Bulletin of the History of Medicine

Bulletin of the History of Medicine 78.2 (2004) 451-460

Not All Nurses Are Good, Not All Doctors Are Bad. . . .

Julie Fairman

American health care is highly dependent upon the collaborative work of nurses and physicians: without the efforts of both professions, health care as we know it could not be provided. Yet, the relationship between nurses and physicians is oversimplified to the point that the two professions often talk about themselves and each other using the language of exclusion and victimization. Many medical scholars present their profession as normative and prioritized, casting the skills of medical diagnosis and prescription of treatment (rather than the combined efforts of several professions) as the most essential and rigorous components of health care. In turn, many nurses write about their victimization by physicians and state that nursing's claims for autonomy and authority require toppling medicine from its lofty pedestal of cultural authority.

This approach is taken by Thetis M. Group and Joan Roberts, in their book Nursing, Physician Control, and the Medical Monopoly.¹ They offer a [End Page 451] chronological and gendered thematic exposition and perpetuation of medicine's victimization of nursing from Florence Nightingale to the present, setting up a schismatic dichotomy of victims and victimizers—a "doctors are bad, nurses are good" perspective."² In this essay I will use this book as a point of departure for a more nuanced way to think about the nurse-physician relationship, one that is perhaps more effective for framing contemporary health care.

To be sure, there are components of truth in each of these perspectives. During acute illness crises, patients indeed require exquisite medical attention and knowledge. Surgery, at present, is clearly in the realm of medicine, although Donna Diers, former dean of Yale University, offers a different spin and illustrates the complexity of the contemporary nurse-physician relationship when she writes that she hopes to live long enough to see nurses hire surgeons in nurse-run institutions.³ And, as physician Alan Rosenstein reports in a recent issue of the American Journal of Nursing, the exercise of medical prerogatives in current clinical practice, especially in chronically ill and older populations, too often leads to instances of unfair treatment, and, at times, the frank abuse of nurses.⁴ Alternatively, nursing sometimes blocks its own progress through internecine conflict;⁵ the discord within professional nursing over the level of education needed for entry into practice is one such example.

As most nurses and physicians might argue, and as historians point out, relationships at the "clinical moment" are much more complicated than simple exclusionist and victimization narratives suggest. Many clinical relationships are saturated with close, respectful, and collaborative experiences. Studies of critical care nurses, nurses in battle, and dialysis nurses, for example, suggest the mutuality of nurses and physicians struggling to comprehend the meaning of new clinical data and technologies.⁶ In my current research I argue that the early nurse practitioner [End Page 452] movement relied heavily on like-minded patient-oriented physicians who felt comfortable sharing and negotiating new roles for nurses.⁷

Still, in other contexts nurses have used active resistance as well as other strategies of implicit noncooperation with both physicians and patients to control their practice. As Barbara Melosh has argued, nurses thrived in the bureaucratic world of particular health-care systems because of the protection that explicit policies and procedures afforded to the capriciousness of others.⁸ And Leonard Stein, in "The Doctor-Nurse Game"—a study that remains a classic in both the nursing and the medical literature—carefully documents the subtle (and not so subtle) ways that nurses, in turn, control the behavior of the physicians with whom they disagree or whom they find inexperienced.⁹ Judith Leavitt describes the highly complex and contested relationships between obstetric nurses and their...