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how's biology, physics and chemistry going to help me put a diagnosis or treat a patient better...honestly

 

On a recent anaesthesia elective, my attending and I probably spent about 45 minutes discussing the shape of a patient's pulse-ox waveform and the physiological, pharmacological and pathological factors that could potentially influence it. And then we had an equally involved discussion about the tracing on the capnograph...

 

Ok so we both trained as engineers and were kinda nerding out, but my point is that if you truly want to grasp physiology, you need to have a good handle on the underlying biology, physics and chemistry.

 

Another data point - I have had similar discussions with ICU docs about vent settings, for instance. The fundamentals often drive the diagnosis and course of treatment, especially when the patients are really, really sick.

 

pb

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In my experience, nursing thought process seems be "Mr. W has symptom X therefore he must have pathology Y so I need to harass the resident to write an order for medication Z." Which is great when Mr. W actually has pathology Y, but not so great when he doesn't.

 

OMG don't get me started on the nurses who think that lasix is the magical cure-all drug. Not every patient whose lungs sound like crap is in CHF and needs 40 of lasix! Having said that, the vast majority of nurses are amazing, and as an R1, I rely a lot on them and their judgement! But I agree, that nursing training is very different in its fundamental approach to problems.

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I found this an interesting debate, so I had my friend who is on the path to becoming an NP, and this is what she wrote:

 

Perhaps I'm beating a dead horse as this thread has not been posted on for a while:

 

1) RN's are NOT taught differentials in nursing school. They are taught about various conditions, what to expect, how to help the person with the condition, and what treatments are provided. They are also taught how to recognize when a patient is sick, and when to respond (and this a lot of times means monitoring, following medication guidelines, and contacting the physician).

 

I would say the reason they are NOT taught differentials is because there is already a professional group that does this. Of course that professional group is Medicine.

 

This, however, does not mean they aren't thinking about differentials (yet not calling it that). For example: A patient is nauseated. Does the nurse just think.. ok I'll give them dimenhydrinate and see if it gets better? Sometimes yes, sometimes no. Nurses are taught to think about the reasons for the nausea: is the patient's bowel obstruction getting worse? Is it the pain medication? is it a reaction to other medication? Is this part of the disease process? Is it just nausea because they didn't eat? Or they ate too much too soon? Should I inform the doctor about this?

 

2) The focus of NP's during NP school is to be taught the differentials they were missing in nursing school. They get additional anatomy, physiology, pathology training, and work specifically to boost their differential skills. Although it is not anywhere near the equivalent training of a person going to medical school, it does help teach NP's the thought process of medicine. Between that, the experience the NP has as a nurse in both nursing school and in practice, does provide a background of knowledge that seems substantial enough to prescribe birth control, do a yearly physical, and teach people about their diabetes. The amount of knowledge, however, that the NP gains from all of his/her experience as a nurse and in NP school is individualistic, but the outcome would be an NP who has differentials on their mind.

 

3) Although the length and type of training doctors get versus nurses is not equivalent, do not discount the experiences that nurses get by being with the patients they work with. They may not understand WPW that well and have a differential for the reason the delta wave occurs on the ECG, however, most nurses can tell you that a patient is sick, and that intervention is required NOW. They are also good at recognizing that the patient needs higher medical intervention then the nurse can provide.

 

4) Family doctors are trained to know the basics about everything, and know when to send to a specialist. However, sometimes that is not completed for XYZ reasons. I would equate that to NP's and their practice. They ARE trained to know their limits, although I'm sure sometimes this doesn't happen and they overstep. This is an individualistic problem, and I wouldn't say that about the profession itself. Some residents get like that too, especially towards the end of their training.

 

5) For those who are worried that NP's will take over the Family Physician role, I say it will not happen. There is an MD needed for a reason. Sort of a checks and balances. Just like in the hospital each person has their role, so it happens in family practice. Right now to make ends meet, physicians have to regulate themselves to less than 20 minutes PER PATIENT. Is this enough time to dedicate to the 80+ year old lady with diabetes, mild dementia, hypertension, gout, 2 previous MI's and atrial fibrillation who is actually visiting because she has had joint pain for the last 2 weeks? I would say not. Just figuring out her medical history would take over 20 minutes. However in the waiting room you also have a mom with a child who has a cough, someone who needs a continuance of their birth control pill, a patient who was in the ED the other day because of chest pain (but not cardiac) who was told to follow up with their primary care physician, and a patient who needs an assessment so they can get their vaccines for a mission trip.

 

The NP, if there is one in the practice, could assess the baby, prescribe the birth control pill post-assessment, and fill out the needed forms for the vaccines while the MD takes the more serious case of the older lady and the chest pain. That, to me, is a very good way of practicing medicine. There WILL be zebras masquerading as horses, and many primary care physicians will tell you that it is expected. What is not necessary is for those primary care physicians to not be able to give excellent care because they are too rushed and need to meet the bottom line. The demands are too high, and the resources are low.

 

Those are my $0.02.

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