Medicine, Health, and History

Remembering the Nurses of WWI (I)

Posted on February 22, 2017 | 1 comment

“Real war at last. Can hardly wait. Here we go!”

[The first of six essays about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917. The outgrowth of these essays is the book, Easing Pain on the Western Front: American Nurses of the Great War and the Birth of Modern Nursing Practice (McFarland, 2020). Hear Paul Stepansky discuss the book with the editor of the American Journal of Nurse Practitioners in a special JAANP podcast.

It was the all-too-common story of the WWI nurses, the narrative thread that linked the vagaries of their wartime experiences. The war was to be the adventure of a lifetime. The opportunity to serve on the Western Front was not to be missed, not by hospital-trained nurses and not by lightly trained volunteer nurses. For both groups, the claim of duty was suffused with the excitement of grand adventure. Beginning in the spring of 1917, the war abroad was the event of the season. Julia Stimson, a Vassar graduate who, as superintendent of nursing at Barnes Hospital, led the St. Louis base hospital unit to Europe in May, 1917, was overwhelmed with the honor bestowed on her and the opportunities it promised. “To be in the front ranks in this most dramatic event that ever was staged,” she wrote her mother, was “all too much good fortune for any one person like me.” For 28-year-old Shirley Millard, a Red Cross volunteer nurse from Portland, Oregon rushed to a field hospital near Soissons in March, 1918, the prospect of nursing work at Chateau Gabriel, close to the Front, was a dream come true: “It is so exciting and we are all thrilled to have such luck. Real war at last. Can hardly wait. Here we go!” “I haven’t the least fear or worry in the world. Am ready for anything,” averred Minnesotan Grace Anderson, a reserve nurse and nurse-anesthetist who embarked from New York harbor in July, 1918. Serving in a base hospital or, more exciting still, in a field hospital or casualty clearing station only miles from the Front, was to be invited to the Grand Cotillion. Volunteer and army nurses alike were typically well-bred young women of substance, often upper-class substance. They were adventuresome and patriotic and given over to a sense of duty informed by literary culture, not battlefield experience. So they experienced happiness on receiving the call; they would make their families proud.[1]

But their sense of exhilaration at being invited to the Patriotic Ball quickly gave way to stunned amazement at the “work” before them. The wounds of French, British, and, soon enough, American troops were literally unimaginable to them and then, in the fevered atmosphere of post-battle “rushes,” wrenchingly imaginable, indeed omnipresent. They grew familiar with the horrid stench of gas gangrene, which crackled beneath the surface of the infected body part or parts and almost always presaged quick death. Under the mentoring of senior nurses, the Sisters, young American women learned how to prep patients for surgery. In the process, they encountered cases in which “there are only pieces of men left.” And yet, having no choice, they quickly made their peace with the stumps of severed limbs and concavities of missing stomachs, faces and eyes and began to help clean, irrigate, and dress what remained, before and after surgery, if surgery could even be attempted. Like their seniors, they learned to remain unflinching in the face of the many soldiers who arrived “unrecognizable as a human being.” And they retained composure before soldiers as young as sixteen or seventeen — “children,” they would say — who arrived at Casualty Clearing Stations (CCSs) caked in mud and blood and covered with lice – children with three, five, nine, even eleven wounds. They learned to accept that many soldiers would die in a matter of hours or days, but to join this realization to an obligation to provide what comfort they could. They ended up working hard to keep the dying alive long enough to warm up and pass under morphine and chloroform, all the while holding their nurse-mother’s hand.[2]

They could not operate on Rochard and amputate his leg, as they wanted to do. The infection was so high, into the hip, it could not be done. Moreover, Rochard had a fractured skull as well. Another piece of shell had pierced his ear, and broken into his brain, and lodged there. Either wound would have been fatal, but it was the gas gangrene in his torn-out thigh that would kill him first.”[3]

Here is “a poor youngster with both legs broken, both arms wounded, one eye shot out and the other badly damaged,” there a “poor lad” who “had both eyes shot through and there they were, all smashed and mixed up with the eyelashes. He was quite calm, and very tired. He said, ‘Shall I need an operation? I can’t see anything’.” Within a week of arrival at her field hospital, Shirley Millard wrote of “bathing [a soldier’s] great hip cavity where a leg once was,” while “a long row of others, their eyes fastened upon me, await their turn. And she followed with the kind of litany offered by many others: “Gashes from bayonets. Flesh torn by shrapnel. Faces half shot away. Eyes seared by gas; one here with no eyes at all. I can see down into the back of his head.” Helen Dore Boylston, an MGH-trained nurse who served with the Harvard Medical Unit from 1915 on, presents an indelible image that affected her for life and affects us still:

There were strings of from eight to twenty blind boys filing up the road, clinging tightly and pitifully to each other’s hands, and led by some bedraggled limping youngster who could still see . . . I wonder if I’ll every be able to look at marching men anywhere again without seeing those blinded boys, with five and six wound stripes on their sleeves, struggling painfully along the road.[4]

A soldier with gangrenous wounds oozing everywhere might morph into a “mass of very putrid rottenness long before he died.” Such was the experience of Edith Appleton, who continued: “The smell was so very terrible I had to move him right away from everyone, and all one could do was dress and redress. Happily I don’t think he could smell it himself but I have never breathed a worse poison.”[5]

All too soon after arrival, then, the cheery young American nurses beheld the fearless young soldiers – or remnants thereof – who came to clearing stations and base hospitals in funereal processions of ambulances. The fearless young men had become “wretched, restless beings.” For Shirley Millard, “The crowded, twisted bodies, the screams and groans, made one think of the old engraving in Dante’s Inferno. More came, and still more.” In Helen Boylston’s field hospital, a “rush” during the German offensive of late March, 1918 brought 1,100 wounded to her base hospital in 24 hours, with three operating teams performing some 90 emergency operations that night and the nights to follow. The operating room nurse, she recalled, “walked up and down between the tables with a bottle of aromatic spirits of ammonia in one hand and a bottle of brandy in the other, ready to pounce on the next person who wilted.” At Beatrice Hopkinson’s CCS 47, just outside Amiens, the situation was even worse. During the March rush many thousands of patients passed through the doors in only a few days and kept seven operating tables working day and night.[6]

And so the narratives captured in these diaries, journals, and memoirs turn a corner into blackness, as the nurses themselves undergo a kind of existential decomposition. The volunteer nurses in particular, many little older than the combatants, became war-weary and war-wise in ways that choked off the childish exhilaration with which they had embarked. They found themselves at the threshold of their own nonnegotiable no-woman’s land. The nurse, wrote Mary Borden in The Forbidden Zone,

is no longer a woman. She is dead already, just as I am – really dead, past resurrection. Her heart is dead. She killed it. She couldn’t bear to feel it jumping in her side when Life, the sick animal, choked and rattled in her arms. Her ears are deaf; she deafened them. She could not bear to hear Life crying and mewing. She is blind so that she cannot see the torn parts of men she must handle. Blind, deaf, dead – she is strong, efficient, fit to consort with gods and demons – a machine inhabited by the ghost of a woman – soulless, past redeeming, just as I am – just as I will be.[7]

Nurses bore up, but in the process many were ground down, their pre-war values pulverized into dust. Comprehending trench warfare in bodily perspective, they became freighted with the pointlessness of the horror, the multitude of mutilated, infection-saturated, and lifeless young bodies. It was, for Helen Boylston, less tragic than unutterably stupid.

