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Nursing II: Sarah DiGregorio
47 Plays1 year ago
Season 2, Episode 18: Sarah DiGregorio is a freelance healthcare journalist from Brooklyn, New York. She is also the author of Taking Care: The Story of Nursing and Its Power to Change Our World. Listen to Sarah talk about the nurse-patient relationship, healthcare billing and the political nature of nursing.
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Transcript
Introduction and Guest Welcome
00:00:09
Speaker
You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare. I'm your host, John Neery.
00:00:22
Speaker
My guest today is Sarah de Gregorio. Sarah is a freelance journalist based in Brooklyn, New York, who has written on healthcare topics for the New York Times and the Washington Post, among other outlets. In 2023, she authored Taking Care, the story of nursing and its power to change the world. Sarah, welcome to the show. Thank you so much for having me.
Nursing vs. Medicine
00:00:45
Speaker
So I've heard you make the distinction that nursing is unique from medicine. Can you articulate the role of nurses and how they bring a unique skill set to the healthcare setting? Yeah. So I think it's important to think about nursing and medicine as
00:01:05
Speaker
to complementary and overlapping disciplines, but they are distinct disciplines. So physicians have a particular role and nurses have a particular role and a particular discipline and expertise. And of course, we need both and we need all of that to attain the best patient care. So I think of nursing, and this comes from many, many interviews with nurses. Nursing is distinct from medicine in that
00:01:34
Speaker
Nursing education and training and practice, of course, is concerned with the physiology of patients and biomedical knowledge. But in general, it goes a bit less deep on the physiology as opposed to physician practice, which goes very deep on the physiology. Nursing practice tends to go broader. So thinking about nursing as
00:02:00
Speaker
understanding the patient in their entire context. So rather than focusing their expertise on one organ system, say, or on one kind of disease, nurses are trained and their practice focuses on understanding a patient's health and wellbeing in their entire context. So thinking about, for instance,
00:02:25
Speaker
What is their mental state like? Is that attributable to a disease or pathology? Or is there something going on in their family? And being able to have conversations that can tease out what's really going on with a patient.
Environmental Factors in Patient Recovery
00:02:41
Speaker
Another example of that might be when a patient is being discharged. Of course, a physician may have done all of their great work figuring out what is going on
00:02:53
Speaker
with a patient physiologically, perhaps prescribing medicine for that patient. But when they're discharged, thinking about how that is going to interact with their environment. So if they're being discharged home with oxygen, what is that like? Is there anyone who smokes in the home? If they are having mobility issues, are there stairs that they need to climb? I think of nursing as this very broad picture
00:03:21
Speaker
kind of expertise, really thinking about the health and wellness of a patient in this 360 kind of way.
Nurse-Patient Relationship
00:03:34
Speaker
And I also think that given the pressures on everyone in our current healthcare system, it can be very difficult for all the providers to have a deep relationship with patients.
00:03:48
Speaker
You know, everyone is pressed for time. There are often shortages in staffing, both for nurses and physicians. But nurses really do have a priority in terms of establishing a relationship with the patient and really understanding them as human beings and understanding their family context. And out of that nurse-patient relationship comes a lot of insight and knowledge that nurses then
00:04:18
Speaker
can use in service of the patient care, also, of course, sharing that information with other providers. So I really think of nursing as both biomedical science and a relational science, and thinking of a patient beyond sort of a sense of pathology or cures, procedures, but really thinking about them in their entire context.
00:04:47
Speaker
Yeah, I think I've heard you kind of talk about that and say like the nurses are really the ones who are in the position to heal the patients. So in your eyes, could you talk more about like that healing that occurs through a nurse patient relationship?
Personal Stories from Sarah
00:05:04
Speaker
Yeah. You know, I think we all, everyone who spends time in healthcare, certainly healthcare providers, but also as a healthcare journalist and someone who has been in healthcare settings personally,
00:05:16
Speaker
as a family member quite often in my life, you know, we know that it's important to identify, you know, any disease that is happening with a patient and then to provide medication or a procedure that might cure or ameliorate that condition. But that's really only part of what happens to patients in healthcare settings.
00:05:41
Speaker
Sometimes there is no cure, right? Sometimes there is no fix, but people still need health care. They still need to be cared for.
00:05:50
Speaker
There is a world of healing that happens after a surgery or after a diagnosis. And nurses are really key to that healing. So I'll give you an example. From my own life first, my daughter was born prematurely. And as a result, she struggled with severe asthma when she was younger. It was very, very hard for us to get it under control.
00:06:18
Speaker
And so as a result, we were, our pulmonologist recommended a bronchoscopy. So she was admitted for a bronchoscopy. It was meant to be an outpatient procedure. And she had been having flare-ups, you know, quite often. And so her, you know, she was going into the bronchoscopy. She wasn't completely well.
00:06:42
Speaker
Her airway reacted very dramatically to the bronchoscopy. She swelled up. She had a lot of mucus and swelling. And so when she came out of it, she was in respiratory distress.
Crisis Management and Family Communication
00:06:54
Speaker
And when they finally called us back, her saturations back into the recovery room, her saturations were in the mid 80s.
00:07:02
Speaker
There was a respiratory therapist in the room putting her on a CPAP machine. And I heard someone say, we have to get her saturations up. And having been in the NICU with her and having experienced a lot of traumatic moments with her around breathing and her ability to breathe, I was immediately in an absolute panic. I knew that her saturation shouldn't be that low. I feared that they might have to intubate her.
