The Nurses Take Over the Physical. You should not think that clinical medicine has been totally abandoned. At the Boston area hospital where I spent a whole month watching a single patient, almost every day a physical examination was performed by the nurses. I was interested in this new development, and approached it with open mind. Nurses are as intelligent as the doctors and quite a few are much brighter. There is no reason why they shouldn't be able to learn the physical examination.
True, some limitations were predictable. The nurses' ability to interpret the findings, and choose the direction of further search, may not equal that of the doctors because the nurses' general medical knowledge is somewhat less broad and less detailed. Further, it took almost 200 years of confronting the physical signs with the findings at postmortem and surgery, and with the data obtained by instrumental methods, before the clinicians' skills in physical examination achieved the peak of exactitude and sophistication. For a century and a half, the training of young doctors in physical examination has been, as a rule, entrusted to clinicians well versed and keenly interested in the subject. There is no comparable tradition behind the nurses' training in this particular field.
I watched six nurses doing the physical examination. They used to begin with auscultation of the chest. This they did in a cursory way, placing their stethoscopes at two or three, seldom four points (a routine auscultation of the lungs involves 10 to 12 points). Most nurses did not listen to the base of the lungs, where the wet crackles of pulmonary congestion or bronchopneumonia are most likely to be heard. The patient was not told to breathe deeply, through open mouth, or to cough. The nurses then proceeded to cardiac auscultation which was limited to counting the heart rate. This was followed by auscultation of the abdomen, rather superfluous in a patient who passed normal stools and had no abdominal complaints. A number of vitally important steps were omitted. The nurses did not look into the patient's mouth or at her skin, did not check the small of her back for edema nor the buttocks for bedsores, and did not inspect the legs. The patient whom I closely observed had a pronounced edema on the legs, feet, and ankles, an important and ominous sign. None of the nurses noticed that.
I saw enough to draw my conclusions. What these nurses were doing was inaccurate and sadly incomplete. Unfortunately, the nurses took the physical examination over from the doctors at a time when the doctors themselves had already deeply neglected this art. The nurses whose work I watched had never had the chance to properly learn the physical examination, or to fully appreciate its importance.
Practicing Medicine. Can non-physicians practice medicine? It was tried in the past. I remember the medics who practiced in Central and Eastern Europe in the 1930s and 40s. The institution was inherited from pre-WWI German and Russian imperial armies. A few civilian schools offered a two year curriculum modeled upon military medics' training.
Around 1950, the institution of practicing medics was abolished in those European countries where it still existed. It was assumed that diagnosing diseases and treating sick people should not be entrusted to half-qualified practitioners.
Fifty years later I learned, much to my surprise, that medical practice of half-qualified persons was being reintroduced in the United States. I recently watched a case of a 13-year old girl who suddenly fell ill, vomited several times (first food, and then some water-like liquid), and complained of a bad pain in her belly. The mother called her pediatric medical center. A nurse answered the phone, asked some questions, diagnosed "abdominal virus," and advised Tylenol. I marveled at this nurse's self-assurance. The girl's symptoms could be due to various conditions, some of which would require immediate intervention. …