced” pharmacy out of his Trappe office.  He maintained an impressive inventory of basic and not-so-basic drugs, and he concocted, among other things, the marvelous “red medicine” of which I have written.  He became a staff research clinician for McNeil Labs and later participated in clinical drug trials with the Psychopharmacology Research Unit of the University of Pennsylvania.  Pharmacy training certainly proved helpful to him and his rural patients, but it was not at the core of his professional identity.  He was not a “pharmacist practitioner” or an “advanced practice pharmacist.”  He was a physician, a general practitioner of medicine.

Perhaps it is time for the nurse practitioner profession to dispense with the “nurse” appellation altogether.  These men and women are not professional nurses as the notion of nurse professionalism took shape over 150 years, even though they come to  medical “practice” through nursing training and the patient-centered values it instills.  But additional clinical training of several years duration beyond the R.N. or B.S.N. level, I suggest, takes them out of the realm of nursing practice altogether.   So, with a nod to perduring intra- and inter-professional politics, let’s cast aside the terms “medical,” “physician,” “nurse,” and “nursing” altogether, and come up with something more accurate.  Advanced practice nurses should henceforth be designated “licensed clinical providers” or “licensed clinical practitioners,” with the appropriate specialty designation appended to their licenses, e.g., “licensed clinical provider – primary care” or “licensed clinical provider – nephrology” or “licensed clinical provider – oncology.”  There, I’ve said it.  These designations are accurate and neutral and therefore certain to please no one.

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[1] J. Fairman, Making Room in the Clinic:  Nurse Practitioners and the Evolution of Modern Health Care (New Brunswick:  Rutgers University Press, 2008), pp. 119-21.

[2] L. Freitas, “Historical roots and future perspectives related to nursing ethics,” J. Prof. Nurs., 197-205, 1990, at 202.

[3]  M. Sandelowski, Devices and Desires:  Gender, Technology, and American Nursing (Chapel Hill: University of North Carolina Press, 2000), pp. 127-28.

[4] Fairman, Making Room in the Clinic, p. 91.

[5] J. Fairman, “Delegated by default or negotiated by need?:  physicians, nurse practitioners, and the process of clinical thinking,” in E. D. Baer, et al., Enduring Issues in American Nursing (NY:  Springer Pub., 2002), pp. 309-333, at p. 323.

[6] Fairman, Making Room in the Clinic, pp. 95ff.

[7] N.B. I do not understand “clinical judgment,” with its reliance on mentoring and tacit knowing, in the same way Fairman understands “clinical thinking,” viz., as a process or skill set. See Fairman, “Delegated by default,” pp. 311-12 and Making Room in the Clinic, p. 187.

[8] For a wonderful popular exposition of  Nightingale’s vision of the nurse transposed to the Bellevue Hospital Training School in the early 1880s,  see F. H. North, “A new profession for women,” The Century, 25:30-37, 1882.

[9] Fairman, “Delegated by default,” p. 323.

[10] These brief remarks allude to, without doing justice to, the brilliant analysis of Thomas Haskell on the emergence of modern professions in postbellum America.  See T. L. Haskell, The Emergence of Professional Social Science:  The American Social Science Association the the Nineteenth-Century Crisis of Authority (Baltimore: John Hopkins, 2000 [1977]), pp. 68-74, 91-121, and passim.

[11] K. Koch, “Agatha Hodgins, Lakeside Alumnae Association, and the founding of the AANA,” AANA Journal, 73:259-62, 2005.

[12] Fairman, Making Room in the Clinic, pp. 175-80.

[13] On Peplau’s graduate training at Teacher’s College and the William Alanson White Institute, see B. J. Callaway, Hildegard Peplau: Psychiatric Nurse of the Century (NY:  Springer Pub., 2002), pp. 167-91.

[14] Dominique Tobbell documents the perceived deficiencies of 1960s graduates of the UCLA and University of Minnesota nursing schools, where the new curriculum was implemented,  in “’Coming to grips with the nursing question’:  the politics of nursing education reform in 1960s America,”  Nurs. Hist. Rev., 22:37-60, 2014.

[15] This paragraph is culled from my memoir of my father’s life and career, P. E. Stepansky, The Last Family Doctor:  Remembering My Father’s Medicine (Montclair, NJ:  Keynote, 2011).

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

Psychotropic Serendipities

Serendipities abound in history of medicine, in our own time no less than in the past.  In the 15 years that followed the end of World War II, a period of special interest to me, the discovery of what we now consider modern psychiatric (or psychotropic) drugs is a striking case in point.

Researchers in the final years of the war and immediately thereafter were hardly looking for psychotropics.  They were looking for other things:  improved antihistamines; preservatives that would permit penicillin to hold up during transport to troops in Europe and Asia; and the development of antibiotics effective against penicillin-resistant microorganisms like the tubercle bacilli that caused tuberculosis.

When Frank Berger, a Czechoslovakian bacteriologist, fled to England in 1939, he gained work as as a refugee camp physician.  Then, in 1943, he was hired by a government laboratory in London and joined in the work that engaged so many British scientists of the time:  the purification and industrial production of penicillin.  Berger’s particular assignment was the search for a penicillin preservative; he was especially interested in finding an agent that would prevent the breakdown of penicillin by gram-negative bacteria (penicillinase) during shipment.  And with the synthesis of mephenesin in 1945, he achieved success – and then some.  Mephenesin not only preserved penicillin, but, in small-scale animal trials on toxicity begun at the end of 1951, it revealed something else:  On injection into mice, rats, and guinea pigs, the preservative produced deep muscle relaxation, a sleep-like state that Berger described in 1946 as “tranquillization.”[1]

Berger emigrated to the United States in 1947, and after a brief stint at the University of Rochester Medical School, became Director of Laboratories at Carter-Wallace in Cranbury, New Jersey.  There, joined by the chemist Bernard Ludwig, he developed a more potent and slowly metabolizing form of mephenesin.  The drug was meprobamate, the first minor tranquilizer, for which a patent was finally granted in 1955.  Released by Carter-Wallace as Miltown and by Wyeth (a licensee) as Equanil, it took the American market by storm.  In 1956, it leaped from less than 1% to nearly 70% of new tranquilizer prescriptions; in1957 more than 35 million prescriptions were sold, the equivalent of one per second. Meprobamate single-handedly transformed American medicine by transmuting the everyday stresses and strains of Everyman (and Everywoman) into pharmacologically treatable anxiety.  For general practitioners in particular it was a godsend.  “If generalists could not psychoanalyze their troubled patients,” the historian David Herzberg has observed, “they could at least ease worries with a pill, possibly preventing a minor condition from worsening into serious mental illness.”[2]  Not bad for a penicillin preservative.

In 1952, at the very time Berger was observing the “tranquillization” of small rodents injected with meprobamate,  Henri-Marie Laborit, a French naval surgeon working at the Val de Grâce military hospital outside Paris, published his first article on the usefulness of chlorpromazine (CPZ), a chlorinated form of the antihistamine Promazine, in surgical practice.  Laborit, who was working on the development of “artificial hibernation” as an anesthetic technique, found that the drug not only calmed surgical patients prior to the administration of anesthesia, but also prevented them from lapsing into shock during and after their operations.  The drug had been synthesized by the Rhône-Poulenc chemist Paul Charpentier at the end of 1951. Charpentier was searching for an improved antihistamine, but he quickly saw the drug’s possible usefulness as a potentiator of general anesthesia,[3] which indeed it proved to be.

Impressed with the drug’s effectiveness (in combination with other drugs as a “lytic cocktail”) in inducing relaxation – what he termed “euphoric quietude” – and in preventing shock, Laborit encouraged his colleague Joseph Hamon to try it on psychiatric patients.  It was subsequently taken up by the French psychiatrists Jean Delay and Pierre Deniker, who tried it on psychiatric patients at the Sainte-Anne mental hospital in Paris.  In six journal articles published in the spring and summer of 1952, they reported encouraging results, characterizing their patients’ slowing down of motor activity and emotional indifference as “neuroleptic syndrome” (from the Greek “that take the nerve”).  Thus was born, in retrospect, the first major tranquilizer, a drug far more effective than its predecessors (including morphine and scopolamine in combination) in controlling extreme agitation and relieving psychotic delusions and hallucinations.[4]

But only in retrospect.  At the time of the preliminary trials, the primary application of chlorpromazine remained unclear.  Rhône-Poulenc conducted clinical trials for a number of applications of the drug: to induce “hibernation” during surgery; as an anesthetic; as an antinausea drug (antiemetic) for seasickness; as a treatment for, respectively, burns, stress, infections, obesity,  Parkinson’s disease, and epilepsy.  When Smith, Kline, & French became the American licensee of the drug in early 1953, it planned to market it to American surgeons and psychiatrists alike, and it also took pains to license the drug as an antiemetic.  Only at the end of 1953 did it recognize the primary psychiatric use of the drug, which it released in May, 1954 as Thorazine.

