The Nurse in Relation to the Physician—Municipal Control of Infectious
Diseases—The Nurse’s Difficulties—A Waiting Policy—Undiagnosed
Cases—The Nurse’s Responsibility to the Conscientious Physician
Only.
=The Nurse in Relation to the Physician.= In the foregoing chapter, we
have seen that the task of preserving and improving the public health is
one which rests, theoretically, on the medical profession as a whole. As
a matter of fact, however, this task is assumed only by certain members
of the profession. We have pointed out the reasons for this—that
physicians vary greatly as to personal character, ability, and ideals.
In the field of public health, the nurse finds herself in contact with
physicians of all classes. Some are able, high-minded, and skilful, and
whether working as public officials or private practitioners, have
nevertheless the same end; improvement of the public health. Others have
standards quite the reverse. This brings us to the question: When the
nurse’s duties bring her in contact with men of the latter class, how is
she to meet the situation? In what relation does she stand to these men?
What shall be her attitude to them, as regards her work? They are not
numerous fortunately, but there are enough to constitute a serious
problem, and one which sooner or later the nurse must face. This
question will also have to be faced by those who are responsible for the
nurse, and for her work.
In our opinion, the answer is simple enough—or, rather it will be,
twenty years hence. For at present, public opinion is in a transition
state and needs moulding. The nurse should work under the direction of,
and in co-operation with, all those physicians who, whether as public
officials or private practitioners, are working for a higher standard of
public welfare. To all such, without discrimination, the public health
nurse is the faithful, efficient, and tireless ally. But to all those
other physicians who have no such aims or desires, the nurse stands in
but remote and casual relation. The old teaching that she is the
handmaiden of the doctor is gone. Both are now co-workers in the field
of public health. The nurse still carries out the doctor’s orders, but
there is this difference—she discriminates as to doctors. As a public
servant, she obeys the orders of the municipal authorities, or of the
private practitioner when the object of both is the same, that is, the
welfare of the community. But she is not responsible to those physicians
who try to defeat this object.
For this reason, the nurse can do more effective work if she is
connected with the Health Department, since it is the Health Department
of a city which must formulate standards of efficiency, and clothe its
employees with authority to carry them out. The authority of the Health
Department physicians should be superior to that of any private
physician, should there be any conflict of opinion between them.
If the nurse cannot be established in connexion with the local Health
Department, she will yet be responsible to a group of public-spirited
citizens, which group will undoubtedly include many advanced and
enlightened physicians. This group of people will represent advanced
public opinion on the subject of tuberculosis, and the authority which
the nurse gets from them will be of almost equal value to that which she
would get from the municipality. Municipal authority, or the authority
of enlightened public opinion, is a dangerous thing to oppose.
=Municipal Control of Infectious Diseases.= In the case of smallpox,
diphtheria, or scarlet fever, the private practitioner attends the
patient under the immediate supervision of the Health Department. Thus,
in diphtheria and scarlet fever, he notifies the Department of each case
that comes under his notice. A municipal physician is at once sent to
take cultures from the patient’s throat, as well as from all the other
members of the household. He placards the house, and instructs the
family in such preventive measures as shall insure their safety and that
of the community. The patient is then left in the charge of the original
physician, who notifies the Health Department when, in his opinion, the
infection is over. His opinion, however, is verified by the municipal
physician, who takes another series of throat cultures, and ascertains,
quite independently, whether or no the danger is past. If it is, he
orders the placard taken down, and arranges for the fumigation of the
house.
In the case of smallpox much more drastic measures are observed. The
patient is summarily removed to quarantine, and all those who have come
in contact with him are vaccinated and kept under observation for a
definite period. In this way the strong hand of authority protects the
community from infection—the private physician has been merely the means
of calling attention to the danger. The time will come, indeed it is
rapidly approaching, when enlightened public opinion will demand this
same care in the matter of tuberculosis. By reason of the chronic nature
of the disease, the care given must include long-continued supervision,
extending if need be, over months and years. This supervision will be
given by municipal physicians and nurses. Furthermore, the private
practitioner will no more resent this, nor consider it interference with
his private business, than he resents municipal care of smallpox or
scarlet fever. The readjustment of the point of view is necessarily
slow, but it is coming, none the less. Those of us on the firing line,
however, who daily witness the loss and sacrifice due to this slow
readjustment, cannot but wish for revolution instead of evolution in
medical ethics.
