Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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A heretics viewpoint
- Chris Laing (16 September 2000)
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Doctors and nurses
- Vasantha Kumar (20 September 2000)
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Nurses and doctors
- John Hopkins (21 September 2000)
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Re: Doctors and nurses
- Peter Morrell (22 September 2000)
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Re: Doctors and nurses
- Joseph Watine (27 September 2000)
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Re: Doctors and nurses
- Anton Sebastian (27 September 2000)
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Please Do Nurses a Favour
- Peter Morrell (28 September 2000)
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Re: Please Do Nurses a Favour
- Joseph Watine (29 September 2000)
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Re: Please Do Nurses a Favour
- Anton Sebastian (29 September 2000)
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Re: Please Do Nurses a Favour
- Vasantha Kumar (4 October 2000)
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Female Perspectives on Nursing & Doctoring
- Peter Morrell (5 October 2000)
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What is Medical History?
- Peter Morrell (12 October 2000)
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Chris Laing, Specialist Registrar in Nephrology and General Medicine University College London/University College Hospitals
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Editor Wouldn't the definition of nursing be better approached from the patient's needs and perceptions rather than the prejudices or political priorities of the nursing heirarchies and their preoccupation with inter- professional status? Patients clearly need due attention to basic care such as hygiene, nutrition, physical observation, administration of drugs and psychological support. They need advocacy and coordinated liason with medical staff and relatives. There is also a crippling need for more efficient delivery of ward based practical and administrative tasks which have traditionally been performed by junior doctors. If nurses will not fulfill these roles then someone else has to. Health care assistants have proliferated while ward life has become increasingly reliant on visiting staff such as therapists, dieticians, psychologists and patient liason officers. Meanwhile "Doctors assistants" have been touted to undertake tasks which some would argue would be a logical extension of the nursing role. Government enthusiasm towards what is percieved as a kind of hostile nursing invasion of "medical territory" is economically driven and politically expedient. However, a disregard of traditional medical education and accreditation of clinical skills in the face of a general drive towards greater accountability and improved standards is counter- intuitive. Nurses deserve the prospect of diverse and rewarding career opportunities and we need an imaginative approach to nursing recruitment. Putting the cart before the horse, however, will drive the NHS nowhere. Dr Chris Laing |
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Vasantha Kumar, Consultant Physician Milton Keynes Hospital
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One only has to look at the history of medicine to appreciate that contributions made by doctors have been massive, by nurses negligible and if there was no intellectual disparity there, then let us call it by another name. By the way it was before everyone decided to change the curriculum- all those doctors were good at passing science examinations. Francine Cheater's argument (BMJ letters 16 September) is like saying that black men are not faster runners than white men, they are only good at running away from a starter's gun! Doctors appreciate what nurses are good at but it is perhaps because of teachers like Ms.Cheater that nurses end up disillusioned, and those who 'progress' in their careers cease to be nurses. Dr Vasantha Kumar
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John Hopkins, General practitioner Darlington
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Dear Dr Smith, Woe betide the BMJ its lack of correctness. As any student of the popular press, the BBC and Department of Health press releases will tell you, the correct mode of address is now " Nurses and doctors ". I am not sure whether the edict has yet reached schools but it can only be a matter of time before four and five year olds are instructed in the new nomenclature. John Hopkins |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
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Sir I am sure I am not alone when I express the view that this letter from Dr Kumar will be seen by many as highly offensive, patronising and elitist. It is directly offensive to women and to the entire nursing profession and he ought to be strongly encouraged at least to reflect on the negative impact of what he has written - if not to apologise. |