Of course, the birth of modern antibiotic therapy begins with penicillin – the first of the wartime “miracle drugs.” And a miracle drug it was, with an antibacterial spectrum that encompassed strep and staph infections, pneumonia, syphilis and gonorrhea.  But the foregoing infections were all caused by gram-positive bacteria.  Penicillin did not touch the kind of gram-negative bacteria that caused tuberculosis.

The first wonder drug effective against TB was streptomycin, an actinomyces (a soil-dwelling, anaerobic bacteria) discovered by Salman Waksman and his doctoral student Albert Schatz at the Rutgers Agricultural Experiment Station in 1943.  Eight years later, in 1951, chemists working at Bayer Laboratories in Wuppertal, Germany, at Hoffman-La Roche in Basel, Switzerland, and at the Squibb Institute for Medical Research in New Brunswick, New Jersey simultaneously discovered a drug that was not only more effective in treating TB than streptomycin; it was also easier to administer and less likely to have serious side effects.  It was isoniazid, the final wonder drug in the war against TB.  In combination with streptomycin, it was more effective than either drug alone and  less likely to elicit treatment-resistant strains of the tubercle bacilli.

But here’s the thing:  A side-effect of isoniazid was its mood-elevating (or, in the lingo of the day, “psycho-stimulative”) effect.  Researchers conducting trials at Baylor University, the University of Minnesota, and Spain’s University of Cordoba reached the same conclusion:  The mood-elevating effect of isoniazid treatment among TB patients pointed to psychiatry as the primary site of its use.  Back in New York, Nathan Kline, an assistant professor of psychiatry at Columbia’s College of Physicians and Surgeons, learned about the “psycho-stimulative” effect of isoniazid from a report about animal experiments conducted at the Warner-Lambert Research Laboratories in Morris Plains, New Jersey.  Shortly thereafter, he began his own trial of isoniazid with patients at Rockland State Hospital in Orangeburg, New York, and published a report of his findings in 1957.

A year later the drug was brought to market as an antitubercular agent (Marsilid), even though it had been given to over 400,000 depressed patients by that time.  Its improved successor drug, iproniazid, was withdrawn from the U.S. market in 1961 owing to an alleged linkage to jaundice and kidney damage.  But isoniazid retains its place of honor among psychotropic serendipities:  It was the first of the monoamine oxidase inhibitors (MAOIs), potent antidepressants of which contemporary formulations (Marplan, Nardil) are used to treat atypical depressions, i.e., depressions refractory to newer and more benign antidepressants like the omnipresent SSRIs.[5]

Nathan Kline was likewise at hand to steer another ostensibly nonpsychotropic drug into psychiatric usage.  In 1952, reports of Rauwolfia serpentine, a plant root used in  India for hypertension (high blood pressure), snakebite, and “insanity,” reached the West and led to interest in the root’s potential as an antihypertensive.  A year later, chemists at the New Jersey headquarters of the Swiss pharmaceutical firm Ciba (later Ciba-Geigy and now Novartis) isolated an active salt, reserpine, from the root, and Kline, ever ready with the mental patients at Rockland State Hospital, obtained a sample to try on the hospital’s depressed patients.

Kline’s results were encouraging.  In short order, he was touting  reserpine as an “effective sedative for use in mental hospitals,” a finding reaffirmed later that year at a symposium at Ciba’s American headquarters in Summit, New Jersey, where staff pharmacologist F. F. Yonkman first used the term “tranquilizer” to characterize the drug’s mixture of sedation and well-being.[6]  As a major tranquilizer, reserpine never caught on like chlorpromazine, even though, throughout the 1950s, it “was far more frequently mentioned in the scientific literature than chlorpromazine.”[7]

So there we have it: the birth of modern psychopharmacology in the postwar era from research into penicillin preservatives, antihistamines, antibiotics, and antihypertensives.  Of course, serendipities operate in both directions:  drugs initially released as psychotropics sometimes fail miserably, only to find their worth outside of psychiatry.  We need only remember the history of thalidomide, released by the German firm Chemie Grűnenthal in 1957 as a sedative effective in treating anxiety, tension states, insomnia, and nausea.  This psychotropic found its initial market among pregnant women who took the drug to relieve first-trimester morning sickness.  Unbeknown to the drug manufacturer, the drug crossed the placental barrier and, tragically, compromised the pregnancies of many of these women.  Users of thalidomide delivered grossly deformed infants with truncated limbs, “flipper” babies, around 10,000 in all in Europe and Japan.  Only 40% of these infants survived.

This sad episode is well-known among historians, as is the heroic resistance of the FDA’s Frances Kelsey, who in 1960 fought off pressure from FDA administrators and executives at Richardson-Merrell, the American distributor, to release the drug in the U.S.  Less well known, perhaps, is the relicensing of the drug by the the FDA in 1998 (as Thalomid) for a totally nonpsychotropic usage: the treatment of certain complications of leprosy.  Prescribed off-label, it also proved helpful in treating AIDS wasting syndrome.  And beginning in the 2000s, it was used in combination with another drug, dexamethasone, to treat multiple myeloma (a cancer of the plasma cells). It received FDA approval as an anticancer agent in 2006.[8]

Seen thusly, serendipities are often rescue operations, the retrieving and reevaluating of long-abandoned industrial chemicals and of medications deemed inadequate for their intended purpose.  Small wonder that Librium, the first of the benzodiazepine class of minor tranquilizers, the drug that replaced meprobamate as the GP’s drug of choice in 1960, began its life as a new dye (benzheptoxidiazine) synthetized by the German chemists K. von Auwers and F. von Meyenburg in 1891. In the 1930s the Polish-American chemist Leo Sternbach returned to the chemical and synthesized related compounds in the continuing search for new “dyestuffs.”  Then, 20 years later, Sternbach, now a chemist at Hoffmann-La Roche in Nutley, New Jersey, returned to these compounds one final time to see if any of them might have psychiatric applications.  He found nothing of promise, but seven years later, in 1957, a coworker undertook a spring cleaning of the lab and found a variant that Sternbach had missed.  It turned out to be Librium.[9]  All hail to the resourceful minds that return to the dyes of yesteryear in search of the psychotropics of tomorrow – and to those who clean their labs with eyes wide open.

______________________

[1] F. M. Berger & W. Bradley, “The pharmacological properties of α:β dihdroxy (2-methylphenoxy)-γ- propane (Myanesin),” Brit. J. Pharmacol. Chemother., 1:265-272, 1946, at p. 265.

[2] D. Herzberg, Happy Pills in America: From Miltown to Prozac (Baltimore: Johns Hopkins, 2009), p. 35.  Cf. A. Tone, The Age of Anxiety: A History of America’s Turbulent Affair with Tranquilizers  (NY:  Basic Books, 2009), pp. 90-91.

[3] P. Charpentier, et al., “Recherches sur les diméthylaminopropyl –N phénothiazines substituées,” Comptes Rendus de l’Académie des Sciences, 235:59-60, 1952.

[4] On the discovery and early uses of chlorpromazine, see D. Healy, The Creation of Psychopharmacology (Cambridge: Harvard, 2002), pp. 77-101; F. Lopez-Munoz, et al., “History of the discovery and clinical introduction of chlorpromazine,”  Ann. Clin. Psychiat., 17:113-135, 2005; and T. A. Ban, “Fifty years chlorpromazine:  a historical perspective,” Neuropsychiat. Dis. & Treat., 3:495-500, 2007.

[5] On the development and marketing of isoniazid,  see H. F. Dowling, Fighting Infection: Conquests of the Twentieth Century (Cambridge: Harvard, 1977), p. 168; F. Ryan, The Forgotten Plague: How the Battle Against Tuberculosis was Won and Lost (Boston:  Little, Brown, 1992), p. 363; F. López-Munoz, et al., “On the clinical introduction of monoamine oxidase inhibitors, tricyclics, and tetracyclics. Part II: tricyclics and tetracyclics,” J. Clinical Psychopharm., 28:1-4, 2008; and Tone, Age of Anxiety, pp. 128-29.

