CHAPTER VIII
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.