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Joseph Watine, Eur Clin Chem, Laboratoire de biologie polyvalente, Hôpital de Rodez
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Peter Morrell can be assured that he is not alone when he expresses the view that the letter from Dr Kumar [1] is directly offensive to women and to the entire nursing profession and he ought to be strongly encouraged at least to reflect on the negative impact of what he has written - if not to apologise. [1] http://www.bmj.com/cgi/eletters/321/7262/698#EL2. |
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Anton Sebastian, Consultatnt physician Ninewells Teaching Hospital, Dundee
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Editor – Dr. Kumar’s statement (rapid response: 20 September 2000) about the disparity between the nurses and doctors in their contribution towards the progress of medicine is unfortunately true. Although both professions are equally old, for various reasons and prejudices nursing profession has taken much longer to establish itself. Never the less the nursing profession should take Dr. Kumar’s comment in a positive manner and strive to contribute more. Let us not be side tracked into raising arguments such as which group is more intelligent (Francine M. Cheater’s letter of BMJ 16 September) and concentrate on what both parties can collectively achieve. Dr. Anton Sebastian
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
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Sir, I think there is a case for stating that it is scientists who have contributed most to the progress of medicine, rather than clinicians. Fleming, Koch, Pasteur and Krebs, for example, were primarily laboratory scientists, rather than medical practitioners. Perhaps Dr Sebastian should be asked to explain, with examples, how doctors have contributed more than nurses ‘to the progress of medicine’. He also ought to explain what he means by saying that “…for various reasons and prejudices nursing profession has taken much longer to establish itself…” [1] He barely paints a true picture of the facts. Manifestly, ‘taking a long time to establish itself’ might be a very different thing from ‘making a negligible contribution’. Is it not also the case that nurses have always been marginalised and subordinated by doctors throughout their mutual histories? “Though some doctors approved of the ladies’ desire to establish a nurses training school…other medical men were opposed….they objected that educated nurses would not do as they were told…” [2] “Before the 1870s, trained nurses were virtually unknown in America…it was a menial occupation taken up by women from the lower classes, some of whom were conscripted from the penitentiary or the almshouse. The movement for reform came not from doctors, but among upper- class women.” [3] “Eventually, of course, physicians came not only to accept but to rely on trained nurses, who proved essential in carrying out the more complex work that hospitals were taking on.” [4] In which case, we might decide that nurses’ ‘contribution to the progress of medicine’ has been modest precisely because their feelings of self-worth has been stifled by working alongside the oppressive arrogance of the medically qualified, and ‘being told what to do’. “In defining the scope of its work, the medical profession also eliminated much competition...” [5] “Within just a few decades, however, in the early part of the 20th century medical doctors had achieved virtually total professional dominance...had successfully eliminated, co-opted, or subordinated all competing health professionals…” [6] “Many physicians believed that women's menstrual cycles made them incapable of professional work...after the turn of the century, women were increasingly excluded from the profession of medicine. All but three of the 17 women's medical colleges closed...coeducational medical colleges...limited women to about 5% of admissions.” [7] This is why Dr Kumar’s letter [8] is so offensive and is rooted in such a profound ignorance of the nursing profession and the good contributions they have made to medicine in its widest sense, not just to scientific discoveries. The transformation of nursing into a true profession was repeatedly delayed by doctors. “Past legislation for Dentists [1921], Nurses [1911], and Midwives [1902] had all been delayed by medical hostility...” [9] “The Midwives Act of 1902 represented the culmination of decades of controversy...and represented a humiliating defeat for the BMA and GMC in that medical practitioners were not in a majority on the Midwives Board.” [10] Yet, nurses have contributed massively to medical practice and to the care of the sick. This is incontestable. They may not offer new discoveries, new drugs or new