[6] E. S. Valenstein, Blaming the Brain: The Truth about Drugs and Mental Health  (NY:  Free Press, 1998), p. 69; D. Healy, The Antidepressant Era (Cambridge: Harvard, 1997),  pp. 59-70;  D. Healy, Creation of Psychopharmacology, pp. 103-05.

[7] Healy, Creation of Psychopharmacology, p. 106.

[8] P. J. Hilts provides a readable overview of the thalidomide crisis in Protecting America’s Health:  The FDA, Business, and One Hundred Years of Regulation (NY:  Knopf, 2003), pp. 144-65.  On the subsequent relicensing of thalidomide for the treatment of leprosy in 1998 and its extensive off-label use, see S. Timmermans & M. Berg, The Gold Standard:  The Challenge of Evidence-Based Medicine and Standardization in Health Care. (Phila: Temple University Press, 2003), pp. 188-92.

[9] On the discovery of Librium, see Valenstein, Blaming the Brain, pp. 54-56; A. Tone,“Listening to the past: history, psychiatry, and anxiety,” Canad. J. Psychiat,, 50:373-380, 2005, at p. 377; and Tone, Age of Anxiety, pp. 126-40.

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

Injections and the Personal Touch

“Fear of the needle is usually acquired in childhood.  The psychic trauma to millions of the population produced in this way undoubtedly creates obstacles to good doctor-patient relationships, essential diagnostic procedures, and even life-saving therapy.”  Janet Travell, “Factors Affecting Pain of Injection” (1955)[1]

It was during the 1950s that the administration of hypodermic injections became a fraught enterprise and a topic of medical discussion.  With World War II over and American psychoanalysis suffusing postwar culture, including the cultures of medicine and psychiatry, it is unsurprising that physicians should look with new eyes at needle penetration and the fears it provoked.

In the nineteenth century, it had been all about pain relieved, sometimes miraculously, by injection of opioids.  Alongside the pain relieved, the pain of the injection was quite tolerable, even minor, a mere afterthought.  But in the mid-twentieth century pain per se took a back seat.  It was no longer about the painful condition that prompted injection.  Nor, really, was it about the pain of injection per se.  Psychodynamic thinking trumped both kinds of pain.  Increasingly, the issue before physicians, especially pediatricians, was about two things:  the anxiety attendant to injection pain and the lasting psychological damage that was all too often the legacy of needle pain.  Elimination of injection pain mattered, certainly, but it became the means to a psychological end.  Relieve the pain, they reasoned, and you eliminate the apprehension that exacerbates the pain and leaves deep psychic scars.

And so physicians were put on notice.  They were enjoined to experiment with numbing agents, coolant sprays, and various counterirritants to minimize the pain that children (and a good many adults) dreaded.  They were urged to keep their needles sharp and their patients’ skin surfaces dry.  Coolant sprays and antiseptic solutions that left a wet film, after all, could be carried into the skin as irritants.  For the muscular pain attendant to deeper injections, still stronger anesthetics, such as procaine, might be called for.  Physicians were also encouraged to reduce injection pain through new technologies, to use, for example, hyposprays and spring-loaded presto injectors.  Injection “technique” was a topic of discussion, especially for intramuscular injections of new wonder drugs such as streptomycin.  To be sure, new technologies and refined technique often failed to eliminate injection pain, especially when a large volume of solution was injected.  But, then again, pain relief was only a secondary goal. The point of the recommendations was primarily psychological, viz., to eliminate “the psychological reaction to piercing the skin.”[2]  It was anticipation of pain and the fear it engendered that jeopardized the doctor-patient relationship.

Psychoanalysts themselves, far removed from the everyday concerns of pediatricians, family physicians, and internists, had little to say on the topic.  They were content to call attention now and again to needle symbolism – invariably phallic in nature – in dreams and childhood memories.  In 1954, the child analyst Selma Fraiberg recalled “The theory of a two-and-a-half-year-old girl who developed a serious neurosis following an observation of coitus.  The child maintained that ‘the man made the hole,’ that the penis was forcibly thrust into the woman’s body like the hypodermic needle which had been thrust into her by the doctor when she was ill.”   Pity this two and a half year old.

Inferences about male sadism and castration anxiety were integral to this train of thought.  In 50s-era psychoanalysis, needle injection could symbolize not only “painful penetration,” but also the sadistic mutilation of a little girl by a male doctor.[3]  One wants to say that such strained psychoanalytic renderings are long dead and buried, but the fact is they still find their way into the literature from time to time, usually in the context of dream interpretations.  Here is one from 1994:

Recently Ms. K mentioned a dream in which she was diabetic and had little packets of desiccated insulin which were also like condoms.  All she needed now was a hypodermic syringe and a needle.  I pointed out the sexual nature of the dream with its theme of penetration; she then remembered that in the dream a woman friend had lifted her skirt and Ms. K had ‘whammed the needle right in’.[4]

Psychoanalytic interpretive priorities change over time, whether or not in therapeutically helpful ways being a perennial subject of debate.  By the 1990s, there was belated recognition that children’s needle phobias really didn’t call for analytic unraveling; they derived from the simple developmental fact that “children are exposed to hypodermic needles prior to their ability to understand what is going on,” and, as such, were more amenable to behavioral intervention than psychoanalytic treatment.  In the hospital setting, in particular, children needed simple strategies to reduce fear, not psychoanalytic interpretations.[5]

In 1950s medicine, psychoanalysis was at its best when its influence was subtle and indirect.  Samuel Sterns’s thoughtful consideration of the “emotional aspects” of treating patients with diabetes, published in the New England Journal of Medicine in 1953, is one such example.  Sterns worked out of the Abraham Rudy Diabetic Clinic of Boston’s Beth Israel Hospital, and he expressed indebtedness to the psychiatrist-psychoanalyst Grete Bibring and other members of her department for “many discussions” on the topic.

For most diabetics, of course, daily injections, self-administered whenever possible, were an absolute necessity.  And resistance to the injections, then as now, undercut treatment and resulted in poor glycemic control.[6]  How then to cope with the diabetic’s resistance to the needle, especially when “the injection of insulin is sometimes associated with a degree of anxiety, revulsion or fear that cannot be explained by the slight amount of pain involved.”[7]

Psychoanalysis provided a framework for overcoming the resistance.  It was not a matter of “simple reassurance” about insulin injections, Sterns observed, but – and it is Bibring’s voice we hear –

Recognition that apparently trivial and unfounded complaints about insulin injections may be based on deeply rooted anxiety for which the patient finds superficial rationalizations enables the physician to be more realistic and tolerant, and more successful in dealing with the problem.

Realism, tolerance, acceptance – this was the psychoanalytic path to overcoming the problem.  Physicians had to accept that diabetics’ anxiety about injections arose from “individual personalities,” and that each diabetic had his or her own adaptively necessary defenses.  Exhortation, criticism, direct confrontation – these responses had to be jettisoned on behalf of the kindness and understanding that would lead to a “positive interpersonal relation.”  This entailed an understanding of the patient’s transference to the physician:

It is particularly apparent that most of the reactions of juvenile diabetic patients to discipline, authoritativeness or criticism by the physician are really identical with their reactions to similar situations involving their parents.

And it included a  like-minded willingness to wrestle with the countertransference as an obstacle to treatment:

Even the occasional display of an untherapeutic attitude by the physician is enough to interfere with the development of a relation that will enable him to obtain maximal cooperation from the patient.  If the physician cultivates awareness of his own reactions to a difficult patient, he will be less easily drawn into retaliation or other negative behavior.[8]

The point of the analytic approach was to lay the groundwork for a “positive interpersonal relation” that would enlist the patient’s cooperation, and “not through anxiety or fear of the disease or the physician, but rather through the wish to be well and to gain the physician’s approval.”[9]  Sympathetic acceptance of the patient’s fears, of the defenses against those fears, of the life circumstances that led to the defenses – this was the ticket to the kind of positive transference relationship that the physician could use to his and the patient’s advantage.

_______________

Sterns’s paper of 1953 remains helpful to this day; it exemplifies the application of general psychoanalytic concepts to real-world medical problems that, as I suggested in the final chapter of Psychoanalysis at the Margins (2009), may breathe new life into a beleaguered profession.  The reasonableness of Sterns’s recommendations stands in contrast to the insular irrelevance of  George Moran’s “Psychoanalytic Treatment of Diabetic Children” (1984), where poor glycemic control among children becomes a “metaphorical expression[s] of psychological disturbance” — framed in terms of “entrenched defensive structures” and “drive derivatives” – that calls for psychoanalytic treatment, sometimes via “prolonged stays” of up to several months in pediatric wards.[10]  And yet, there is something missing from Sterns’s commentary.  Like other writers of his time, he was concerned lest needle anxiety become an obstacle to a good doctor-patient relationship.  Cultivate the relationship through sympathetic insight into the problem, he reasoned, and  the obstacle would diminish, perhaps even disappear.  What he ignored – indeed, what all these hospital- and clinic-based writers of the time ignored – is the manner in which a preexisting “good doctor-patient relationship” can defuse needle anxiety in the first place.

