As a nurse practitioner in hospital medicine I have multiple opportunities to interact with all sorts of physician hospitalist colleagues, hospital medicine group leaders, quality officers etc. Often their interactions with me take on a certain wary curiosity, like I am some exotic monkey or another creature that is unfamiliar to them. If I am speaking with someone who has had the benefit of successful collaboration with an NP or PA in hospital medicine that same interaction may take on a particular respectful reverence. Or if the physician hospitalist has had a less than stellar experience with a NP or PA in hospital medicine there may be regret, or reluctance to connect.
I often wonder, after these interactions, when I and my other NP/PA colleagues will be seen as we wish to be seen: as highly valued and productive members of the hospital medicine team. I have been taking care of inpatients literally for a quarter of a century. I am a member of SHM and have been for seven years. I am chair of the NP/PA committee at SHM. I feel more supported and included at SHM than at any other professional organizations with which I have been involved. SHM has the wherewithal and future vision to espouse the values of the “big tent” philosophy. They know that the future includes us. It must. Yet my interactions often leave me somewhat frustrated and bemused.
When I attempt to analyze this frustration I believe the foundation of migration is simply this: language. Language is powerful. I am not a nurse. I am a nurse practitioner. I am not a “physician extender” anymore than a cornerback on the football team is a “quarterback extender.” I am not a non-physician anymore than a catcher is a “non-pitcher.” I am not a “mid level.” What the heck does that mean anyway? I am a professional, seasoned, experienced, hard-working, intelligent, energetic member of the hospitalist team engaged in the sacred and sometimes profane mission of caring for the poor and down trod, the sick and infirm, the sad and scared, just as my physician colleagues are.
Over time I have utilized many methods to heal my tiny wounds from the perceived slights. Chief of all these methods is the simple understanding that these minor cuts and bruises are rarely, if ever, intentional. I am sure my physician colleagues would be horrified at the idea they would ever intentionally cause me consternation. When these “cringe worthy” moments occur, and if I have felt a bit of sting from them, I just press the pause button, as Stephen Covey so eloquently describes, and then I think about the interaction. If time goes by and it’s still bothering me, I may find a non-stressful time to bring it up, giving the other party “the sandwich.” The dialogue might go something like this: “Hey great call on that patient the other day! Truly! Listen, I’ve been meaning to talk with you about something that was bothering me. When you were talking to that patient the other day, you referred to me as “your nurse.” I would really, really prefer that you refer to me as the nurse practitioner. I know you didn’t mean any offense by this and of course I value your support and love working with you.”
I do find it difficult to express my frustration with these flaws in language. I don’t want to be militant and strident, calling people out amongst their peers in a demeaning way. I also don’t want to let these breaches blow past as I believe these changes are the cornerstone to a larger and more definitive change in the way my NP/PA colleagues are treated and perceived. I think this issue too, is complicated by my own NP/PA colleagues who often refer to themselves as “mid-levels” without acrimony or dismay. But I feel strongly that we must identify ourselves with accurate reflection. I guess the best option is for all of us, gently, professionally and one on one to demand and expect, from ourselves as well as others, to be named for what we are: Nurse Practitioners and Physician Assistants in hospital medicine.
Tracy, I really enjoyed your blog and have forwarded it onto my NP and PA faculty colleagues. It is interesting that we struggle so much with this issue in hospital medicine given that physician hospitalists have often had similar issues with wanting to be perceived as colleagues to cardiologists, intensivists and other subspecialty practitioners. You would think that this would generate a better understanding, but it often does not.
One item that will potentially forward this cause if we better define the system and roles that NPs and PAs play in hospital medicine. While standardization across clinical sites is not possible, as each unique care environment poses different needs to its NP, PA and MD providers, it would be helpful if we better clarified the competencies that NPs and PAs should possess to hold certain roles. Just as it should not longer be acceptable for a physician hospitalists to be cost-unaware or not understand core measures or the coming value based purchasing changes, we should elevate what the role of NP and PA hospitalists mean. For example an NP or PA that is simply wiring orders, discharging and carrying out other “physician-extender” roles is very different than my colleagues that independently (with physician back up) manage a busy inpatient team as the primary hospitalist provider. While there are certainly fantastic folks helping their clinical operations function efficiently by filling these extender roles, a hospitalist NP or PA (from my perspective) should be defined by his or her ability to care for complex hospitalized patients with significant autonomy and authority. By defining this role more clearly and consistently, I think physician hospitalists would more easily understand and respect their NP and PA hospitalist colleagues.