Today a ditch is full of Germans, and tomorrow it is full of Englishmen. Neither side really wants the silly muddy ditch, yet they kill each other persistently, wearily, ferociously, patiently, in order to gain possession of it. And whoever wins, it has won – nothing.[8]

They pondered the paradox of pain – the impossibility of knowing its nature in another along with the inability to nurse without imagining it. They grew into a capacity for shame – shame in their own strength, in their ability to stand firm and straight alongside a bedside “whose coverings are flung here and there by the quivering nerves beneath it.” They empathized with shell-shocked patients who, having endured the prospect of “glorious death” under the guns, were sent home “to face death in another form. Not glorious, shameful.” And finally there was the shame, thinly veiled, attendant to witnessing the unremitting pain of the dying. “No philosophy,” reflected Enid Bagnold, “helps the pain of death. It is pity, pity, pity, that I feel, and sometimes a sort of shame that I am here to write at all.”[9]

And then, as hostilities drew to a close, there were the larger reflections, the alterations of life philosophy that grew out of nursing their boys. For Helen Boylston,

The war has done strange things to me. It has given me a lot and taken away a lot. It has taught me that nothing matters, really. That people do not matter, and things do not matter, and laces do not matter, except for a minute. And the minute is always now.[10]

For Shirley Millard, Armistice Day and the immediate dismissal of her unit of volunteer nurses marked her epiphany:

Only then did the enormous crime of the whole thing begin to come home to me. All very well to celebrate, I thought, but what about Charley? All the Charlies? What about Donnelly, Goldfarb, Wendel, Auerbach? And Rene? And the hundreds, thousands of others.”[11]

The enormity of the crime and the absurd reasoning that justified it coalesced in the wartime essays of Ellen LaMotte and Mary Boyden, one recurrent theme of which is the impossibility of a good death in war, where the very effort to “restore” bodies and minds that are shattered, literally and figuratively, becomes oxymoronic. War, they insist, occurs in an alternate universe where any claim to morality is, from the standpoint of ordinary life, self-willed delusion. In this universe, surgeons function as cavalier automatons and even life-saving surgery is specious, because the lives saved, more often than not, are no longer human lives, psychologically or physically. In this alternate universe, death withheld, ironically, is the ultimate act of inhumanity.[12]

What makes the nurses of World War I gallant is that so many of them were able to bracket their encroaching horror, with its undercurrents of anger, depression, and numbing – and simply care for their patients. They were able to function as nurses in a nurses’ hell. Military directives pushed them to an even lower circle of the Inferno, since the nurses’ primary task, they were told over and over, was to get injured troops back to the Front as soon as possible. They were to fix up serviceable (and hence service-able) soldiers so that they could be reused at least one more time before breakdown precluded further servicing and the soldier’s obligation to serve further.

But the nurses knew better and unfailingly did better. Nursing practice, it turns out, had its own moral imperative, so that military directives were downplayed, often cast to the wind. As the nursing historian Christine Hallett observes, the emotional containment nurses provided for suffering and needy soldiers did not – indeed could not – preclude caring.[13] In essays to follow, I hope to explore further the remarkable elements of this caring, which blurred the boundary between comfort care and healing and took nursing practice into the domains of emergency medicine, infectious disease management, surgery, and psychotherapy. It is as agents of care and caring that the nurses of World War I rose to the status of gallants. Flying in the face of military priorities and surgical fatalism, they bravely dispensed cure in a manner true to the word’s etymology, the Latin curare, a taking care of that privileges the patient’s welfare above all else.

_____________________

[1] Julia, C. Stimson, Finding Themselves: The Letters of an American Army Chief Nurse in a British Hospital in France (NY: Macmillan, 1918), 3-4.; Shirley Millard, I Saw Them Die: Diary and Recollections, ed. E. T. Gard (New Orleans: Quid Pro, 2011), location in Kindle edition (loc), 388; Shari Lynn Wigle, Pride of America: The Letters of Grace Anderson, U.S. Army Nurse Corps, World War I (Rockville, MD: Seaboard, 2007), 9.

[2] Agnes Warner, ‘My Beloved Poilus’ (St. John: Barnes, 1917), loc 75; Beatrice Hopkinson, Nursing Through Shot & Shell: A Great War Nurse’s Story, ed. V. Newman (South Yorkshire: Pen & Sword, 2014), loc 1425; Helen Dore Boylston, Sister: The War Diary of a Nurse (NY: Washburn, 1927), loc 463; Enid Bagnold, A Diary Without Dates (London: Heinemann, 1918), 125: “Among his eleven wounds he has two crippled arms.”

[3] Ellen N. La Motte, The Backwash of War: The Human Wreckage of the Battlefield as Witnessed by an American Hospital Nurse (NY: Putnam’s, 1916), 51-52.

[4] Edith Appleton, A Nurse at the Front: First World War Diaries, ed. R. Cowen (London: Simon & Schuster UK, 2012), 138, 161; Millard, I Saw Them Die, loc 428; Boylston, Sister, loc 463.

[5] Dorothea Crewdson, Dorothea’s War: A First World War Nurse Tells her Story, ed. Richard Crewdson (London: Weidenfeld & Nicolson, 2013, 2013), loc 1189; Appleton, Nurse at the Front, 189.

[6] Crewdson, Dorothea’s War, loc 1192; Millard, I Saw Them Die, loc 388; Boylston, Sister, loc 1101; Hopkinson, Nursing Through Shot & Shell, loc 1719, 1780.

[7] Mary Borden, The Forbidden Zone, ed. H. Hutchison (London: Hesperus, 1928/2008), 44.

[8] Boylston, Sister, loc 648.

[9] Bagnold, Diary without Dates, loc 25, 104; LaMotte, Backwash of War, 139.

[10] Boylston, Sister, loc 1373.

[11] Millard, I Saw Them Die, loc 1562.

[12] All the brief essays in LaMotte’s The Backwash of War and Borden’s The Forbidden Zone circle around these and related themes. Among them, I was especially moved by LaMotte’s “Alone,” “Locomotor Ataxia,” and “A Surgical Triumph,” and Borden’s “Rosa,” “Paraphernalia,” and “In the Operating Room.”

[13] Christine E. Hallett, Containing Trauma: Nursing Work in the First World War (Manchester: Manchester University Press, 2009), 177.