Nineteen fifty three, the year Sterns’s paper was published, was also the year my father, William Stepansky, opened his general practice at 16 East First Avenue, Trappe, Pennsylvania.  My father, as I have written, was a Compleat Physician in whom wide-ranging procedural competence commingled with a psychiatric temperament and deeply caring sensibility.  In the world of 1950s general practice, his office was, as Winnicott would say, a holding environment.  His patients loved him and relied on him to provide care.  If injections were part of the care, then ipso facto, they were caring interventions, whatever the momentary discomfort they entailed.

The forty years of my father’s practice spanned the first 40 years of my life, and, from the time I was around 13, we engaged in ongoing conversations about his patients and work.  Never do I recall his remarking on a case of needle anxiety, which is not to deny that any number of patients, child and adult, became anxious when injection time arrived.  My point is that he contained and managed their anxiety so that it never became clinically significant or worthy of mention.  At the opposite end of the spectrum, I know of elderly patients who welcomed him into their homes several times a week for injections – sometimes just vitamin B-12 shots – that amplified the human support he provided.

Before administering an injection, my father firmly but gently grasped the underside of the patient’s upper arm, and the patient felt held, often in just those ways in which he or she needed holding.  When one’s personal physician gives an injection, it may become, in some manner and to some extent, a personal injection.  And personal injections never hurt as much as injections impersonally given.  This simple truth gets lost in the contemporary literature that treats needle phobia as a psychiatric condition in need of focal treatment.   A primary care physician remarked to me recently that she relieved a patient’s severe anxiety about getting an injection simply by putting the injection on hold and sitting down and talking to the patient for five minutes.  In effect, she reframed the meaning of the injection by absorbing it into a newly established human connection. Would that all our doctors would sit down with us for five minutes and talk to us as friendly human beings, as fellow sufferers, before getting down to procedural business.

I myself am more fortunate than most.  For me the very anticipation of an injection has a positive valence.  It conjures up the sights and smells and tactile sensations of my father’s treatment room.  Now in my 60s, I still have in my nostrils the bracing scent of the alcohol he used to clean the injection site, and I still feel the firm, paternal grasp of his hand on my arm at the point of injection.  I once remarked to a physician that she could never administer an injection that would bother me,  because at the moment of penetration, her hand became my father’s.

Psychoanalysts who adopt the perspective of object relations theory speak of “transitional objects,” those special inanimate things that, especially in early life, stand in for our parents and help calm us in their absence.  Such objects become vested with soothing human properties; this is what imparts their “transitional” status.  In a paper of 2002, the analyst Julie Miller ventured the improbable view, based on a single case, that the needle of the heroin addict represents a “transitional object” that fosters a maternal connection the addict never experienced in early life.[11]  For me, I suppose, the needle is also a transitional object, albeit one that intersects with actual lived experience of a far more inspiriting nature.  To wit, when I receive an injection it is always with my father’s hand, life-affirming and healing.  It is the needle that attests to a paternal connection realized, in early life and in life thereafter.  It is an injection that stirs loving memories of my father’s medicine.   So how much can it hurt?

_______________

[1] J. Travell, “Factors affecting pain of injection,” JAMA, 58:368-371, 1955, at p. 368.

[2] J. Travell, “Factors affecting pain of injection,” op. cit.; L. C. Miller, “Control of pain of injection,” Bull Parenteral Drug A., 7:9-13,1953; E. P. MacKenzie, “Painless injections in pediatric practice,” J. Pediatr., 44:421, 1954; O. F. Thomas & G. Penrhyn Jones, “A note on injection pain with streptomycin,” Tubercle, 36:157-59, 1955; F. H. J. Figge & V. M. Gelhaus, “A new injector designed to minimize pain and apprehension of parenteral therapy,” JAMA, 160:1308-10, 1956.  There were also needle innovations in the realm of intravenous therapy, e.g., L. I. Gardner & J. T. Murphy, “New needle for pediatric scalp vein infusions,” Amer. J. Dis. Child., 80:303-04, 1950.

[3] S. Fraiberg, “A critical neurosis in a two-and-a-half-year girl,” Psychoanal. Study Child, 7:173-215, 1952, at p. 180; S. Fraiberg, “Tales of the discovery of the secret treasure,” Psychoanal. Study Child, 9:218-41, 1954, at p. 236.

[4] I. D. Buckingham, “The effect of hysterectomy on the subjective experience of orgasm,” J. Clin. Psychoanal., 3:607-12, 1994.

[5] D. Weston, “Response,” Int. J. Psychoanal., 78:1218-19, 1997, at p. 1219; C. Troupp, “Clinical commentary,” J. Child Psychother., 36:179-82, 2010.

[6] There is ample documentation of needle anxiety among present-day diabetics, e.g., A. Zambanini, et al., “Injection related anxiety in insulin-treated diabetes,” Diabetes Res. Clin. Prac., 46:239-46, 1999 and A. B. Hauber, et al., “Risking health to avoid injections: preferences of Canadians with type 2 diabetes,” Diabetes Care, 28:2243-45, 2005.

[7]S. Stearns, “Some emotional aspects of the treatment of diabetes mellitus and the role of the physician,” NEJM, 249:471-76, 1953, at p. 473.

[8] Ibid., p. 474.

[9] Ibid.

[10]P. E. Stepansky, Psychoanalysis at the Margins (NY: Other Press, 2009), pp. 287-313; G. S. Moran, “Psychoanalytic treatment of diabetic children,” Psychoanal. Study Child, 39:407-447, at pp. 413, 440. 

[11]J. Miller, “Heroin addiction: the needle as transitional object,” J. Amer. Acad. Psychoanal., 30:293-304, 20.

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

It Was All About the Pain

“. . . and although the patient had long been a sufferer from dyspnea, chronic bronchitis, and embarrassed heart, we believed that the almost miraculous resurrection which took place would be permanent.  He died, however, on the second day.”   — Cameron MacDowall, “Intra-Peritoneal Injections in Cholera” (1883)[1]

Among the early British and American proponents of subcutaneous hypodermic injection, especially of liquefied morphine, the seeming miracle of instantaneous pain relief sufficed to bring physician and patient into attitudinal alignment.  We are a century removed from the psychoanalytic sensibility that encouraged physicians to explore the personal side of hypodermic injection and to develop strategies for overcoming patients’ anxieties about needle puncture, their “needle phobia.”

There is no need to read between the lines of nineteenth-century clinical reports to discern the convergence of physician delight and patient amazement at the immediate relief provided by hypodermic injection.  The lines themselves tell the story, and the story is all about the pain.  Patients who received hypodermic injections in the aftermath of Alexander Wood’s successful use of Daniel Ferguson’s  “elegant little syringe” were often in extremis.  Here is a woman of 40, who presented with a case of acute pleurisy (inflammation of the membrane around the lungs) in 1867:

The pain was most intense; great dyspnea [difficulty breathing] existed; sharp, lancinating pains at each rapid inspiration completely prostrated the patient, whose sufferings had been continuous for twelve hours.  About one-sixth of a grain of the acetate of morphia was used hypodermically, and with prompt relief, a few minutes only elapsing after its injection before its beneficial results followed.  The ordinary treatment being continued, a recovery was effected in a short time.[2]

Consider this “delicate elderly spinster” of 1879, who presented to her physician thusly:

I found her nearly unconscious, cramped all over body and legs, vomiting violently every minute or two, purging every few minutes, the purging being involuntary and under her.  She was showing the whites of the eyes, and the countenance was changed.  She was certainly all but gone.  Gave at once two-fifths of a grain of sulphate of morphia hypodermically.  She did not feel the prick of the needle in the least.[3]

And here is a surgeon from Wales looking in on a 48-year old gardener in severe abdominal pain at the Crickhowell Dispensary on August 1, 1882:

On my visiting him at 11:30 on the morning of the above date, I found him in great agony, in which condition his wife informed me he had been during the greater part of the previous night.  He implored me to do something for relief, saying he could endure the suffering no longer; and as I happened to have my hypodermic syringe in my pocket, I introduced into his arm four minims of a solution of acetate of morphia.  I then left him.[4]