surgical techniques, but they do offer hard work and compassion. And often a cheerful smile, too. And I am sure that the vast majority of patients who have spent any time in hospital, will remember the nurses who cared for them far longer than the doctors. “In this situation the doctor is also so culturally distant from the patient that he is ignorant of the ideas and social practices that inform her own understanding of her situation...” [11] Are Drs Kumar and Sebastian belittling that as an insignificant contribution to medicine? I would say that they are all contributing to the progress of medicine, which is, in case they had forgotten, the care of the sick. And I think that is an inoffensive, un-prejudicial, non- patronising, and un-elitist viewpoint as well as being more historically accurate and balanced. It is a shame that Dr Sebastian chooses to portray himself as such authority and a published medical historian and yet patently, he has barely studied an important aspect of the subject. And these quotes clearly reveal a fairly breathtaking ignorance on Dr Kumar’s part of the profession he is so eager to publicly lambast - nursing. Sources [1] BMJ letter, Re: Doctors and nurses, Dr. Anton Sebastian, Consultant physician, bmj.com, 27 Sep 2000 [2] Paul Starr, 1982, The Social Transformation of American Medicine, Harper & Row, New York, p.155 [3] Starr, op cit., p.155 [4] Starr, op cit., p.155 [5] Freund & McGuire, op cit., p.211 [6] Peter E S Freund, & Meredith B McGuire, 1995, Health, Illness and the Social Body: A Critical Sociology, Prentice Hall, New Jersey, USA, p.207 [7] Freund and McGuire, op cit., p.210 [8] BMJ letter, Doctors and nurses, Dr Vasantha Kumar, bmj.com, 20 Sep 2000 [9] Gerald Larkin, 1983, Occupational Monopoly and Modern Medicine, Tavistock, London, p.136 [10] Larkin, op cit., p.19 [11] Freund & McGuire, op cit, p.237 |
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Joseph Watine, Eur Clin Chem Hôpital de Rodez
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I fully agree with Peter Morrell’s last e-response to Vasantha Kumar’s and Anton Sebastian’s recent e-letters [1, 2]. I simply wish to add some other points which might reinforce Peter Morrell’s ones. In some other e-responses to this topic, one can be dismayed to see that some doctors do seem to expect nurses to do the things which they dislike or which they consider as boring. Bearing in mind that each medical doctor may have his own particular tastes, and that these tastes may change completely according to each doctor, one would have to accept that nurses’ duties should completely change depending on the doctor whom they work with. If these doctors call this a professional attitude, then they can as well call black and white different shades of grey. In the same way, most medical doctors who publish in the biomedical literature have the regrettable habit to neglect to recognise the expertise of nurses, laboratory scientists, and other colleagues, who were involved in their publications and without whom their publications would very often be impossible or completely worthless [3]. If these doctors call this scientific honesty, then they can as well tell us that their attitudes do not resemble those of the old aristocracy [4]. This is why I was also wondering if Vasantha Kumar and Anton Sebastian would accept to give us the references of some of their major contributions to the biomedical literature and precisely indicate how and/or to what extent nurses and/or other non doctors participated in their contributions. [1] http://www.bmj.com/cgi/eletters/321/7262/698#EL2 [2] http://www.bmj.com/cgi/eletters/321/7262/698#EL6 [3] WATINE J, HACINI J, BREVET E. Le défaut d’expertise biologique de certaines publications médicales. Ann Biol Clin 1998; 56:228-229. [4] WATINE J. Doctors' attitudes resemble those of the old aristocracy. BMJ 2000; 321:447. |
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Anton Sebastian, Consultant physician Ninewells Teaching Hospital, Dundee
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Editor- Peter Morrell (rapid response, 28 September 2000) by pointing out some of the prejudices and difficulties experienced by the nurses has already answered (for various reasons and prejudices nursing profession has taken much longer to establish itself) the queries that he has raised with me. Also his statement ‘Before the 1870s, trained nurses were virtually unknown in America…’ reiterates the fact that nursing profession did take a longer time establish. It is also unfortunate while there are tens of thousands of volumes on the contributions made by medical men to the progress of medicine relatively only a few books are available on the contributions made by the nurses to medicine. Being a Honorary Research Associate in the History of Medicine and given his interest and knowledge in the field Peter Morrell would be well placed to transform this discussion into a significant publication that would bring out all the contributions and sacrifices made by the nurses which have been largely ignored up to now. Nursing is a honourable profession needing a lot of self-sacrifice and will have to be given its due place in history. Let us not turn responses such as this in the e-bmj in to personal issues but instead strive to make it constructive so that the readers can take home a positive message. Dr. Anton Sebastian
