Nurse Consultant? Or Physician Peer?

Let me just start off by saying (heading illustration notwithstanding) I’m not comparing legal nurse consultants to monkeys at a typewriter! The analogy is for something else that I’ll explain in a bit.

One of the things I’ve noticed in the medical legal consulting business is that it is heavily dominated by registered nurses. I suspect it possibly has something to do with most doctors just not having enough time to engage in such hijinks (see my post here). Or maybe it’s that physicians look upon consulting on the plaintiff’s behalf as a kind of selling out, or ‘biting the hand that feeds you’. What I do know, is that I see it as getting to the truth of a matter. Sometimes I find there actually was no mistake, and I can sleep well knowing an unfairly-accused physician has been vindicated. And other times the error is so egregious, the culprit deserves what they get. Physicians come in all stripes, just like any other field, and we need to watch out for the jerks… but we also need to look out for the good ones.

But either way I feel there is a serious pitfall in relying solely on nurse consultants, and it has everything to do with medical decision-making. Now bear with me, because in order to illuminate this, I’m going to have to take the scenic route:

When I was a junior in college working on my math degree and had progressed past working equations into learning the theory behind?calculus, algebra, number theory and so forth, I started finding out why?the equations worked the way they did. How we got those equations in the first place. This was an entirely different approach to math that was less ‘cranking the handle’ on an equation and more diving into the philosophy of logical thought. Kind of like, less pulling the little knob out on your wristwatch to set the time, and more of learning how the gears and springs worked together to track the hours. Surprisingly I found this training in logical thinking was very useful in sorting out diagnoses, but that’s a topic for another day.

Next let’s discuss something of the training involved for nurses versus doctors. I’ve had people close to me go through nursing school, and I’ve seen their homework, so I feel confident in pointing out that nurses are trained to work within a protocol. If you’ve ever seen a nursing care plan, it’s a lot like an IT flowsheet. ‘If this happens, do this… if that happens, do that’. Granted those protocols can get pretty impressively complicated, but the fact of the matter is, nurses work within parameters. This means there is a standard of care established, to which they must adhere. Deviations without authorization can spell real trouble for an RN. It’s a lot like operational mathematics: every task has an equation. You follow the equation strictly if you want the correct answer. This isn’t a failing in a nurse’s training. It’s just that their job description is very hands-on and technique-heavy. They have to learn how to do a lot of things well, and why those things are the way they are isn’t necessarily relevant to the job, in the same way a pilot doesn’t have to understand aeronautical engineering to know it’s important not to exceed an aircraft’s limits.

Doctors, on the other hand, start out in the hinterlands of possibility and sort out what is happening. Then?they establish the protocol. In a sense, where nurses work from within the protocol to its outer limits, doctors start out in the ether and work down to the boundaries of the protocol. It’s kind of like working on mathematical theory to determine the equations we’re going to use.

It’s not a perfect analogy. After all, there is a definite progression of thought going from basic arithmetic to calculus theory, whereas the difference in nurse training versus doctors is, they are covering different aspects of the problem. It’s not a ladder, starting with an STNA, going through LPN to RN to NP and then on to MD. Each field definitely does not?encompass all the knowledge of the ones ‘below’ it. (Don’t ask me to run an IV pump!) They’re more like pieces of a puzzle. Each has their place, and each is needed to create the Big Picture.

But back to the question at hand: is a nurse consultant on a par with a physician peer? I would respectfully say no, and the reason is an understanding of the why behind doctors’ decisions. The ‘medical decision-making’. Nurses are very good at knowing what the standards of care are. Those are usually pretty well defined, and thus it’s easy to see when they’ve been violated.

But doctors, by virtue of their training, have been granted a special dispensation: we can exercise our clinical judgement. We are given the privilege of going against the standard of care when, in our best clinical judgement?and when in the best interests of the patient, it’s called for. Now, to be sure, we need to make sure our reasons are ironclad and based on the best reasoning and evidence available at the time. But given the proper circumstances, sometimes the ‘wrong’ action is the right one. Just ask any hospice doc. This was the essential struggle behind establishing the Do-Not-Resuscitate order as an option many years ago.

Do nurses pick up on this? Can they see into a doctor’s mind and determine what the MD was thinking? Maybe they can… but they don’t have the training or licensing to state that with confidence, officially. They must limit themselves to pointing out where the deviation from standard occurred. I’ve consulted on cases where an RN had first crack at it, and while they’re typically very good at picking out mistakes, they just don’t have the knowledge base to definitively say if the deviation was?justified. They just aren’t allowed to track the reasoning behind it, and it’s only by following that thought trail can one say that negligence occurred.

Now for the monkey: when I was a med student just beginning clinical rotations a surgical resident was explaining our roles as doctors in the mountainous landscape of Health Care. When we see a patient, we write up what’s called an ‘H&P’: a History and Physical. The two-part name doesn’t do the document proper service because there are actually four parts: the History (what happened and how the patient got there), the Physical (your exam, any labs, imaging and so forth), the Assessment (what you?as the doctor think is happening), and the Plan (what you’re going to do about it). The history and physical parts are just copying data. It’s the assessment and plan that reveal your actual thought process. As the resident put rather derisively, ‘Any monkey can write a history and physical. You get paid for the assessment and plan’. It’s really only in the Assessment & Plan that I find the insights necessary to start following the provider’s thought process.

Ultimately the question of a nurse consultant versus a physician peer is this: a nurse can certainly tell you what happened. But only another doctor can tell you why. And that’s what we really want to know, isn’t it?