A bit better off, one supposes – if only a bit – were patients who suffered  severe chronic pain, whether arthritic, gastrointestinal,  circulatory, or cancerous in nature.  They too were beneficiaries of the needle.  We encounter a patient with “the most intense pain in the knee-joint” owing to a six-year-long attack of gout.  Injection of a third of a grain of acetate of morphia was followed by “the most delightful results,” with “the patient expressing himself in glowing terms as to the efficacy and promptness of this new remedy.”  Instantaneous relief, compliments of the needle, enabled him to turn the corner; he “rallied rapidly, having none of the depression and debilitating effects, the resultant of long-continued pain, to recover from, as in former times.”[5]

So it was with patients with any number of ailments, however rare or nebulous in nature.  A 31-year-old woman was admitted to Massachusetts General Hospital in 1883 with what her physician diagnosed as multiple sarcomas (malignant skin tumors) covering her upper arms, breasts, and abdomen; she was given subcutaneous injections of Fowler’s Solution, an eighteenth-century tonic that was one percent arsenic.  Discharged from the hospital two weeks later, she self-administered daily injections of Fowler’s for another five months, by which time the lesions had cleared completely; a year later she remained “perfectly well to all appearance.”  In the 1890s, the decade when subcutaneous injections of various glandular extracts gripped the clinical imagination, it is hardly surprising to read that injection of liquefied gray matter of a sheep’s brain did remarkable things for patients suffering from nervous exhaustion (neurasthenia).  Indeed, its tonic effect comprised “increase of weight, appetite and weight, restoration of spirits and bien-être, disappearance of pain, sexual impotence and insomnia.”  At the other end of the psychophysical spectrum, patients who became manic, even violently delirious, during their bouts with acute illnesses such as pneumonia or rheumatic fever, “recovered in the ordinary way” after one or more injections of morphia, sometimes in conjunction with inhaled chloroform.[6]

Right through century’s end, the pain of disease was compounded by the pain of pre-injection treatment methods.  What the Boston surgeon Robert White, one of Wood’s first American followers, termed the “revolution in the healing art” signaled by the needle, addressed both poles of suffering.  Morphia’s “wonderful effects” on all kinds of pain — neuralgic pain, joint pain, digestive pain (dyspepsia), the pain of tumors and blockages – were heightened by the relative painlessness of injection.  Indeed, the revolutionary import of hypodermic injection, according to White, meant that “The painful and decidedly cruel endermic mode of applying medicines [i.e., absorption through the skin] may be entirely superseded, and the pain of a blistered surface completely avoided.”[7]  When it came to hemorrhoids, carbuncles, and small tumors, not to mention “foul and ill-conditioned ulcers,” hypodermic injections of carbolic acid provided “the only absolute and painless cure [original emphasis] of these exceedingly painful affections.”[8]

And what of the pain of the injection itself?  When it rates mention, it is only to put it in perspective, to underscore that “some pain at the moment of injection” gives way to “great relief from the pain of the disease” – a claim which, in this instance, pertained to alcohol solution injected in and around malignant tumors.[9]  Very rarely indeed does one find references to the pain of injection as a treatment-related consideration.[10]

Recognition of the addictive potential of repeated morphine injections barely dimmed the enthusiasm of many of the needle’s early proponents. Then, as now, physicians devised rationalizations for preferred treatment methods despite well-documented grounds for concern. They carved out diagnostic niches that, so they claimed, were exempt from mounting evidence of addiction.  A Melbourne surgeon who gave morphine injections to hospitalized parturients suffering from “puerperal eclampsia” (convulsions and coma following childbirth) found his patients able “to resist the dangerous effects of the drug; it seems to have no bad consequences in cases, in which, under ordinary circumstances, morphia would be strongly contra-indicated.” A physician from Virginia, who had treated puerperal convulsions with injectable morphine for 16 years, seconded this view.  “One would be surprised to see the effect of morphine in these cases,” he reported in 1887.  It was “as if bringing the dead to life.  It does not stupefy the patients, but renders them brighter.”[11]  A British surgeon stationed in Burma “cured” a patient of tetanus with repeated injections of atropine (belladonna), and held that his case “proved” that tetanus “induced” a special tolerance to an alkaloid known to have serious, even life-threatening, side effects.[12]  Physicians and patients alike stood in awe before a technology that not only heightened the effectiveness of the pharmacopeia of the time but also brought it to bear on an extended range of conditions.

Even failure to relieve suffering or postpone death spoke to the importance of hypodermic injection.  For even then, injections played a critical role in differential diagnosis: they enabled clinicians to differentiate, for example, “choleric diarrhea,” which morphine injections greatly helped, from, respectively, “malignant” (or Asiatic) cholera and common dysentery, which they helped not at all.[13]

To acknowledge that not all injections even temporarily relieved suffering or that not all injections were relatively painless was, in the context of nineteenth-century therapeutics, little more than a footnote.  Of course this was the case.  But it didn’t seem to matter.  There was an understandable wishfulness on the part of nineteenth-century physicians and patients about the therapeutic benefits of hypodermic injection per se, and this wishfulness arose from the fact that, prior to invention of the hypodermic syringe and soluble forms of morphine and other alkaloids, “almost miraculous resurrection” from intractable pain was not a possibility, or at least not a possibility arising from a physician’s quick procedural intervention.

For those physicians who, beginning in the late 1850s, began injecting morphine and other opioids to relieve severe pain, there was something magical about the whole process – and, yes, it calls to mind the quasi-magical status of injection and injectable medicine in some developing countries today.  The magic proceeded from the dramatic pain relief afforded by injection, certainly.  But it also arose from the realization, per Charles Hunter, that an injected opioid somehow found its way to the site of pain regardless of where it was injected.  It was pretty amazing.

The magic, paradoxically, derived from the new scientific understanding of medicinal therapeutic action in the final three decades of the nineteenth century.  The development of hypodermic injection is a small part of the triumph of scientific medicine, of a medicine of specific remedies for specific illnesses, of remedies increasingly developed in laboratories but bringing the fruits of laboratory science to the bedside.  We see the search for specific remedies in early trial-and-error efforts to find specific injectables and specific combinations of injectables for specific conditions – carbolic acid for hemorrhoids and carbuncles; morphine and atropia (belladonna) for puerperal convulsions; whisky and water for epidemic cholera; alcohol for tumors; ether for sciatica; liquefied sheep’s brain for nervous exhaustion; and on and on.

This approach signifies a primitive empiricism, but it is a proto-scientific empiricism nonetheless.  The very search for injectables specific to one or another condition is worlds removed from the Galenic medicine of the 1830s and ’40s, according to which all diseases were really variations of a single disease that had to do with the degree of tension or excitability in the blood vessels.

Despite the paucity of injectable medicines into the early twentieth century, hypodermic injection caught on because, despite the fantastical claims (to our ears) that abound in nineteenth-century medical journals, it was aligned with scientific medicine in ascendance.  Yes, the penetration of the needle was merely subcutaneous, but skin puncture was a portal to the blood stream and to organs deep inside the body.  In this manner, hypodermic injection partook of the exalted status of “heroic surgery” in the final quarter of the nineteenth century.[14]  The penetration of the needle, shallow though it was, stood in for a bold new kind of surgery, a surgery able to penetrate to the very anatomical substrate of human suffering.  Beginning in the late 1880s, certain forms of major surgery became recognizably modern, and the lowly needle was along for the ride.  The magic was all about the pain, but it was also all about the science.


[1] C. MacDowall, “Intra-peritoneal injections in cholera,” Lancet, 122:658-59, 1883, quoted at 658.

[2] T. L. Leavitt, “The hypodermic injection of morphia in gout and pleurisy,” Amer. J. Med. Sci., 55:109, 1868.

[3] W. Hardman, “Treatment of choleraic diarrhea by the hypodermic injection of morphia,” Lancet, 116:538-39, 1880, quoted at 539.

[4] P. E. Hill, “Morphia poisoning by hypodermic injection; recovery,” Lancet, 120:527-28, 1882, quoted at 527.

[5] Leavitt, “Hypodermic injection of morphia in gout and pleurisy,” op. cit.

[6] F. C. Shattuck, “Multiple sarcoma of the skin: treatment by hypodermic injections of Fowler’s solution; recovery,” Boston Med. Surg. J., 112:618-19, 1885; N.A., “Treatment of neurasthenia by transfusion (hypodermic injection) of nervous substance,” Boston Med. Surg. J., 126:273-74, 1892, quoted at 274; T. Churton, “Cases of acute maniacal delirium treated by inhalation of chloroform and hypodermic injection of morphia,” Lancet, 141:861-62, 1893.