Email: Ksebastian@msn.com Website:www.medicalhistory.uk.com |
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Vasantha Kumar, Consultant Physician Milton Keynes Hospital
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It is the fact that I am a doctor that seems to upset many (two) people when I objected to the statement that doctors are just people who are good at passing science examinations. My comments were made because political correctness allows a nurse to say this in the BMJ but does not allow a doctor to say that this is crass logic. Perhaps some economist will come forward to tell why doctors are able to get bigger mortgages than nurses. The argument has gone at a tangent- I never questioned the value of nursing and its integrity as a profession. My point was that it should be a parallel and complementing profession, not one to compare/compete with doctors and that this latter culture may be a reason for the disillusionment that seems to affect nurses. I would have said all this even if were a train driver; I wish I was- that is what I wanted to be and may be no one would then have blamed me with elitism etc etc. |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
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Sir, Some reactions to Dr Kumar’s recent email [1]. Dr Kumar [1] says: "It is the fact that I am a doctor that seems to upset many (two) people when I objected to the statement that doctors are just people who are good at passing science examinations." It is not the fact that he is a doctor; it is just the statement itself which seems patronising and divisive. Doctors ARE good at passing science examinations and THEN from that they gain entry to the profession of medicine, much as a 14 year old child would have gained entry to a guild of painters in the middle ages. Then they can train and begin medical practice. Dr Kumar goes on: "My comments were made because political correctness allows a nurse to say this in the BMJ but does not allow a doctor to say that this is crass logic. Perhaps some economist will come forward to tell why doctors are able to get bigger mortgages than nurses." The differences in salary might be a separate issue and presumably reflect the relative worth of each as judged by society, rather than by each other. Political correctness is not the basis of this matter. To say that doctors are more intelligent than nurses is a divisive thing to say [2], even if it is true. In any case, there are presumably other reasons than salary and passing examinations that attract people to nursing or medicine. There are also social and psychological factors, for example, and a desire to help people and a liking for certain types of tasks. There are significant differences in social class from which these two professions draw their members, and one might seek to explore the likely implications of these differences. Then also there are certain psychological, financial and other motivations that draw people to these respective occupations, and which, if studied more deeply, could also throw much light upon this matter. Some appraisal of other factors seems appropriate here too. Consider, for example, the female domination of nursing, which in years past meant that very few got married. If and when they did marry they were expected to promptly leave the profession to have a family. Only some 7-12% of American nurses were married in the 1900-1930 period [3], as compared, for example, to 19-40% in 1940-60. Changing social patterns in society that affected women more than men, would also have impacted more upon nursing than upon doctoring, which, until very recently, was a male dominated profession. As regards the entry of women into doctoring, then different forces apply again: “Doctors would begin gradually to overlook treatment of the whole patient, concentrating instead merely on the disease. The nurturing aspects of 19th century practice, with its heavy emphasis on intuition, sympathy, and art, would gradually give way to a medical science becoming aggressively more ‘masculine’.” [4] “As long as medical practice remained more a matter of ‘art’ than ‘science’, women found themselves drawn to it as their own. In contrast…after 1900…[it] moved from the intimacy of the home to the public arena and impersonal setting of the hospital…it became increasingly more difficult for a woman to be admitted to a first-rate school…and fewer women were trying to do so.” [5] ‘…it is also likely that middle-class women, for a variety of reasons, found it less desirable to study