The following is an excerpt from a new book, Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare, by Rebekah Bernard, MD.
What is the difference between the practice of medicine and the practice of advanced nursing?
Advocates say that nurse practitioners are capable of autonomously diagnosing and treating acute and chronic medical conditions. While this sounds like the practice of medicine, nurse practitioners insist that they do not practice medicine, but rather, they practice “advanced nursing.” What is the difference, and why is the distinction important? Orla Weinhold, MD, a physician who was a family nurse practitioner for eight years before attending medical school characterizes the differences. “Nurse practitioners are taught pattern-based thinking, and physicians are taught more critical thinking.” Another physician who was a nurse practitioner first, Dara Grieger, MD, agrees. “As a nurse practitioner, I was taught to recognize the patterns but not the ‘why’ behind them.” What Weinhold and Grieger describe as the difference in the way that nurses and doctors think is the difference between forward reasoning and backward reasoning.
Nursing education tends to emphasize a reverse reasoning methodology because it uses a framework built upon symptom identification from patterns rather than a diagnostically driven focus. There is nothing inferior about this method. It is a necessary technique when caring for patients at the bedside.
“Nursing is not medicine and medicine is not nursing. We care about different things,” says Nixi Chesnavich, DO, a physician who worked as a nurse for ten years before attending medical school. “Nursing theory is what the patient would do for themselves if they understood or had the information or could physically perform themselves.” To provide this care, nurses learn to follow a multi-step framework called the “Nursing Process.”
In following this process, nurses become intimately acquainted with their patients, particularly when they are working at a patient’s bedside. Joann D’Aprile, DO, worked as a nurse and taught nursing school before becoming a physician. “Nurses identify the biopsychosocial needs of patients, provide symptom relief and comfort, and assist patients in regaining optimal function.” She compares the care that nurses give to that of a mother caring for an ill child. “Add in a fundamental understanding of the human body and condition, and what types of nursing interventions will help that person regain your health; that is nursing.” D’Aprile also adds that the role of the nurse is to advocate for the patient. “If there is an error in an order, a nurse would bring the issue to the physician’s attention.” Truly, there is nothing like a nurse.
Medicine follows a different model. Cheryl Ferguson, MD, is a physician who worked as a nurse and even attended a semester of nurse practitioner school before she decided to pursue medical school. Ferguson notes that nursing is “knowing how to take care of patients’ needs, whether they are physical, social, psychological. Medicine is much more scientific; diagnosing the disease, not just the symptoms, weighing risks and benefits of treatment, understanding lab results and what they really mean. Nursing is not medicine. Medicine is not nursing. They overlap but should be separate entities to be best for patient care.”
Rather than focusing on the moment-to-moment needs of the patient, physicians are trained to search for one unifying diagnosis for their symptoms and focus on the most effective way to manage their disease process. This does not mean that physicians do not deeply care about the patient’s biopsychosocial needs. Henry Travers, MD, notes that just like nurses, physicians are also interested in becoming intimately acquainted with the patient and providing symptom relief and comfort. Travers says, “the point is that the total care of the patient is critically dependent on the correct diagnosis while being mindful of the difference between disease and illness.”
The difference in models may be one of the reasons that patients value nurses so highly. Indeed, the work done by nurses should be highly valued by everyone in healthcare. There is nothing that can replace the one-on-one personal attention and care that a good nurse provides. But patients also need a diagnostician — someone who can determine why they have a medical symptom — and ideally, help them to recover fully. This is where physician-training focuses. The training provided for a registered nurse as described in the nursing process does not provide the tools to independently diagnose and treat patients.
Can a nurse practitioner gain the necessary knowledge to take on this role in an additional two years of training? Physicians who were previously nurse practitioners say no. The biggest reason: nurse practitioner school did not adequately prepare them to be able to develop an adequate differential diagnosis, the essential list necessary to accurately diagnose disease.
Nurse practitioners do not have the time or in-depth training during a two-year program to learn how to develop a comprehensive differential diagnosis. Orla Weinhold, MD, notes, “When I was a nurse practitioner, I never knew how to form a differential diagnosis. This was one of the most challenging parts of my clinical rotations in medical school. I didn’t know how much I didn’t know.”
Ronald Epstein, MD, writes in Attending: Medicine, Mindfulness, and Humanity (2017) that even a non-medical person can learn how to recognize the signs and symptoms of various medical ailments and be correct most of the time. The need for physician training occurs during those rare times when a medical situation is unusual or more complicated — and potentially life-threatening. Epstein argues that this is the very reason for the long and arduous journey of medical training. Without additional training on how to perform a differential diagnosis and the fund of knowledge required to expand the potential diagnoses to include the most serious causes of a patient’s symptoms, non-physician practitioners may put patients at risk.
Fortunately, most of the time, patients do not present with a critical illness or life-threatening problems. The problem arises with the occasional patient who truly needs an expert diagnostician. As Dara Grieger, MD, notes, “As a nurse practitioner, most of the time I was OK. The problem was that I couldn’t recognize when things were not OK.”
Rebekah Bernard, MD, is a family physician in Fort Myers, Florida, and president of Physicians for Patient Protection.
Last Updated November 25, 2020