[7] R. White, “Hypodermic injection of medicine, with a case,” Boston Med. Surg. J., 61:289-292, 1859, quoted at 290.

[8] N. B. Kennedy, “Carbolic acid injections in hemorrhoids and carbuncles,” JAMA, 6:529-30, 1886.

[9] E. Andrews, “The latest methods of treating carcinoma by hypodermic injection,” JAMA, 26:1159-60, 1897, quoted at 1159.

[10] For one such example, see NA, “The hypodermic injection of mercurials in the treatment of syphilis,” Boston Med. Surg. J., 131:246, 1894.

[11] S. Maberly-Smith, “On the treatment of puerperal convulsions by hypodermic injection of morphia,” Lancet, 118:86-87, 1881;  J. D. Eggleston, quoted in “The treatment of puerperal convulsions,” JAMA, 8:295-96, 1887, at 295.

[12] D. H. Cullumore, “Case of traumatic tetanus, treated with the hypodermic injection of atropia; amputation of great toe; recovery,” Lancet, 114:42-43, 1897.

[13] Hardman, “Treatment of choleraic diarrhea,” op. cit.; C. MacDowall, “Hypodermic injections of morphia in cholera,” Lancet, 116:636, 1880.

[14] On the “heroic surgery” of the final decades of the nineteenth century and the exalted status of late-nineteenth-century surgeons, see P. E. Stepansky, Freud, Surgery, and the Surgeons (Hillsdale, NJ: Analytic Press, 1999), pp. 23-34 and passim.

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

Will It Hurt?

“. . . the children’s population of this century has been submitted progressively as never before to the merciless routine of the ‘cold steel’ of the hypodermic needle.”  –Karl E. Kassowitz, “Psychodynamic Reactions of Children to the Use of Hypodermic Needles” (1958)

Of course, like so much medical technology, injection by hypodermic needle  has a prehistory dating back to the ancient Romans, who used metal syringes with disk plungers for enemas and nasal injections.  Seventeenth- and eighteenth-century physicians extended the sites of entry to the vagina and rectum, using syringes of metal, pewter, ivory, and wood.  Christopher Wren, the Oxford astronomer and architect, introduced intravenous injection in 1657, when he inserted a quill into the patient’s exposed vein and pumped in water, opium, or a purgative (laxative).

But, like so much medical technology, things only get interesting in the nineteenth century.  In the first half of the century, the prehistory of needle injection includes the  work of G. V. Lafargue, a French physician from the commune of St. Emilion.  He treated neuralgic (nerve) pain – his own included – by penetrating the skin with a vaccination lancet dipped in morphine and later by inserting solid morphine pellets under the skin through a large needle hole.  In 1844, the Irish physician Francis Rynd undertook injection by making a small incision in the skin and inserting a fine cannula (tube), letting gravity guide the medication to its intended site.[1]

The leap to a prototype of the modern syringe, in which a glass piston pushes medicine through a metal or glass barrel that ends in a hollow-pointed needle, occurred on two national fronts in 1853.  In Scotland, Alexander Wood,  secretary of Edinburgh’s Royal College of Physicians, injected morphine solution directly into his patients in the hope of dulling their neuralgias.  There was a minor innovation and a major one.  Wood used sherry wine as his solvent, believing it would prove less irritating to the skin than alcohol and less likely to rust his instrument than water.  And then the breakthrough:  He administered the liquid morphine through a piston-equipped syringe that ended in a pointed needle.  Near the end of the needle, on one side, was an  opening through which medicine could be released when an aperture on the outer tube was rotated into alignment with the opening.  It was designed and made by the London instrument maker Daniel Ferguson, whose “elegant little syringes,” as Wood described them, were intended to inject iron percholoride (a blood-clotting agent, or coagulant) into skin lesions and birthmarks in the hope of making them less unsightly.  It never occurred to him that his medicine-releasing, needle-pointed syringes could be used for subcutaneous injection as well.[2]

Across the channel in the French city of Lyon, the veterinary surgeon Charles Pravez employed a piston-driven syringe of his own making to inject iron percholoride into the blood vessels of sheep and horses.  Pravez was not interested in unsightly birthmarks; he was searching for an effective treatment for aneurysms (enlarged arteries, usually due to weakening of the arterial walls) that he thought could be extended to humans.  Wood was the first in print – his “New Method of Treating  Neuralgia by the Direct Application of Opiates to the Painful Points” appeared in the Edinburgh Medical & Surgical Journal in 1855[3] — and, shortly thereafter, he improved Ferguson’s design by devising a hollow needle that could simply be screwed onto the end of the syringe.  Unsurprisingly, then, he has received the lion’s share of credit for “inventing” the modern hypodermic syringe.  Pravez, after all, was only interested in determining whether iron percholoride would clot blood; he never administered medication through his syringe to animals or people.

Wood and followers like the New York physician Benjamin Fordyce Barker, who brought Wood’s technique to Bellevue Hospital in 1856, were convinced that the injected fluid had a local action on inflamed peripheral nerves.  Wood allowed for a secondary effect through absorption into the bloodstream, but believed the local action accounted for the injection’s rapid relief of pain.  It fell to the London surgeon Charles Hunter to stress that the systemic effect of injectable narcotic was primary.  It was not necessary, he argued in 1858, to inject liquid morphine into the most painful spot; the medicine provided the same relief when injected far from the site of the lesion.  It was Hunter, seeking to underscore the originality of his approach to injectable morphine, especially its general therapeutic effect, who introduced the term “hypodermic” from the Greek compound meaning “under the skin.”[4]

It took time for the needle to become integral to doctors and doctoring.  In America, physicians greeted the hypodermic injection with skepticism and even dread, despite the avowals of patients that injectable morphine provided them with instantaneous, well-nigh miraculous relief from chronic pain.[5]  The complicated, time-consuming process of preparing injectable solutions prior to the manufacture of dissolvable tablets in the 1880s didn’t help matters.  Nor did the trial-and-error process of arriving at something like appropriate doses of the solutions.  But most importantly, until the early twentieth century, very few drugs were injectable.  Through the 1870s, the physician’s injectable arsenal consisted of highly poisonous (in pure form) plant alkaloids such as morphine, atropine (belladonna), strychnine, and aconitine, and, by decade’s end, the vasodilator heart medicine nitroglycerine.  The development of local and regional anesthesia in the mid-1880s relied on the hypodermic syringe for subcutaneous injections of cocaine solution, but as late as 1905, only 20 of the 1,039 drugs in the U.S. Pharmacopoeia were injectable.[6]  The availability of injectable insulin in the early 1920s heralded a new, everyday reliance on hypodermic injections, and over the course of the century, the needle, along with the stethoscope, came to stand in for the physician.  Now, of course, needles and doctors “seem to go together,” with the former signifying “the power to heal through hurting” even as it “condenses the notions of active practitioner and passive patient.”[7]

The child’s fear of needles, always a part of pediatric practice, has generated a literature of its own.  In the mid-twentieth century, in the heyday of Freudianism, children’s needle anxiety gave rise to psychodynamic musings.  In 1958, Karl Kassowitz of Milwaukee Children’s Hospital made the stunningly commonsensical observation that younger children were immature and hence more anxious about receiving injections than older children.  By the time kids were eight or nine, he found, most had outgrown their fear.  Among the less than 30% who hadn’t, Kassowitz gravely counseled, continuing resistance to the needle might represent “a clue to an underlying neurosis.”[8]  Ah, the good old Freudian days.

