Intended for healthcare professionals

Lessons From Everywhere

Garages and hospitals, doctors and nurses

BMJ 2000; 321 doi: (Published 23 December 2000) Cite this as: BMJ 2000;321:1621
  1. Frank Leavitt, chairman
  1. Centre for Asian and International Bioethics, Ben Gurion University of the Negev, Beer Sheva, Israel

When I take my car to the local garage, the owner, Boaz, greets me, listens to my complaints, and checks the car over. Then he calls in the shop foreman, Raffi, who examines it in more detail, calling in the mechanic or the electrician and carburation expert, each to carry out the requisite work in his particular specialty. During all this time Boaz hovers over his employees making sure that the work goes well, bringing them tools and parts, making sure they get their coffee, sometimes getting into his own car and driving to another city for a part, chatting with me to ensure customer satisfaction.

For Boaz is the owner of the garage and is personally interested that the work should go well. And when Boaz is satisfied that his employees have done their work and the car is fit to return to the road, he calls me into the office, hands me the bill, and asks how I prefer to pay.

The above names are real, but there will be some fictitious ones below.

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My son, Shmulik, a sailor home for a short break, was galloping on an unruly horse. The horse slipped and fell with Shmulik under him, dragging him as he slid on rocky ground. An ambulance rushed Shmulik to the emergency room of a major hospital. I followed in my car and arrived in time to observe a pleasant young woman, Sveta, as she listened to Shmulik's story, examined him, and decided to call in Shlomi, an orthopaedic surgeon. While waiting for Shlomi to arrive she sent Shmulik to have an x ray examination.

The pictures were ready by the time Shlomi arrived. Shlomi examined the pictures and the wounds in Shmulik's arm and knee while Sveta hovered around, calming Shmulik and making sure Shlomi had everything he needed to work efficiently. Shlomi then told Sveta that Shmulik needed only stitches in his knee, but he wanted a maxillofacial surgeon to look at Shmulik's face wounds.

After Sveta made sure that Kobi, the maxillofacial surgeon, performed the necessary examination, and after Kobi declared that the face wounds were superficial, Sveta called in Mimi, the orthopaedic registrar, to do the stitching. Shlomi then exchanged a few words with Mimi about the style of the stitches, and emphasised the need to rinse the deep knee wound copiously with saline. Shlomi then disappeared, never to be seen again.

Mimi then proceeded to rinse and then to stitch while Sveta hovered over her, observing every move and rushing here and there to bring her the proper equipment. Sveta also knew how to make suggestions to Mimi, but with such deference and modesty that Mimi seemed to think they were her own ideas and not Sveta's. At the same time Sveta chatted cheerfully with Shmulik and with me, the father, to calm and reassure us.

When Mimi's work was finished, Sveta took us both to the office. Since Shmulik is in the military, she explained the procedures to ensure that the Israeli defence forces cover the bill. Then she released us with a smile, kind words, and firm instructions to bring him back immediately if a fever should develop.

Anyone who reads the two stories and is not familiar with hospital reality ought immediately to conclude that Sveta, in position and status, parallels Boaz, the owner of the enterprise who takes a personal interest in the efficiency and precision of the technicians' work, in the safety and satisfaction of his customers, and in the proper economic management of the business. But we know that this is not the case, because Sveta is a nurse and not a doctor. Sveta, the nurse, earns less than half the salaries of the doctors who often (although certainly not always) relate to her with an attitude of superiority, regarding her as only their little helper.

I teach ethics and philosophy in a health science faculty (not connected to the hospital where Shmulik was treated), and I spend about half my time with doctors and medical students and the other half with nurses and nursing students. So while Shmulik was getting his stitches, it was particularly educational for me to watch the dynamics between the two women.

Although Sveta was a self confident professional, quietly in control of the situation, Mimi took every opportunity to assert her superiority, at times even unnecessarily poking fun at Sveta's “ignorance.” This was especially ridiculous because in fact Sveta was highly experienced (and qualified to assume the same role in all emergency room specialties, not just orthopaedics), while Mimi was only a registrar.

It seems obvious that nurses deserve recognition appropriate to the reality. And they should be listened to more, not only in emergency orthopaedics but also in discussions about whether to resuscitate or not, discussions of how and how much truth to tell the patient, genetic counselling, etc. But I do not know how to get this idea across to medical students without preaching.

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