medicine…whereas the 19th century physician approached a patient with a predisposition to physiological holism, 20th century therapeutics transformed the doctor into a specialist whose knowledge encompassed some specific symptom…many [women] chose nursing in these years.” [6] Arguably, these quotations nicely illustrate very different aspects of nursing and doctoring from a female perspective, which reflect its relative attractiveness or unattractiveness in different periods. Dr Kumar says: "I never questioned the value of nursing and its integrity as a profession. My point was that it should be a parallel and complementing profession, not one to compare/compete with doctors and that this latter culture may be a reason for the disillusionment that seems to affect nurses." It is most reassuring to hear that Dr Kumar values nurses as professional people of integrity and usefulness. It is true that nursing is a complementary profession to medicine, and it is subordinate to medicine; whether that leads to disillusionment is another question. It is valued and does have integrity. The disillusionment might arise in part because of their being subordinate and having conflicting superiors, one administrative and one medical. They are answerable to others and only have certain demarcated areas of their own responsibility. Inevitably, this means that they are only partially in control of their daily working lives and career path. However, the central and most notable feature about the history of nursing, which again he has failed to mention, is their subordinate role as a para-profession of medicine proper. In what we might term their occupational power dynamics, they are subordinate to doctors, under doctor’s control and at their beck and call. This comprises the central and most interesting point about nursing, because it acts like a key with which to unlock and interpret all their attitudes, aspirations, frustrations, behaviour and problems. It enables us to UNDERSTAND their history, rather than just describe it. This is why Freidson [8] calls them a semi-profession, denied, as they have been, by such subordination, any full flowering into an independent profession proper. It is therefore true to say that their history has been conflict-ridden. “...nursing maintained an ancient function, while being brought firmly under medical control.” [7] “The nurse...sought to establish unique skills and full professional status, seems fated to remain subject to the doctor’s orders in part because of the fact that her work is largely carried on in the hospital...in order to attain semi-professional status, the nurse had to become part of the subordinate paramedical division of labor.” [8] “...the nurse serves as an adjunct of both medical and administrative authority, that she seems to be the intense focus of conflicting perspectives.” [9] Dr Kumar continues: "I would have said all this even if were a train driver; I wish I was- that is what I wanted to be and may be no one would then have blamed me with elitism etc etc." I think the comment did sound very elitist and patronising. Whether it was meant to is a different question. I thank Dr Kumar for clarifying the background to the remarks he initially made, which did seem so divisive and unhelpful. And I hope this letter helps to clarify why I said what I did. Sources [1] Re: Please Do Nurses a Favour, 4 October 2000, Vasantha Kumar, BMJ letter bmj321/7263/732/EL1321/7263/732/EL1321/7261/639/EL1 [2] BMJ letter, Doctors and Nurses, Dr Kumar, 20 Sept 2000 [3] Regina M Morantz-Sanchez, 1985, Science and Sympathy, Women Physicians in American Medicine, OUP, New York, p.137 [4] Morantz-Sanchez, p.202 [5] ibid., p.263 [6] ibid., pp.261-2 [7] Eliot Freidson, 1970, Profession of Medicine, Dodd Mead & Co, New York, p.52 [8] Freidson, p.57 [9] Freidson, p.126 |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University
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Sir, A number of points arising from Dr Sebastian’s email [1]. Thusfar, Dr Sebastian has declined to supply any evidence to support his claim that clinicians have contributed more than nurses to ‘the progress of medicine’. Perhaps he could furnish us with some examples from his books. None of Dr Sebastian’s books, as far as I can tell, is actually histories of medicine. One is “A Dictionary of the History of Medicine” and the other is “Dates in Medicine”. These are what I would call partial histories of one form of medicine - allopathy. This is what happens a lot: allopaths insist on writing histories of allopathy and on then calling them histories of medicine, which they patently are not – they are histories of one form of medicine. In addition, that comprises the single most important reason why the field should be kept scrupulously free of such medical bias. Clinicians are therefore probably uniquely unsuited to write histories of medicine. Consider this example: “Garrison devoted a mere half-page to homeopathy in the first edition of his comprehensive ‘Introduction to the History of Medicine’, published in 1913. He briefly stated the three salient principles and noted that Hahnemann’s doctrines found wide acceptance, especially in America. Their ‘extreme popularity...’ he wrote, ‘is probably due to the fact that they lessened the scale of dosage of drugs in practice...otherwise this system is but an offshoot of eighteenth century theorizing.’...” [2] The position here is much worse than Blake indicates. This book by Garrison is a monumental tome of 996 pages! Thus to give homeopathy only half a page in such a book indicates an appalling degree of allopathic vindictiveness on Garrison’s part. It speaks volumes about the degree of hatred which homeopathy has been forced to endure, and nor is it an accurate presentation of the massive presence of homeopathy in American medicine between 1850 and 1900, which at its height in the 1890s approached 20% of all clinicians [3]. To present such a woefully inaccurate and deliberately distorted picture as a true account of medical history is somewhat unjust. Garrison was deliberately trying to diminish down into invisibility the major role homeopathy had played in nineteenth century medicine, presumably because he hated it. Plainly, such reprehensible behaviour should not be tolerated in a neutral academic discipline, and wherever it occurs it should be exposed. Nor is it factually true that Hahnemann’s system was “but an offshoot of eighteenth century theorizing”. It is a banal and simplistic view that only reveals his ignorance. Such matters may seem trivial, but they are very important in the presentation of information into the public domain where they will doubtless go accepted by undiscerning readers as accurate and truthful accounts. All too frequently, brief medical histories sensationalise great medical discoveries and thus tend to canonise great figures, like Pasteur and Fleming, as heroes and perfect scientists. A more sober examination of the facts, however, all too often reveals that they were very haphazard and creative people who did not always approach things as systematically as people are led to think. Shryock gives two excellent examples of this regarding Pasteur, preferring a ‘warts and all’ account of his work and thus deliberately resisting the temptation to glorify him solely as a champion of the scientific method, which is not the whole story on the man [4]. Shryock also goes to some lengths to emphasise that laboratory-based workers, and their unqualified research collaborators, have probably made more contributions to ‘medical progress’ than clinicians. All this brings us back to Dr Sebastian’s books and a more general point. Histories are not simply lists of dates, or data presented alphabetically by topic. They must reveal deep narrative and human affairs. Any history worthy of that title must concern itself with motives and social matters. It must insinuate itself into the human heart and mind and thoroughly concern itself with that which lies behind events - human affairs, motives, reasons. The historian must deeply empathise with human beings, contemplate human affairs and seek out the reasons and social context that lie behind the events. Histories must not just play with accurate information, but they must also weave a story. That is very hard to do unless you can very deeply engage with the social realities of the time in question. Even the most skilled interpretation is susceptible to varying and subjective factors that often make it contingent upon the time and social climate of the interpreter, at least as much as those of the period under focus. We look into the past and take with us attitudes, presumptions and biases deriving from the present that may not have applied in times past. And much of the time we do this without even realising it. For all these reasons, much glitters that is not gold. If Dr Sebastian’s works conform to all these important requirements, then they are entitled to be called histories; if they don’t, then they do not deserve such a title. It would be useful for any reader to be told beforehand the length, price and table of contents of any books, if s/he were to be remotely interested in buying one. Who would consider buying a book without having this vital information in advance? None of this information is presented on Dr Sebastian’s website and if only for the sake of sales it would be very useful to see all three. Sources [1] Re: Please do nurses a favour, BMJ Letter, Dr Anton Sebastian, 29 September 2000 [2] John B Blake, 1981, Homeopathy in American History, Trans. Stud. Coll. Phys., Philadelphia, Series 5, vol. 3, 1981, pp.83-92; quote from pp.86-7 [3] Paul Starr, 1982, The Social Transformation of American Medicine, Harper & Row, New York, p.99 [4] Richard H Shryock, 1936, The Development of Modern Medicine, Univ. Pennsylvania Press, pp.269-71 & pp.284-7 |
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