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Posted in Nurses in WWI, Nursing, Nursing Care

Tagged WWI Nursing; American nurses in WWI; WWI medicine

Food and Candy

Posted on November 7, 2016 | 1 comment

No one leaves Montclair’s Human Needs Food Pantry without food. Even folks from surrounding communities who are not among our registered clientele leave with a bag of groceries, a loaf of bread, often a pastry or a half gallon of juice, and an item or two from the table of donated cans and cartons adjacent to the check-in desk. Mike sees to it. He fills out an emergency food slip for anyone who comes through the door. Then he explains what info the person needs to bring back to him (e.g., a rent receipt) to qualify for weekly groceries. Mike writes out such a slip for one man who brings it to me. After I tell him that, in addition to his bag of food, he may also take two items from the table and a loaf of bread from the rack, he looks me straight in the eye, squeezes my hand, and with disarming directness says: “Thank you for feeding me.”

Mike is the director and one of the good guys. His associate Janet is another remarkably good and caring person. Mike is a retired police chief who knows all about hunger and need. I man the front desk, greeting our clients, many now by name, retrieving their file cards, filling out the sign-in forms, and telling them how many supplementary items they may take from the adjacent table and how many breads they may take from the bread rack on the opposite wall. Then I yell out to Chris the size of the household so that he knows how many bags of groceries to place on his table for them. I do this over 120 times during a three-hour shift. Earlier in the day, before the pantry opens its doors to social workers at 12 and then to clients at 12:30, my wife Deane and I wait while Tyrell loads our SUV with the bags we will deliver to our list of clients unable to make it to the pantry – the elderly indigent, sometimes bedridden, often living alone.

This is my world every Tuesday, when I stop trying to understand the connection between medical history and present-day health care and seek out connection with people who need food and all kinds of care, medical and otherwise. Some future historian can try to place my experience in sociohistorical context. I simply want to give them food, to ask them how they’re doing, to tell them their children are beautiful, and to wish them a good week.

There is something primal about giving food to people who need it and appreciate getting it, people who are down on their luck but not down on their lives. “How are you,” I ask the people I serve. “I am blessed,” they sometimes reply. Working at the pantry has helped me reengage issues that have nothing to do with scholarly writing, to reorder my priorities in a life-affirming way. At a time when American political discourse has, in a different, twisted way, turned primal, hateful, exclusionary, it takes me to a place where real-world suffering can be addressed one family at a time through food and the nutrient of human connection.

Giving food to people is cleansing. It changes the way one feels about food, even the way one shops and eats. More importantly, it enlarges one’s sense of shared humanity with the low-income folks in one’s own community, almost all of whom, I have found, are dignified, convivial, and grateful. It takes me away from the sickening world of Donald Trump, whose inborn caring instincts flattened out long ago under the weight of narcissistic bloat. Our clients offer me a smile, a fist bump, a hand shake, occasionally a hug. They touch me with their hands but also with their eyes and their words. They ask me how I’m doing, and – knowing that I am a volunteer – thank me for doing this work, which, some tell me, is “the Lord’s work.” I do not know these people outside the food pantry. But within its walls, they are admirable – veterans, working single moms, unemployed or underemployed dads, the disabled, the down on their luck, the elderly indigent, the recently incarcerated.

Yes, we touch one another, and an offering of food and candy is the conduit to the touching. There is nothing extraordinary about food-mediated touch – it happens all the time, not only in the real world but in the world of medicine as well. Even Freud, who wanted the psychoanalyst to be as emotionally detached from his patients as the operating surgeon, invited many of his patients to lunch and dinner; he even fed his aristocratic Russian patient Sergei Pankejeff (aka the “Wolf Man”) during their analytic sessions. Doctors of our own time occasionally give needy patients food or money when food stamps have run out, and it becomes a matter of choosing between food and medication co-pays. Even nonprofits have gotten into the act. Through the Fruit and Vegetable Prescription Program (FVRx), for example, physicians now write fresh produce scripts for their low-income patients to fill at local farmers markets.[1]

A tiny Asian woman, well into her 70s but wondrously youthful, marches up to the desk each week and, with warm-hearted brio, greets my coworker and me with: “Hello beautiful woman and most handsome gentleman.” When she becomes ill and her neighbor comes to pick up her food, I always send her my love, and when she finally returns some months later, I walk around the desk and we hug. The smiles of some of the women captivate me, I admit it. I have complimented several of them so often that they come to the desk smiling and laughing, knowing I will gaze at them for an extra second before turning to my file box. We have established rapport through a smile and a fleeting gaze of appreciation – an expression of my own gratitude to these women who come to us for food. When I remark to another woman how pretty she looks in her stylish jacket and hat, she almost breaks down, telling me she can’t remember when anyone last paid her a compliment, and that I have made not only her day but her week.

My exchanges with my friend Herb are of a different sort. He is one of our regulars for whom the pantry is a place not only to receive food but to linger and socialize – a convivial time-out from the lives they will return to. We all know who these folks are and, to a person, we accept their prolonged visits, talk to them supportively, and let them feel at home with us. At one point Herb shared his multiple health concerns with me, and I responded with, as they say, advice and sympathy. Herb is, inter alia, an unhappy diabetic, chafing under the weight of seriously poor numbers and recent medical injunctions about diet and lifestyle. Being an insulin-dependent diabetic myself, I warm to Herb’s plight, and we begin an ongoing dialogue about being diabetic. But Herb remains irreconcilable and, as if to put the cherry on the icing of his medical misery, he waits for me outside the pantry one day with his most recent medical labs in hand. Will I look at the report and tell him what it means? Well, Herb, I’m not a doctor, but sure, why not, let’s take a look at your numbers and see how you’re doing. Now, a year later, Herb still takes candy from the basket when he arrives at the desk, but now he looks at me and asks, either with his words or his eyes, how many he may take. Diabetic self-control was not built in a day.

It is the children especially who affect me. They come with their mothers or fathers or grandmothers, the babies and toddlers in strollers, the older kids standing patiently in line with the adults. They usually wait for more than an hour to sign in. When candy or snack bars come our way, we place them in a basket on the desk and – with the adult’s permission – ask the children to help themselves. But what happens when we have none? I solved the problem by bringing with me each week a large bag of candy – starbursts and skittles are special favorites – and offering every child a small handful. I always check with the moms, but with only a few exceptions over the years, they always smile, tell me its fine to give their children candy, and thank me. I do not have the impression these kids eat candy on a regular basis. So I become the pantry’s “candy man,” the dispenser of goodies, and the kids are (perhaps) a tad more accepting of the long wait in line, knowing that a special treat awaits them at the desk they will finally arrive at.