In this chapter, however, we must deal with the situation as it exists
to-day. The infectious nature of tuberculosis has become known
comparatively recently, hence we find ourselves confronted with a
delicate and difficult situation, as must always be the case when public
opinion is evolving. To-day if a private physician forbids a nurse to
visit his patient (and for nurse, read also Health Department), the
present status of public opinion will usually uphold him in his
decision. It is for us, therefore, to find out the reasons which prompt
him to this decision, and to lay them frankly before the public, and let
the public pass judgment. In no other way can opinion be altered, or can
we gain for tuberculosis the same supervision and control that we have
obtained for the other infectious diseases.
=The Nurse’s Difficulties.= Let us take a few examples of the
difficulties the nurse meets. A boy of fifteen had been diagnosed by the
Phipps Dispensary as a moderately advanced case, and the nurse was asked
to follow him up. On her first visit, the patient’s mother refused to
let the nurse enter, saying that her son had since called in a private
physician, who assured him that the dispensary diagnosis was all
nonsense. The dispensary man had counselled rest; the newcomer told the
mother to buy her son a bicycle and let him take all the exercise he
could. This treatment was followed out, and, still acting on the
physician’s advice, the nurse was refused admission to the house. The
mother was friendly enough when they met on the street, and she even
permitted the nurse to stop and inquire for her son, always cheerfully
replying that he was doing well. Useless as they were, the nurse
continued these visits, since she was anxious to see the outcome of the
case. Finally, one day six months later, the mother threw open the door,
and in deep distress, begged the nurse to come in. “Do what you can for
my boy,” she pleaded, and led the way to an upper bedroom, where the
young fellow was lying in a moribund condition. A few days later he
died. The mother bitterly accused herself for her folly in refusing the
disinterested advice of the dispensary physician, and her grief,
remorse, and opinions were given wide circulation in the neighbourhood.
At no time during his illness had instruction been given as to the
nature and danger of the disease, and not until a week before death did
the attending physician admit that something was seriously wrong. In
consequence of this wrong diagnosis, the boy lost his life, and the
physician’s reputation was damaged. Apparently he had not taken into
sufficient consideration the risk of contradicting a diagnosis that came
from such an expert source.
In this particular case, it was impossible for the nurse to force her
way in, or to do anything except await developments. As it happened,
there was no one in the family likely to become infected, since the
patient had no brothers or sisters, no one except his mother with whom
he came in contact. The sacrifice of this boy to the ignorance,
obstinacy, jealousy, or stupidity of the local physician proved a
striking object lesson to the neighbourhood. The bereaved and indignant
mother was a factor in forming public opinion in this particular
vicinity.
Another case is that of a woman who had in her employ a favourite
coloured servant, whom she suspected to be tuberculous. Accordingly, she
sent for the nurse, asking her to take all necessary steps towards
getting the case diagnosed. As the patient was too ill to go to a
dispensary and could not afford a doctor, the nurse brought a specimen
of sputum to the laboratory of the Health Department, where it was
proved positive. So far, all was clear going. The patient was given her
prophylactic supplies, put to bed in a clean, airy room, and the nurse
called daily to give her a bath and such attention as she required. This
should have been a hospital case, but at that time the hospital was
crowded and there was no available bed. One day, when the nurse called
as usual, she found the patient suddenly become very impudent. She was
lying in a room with all windows closed, and a coal oil stove in full
blast; no supplies were in sight and the patient was expectorating at
random over the floor. This change had occurred because the patient had
taken some of the money given by her employer, and had called in a
“private doctor,” who declared she had nothing but a passing cold. He
also told her the supplies were nonsense, and that he could cure her in
two or three weeks. Furthermore, this physician himself came down to the
Health Department, and forbade the nurse to continue her visits, and all
“interference” with his case. A few days later, the employer also came
to the Health Department, in considerable heat, and wished to know why
the nurse was neglecting her duty. The explanation was satisfactory, and
a visit to her servant amply corroborated the statements that had been
made. This woman had been paying her servant full wages while off duty,
as well as providing her with many little luxuries and necessities. She
was therefore in a position to dictate the terms upon which she would
continue this assistance, and these terms did not include visits from a
physician of the calibre of the man now in attendance. In every case,
however, it is not so easy to obtain the whip-hand of the situation.
