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Dr. Nurse

March 28, 2013

I recently blogged about the question of what the difference is between a doctor and a nurse, now that advanced-practice nurses can do so many of the same things physicians do.  As both a nurse and a doctor I thought maybe I could wade into that quagmire.  In that post I suggested that the real difference is one of ultimate responsibility.  A reader pointed out that this is actually not true: in some states NPs and others practice independently.  I also realized this statement of mine was a little insulting to nurses, somehow suggesting that they willingly abdicate responsibility for their patients.  So I’ve thought about it and I have a new opinion.

The difference is one of philosophy.  The medical model vs. the nursing model.  Until recently I found this distinction annoying and reductive, diminishing the individual differences each of us have.  There is an actual definition for “the medical model”.  Here is what says:

“The traditional approach to the diagnosis and treatment of illness as practiced by physicians in the Western world since the time of Koch and Pasteur. The physician focuses on the defect, or dysfunction, within the patient, using a problem-solving approach. The medical history, physical examination, and diagnostic tests provide the basis for the identification and treatment of a specific illness. The medical model is thus focused on the physical and biologic aspects of specific diseases and conditions.”

The term medical model has been used in both complimentary and derogatory ways, but it is generally the way doctors think.  There is no definition of the nursing model, but nursing has some practice models/theories that emphasize the more wholistic approach to disease that is taken by nursing.  For example, three British nurses back in the ’90s came up with a model called “The Activities of Living” model.  It views a disease in the context of what the patient can and cannot do for themselves.  They list activities of living like so:

  • Breathing
  • Eating and drinking
  • Eliminating
  • Controlling body temperature
  • Mobilising
  • Sleeping
  • Maintaining a safe environment
  • Communicating
  • Personal care and dressing
  • Working and playing
  • Expressing sexuality
  • Dying

No actual disease diagnosis there, right?  More of a life-systems overview than an organ-systems overview. Another famous nursing model is one by Dorthea Orem.  Similar to the Activitis of Living model, this one defines areas of self-care deficits brought on by the disease process.  So you might have “deficit in urinary function” for an enlarged prostate, or “deficit in oxygenation” or “deficit in respiratory function” for someone with pneumonia.  In a way this is kind of silly, since the model sort of seems like it’s re-naming diseases with different names, but what it emphasizes is that although the nurse knows pathophysiologically what pneumonia is and how to treat it, she/he also sees the pneumonia in the larger context of the patient not being able to do something he could do before, that is: breathe normally.

You kind of need both viewpoints don’t you?  Say you broke your foot.  You need a doctor (or an advanced practice nurse experienced with orthopedics, or a physician assistant who reads x-rays every day) to confirm that your foot is broken.  You also need someone who is going to recognize that this foot injury causes you to lose the ability to do things in your life that you could do easily before.  The doctor might prescribe pain-killers, but the nurse might come along and also prescribe a visiting nurse, extra ace-wraps, the number of a good babysitter, etc.  The medical model might consider this “soft science” but which person is going to make your actual life better, not just your foot?  That’s the difference.



From → Healthcare

  1. Hummingbird permalink

    Nice comeback on this topic. I like the title as well.

    • Yugep permalink

      in other words the doctor sees the disease and the nurse sees the person AND the disease

  2. Ann Soutter permalink

    I like the comeback. I always said the circulating nurse in the OR saw the whole picture, and was the only one focused on the overall patient. Everyone else had a specific role, and could/would become focused on that part only. Now, working with the same MD in an office for 12+ years, we talk about how we complement each other, and are still learning from each other. I am held responsible for my work, and my patients.

  3. Unfortunately, I find my communications with nurses is getting worse and worse, both as a patient and as an advocate. I’ve spent a few decades working with clinical decision support and medical education, and have a substantial knowledge of clinical sciences. As a patient, I expect to exercise autonomy based on science.

    While the holistic or nursing model may be less well-defined than the pathological model, I still find the former frustrating. Too many nurses seem hell-bent on simplifying and “educating”, regardless what the patient or proxy’s knowledge level may be. In the most recent set of encounters, I held health care proxy and HIPAA releases, yet it was enormously difficult to get objective information, such as labs and even medication orders. A few months previously, I had had an order for visiting nurse services, explicitly for a few days of dressing changes for a hard-to-reach spot. The nurses showed up and demanded that they visually audit all my medications, review my living circumstances, develop a nursing plan, and bring it to the surgeon for approval. Neither the surgeon nor I wanted these additional services, but the nursing service was adamant, possibly, according to my PCP, to increase the acuity of visits and thus billing.

    I recognize that the average patient may not have specialized knowledge, but I encounter more and more problems with nurses creating a barrier to focused communications with physicians.

    • Mr. Berkowitz – you have run into what I call the nursing mindset, which at least at the RN level tends toward the rigid and protocol-driven. Partly because of educational levels (RNs are still not required to have bachelors degrees), partly due to regulation and litigation, and maybe because of nursing administration, nurses, particularly floor nurses, have little chance to practice critical thinking. I would add that the chance for independent thought has diminished in medicine as well for many of the same reasons. You were a victim of this rigidity. I ran into the same problem when my second daughter was in the hospital.
      I also think that with the advent of better education for women, the field of nursing decided it needed to deal with a bit of an inferiority complex. Nurses, after all, “take orders” from physicians. So nurses in academia came up with these nursing theories and care plans as a way of distinguishing the profession as more than just the doctor’s handmaiden. Two problems occurred: one, nursing came up with a new language for medical terms that the physicians didn’t buy into. Second, they seized on what they see as their turf, ie, education and assistance carrying out treatments, and insisted that everybody needed a “care plan” and an aggressive nursing intervention, as separate from the medical one. This works great for some patients, but not everyone needs that level of intervention.
      I like to think that the advanced practice nurses, who have more education and training and presumably more independent thinking skills, fall less into this rigid thought pattern.

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