A little girl of four, virtually Dickensian in her placid soulfulness, stands silently by my side as I write furiously to complete her mother’s paperwork. Then, without uttering a word, she lightly places a finger on my forearm. “I know you’re here, sweetheart,” I remark as I continue to write at breakneck speed. “As soon as I’m done with Mom’s form, I’ll give you some candy.” And she waits, and I give her the candy, and she thanks me, takes her mother’s hand, and is off to the counter for their food bags. I wish a young man of nine or ten a good school year and extend my hand. He takes it and looks up mildly startled because the hand that clasped his own is filled with starbursts. Another little girl is so exhilarated with her handful of starbursts that she runs around the pantry, crying out for all to hear, “I have a cherry, and I have a grape, and I have a lemon, and I have an orange.” A little fellow of six or seven stares long and hard at the large basket of candy on the desk and gingerly takes a single small piece. “Take more,” I urge him. “Take a few. Go ahead.” “No, it’s okay,” he replies. “One is enough.” But it’s not, not on my watch. So I tell him to come around the desk where I am sitting and reach back for my big bag of candy, and then I instruct him, warmly but firmly, to take a handful. He seems momentarily confused, but then slowly, deliberately, reaches down into the bag and emerges with a handful of treats. “See,” I tell him, “that wasn’t so hard, was it?” To which he leans in closely and whispers into my ear, “I only took a little handful.”

Giving food to adults and candy to children is no small matter. It is a relational cement that binds us to others. When friends or relations or colleagues or acquaintances experience major life events, good or bad, we send them food baskets. When we want to acknowledge a special kindness or favor, we send food. We express condolences through food, and we express loving gratitude as well. Growing up the son of a beloved small-town family doctor in the 1950s and ’60s, I well remember the steady flow of home-baked goods that transformed our kitchen into a bakery every holiday season. The cakes, pies, and cookies not only expressed gratitude for medical care; they reaffirmed a human connection made tangible through the very sweetness of their baked offerings. As such, they affirmed my father in his calling as physician and healer. So it is with the children at the food pantry. When we offer a low-income child a bit of candy, we convey our appreciation of the child’s essential rightness and affirm the beautiful potential that inheres in this or that child, which is to say in any child.

So here is my advice to anyone repulsed by what has passed as presidential politics these past several months. Go to your community food pantry or food bank or soup kitchen and become a volunteer. Connect with the adults and connect with the children, and make sure to bring your own candy to give the kids. Enter their lives and learn from them about your own. In giving food to those who need it, you will feed your own humanity, and it is arguable which party to the transaction goes home better nourished.

________________________________

[1] See Danielle Ofri, “When Doctors Give Patients Money” (http://well.blogs.nytimes.com/2014/01/30/when-doctors-give-patients-money/?_r=0) and Sally Wadyka, “Food as Medicine: Why Doctors are Writing Prescriptions for Produce” (http://blog.foodnetwork.com/healthyeats/2015/03/26/food-as-medicine-why-doctors-are-writing-prescriptions-for-produce/).

PRAISE FOR PAUL STEPANSKY’S IN THE HANDS OF DOCTORS: TOUCH AND TRUST IN MEDICAL CARE (PRAEGER, 2016).

“This book takes many conversations occurring in the world of medicine and reframes them in historical perspective. The result is a body of work with pearls of wisdom strung between the pages. . . . In the Hands of Doctors is an engaging and relevant read for anyone interested in the nuances of the doctor-patient relationship; a historical framework for understanding today’s questions in the medical humanities; or a thoughtful narrative on cultivating humanity in the modern practice of medicine.” – Ali Rae, review on the website of The Arnold P. Gold Foundation

“Paul Stepansky’s In the Hands of Doctors is a unique and compelling reexamination of American medical practice and patient expectations in historical and cultural context. Examining the many ways in which we seek health, literally from the doctor’s touch, Stepansky draws on his skills as a respected cultural historian and his perspective growing up the son of a rural general practitioner in the 1950s and 1960s. The result is a multilayered, nuanced, and accessible study that focuses on what physicians have offered and patients have sought, especially since the Second World War. . . . This book deserves a wide audience not only of health practitioners and patients, but also of medical historians and medical humanities scholars.” – Howard I. Kushner, Ph.D., Nat C. Robertson Distinguished Professor, Emeritus, Rollins School of Public Health, Emory University

available from Amazon.com and other online sellers

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Posted in Family Doctors, General

Tagged candy and relationality, community giving, food and attachment, food as care, food pantry (Montclair, NJ)

Patient Ratings and ER Burnout

Posted on March 31, 2016 | Leave a comment

[You can now preorder Dr. Stepansky’s new book, In the Hands of Doctors: Touch and Trust in Medical Care,** at Amazon.com]

The lot of ER physicians is not an easy one, and their tendency to early-career burnout, relative to physicians in other specialties, has been well documented over the past quarter century. Surveys show that a majority of ER Docs (usually around 60%) report moderate to high degrees of burnout, of which feelings of emotional exhaustion and depersonalization along with a low sense of personal accomplishment are all components.[1] In recent years their “burnout syndrome” has been aided and abetted by the unregulated patient ratings services that glut the internet.

How has this come about? It results from the fact that salaried ER Docs working in hospital emergency rooms face a ratings-related predicament inapplicable to colleagues outside hospital walls. To wit, the hospitals that employ and pay ER Docs are now obligated to survey discharged patients on their hospital experience, and this includes patients discharged from hospital emergency rooms. So ER Docs are participants in a development that has come to embrace inpatient hospital care in general. In the U.S., beginning in 2006, hospital patients have, on discharge, been asked to complete the 27-item “Hospital Consumer Assessment of Healthcare Providers and System” (HCAHPS) survey, with the understanding that the survey was designed to provide data about patients’ perspectives on care that can be compared among hospitals and, in so doing, create incentives for hospitals to improve quality of care.[2] For ER units, the American Board of Emergency Medicine’s Maintenance of Certification requirement of a “communication/professionalism activity” can become an additional circle of ratings hell. It may include collection of patient feedback (e.g., Press-Ganey scores), and if the feedback is not sufficiently positive, the unit’s contract may be in jeopardy.[3]

More onerously still, a portion of ER Docs’ compensation may be tied to the “quality” of services they provide, with such quality linked to the patient ratings they receive. This means that ER Docs are under mounting pressure to send happy ER patients off into the survey-ready night. And happy ER patients, unsurprisingly, are those whose pain has been taken to heart, and whose ER Docs have ordered the studies and prescribed the meds the patients’ themselves know they require.