In these two instances, there was little danger of spreading the
infection, since neither patient was in close contact with children, or
other persons likely to contract the disease. The young boy suffered an
early death, while the coloured woman suffered personal inconvenience
and discomfort, due to lack of nursing, care, and attention. In neither
case, however, was there danger to other people. Whenever other people
are involved, it is less easy to stand by and do nothing, while waiting
for that slow change in public sentiment which shall give one the right
to interfere. Thus, a physician diagnosed a case as tuberculous, and
asked the nurse to take charge of the patient, telling her that he had
carefully examined all the other members of the family, and found them
in apparently good condition. He added, however, that he had been
dismissed as soon as he had told the family the disease from which the
patient was suffering. For this reason, he feared the nurse would find
difficulty in entering the home. His fears were only too well grounded.
The family had straightway called in another doctor, who calmed their
anxiety by denying the previous diagnosis. He also advised them to turn
away the nurse, which they did.
The patient lived some eight months after this, during which time she
was given no supplies, no instructions of any sort, and the family were
kept in ignorance of the nature of her illness. When she died, the nurse
as agent of the Health Department went to the house to arrange for the
fumigation. The front door was opened by a young girl obviously
tuberculous—the nurse was struck with her appearance; further search
revealed still another member of the household who presented suggestive
symptoms. In their distress, the family turned to the nurse and asked
for advice and assistance, and she at once referred them to the
physician who had diagnosed the original patient, eight months ago. The
family obediently presented themselves to him, and he found that three
more members had become infected. Since they were all in the early
stages, it is probable that they had become infected during the last few
months of the patient’s life—during which time not one precautionary
measure had been observed. The day will surely come when the possibility
of treating tuberculosis lightly, at the option of the attending
physician, will not be allowed. Public sentiment will finally insist
upon full municipal control, which will do away with such malpractice
and sacrifice of human life.
=A Waiting Policy.= As matters stand to-day, we can do nothing but
accept the situation as we find it, and do the best that circumstances
will permit. Which brings us to the question of the hour—What is to be
done if the physician refuses to let the nurse visit his patient? Is she
to accept his dismissal and turn away, or is she to continue her visits
in spite of his objections, on the ground that the patient is hers as
well as his?
If the case is a positive one, diagnosed on unquestionable authority,
and if the nurse has been sent by a dispensary, the Federated Charities,
or through some other disinterested source, she should be readily able
to gain admission. Having gained this, she should be able to hold her
own against all comers. As a rule, it is the opposition she encounters
before, rather than after her first visit, which determines her ability
to do her work in the home. Once in the home, however, it should make
little difference whether or not the patient changes doctors. If he
does, she should continue her visits as usual—her knowledge of his
condition makes it advisable to hang on to the family at all costs. If
this change brings a friendly doctor, he will not object to the nurse.
If it brings a prejudiced one, she should do nothing to excite his
hostility. Thus, if the new doctor denies the presence of tuberculosis,
it may become necessary for her to seem to assent to this opinion—for a
time she may have to visit merely in the capacity of a friend, offering
no advice, and distributing no supplies. She must be careful not to
antagonize the family, for after all, it is the family, at the doctor’s
instigation, which is able to turn her out. Thus, when they triumphantly
tell her that the patient no longer has consumption, she should not
contradict them. Time will do it for her. She may express pleasure at
the happy change, and ask for permission to stop in now and then, in
passing, in the capacity of an old acquaintance. This request will
seldom be denied, and at all costs she must keep in touch with the
family which now, more than ever, needs her supervision and aid. She
must stand by, ready to give this as soon as it is wanted. During this
time it will be very hard to wait, to see the patient relax all
vigilance, and to see the family recklessly exposed. But this waiting
policy will pay in the end. As we have said elsewhere, the consumptive
changes doctors more often than any other class of patients, and the
nurse must realize this, and be ready to follow him through the
vicissitudes which these changes involve. She must avoid all criticism
when the family is fallen upon evil times, and be ready to uphold and
encourage them when they are fallen upon good times.