In the second half of the last century, anxiety about receiving injections was “medicalized” like most everything else, and in the more enveloping guise of BII (blood, injection, injury) phobia, found its way into the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual in 1994. Needle phobia thereupon became the beneficiary of all that accompanies medicalization – a specific etiology, physical symptoms, associated EKG and stress hormone changes, and strategies of management.  The latter are impressively varied and range across medical, educational, psychotherapeutic, behavioral, cognitive-behavioral, relaxation, and desensitizing approaches.[9]  Recent literature also highlights the vasovagal reflex associated with needle and blood phobia.  Patients confronted with the needle become so anxious that an initial increase in heart rate and blood pressure is followed by a marked drop,   as a result of which they become sweaty, dizzy, pallid, nauseous (any or all of the above), and sometimes faint (vasovagal syncope).  Another interesting finding is that needle phobia (especially in its BII variant) along with its associated vasovagal reflex probably have a genetic component, as there is a much higher concordance within families for BII phobia than other kinds of phobia. Researchers who study twins put the heritability of BII phobia at around 48%.[10]

Needle phobia is still prevalent among kids, to be sure, but it has long since matured into a fully grown-up condition. Surveys find injection phobia in anywhere from nine to 21% of the the general population and even higher percentages of select populations, such as U.S. college communities.[11]               A study by the Dental Fears Research Clinic of the University of                               Washington in 1995 found that over a quarter of surveyed students and university employees were fearful of dental injections, with 5% admitting they avoided or canceled dental appointments out of fear.[12]  Perhaps some of these needlephobes bear the scars of childhood trauma.  Pediatricians now urge control of the pain associated with venipuncture and intravenous cannulation (tube insertion) in infants, toddlers, and young children, since there is evidence such procedures can have a lasting impact on pain sensitivity and tolerance of needle picks.[13]

But people are not only afraid of needles; they also overvalue them and seek them out.  Needle phobia, whatever its hereditary contribution, is a creation of Western medicine.  The surveys cited above come from the U.S., Canada, and England.  Once we shift our gaze to developing countries of Asia and Africa we behold a different needle-strewn landscape.  Studies attest not only to the high acceptance of the needle but also to its integration into popular understandings of disease.  Lay people in countries such as Indonesia, Tanzania, and Uganda typically want injections; indeed, they often insist on them because injected medicines, which enter the bloodstream directly and (so they believe) remain in the body longer, must be more effective than orally injected pills or liquids.

The strength, rapid action, and body-wide circulation of injectable medicine – these things make injection the only cure for serious disease.[14]  So valued are needles and syringes in developing countries that most lay people, and even Registered Medical Practitioners in India and Nepal, consider it wasteful to discard disposable needles after only a single use.  And then there is the tendency of people in developing countries to rely on lay injectors (the “needle curers” of Uganda; the “injection doctors” of Thailand; the informal providers of India and Turkey) for their shots.  This has led to the indiscriminate use of  penicillin and other chemotherapeutic agents, often injected without attention to sterile procedure.  All of which contributes to the spread of infectious disease and presents a major headache for the World Health Organization.

The pain of the injection?  Bring it on.  In developing countries, the burning sensation that accompanies many injections signifies curative power.  In some cultures, people also welcome the pain as confirmation that real treatment has been given.[15]  In pain there is healing power.  It is the potent sting of modern science brought to bear on serious, often debilitating disease.  All of which suggests the contrasting worldviews and emotional tonalities collapsed into the fearful and hopeful question that frames this essay:  “Will it hurt?”


[1] On the prehistory of hypodermic injection, see D. L. Macht, “The history of intravenous and subcutaneous administration of drugs,” JAMA, 55:856-60, 1916; G. A. Mogey, “Centenary of Hypodermic Injection,” BMJ, 2:1180-85, 1953; N. Howard-Jones, “A critical study of the origins and early development of hypodermic medication,” J. Hist. Med., 2:201-49, 1947 and N. Howard-Jones, “The origins of hypodermic medication,” Scien. Amer., 224:96-102, 1971.

[2] J. B. Blake, “Mr. Ferguson’s hypodermic syringe,” J. Hist. Med., 15: 337-41, 1960.

[3] A. Wood, “New method of treating neuralgia by the direct application of opiates to the painful points,” Edinb. Med. Surg. J., 82:265-81, 1855.

[4] On Hunter’s contribution and his subsequent vitriolic exchanges with Wood over priority, see Howard-Jones, “Critical Study of Development of Hypodermic Medication,” op cit.  Patricia Rosales provides a contextually grounded discussion of the dispute and the committee investigation of Edinburgh’s Royal Medical and Chirurgical Society to which it gave rise.  See P. A. Rosales, A History of the Hypodermic Syringe, 1850s-1920s.  Unpublished doctoral dissertation, Department of the History of Science, Harvard University, 1997, pp. 21-30.

[5] See Rosales, History of Hypodermic Syringe, op. cit., chap. 3, on the early reception of hypodermic injections in America.

[6] G. Lawrence, “The hypodermic syringe,” Lancet, 359:1074, 2002; J. Calatayud & A. Gonsález, “History of the development and evolution of local anesthesia since the coca leaf,” Anesthesiology, 98:1503-08, 2003, at p. 1506; R. E. Kravetz, “Hypodermic syringe,” Am. J. Gastroenterol., 100:2614-15, 2005.

[7] A. Kotwal, “Innovation, diffusion and safety of a medical technology: a review of the literature on injection practices,”  Soc. Sci. Med., 60:1133-47, 2005, at p. 1133.

[8] Kassowitz, “Psychodynamic reactions of children to hypodermic needles,”  op. cit., quoted at p. 257.

[9] Summaries of the various treatment approaches to needle phobia are given in J. G. Hamilton, “Needle phobia:  a neglected diagnosis,” J. Fam. Prac., 41:169-75 ,1995  and H. Willemsen, et al., “Needle phobia in children:  a discussion of aetiology and treatment options, ”Clin. Child Psychol. Psychiatry, 7:609-19, 2002.

[10] Hamilton, “Needle phobia,” op. cit.; S. Torgersen, “The nature and origin of common phobic fears,” Brit. J. Psychiatry, 134:343-51, 1979; L-G. Ost, et al., “Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia,” Behav. Res. Ther., 29:561-74, 1991;  L-G. Ost, “Blood and injection phobia: background and cognitive, physiological, and behavioral variables,” J. Abnorm. Psychol., 101:68-74, 1992.

[11] References to these surveys are provided by Hamilton, “Needle phobia,” op. cit.

[12] On the University of Washington survey, see P. Milgrom, et al., “Four dimensions of fear of dental injections,” J. Am. Dental Assn., 128:756-66, 1997 and T. Kaakko, et al., “Dental fear among university students: implications for pharmacological research,” Anesth. Prog., 45:62-67, 1998.  Lawrence Prouix reported the results of the survey in The Washington Post under the heading “Who’s afraid of the big bad needle?” July 1, 1997, p. 5.

[13] R. M. Kennedy, et al., “Clinical implications of unmanaged need-insertion pain and distress in children,” Pediatrics, 122:S130-S133, 2008.

[14] See Kotwal, “Innovation, diffusion and safety of a medical technology,” op. cit., p. 1136 for references.

[15] S. R. Whyte & S. van der Geest, “Injections: issues and methods for anthropological research,” in N. L. Etkin & M. L. Tan, eds., Medicine, Meanings and Contexts (Quezon City, Philippines: Health Action Information Network, 1994), pp. 137-8.

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.

Your Tool Touches Me

It is little known that René Laënnec, the Parisian physician who invented the stethoscope at the Necker Hospital in 1816, found it distasteful to place his ear to the patient’s chest.  The distastefulness of “direct auscultation” was compounded by its impracticality in the hospital where, he observed, “it was scarcely to be suggested for most women patients, in some of whom the size of the breasts also posed a physical obstacle.”[1]  The stethoscope, which permitted “mediate auscultation,” not only amplified heart and lung sounds in diagnostically transformative ways; it enabled Laënnec to avoid repugnant  ear to chest contact.

Many women patients of Laënnec’s time and place did not see it that way.  Accustomed to the warmly human pressure of ear on chest, they were uncomfortable when an elongated wooden cylinder was interposed between the two.  By the closing decades of the nineteenth century, of course, the situation was inverted:  The stethoscope, in its modern binaural guise, had become so integral to physical examination that patients  hardly viewed it as a tool at all.  It had become emblematic of hands-on doctoring and, as such, a sensory extender of the doctor.  Even now, the stethoscope virtually stands in for the doctor, especially the generalist or the cardiologist, so that a retiring physician will announce that he is, or will be characterized by others as, hanging up his stethoscope.[2]

It’s easy to argue for the “oneness” of the physician and his or her instruments when it’s a matter of simple tools that amplify sensory endowment  (stethoscopes), provide a hands-on bodily “reading” (of temperature or blood pressure), or elicit a tendon reflex (e.g., the reflex hammer).  And the argument can be extended without much difficulty to the more invasive, high-tech “scopes” used by medical specialists to see what is invisible to the naked eye.  Instruments become so wedded to one or another specialty that it is hard to think of our providers without them.  What is an ophthalmologist without her ophthalmoscope?  An ENT without his nasal speculum?  A gynecologist without her vaginal speculum?  An internist without his blood pressure meter?  Such hand-held devices are diagnostic enablers, and as such they are, or at least ought to be, our friends.