This development is not anecdotal and is borne out by recent surveys that attest to the tendency of ER Docs to overprescribe and order unnecessary studies in order to send happier patients out of ER rooms to the patient-satisfaction forms that await them. And the tendency to give way to patient insistence on inappropriate care has been consequential: it has led to dramatically inflated costs to Medicare among patients who make ER visits. And here is the irony: high patient satisfaction ratings by patients have not been shown to correlate with measurable indices of higher quality care. A 2012 survey of 52,000 respondents to the national Medical Expenditure Panel Survey by researchers at the University of California, Davis, for example, showed that over a seven-year period (2000-2007) respondents in the highest patient satisfaction quartile not only spent more on prescription drugs, but were 12% more likely to be admitted to the hospital. They also accounted for 9% more in total health care costs than survey respondents who did not give their providers such stellar ratings.^{^[4]}

For ER patients, especially, the kind of “patient satisfaction” associated with surveys is not the “satisfaction” associated with patient-centered care, much less long-term trusting relationships rooted in procedural and expressive touch. Rather, it is a commodified, point-of-service satisfaction that revolves around pain management and brings in its wake another irony: ER Docs reliant on happy patients who give them positive ratings are, to their own dismay, becoming less concerned with patients’ compliance with their medical directives (now “recommendations” or “suggestions”) than with their own compliance with their patients’ expectations. And patients, in turn, increasingly rely more on met expectations than on objective medical outcomes in rating their doctors.

The predicament of ER Docs amplifies a general trend in primary care, where office visits are brief and pressure on clinicians to maximize “throughput” (i.e., to see as many patients as possible during office hours) is intense. In doctors’ offices, as in emergency rooms, there is pressure to make patients happy by, for example, prescribing addictive opioids rather than taking the time to discuss alternative treatments. So ER Docs and PCPs alike are in a tightening bind: their desire to satisfy patients and avoid poor satisfaction scores may trump medical judgment, in which case they “may find themselves in the role of ‘customer service’ providers rather than medical professionals or healers.”^{^[5]} Unsurprisingly, we have a new round of survey data on burnout syndrome that adds a new burnout factor to those documented in the 1990s: the association between utilization of patient satisfaction surveys, on the one hand, and job dissatisfaction and attrition among physicians, especially ER and primary care physicians, on the other.^{^[6]} An online survey of over 700 ER doctors reported in Emergency Physicians Monthly, for example, found that 59% of the ER Docs admitted increasing the number of tests they ordered because of patient satisfaction surveys. When the South Carolina Medical Association asked its members whether they ever ordered a test they felt was inappropriate because of such pressure, 55% said “yes,” and nearly half of the 131 respondents admitted improperly prescribing antibiotics and narcotics in direct response to patient satisfaction surveys.[7]

So let’s end this dismal reportage by noting a final unsettling irony. We now face a veritable epidemic of opioid addiction for which the emergency room has become ground zero. Between 2004 and 2011, visits to ERs for misuse or abuse of prescription opioids increased 153%. And yet, at the very moment in history that the nation belatedly confronts this epidemic, with states, state-wide hospital organizations and, most recently, the Center for Disease Control (CDC) all issuing restrictive guidelines for prescribing painkillers such as Vicodin and OxyContin,[8] we have ER Docs and their colleagues in primary care reaching for prescription pads in their quest for happy (or happy enough) patients who will give them a favorable nod and let them move on to the next patient. These Docs are not overprescribing with reckless abandon. Far from it. The surveys all suggest they are miserable overprescribers boxed into a corner by throughput pressures and the addictive quest for positive ratings.

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[1] K. L. Keller & H. J. Koenig, “Management of stress and prevention of burnout in emergency physicians,” Ann. Emerg. Med., 18:42-47, 1989; S. Lloyd, et al., “Burnout, depression, life and job satisfaction among Canadian emergency physicians,” J. Emerg. Med., 12:559-565, 1994; R. Goldberg, et al., “Burnout and its correlates in emergency physicians: four years’ experience with a wellness booth,” Acad. Emerg. Med., 3:1156-1164, 1996.

[2] See “The HCAHPS Survey – Frequently Asked Questions” (https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/downloads/hospitalhcahpsfactsheet201007.pdf).

[3] E. Schwarz, “The CDC Weighs In With Opioid Prescribing Guidelines,” Emergency Physicians Monthly, March 30, 2016 (http://epmonthly.com/article/the-cdc-weighs-in-with-opioid-prescribing-guidelines/).

[4] J. J. Fenton, et al., “The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality,” Arch. Intern. Med., 172:405-411, 2012.

[5] J. T. Chang, et al., “Patients’ global ratings of their health care are not associated with the technical quality of their care,” Ann. Intern. Med., 144:665-672, 2006; D. S. Lee, et al., “Patient satisfaction and its relationship with quality and outcomes of care after acute myocardial infarction,” Circulation, 118:1938-1945, 2008; A. Zgierska, M. Miller, & D. Rabago, “Patient satisfaction, prescription drug abuse, and potential unintended consequences,” JAMA, 307:1377-1378, 2012, quoted at 1378; A. Lembke, “Why doctors prescribe opioids to known opioid abusers,” N. Engl. J. Med., 367:1580-1581, 2012.

[6] A. Zgierska, D. Rabago, & M. M. Miller, “Impact of patient satisfaction ratings on physicians and clinical care,” Patient Prefer. Adherence., 8:437-446, 2014.

[7] These studies are cited by Kai Falkenberg in “Why rating your doctor is bad for your health,” Forbes, January 21, 2013 (http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health).

[8] “Doctors told to avoid prescribing opiates for chronic pain” (http://www.usatoday.com/story/news/2016/03/15/cdc-issues-new-guidelines-opiate-prescribing-reduce-abuse-overdoses/81809704/).

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**ADVANCE PRAISE FOR IN THE HANDS OF DOCTORS

“An engaging, richly documented, brilliant critique of the bond between doctor and patient, ranging from classical times through the present. The need for the bond continues, Stepansky argues; patients trust doctors, not teams, medical homes or health care systems. Along the way he discusses what it means to “care” for someone as a professional, whether empathy can be taught, the narrowed scope of family medicine as a field, and how far science and the procedural aspects of medicine are antagonistic to, or simply part of, the humanity inherent in medicine. He offers his own ideas for change. This is a superb introduction to the role of the doctor in a continuing historical context.”- Rosemary Stevens, Ph.D., DeWitt Wallace Distinguished Scholar, Weill Cornell Medical College; author, American Medicine and the Public Interest: A History of Specialization and A Time of Scandal: Charles R. Forbes, Warren G. Harding and the Making of the Veterans Bureau

“Paul Stepansky’s In the Hands of Doctors is a unique and compelling reexamination of American medical practice and patient expectations in historical and cultural context. Examining the many ways in which we seek health, literally from the doctor’s touch, Stepansky draws on his skills as a respected cultural historian and his perspective growing up the son of a rural general practitioner in the 1950s and 1960s. The result is a multilayered, nuanced, and accessible study that focuses on what physicians have offered and patients have sought, especially since the Second World War. Stepansky laments the impact of specialization on what he terms “true doctoring,” even while recognizing its great benefit in treating illness. Eschewing nostalgia, while acknowledging the complexity of today’s health care delivery, Stepansky nevertheless offers a way back to the type of care his father provided. This book deserves a wide audience not only of health practitioners and patients, but also of medical historians and medical humanities scholars.” – Howard I. Kushner, Ph.D., Nat C. Robertson Distinguished Professor, Emeritus, Rollins School of Public Health, Emory University