=Undiagnosed Cases.= In the matter of suspected or undiagnosed cases,
there is greater difficulty. In these cases the nurse has nothing to go
on but her own keen observation of symptoms, therefore the physician in
charge may make it very difficult for her to continue her visits. He can
withhold his diagnosis, ignorantly or wilfully, and there is nothing to
do but to accept this state of affairs. As before, the nurse must
quietly hold on to the case, saying nothing that can possibly imply
criticism or involve her in difficulty with the doctor. Time must be
trusted to clear the situation—either the patient will get better, or he
will get so much worse that a diagnosis may be forthcoming. Or else he
may change doctors. When a nurse is visiting a case in charge of one
doctor, she must be exceedingly careful never to advise another or to
suggest a dispensary. All this involves infinite waste of time and loss
of life, but as matters stand to-day, there is no other course to
pursue. When a nurse is visiting a case of this kind—it may be one who
presents every symptom of tuberculosis, including even hemorrhage—she
must be particularly careful. She may call up the doctor, tell him that
she has been called to his case through such and such an agency (these
cases are usually referred by a layman) and ask if there are any orders
he would like carried out. She may also ask him to tell her the nature
of the disease. If he refuses, it is then a question of further
“watchful waiting.” If the patient is expectorating a great deal, she
may provide him with a sputum cup and other supplies, taking care,
however, never to use the word “tuberculosis” in connection with them.
She simply offers them as a convenience for a distressing symptom. We
have known patients of this kind who died after being ill for months,
most of the time being spent in bed. Meanwhile, they had extreme
emaciation, night sweats, fever, cough, profuse expectoration, even
hemoptysis, yet the death certificate read “bronchitis.” It is true,
that these patients may really have died of bronchitis; as nurses, we
cannot make diagnoses, therefore we have no right to question the
physician’s findings. But it is impossible for an intelligent nurse to
look on at a case of this kind without wishing it were possible to
obtain a second opinion. As public health nurses we cannot but object
that the last word on so serious a disease should be said by men whose
diagnoses we distrust. That the health of the community should be
endangered by even a few physicians of this sort,—either ignorant, or
dishonest, or both,—is grave commentary upon the medical ethics of the
day. It is a severe criticism on that “professional courtesy” which
forbids intervention, even by the health authorities, with a physician
who drives his trade at the community’s expense. The war against
tuberculosis cannot be fought to a successful finish until the public
refuses to countenance ethics of this sort.
=The Nurse’s Responsibility to the Conscientious Physician Only.= In all
tuberculosis work, the nurse is singularly independent. When the patient
is in charge of the dispensary physician, or is in charge of a doctor in
sympathy with the tuberculosis movement, she may be said to be acting
under their orders. Or rather, there are no special orders, except in
individual instances, for the routine prescribed is always practically
the same. When a doctor reports a case, with the laconic statement,
“John Smith, such and such an address, usual thing,” he has fully stated
the situation. The doctor knows what should be done, and the nurse knows
what to do, and further words are unnecessary. Therefore, when for any
reason the patient gives up his doctor, the nurse can still continue to
supervise and direct. Months may pass before the patient revisits a
physician, and during these months the nurse is the only person in touch
with him. She also knows how to advise and direct those who are in
contact with him. When he finally calls upon a doctor again, her visits
still continue without a break—there should be nothing in her teaching
that is at variance with that of the newly arrived physician. The
chronic nature of tuberculosis makes this situation possible, and also
makes for the extremely independent position of the nurse.
Whenever the physician is in the vanguard of the anti-tuberculosis
movement, he will recognize the nurse as an ally, not a rival. He will
know that she will make no attempt to supplant him with the patient,
since the chances are that she has been caring for the patient for
months before he, the doctor, has been called in. He will regard her,
therefore, as a highly efficient ally, who will relieve him of tiresome,
time-consuming details connected with the case. She will take charge of
routine matters that he has no time for, and thus set him free for
larger and more important tasks.
If, on the contrary, the physician is one who exploits his patients, who
keeps the nature of the disease hidden, whether through ignorance or
design, and fails to give proper instruction as to its infectiousness,
then we must look for nothing but opposition and antagonism. We must
hear objections as to the nurse’s interference, to her uniform, to her
tactlessness, to her scaring the patient to death—and we must consider
the motives which underlie them. This brings us once more to the
question—under these circumstances, what is the nurse to do? Is she to
discontinue her visits, or is the value of her instruction to be
nullified by contradictory advice? Is a physician, who has consideration
for neither the patient nor the community to be allowed to jeopardize
both?
To men of this stamp, the tuberculosis nurse owes nothing. Her business
is to do her duty, even when it brings her to cross-purposes with them.
She has been taught her work by the most advanced and progressive
members of the medical profession, and in the homes of patients she is
but carrying out the orders of these abler men. That they themselves may
have no direct connection with the patient does not alter the situation.
She is their agent, not the agent of the hold-overs from a passing
régime. Therefore, we look to the former to establish their agent, the
public health nurse, in a position of unassailable dignity and
authority.