As a diabetes nurse practitioner and consulting associate faculty member in the Duke University School of Nursing nurse practitioner program, I read this article with great interest. I have practiced in inpatient diabetes care as an acute care nurse practitioner since 2001; I have been a nurse since 1993 and was a ward clerk in the early 1980s, when patients were admitted for respite care. Care has changed dramatically over those years. Unfortunately, I could see any of the things that happened to Dr. Unger during his hospitalization happening at almost any hospital (academic or otherwise) today. I am completely dismayed at times by the quality of education related to diabetes care, comprehensive history taking, review of systems, and physical examinations, as well as by the lack of supervision of staff in training to ensure that students/new graduates/residents have learned and are practicing their skills.
Two years ago, one of our senior endocrinologists—one of the last of the great hands-on clinicians—retired. I learned much from him about history taking, review of systems, and physical exams, but, unfortunately, I did not master all of his physical exam skills. I continue to practice but will probably never have those subtle assessment skills that allowed him to confirm his diagnosis with tests. He assessed and used diagnostic reasoning to determine what was wrong with a patient and often did not need many of the tests others order to confirm a diagnosis. As he would have said, “What will you do differently based on the test?”
Don’t get me wrong; he ordered tests appropriately, but not nearly the battery I see so many others order. I hope I have learned some of that from him. I often ask students, colleagues, residents, and fellows why they are ordering specific tests. They are surprised, but then I follow up by asking how the results of those tests will change the plan of care or the long-term follow-up of their patient.
The inpatient world has changed so much. Attending physicians are on “service” but often have to see patients in clinic before making rounds at the hospital. They often cannot supervise, much less teach, as Dr. Unger and I agree that they should. Teaching does not pay what seeing patients independently in clinic does. I see that Dr. Unger is in a concierge service. I have known a few physicians who have gone to this type of practice. They do not want to be controlled by the numbers game, but rather are dedicated clinicians who want to provide the care patients deserve and that they were trained to provide.
Dr. Unger rightly pointed out the importance of learning to listen with ears, brains, and heart and of working with heart, brains, and hands. We have bright students coming through medical, physician’s assistant, and nurse practitioner programs. They clearly have the brains and hands to do these skills, but I worry about whether they have the heart. Why are they in this field? It is a question I ask every student in interviews for our program and every nurse practitioner I have ever hired. If they cannot tell me their interest involves the patients, they are not candidates I want to consider. I honestly believe I would rather have a student or provider who is not as brain-focused, but who truly cares. Caring students want to learn, are passionate about patient care, and will seek out opportunities to learn more. They will stay late, see extra patients, and read more because they want to provide the best care possible.
I am going to make Dr. Unger’s editorial required reading for my students and ask others to do the same.