“In the Hands of Doctors is an original contribution to medical history and, in addition, a book that will appeal to all those in the caring professions: psychotherapists, psychiatrists, psychologists, social workers, nurse practitioners, and others. Dr. Stepansky gives new meaning to the roles of touch, empathy, and friendship as these are involved in medical practice, and he presents original ideas about the shape of such practice as it moves into the next decades. In short, a clearly written and profoundly argued book.” – Louis Breger, Ph.D., Professor of Psychoanalytic Studies, Emeritus, California Institute of Technology

“One of the greatest challenges confronting 21^st-century medical education is how to train physicians who are not only competent but also compassionate, and who know how to demonstrate that caring to the patient. In this engaging and deeply personal book, Paul Stepansky gives us a valuable historical perspective on caring in medicine and offers suggestions that will be useful for medical educators, practicing physicians, nurse practitioners, and patients alike.” – Joel D. Howell M.D., Ph.D., Victor Vaughan Professor of the History of Medicine, University of Michigan

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Posted in ER Medicine, Patient Rating Services, physician burnout, Primary Care

Tagged CDC, opiods, patient satisfaction

Why I Care About Caring

Posted on December 26, 2015 | Leave a comment

When it comes to doctoring in America, there is a long-established and growing rift between being well treated and feeling well cared for. On the one hand, patients want doctors who know them and are caring of them. They are frustrated with the kind of care dispensed in very brief office visits. They are unhappy having their bodies parsed into organs and systems that elicit matter-of-fact diagnoses and impersonally rendered treatments. They may want the “facts,” but they want them conveyed by a human being who understands their apprehension, uncertainty, and confusion in the face of them. The facts are never neutral in their psychological impact on the patient’s sense of self. They establish that the patient is in some manner and to some degree damaged, and therefore in need of a physician able to bring expert knowledge to bear in helping the patient overcome his illness and dis-ease and regain his peace of mind and wholeness. This means that patients expect their physicians to be able and willing to give them enough time to come to know them as persons whose apprehension, uncertainty, and confusion are deeply personal. To the extent that the doctor humanizes the encounter by providing the patient with sympathy and support, perhaps even empathy, the patient feels he is in the hands of a knowing and caring doctor. This is the viewpoint of the bioethicist Edmund Pellegrino.

On the other hand, patients expect their doctors to respect their right to make their own medical decisions. And they want doctors who not only grant them autonomy in principle but cede autonomy in action. In order to make informed decisions about their bodies, they need the facts, all of them. And so patients expect to be told, directly, perhaps even collegially, what may ensue if they accept or reject one or another of the treatment recommendations that follow from the facts. But that is where medical care ends. The patient alone must decide what to do with the facts of the matter, the facts of his or her bodily matter as the doctor has scientifically arrived at them. Armed with information, explanation, and expert risk assessment, the patient will choose a course of treatment, which the physician and/or his colleagues will then implement to the best of their ability. To the extent the physician implements the patient’s treatment plan absent any intrusion of his or her own preferences and values, he or she treats the patient well and truly, and leaves the patient, in turn, feeling well treated and well cared for. This is the perspective of the bioethicist Robert Veatch.

Between these polar viewpoints on what it means to be a doctor and a patient, respectively, I interpose the notion of medical caring, which is less simple than it appears. Medical caring can humanize the doctor-patient relationship without imposing values and goals that are antithetical to the patient. At its best, medical caring is a reaching out to the patient that transcends the banalities (and uncertainties) of diagnosis and treatment in ways that patients throughout history have welcomed, and this because patienthood often compromises personhood. Here I side with Pellegrino: In some primal way, we call on doctors when we feel not fully ourselves, or less than ourselves, or anxious about our ability to remain ourselves, and we look to doctors to return us to the normal selves we want to be.

Medical caring has its own historical trajectory; it is responsive not only to the medical knowledge of a given time and place, but also to the cultural and political arrangements through which a society provides for the coming together of doctors and patients. It is from these arrangements that the mindsets of patients and doctors arise and, with varying degrees of success, arrive at a concordant notion of what it means for the one to be in the care of the other.

In a society that increasingly commands patient empowerment in the service of unilateral decision making, a focal concern with medical caring adds the cautionary reminder that we deprive physicians of their own right to counsel, admonish, and persuade at our peril. At a certain point, however variable among different patients and different doctors, the legal assertion of rights begins to undermine the doctor’s prerogative to doctor in ways responsive to the patient’s needs and expectations. Doctors, after all, are also moral agents with a Hippocratic obligation to draw on their humanity, however flawed, in ministering to their patients. And patients, for their part, have the right to rely on physicians in ways that are human but not strictly factual as to diagnosis and treatment. To relinquish voluntarily a measure of autonomy to a trusted physician is an act of autonomy.

The notion of medical caring captures the sense that doctors are not just “doctors” in some timeless, generic sense, any more than patients are just generic purchasers of medical treatment as a commodity. The same doctors who, mindful of patient rights, seek to make contact with their patients in more than bland informational ways are themselves the patients of other doctors, as are their loved ones, so the predicament of the patient, whose decision-making autonomy is often compromised, will not be so alien to the doctor as proponents of value-free medicine believe. Doctors are all patients, or patients in potentia. And patients, for their part, come in all shapes and sizes, maturationally, temperamentally, characterologically, and otherwise. Some will neither want nor possess the ability to be autonomous decision makers. In a caring relationship, doctor and patient together, with or without participation of the patient’s significant others, make the determination together, person to person.

A historical perspective on medical caring is cautionary in another respect. It reminds us that concepts such as “paternalism” and “autonomy” are themselves historical constructs, not timeless Platonic forms. Bioethicists who use these terms in essentialist ways overlook the historical and cultural location of doctor-patient relationships. The “paternalism” of physicians in ancient Rome, in Renaissance Florence, in seventeenth-century Paris, in nineteenth-century London, in postbellum America, in America of the mid- twentieth century – these are not the same thing. And none of them is tantamount to what paternalism – or maternalism, or avuncular regard or brotherly or sisterly concern – may still mean in an age of digital medicine, the internet, and patient rights.