In “Caring Technology” I  suggested that even large-scale technology administered by technicians, and therefore outside the physician’s literal grasp, can be linked in meaningful ways to the physician’s person.  A caring explanation of the need for this or that study, informed by a relational bond, can humanize even the most forbidding high-tech machinery.  To be sure, medical machinery, whatever the discomfort and/or bodily bombardment it entails, is often discomfiting.  But it need be alienating only when we come to it in an alienated state, when it is not an instrument of physicianly engagement but a dehumanized object – a piece of technology.

Critical care nurses, whose work is both technology-laden and technology-driven, have had much to say on the relationship of technology to nursing identity and nursing care.  This literature includes provocative contributions that look at where nurses stand in a hospital hierarchy that comprises staff physicians, residents, students, administrators, patients, and patients’ families.

For some CCU nurses, the use of technology and the acquisition of technological competence segue into issues of power and autonomy and they, in turn, are linked to issues of gender, medical domination, and “ownership” of the technology.[3]  A less feminist sensibility informs interview research that yields unsurprising empirical findings, viz.,  that comfort with technology and the ability to incorporate it into a caring, “touching” disposition hinge on the technological mastery associated with nursing experience.  Student and novice nurses, for example, find the machinery of the CCU anxiety-inducing, even overwhelming.  They resent the casual manner in which physicians relegate to them complex technological tasks, such as weaning patients from respirators, without appreciating the long list of  nursing duties to which such tasks are appended.[4]  Withal, beginners approach the use of technology in task-specific ways and have great difficulty “caring with technology.”[5]   Theirs is not a caring technology but a technology that causes stress and jeopardizes fragile professional identities.

Experienced CCU nurses, on the other hand, achieve a technological competence that lets them pull the machinery to them; they use it as a window of opportunity for being with their patients.[6]   Following Christine Little, we can give the transformation from novice to expert a phenomenological gloss and say that as technological inexperience gives way to technological mastery, technological skills become “ready-to-hand” (Heidegger) and “a natural extension of practice.”[7]

Well and good.  We want critical care nurses comfortable with the machinery of critical care – with cardiac and vital signs monitors, respirators, catheters, and infusion pumps – so that implementing technological interventions and monitoring the monitors do not blot out the nurse’s “presence”  in the patient’s care.   But all this is from the perspective of the nurse and her role in the hospital.  What, one wonders, does the patient make of all this technology?

Humanizing technology means identifying with it in ways that are not only responsive to the patient’s fears but also conducive to a shared appreciation of its role in treatment.  It is easier for patients to feel humanly touched by technology, that is, if their doctors and nurses appropriate it and represent it as an extender of care.  Perhaps some doctors and nurses do so as a matter of course, but one searches the literature in vain for examples of nurse-patient or doctor-patient interactions that humanize technology through dialogue.  And such dialogue, however perfunctory in nature, may greatly matter.

Consider the seriously ill patient whose nurse interacts with him without consideration of the technology-saturated environment in which care is given.  Now consider the seriously ill patient whose nurse incorporates the machinery into his or her caregiving identity, as in “This monitor [or this line or this pump] is a terrific thing for you and for me.  It lets me take better care of you.”  Such reassurance, which can be elaborated in any number of patient-centered ways, is not trivial; it may turn an anxious patient around, psychologically speaking.  And it is all the more important when, owing to the gravity of the patient’s condition, the nurse must spend more time assessing data and tending to machinery than caring for the patient.  Here especially the patient needs to be reminded that the nurse’s responsibility for machinery expands his or her role as the patient’s guardian.[8]

The touch of the physician’s sensory extenders, if literally uncomfortable, may still be comforting.  For it is the physician’s own ears that hear us through the stethoscope and whose own eyes gaze on us through the ophthalmoscope, the laryngoscope, the esophagoscope, the colposcope.  It is easier to appreciate tools as beneficent extenders of care in the safe confines of one’s own doctor’s office, where instrumental touching is fortified by the relational bond that grows out of continuing care.  In the hospital, absent such relational grounding, there is  more room for dissonance and hence more need for shared values and empathy.  A nurse who lets the cardiac monitor pull her away from patient care will not do well with a frightened patient who needs personal caring.  A parturient who welcomes the technology of the labor room will connect better with a labor nurse who values the electronic fetal monitor (and the reassuring visualization it provides the soon-to-be mother) than a nurse who is unhappy with its employment in low-risk births and prefers a return to intermittent auscultation.

In the best of circumstances, tools elicit an intersubjective convergence grounded in an expectation of objectively superior care.  It helps to keep the “objective care” part in mind, to remember that technology was not devised to frighten us, encumber us, or cause us pain,  but to help doctors and nurses evaluate us, keep us stable and comfortable, and enable treatments that will make us better, or at least leave us better off than our technology-free forebears.

My retinologist reclines the examination chair all the way back and begins prepping my left eye for its second intravitreal  injection of Eylea, one of the newest drugs used to treat macular disease.  I am grateful for all the technology that has brought me to this point:  the retinal camera, the slit lamp, the optical coherence tomography machine.  I am especially grateful for the development of fluorescein angiography, which allows my doctor to pinpoint with great precision the lesion in need of treatment.  And of course I am grateful to my retinologist, who brings all this technology to bear with a human touch, calmly reassuring me through every step of evaluation and treatment.

I experienced almost immediate improvement after the first such injection a month earlier and am eager to proceed with the treatment.  So I am relatively relaxed as he douses my eye with antiseptic and anesthetic washes in preparation for the needle.  Then, at the point of injection, he asks me to look up at the face of his assistant, a young woman with a lovely smile.  “My pleasure,” I quip, slipping into gendered mode.  “I love to look at pretty faces.”   I am barely aware of the momentary pressure of the needle that punctures my eyeball and releases this wonderfully effective new drug into the back of my eye.  It is not the needle that administers treatment but my trusted and caring physician.  “Great technique,” I remark.  “I barely felt it.”  To which his young assistant, still standing above me, smiles and adds,  “I think I had something to do with it.”  And indeed she had.


[1] Quoted in J. Duffin, To See with a Better Eye: A Life of R. T. H. Laennec (Princeton: Princeton University Press, 1998), p. 122.

[2] Here are a few recent examples:  O. Samuel, “On hanging up my stethoscope,” BMJ, 312:1426, 1996; “Dr. Van Ausdal hangs up his stethoscope,” YSNews.com, September 26, 2013 (http://ysnews.com/news/2013/09/dr-van-ausdal-hangs-up-his-stethoscope);  “At 90, Gardena doctor is hanging up his stethoscope,” The Daily Breeze, October, 29, 2013 (http://www.dailybreeze.com/general-news/20131029/at-90-gardena-doctor-is-hanging-up-his-stethoscope);  “Well-known doctor hangs up his stethoscope,” Bay Post, February 8, 2014 (http://www.batemansbaypost.com.au/story/1849567/well-known-doctor-hangs-up-his-stethoscope)

[3] See, for example, A. Barnard, “A critical review of the belief that technology is a neutral object and nurses are its master,” J. Advanced Nurs., 26:126-131, 1997; J. Fairman & P. D’Antonio, “Virtual power: gendering the nurse-technology relationship,” Nurs. Inq., 6:178-186, 1999; & B. J. Hoerst & J. Fairman, “Social and professional influences of the technology of electronic fetal monitoring on obstetrical nursing,” Western J. Nurs. Res., 22:475-491, 2000, at pp. 481-82.

[4] C. Crocker & S. Timmons, “The role of technology in critical care nursing,” J. Advanced Nurs., 65:52-61, 2008.

[5] M. McGrath, “The challenges of caring in a technological environment:  critical care nurses’ experiences,” J. Clin. Nurs., 17:1096-1104, 2008.

[6] A. Bernardo, “Technology and true presence in nursing,” Holistic Nurs. Prac., 12:40-49, 1998;  R. C. Locsin,  Technological Competency As Caring in Nursing: A Model For Practice (Indianapolis: Centre Nursing Press, 2005);  McGrath, “The challenges of caring,” op. cit.

[7] C. V. Little, “Technological competence as a fundamental structure of learning in critical care nursing: a phenomenological study,” J. Clin. Nurs., 9:391-399, 2000, at pp. 398, 396.

[8] See E. A. McConnell, “The impact of machines on the work of critical care nurses,” Crit. Care Nurs. Q., 12:45-52, 1990, at p. 51; D. Pelletier , et al., “The impact of the technological care environment on the nursing role, Int. J. Tech. Assess. Health Care, 12:35     8-366, 1996.C

Copyright © 2014 by Paul E. Stepansky.  All rights reserved.