It bears remembering, finally, that the feeling of being well cared for by a doctor is responsive not only to the treatment options of a given time and place, but also to cultural assumptions that enter into doctor-patient relationships. Different norms of caring typify different periods in the history of medicine. Patients in the eighteenth century who were bled to syncope (fainting) felt well cared for. Several decades into the nineteenth century, many insisted on being bled, and some would seek out new doctors when their own refused to drain them further. Plenty of caring surgeons of the late nineteenth century applied vaginal leeches and performed ovariotomy on women who, without signs of serious gynecological disease, demanded that doctors recognize their complaints and do something to relieve their suffering. Within a medical paradigm in which even minor pelvic abnormalities explained symptoms of depression and nervous exhaustion (neurasthenia), surgery counted as a caring intervention and was widely understood as such. Similarly, paternalistic obstetricians of the late nineteenth century who treated postpartum women suffering from exhaustion and agitated depression (“puerperal insanity”) by legitimating their symptoms and ordering compulsory “time outs” from stifling domestic obligations were caring physicians within the gendered constraints of Victorian society. Prefrontal lobotomy was widely considered a caring intervention for schizophrenics during the 1930s and ’40s. The surgery, for its many proponents, restored a measure of function (however compromised) to patients who would otherwise have ossified in the chronic wards of mental hospitals. Now the care of schizophrenic patients is far different and, from a twenty-first century vantage point, far more humane.

But this is beside the point. It is easy to dismiss bleeding to syncope, vaginal leeching, prefrontal lobotomy, and innumerable other treatments as relics of the past, misguided, unscientific, often harmful. But such judgments, such exercises in presentism, do not negate the caring intent with which such treatments were administered by doctors and received by patients. There is more to medical caring than meets the contemporary eye. This is why my forthcoming book, In the Hands of Doctors: Touch and Trust in Medical Care,** puts aside the triumphal march of medical treatment in the nineteenth and twentieth centuries and focuses instead on the history of caring and feeling cared for. It is with respect to these intertwined dimensions of doctoring that the past is more than past. The period in American history covered in the book, roughly from the end of the American Civil War through the 1960s – guides us to a deeper understanding of what “modern” patients want and expect from doctors and what, if anything, their doctors can do for them beyond diagnose and treat.

By mining the vagaries of caring and feeling cared for over time, we gain historical perspective and move a little closer to the intersubjective bedrock of what it has meant, and continues to mean, to be a doctor and to place oneself in the doctor’s hands. What we discern can be unsettling, as the examples above suggest. But taken together, they provide a luminous counterpoise to the progressively depersonalized, cost-driven, productivity-obsessed medicine of the past 40 years. I offer my work as an example of how thinking with history validates Francis Peabody’s tired but never tiresome insistence that “the secret of the care of the patient is in caring for the patient.”

**Paul E. Stepansky, In the Hands of Doctors: Touch and Trust in Medical Care (Santa Barbara: Praeger Publishers, scheduled for release in May, 2016).

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Posted in Bioethics, General, Medical Humanities

Tagged Edmund Pellegrino, medical caring, patient rights, Robert Veatch

Doctor, How Do You Rate?

Posted on May 15, 2015 | 2 comments

As if the challenges of “online professionalism” and Facebook “friending” don’t complicate doctor-patient relationships enough, there is the additional strain of online rating services, where patients rate their physicians along several service-related parameters and then, if they choose, append brief evaluative comments. The physician rating websites that first appeared in the late 1990s – HealthGrades.com, RateMDs.com, WebMD.com, Vitals.com, et al. – are another outgrowth of the patient rights movement of the 1970s. Indeed, taken together these sites are the apotheosis of the consumerist vision of healthcare: We are consumers, our doctors provide services, and we have every right to evaluate their performance in ways that matter to us and presumably to others “in the market” for medical services. And who is to say this is a bad thing? What is wrong with knowing that the wait time for one doctor is unacceptably long or that another spends most of an office visit making eye contact only with his laptop?

There is nothing at all wrong here, as long as we are content with a consumerist orientation toward health care. If doctors are merely the corporeal equivalents of home repair experts, then perusing their star gradings, reading their consumer feedback, and noting if they are “Recognized Doctors” are good things entirely. The problem arises for those patients who persist in viewing their physicians as something more than body-maintenance tradesmen. For them, the rating websites, no less than Facebook and Twitter, have a downside.

For doctors, of course, ratings and comments can be damaging because – excepting only the review/scheduling service ZocDoc^{^[1]} – they are not vetted. They encourage impulsiveness and verbal “acting out” on the part of individuals who may bear a grudge and may not even be patients of the doctor in question. Rare is the physician who cheerfully accepts rating websites because, “though virtually useless for meaningful evaluation of an individual physician,” they “make for refreshing reading” and, taken in the aggregate, may provide useful qualitative data on patients’ needs and preferences.^{^[2]} One wonders how many physicians have the time and inclination to read and ponder patient ratings “in the aggregate” while remaining unconcerned with their own location on the totem pole of patient appraisal.

But my concern here is not for the doctor but for patients in search of more than body work. For them, the rating websites have an insidious long-term consequence, and this has to do with their impact on doctors’ emotional availability to patients and willingness to make this availability the lynchpin of the special friendships associated with medical caring. Never mind that, according to one 2012 study, online ratings of physicians are generally very positive, with rating variations deriving largely from evaluations of punctuality and staff.^{^[3]} To the extent that doctors feel vulnerable – both professionally and financially – to the vagaries of patient feedback, they are forced to devalue that aspect of their professional identities that, in the pre-internet world, was integral to doctoring.

It is a matter, once more, of the caring aspect of care, which over time becomes embedded in meaningful human connections that resist decomposition into discrete units of bodily tune-up and repair, more or less conveniently rendered. This kind of personalized caring, with its procedurally driven, hands-on component, was integral to family medicine through the 1960s, and lives on among a dwindling minority of generalists, especially those who care for underserved, often rural, communities. But for the vast majority of physicians, including frontline primary care physicians, the rating sites have put them on the defensive and, in so doing, rendered mutual the consumerist orientation toward medical treatment (not care) that makes doctors plumbers of the body.

Some doctors who have felt the sting of negative feedback – whether “fake reviews” by fired employees, diatribes by angry patients denied medications they sought but didn’t need, or constructive comments on professional shortcomings – have gone on the offensive. Medical Justice, a member-based “medical identity management” firm launched in 2002, developed a contract to be signed by the patients of its client physicians. Via the contract, which came into use in 2007, patients assigned copyright to any subsequent online review of the physician to the physician being reviewed. In this manner, doctors who received less than flattering feedback could claim copyright infringement and have the offending patient review removed from the rating service. In exchange for the patient’s assignment of copyright, doctors agreed, by contract, not to share the patient’s medical data with marketers. Unsurprisingly, the contracts neglected to inform patients that by law doctors cannot share their confidential data with marketers without the patient’s prior authorization. The “privacy blackmail” contracts were jettisoned at the end of 2011, subsequent to a lawsuit and complaint filed with the Federal Trade Commission by the Center for Democracy and Technology.^{^[4]}

Copyright law is no longer being misused to suppress patients’ rights to evaluate doctors, but physicians and their advocates remain inventively proactive in coping with the prospect of negative ratings. Rather than absorbing body blows to their professional selves, and having learned that courts provide no redress, they have embraced the growing role of physician ratings in medical practice and begun soliciting patient feedback through their own websites. Patients may be contacted by staff and invited to provide positive feedback on one or more of the rating websites.^{^[5]} In a dramatic about face in 2012, Medical Justice began supplying client doctors with iPads to give to patients at the point of leaving the office. Patients are asked to write a review, and the firm makes sure that comments (presumably positive, possibly coerced) are posted on a review site. In the medical free market, there apparently is no defense like a good offense.^{^[6]}

Even when preemptive strategies for garnering positive feedback fall short, there are things to do. In “Responding to Negative Online Comments,” the featured article in a recent issue of MCMS [Montgomery County Medical Society] Physician, a risk management specialist takes physicians down the list. “Don’t panic,” he tells them, and don’t respond immediately or impulsively to negative feedback. “Not all negative comments are worthy of your time to respond,” he continues. “A response may start a chain reaction of negative slurs and comments, potentially leading to litigation.” Clearly false or inflammatory feedback warrants contact with the website administrator in the hope that the site’s content guidelines will effect removal of the offensive posting. But suing a reviewer, he cautions, is a problematic affair, and physicians contemplating such action shuld consult with their attorneys as soon as possible. And there is the otherwise proactive strategy given here as a postscript to negative feedback: “Follow up with positive information about your practice,” but never, he warns, resort to posting fake consumer reviews.^{^[7]}

What’s wrong with this picture? The physician rating websites provide the kind of transparency in health care long urged by consumer groups and the federal government, especially through the Centers for Medicare and Medicaid Services. Such transparency, it is held, will improve the quality and costs of care. But what is the nature of this transparency, and what exactly does it allow us to see? For the vast majority of doctors, those who receive a rating or two or none at all, we see very little. We do not see these men and women as human caregivers bound by professional ethics to reach out to other humans who come to them as needy “petitioners”[8] hopeful that the doctor’s care will restore their damaged humanity. Less grandiloquently, we do not see how willingly these men and women embrace – or fail to embrace – the relational matrix in which care and caregiving traditionally came together. The ratings provide only a black-and-white, two-dimensional x-ray, often tendentiously rendered, of the “bones” that frame a doctor’s activities: office appearance; wait times; staff friendliness; time spent with a particular patient; and the like. And the energy spent soliciting, monitoring, and worrying about patient ratings is energy that might otherwise be deployed caring for patients in conflict-free ways far removed from the commercial world of consumer feedback.

So here, finally, is the payoff: between the Scylla of eviscerated Facebook “friending” and the Charybdis of skeletal patient ratings, physicians, especially general physicians who provide continuing care, are increasingly pulled away from a relational model of caregiving, a trend that all the patient-centered training and empathy workshops in the world cannot reverse. The fact is that the vast majority of physicians today have less energy and/or inclination to give patients in search of something more than body maintenance what physicians have traditionally offered them: a special kind of friendship.

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[1] ZocDoc, founded in 2007, differs from other rating services. It requires registration by patients and physicians alike, and provides online scheduling of appointments along with physician reviews. But Zocdoc, unlike HealthGrades, et al., only allows reviews from patients who have actually seen a physician through Zocdoc. As such, it is a “closed loop” review system. See O. Kharraz, “Providers should think seriously about leveraging online reviews,” March 12, 2013 (http://www.thedoctorblog.com/providers-should-think-seriously-about-leveraging-online-/reviews/).

[2] S. Jain, “Googling ourselves – what physicians can learn from online rating sites,” N. Engl. J. Med., 362:6-7, 2010.

[3] G. Gao, et al., “A changing landscape of physician quality reporting: Analysis of patients’ online ratings of their physicians over a 5-year period,” J. Med. Internet Res., 14:e38, 2012.

[4] R. Reitman, “Medical justice: Stifling speech of patients with a touch of ‘privacy blackmail’,” May 4, 2011 (https://www.eff.org/deeplinks/2011/05/medical-justice-stifling-speech-patients-touch); E. Goldman, “Medical justice capitulates by ‘retiring’ its anti-patient review contracts,” December 1, 2011 (http://blog.ericgoldman.org/archives/2011/12/medical_justice.htm); R. Lieber, “The web Is awash in reviews, but not for doctors. Here’s why,” New York Times, March 9, 2012 (http://www.nytimes.com/2012/03/10/your-money/why-the-web-lacks-authoritative-reviews-of-doctors.html?_r=0&pagewanted=print).

[5] S. Reddy, “Doctors check online ratings from patients and make change,” Wall Street Journal, May 14, 2014. Cf. C. Ellimootil, et al., “Online reviews of 500 urologists, J. Urology, 189:2269-2273, 2013 and D. B. Bumpass & J. B. Samora, “Understanding online physician ratings,” AAOS Now [American Academy of Orthopedic Surgeons], September, 2013 (http://www.aaos.org/news/aaosnow/sep13/advocacy4.asp).

[6] Lieber, “Web awash in reviews,” op. cit.

[7] J. Hyatt, “Responding to negative online comments,” MCMS Physician (Official Publication of the Montgomery County Medical Society of Pennsylvania), Summer, 2014, 6-8.

[8] This is the language of the influential bioethicist Edmund Pellegrino, for example in Humanism and the Physician (Knoxville: University of Tennessee Press, 1979), 124, 146, 184, and passim.

Medicine, Health, and History | A Blog by Paul E. Stepansky, Ph.D.//

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Posted in Doctor-Patient Communication, Patient Rating Services

Tagged Facebook, HeathGrades, medical consumerism, RateMDs, WebMD, ZocDoc

“Scope of Practice” Minefields

Posted on September 15, 2014 | Leave a comment

“. . . 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.

__________________________

[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).

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Posted in Diabetes, Medical Politics, Nurse practitioners, Nursing

Tagged Institute of Medicine, Physician's Foundation, prescriptive authority

What Do Nurse Practitioners Practice?

Posted on August 22, 2014 | Leave a comment

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]

_______________________

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.

__________________

[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).

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Posted in Nurse practitioners, Nursing, Nursing and Gender, Nursing education, Primary Care

Tagged American Nurses Association, Esther Brown, Florence Nightingale, Hildegard Peplau, pediatric nurse practitioner, pharmacy, William Alanson White Institute, William Stepansky

Psychotropic Serendipities

Posted on July 5, 2014 | Leave a comment

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.

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Posted in Psychiatry in Medicine, Psychopharmacology, TB

Tagged chlorpromazine, Frank Berger, isoniazid, Leo Sternbach, Librium, Miltown, Nathan Kline, penicillin, reserpine, thalidomide, WWII medicine

Injections and the Personal Touch

Posted on April 18, 2014 | Leave a comment

“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.

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Posted in Diabetes, Hypodermic Injection, Psychoanalysis

Tagged doctor patient relationship, needle phobia, William Stepansky

It Was All About the Pain

Posted on March 24, 2014 | Leave a comment

“. . . 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.

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Posted in Hypodermic Injection, Medical Instruments, Medical Technology, Old & New

Tagged Alexander Wood, morphine, needle phobia, opioid

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