00:07:31
Speaker
And I said out loud, I said, are you going to have to intubate her? And someone said, that's one possibility. And then this nurse, the recovery room nurse who was standing right by my daughter's bed, she caught my eye from across the room and she said to me, we are going to get her saturations up. This looks worse than it is. And she was really the only person who connected with me in that moment.
00:08:00
Speaker
and who helped me understand what was really happening. And as a result, I was able to modulate my own trauma response, which was important also for my daughter, right? Because there's research that shows that when children are hospitalized, when parents have less fear and anxiety, the children tend to do better. And so this nurse intervened for me in this moment for me, but also she was intervening for my daughter. So she was, of course,
00:08:30
Speaker
monitoring her vital signs. She was talking to the respiratory therapist and to the pulmonologist. And they did get her saturations up on the CPAP machine. And this nurse interacted with my husband and me and my daughter in the recovery room
00:08:46
Speaker
In a way that was incredibly healing. So for instance, you know, she she was doing chest PT on my daughter She showed us how to do it. She told us exactly what she was doing She was able to establish a trusting relationship with me and my husband really in a matter of minutes and all of this, right she was working on so many levels so she was communicating with the rest of the health care team and
00:09:10
Speaker
She was monitoring my daughter's vitals and making sure her respiratory status stayed stable. And she was including us in the care, educating us, making sure that we had our questions answered and that we felt that we knew what was happening. And when I think about all of the things that happened that day to my daughter, of course, she needed the bronchoscopy. She needed the information we got out of that.
00:09:38
Speaker
But we as a family unit and for my daughter's well-being, we really needed that nursing that day. My daughter needed it physically and we needed it for our education and for our ability to take care of my daughter. And so, you know, that's the kind of healing that I'm thinking about. I'm thinking about sort of in these layers of nursing practice, which is
00:10:03
Speaker
which is, of course, taking care of the patient's physiology, but then also thinking about, what do these parents need right now? These parents who are in the NICU, they're really scared. They need their questions answered. They need a little reassurance. And all of that is really towards the wellbeing of the patient. So I like to give that in this example. I can give you another example.
Hospice Care and Comfort
00:10:30
Speaker
There are times when healing
00:10:34
Speaker
means something other than a cure, right? And so I think about the hospice nurses that I accompanied on their home visits as part of my reporting for the book. I accompanied this wonderful hospice nurse named Mariana Sandarascoya, and she
00:11:03
Speaker
let me sit in on a visit that she made to the home of an elderly man who was very slowly dying of a heart condition. He had been in hospice for about six months and he was pretty stable, but he needed a lot of management in terms of his symptoms. His heart condition gave him uncomfortable symptoms.
00:11:29
Speaker
He wasn't really able to get up very much. And so this is a context where, of course, a cure is not possible, but healing is possible. And so she had established this very deep relationship with him and his wife. And so she would go in, sat down. She would talk to him about what his symptoms had been. She would make sure that the medications that he might need were filled, were available to him to take any time that he needed them.
00:12:00
Speaker
And all of this towards the goal of, you know, feeling comfort, you know, being able to enjoy your last months or, you know, days. And the healing that she was providing to this gentleman and his wife, you know, it had to do with managing his Foley catheter. It had to do with making sure he had his medications available. He knew how much to take all of those, you know,
00:12:30
Speaker
tending to his bodily needs. But it also had to do with a sense of reassurance that she had gone through this death process with many other patients before, that it was nothing to be afraid of, that you could be prepared. That sort of her expertise was in, there doesn't need to be a moment of panic. You don't need to call 911. That there is a sense that you're being taken care of.
00:12:56
Speaker
that your well-being is being understood and expertly taken care of. And both he and his wife said that there is this tremendous sense of relief in that, in being able to just try to, you know, try to be comfortable and enjoy the time that they had with each other. So when I talk about the
00:13:19
Speaker
kinds of healing that nurses provide. That's what I mean. It's so multifactorial. It's in so many different settings. And it looks different in every setting. But we all know that our health and well-being is not just about our organ systems. And it's incredibly complex. And so I think that that attention to
00:13:47
Speaker
each person in their context when done expertly and with all of that knowledge and insight can be incredibly healing and that that's a lot of the power of nursing.
00:14:02
Speaker
Yeah, I think what you're, you're getting at is basically nurses are in the position, right? To be the superstars of the, the biopsychosocial spiritual, you know, level of patients. Um, I think that's like, it's obviously super overlooked, super important. Um, and hope hoping that we can kind of appreciate that and build that into healthcare more as we move forward. Um,
00:14:30
Speaker
I know you originally started out thinking of writing the book as like a chronological history of nursing and that kind of evolved. I know you kind of in the book, you kind of like split it up into different disciplines that nurses work in and kind of exploring those. But just kind of like bigger picture, you know, how did nursing start and how has it evolved to where it is today?
History and Evolution of Nursing
00:14:57
Speaker
Yeah.
00:14:58
Speaker
That's a really big question, and you're right. I decided not to attempt to write a straight-ahead history of nursing, in part because I realized that it's actually so big. It's so much bigger than I appreciated at first, which was my mistake, and I think many people's mistake. And so I ended up
00:15:24
Speaker
deciding to structure it around a history of what I see as the power of nursing and pulling those threads. But nursing has existed, you know, since the dawn of human civilization. So if you think about nursing, well, first I should back up and say, in other cultures and in other times, particularly in the past, there wasn't so much of an emphasis on delineating
00:15:52
Speaker
different disciplines the way that we do. So we have a very strict system of you're a physician, you're a physical therapist, you're a nurse, you're a nurse practitioner, you're a pharmacist. So we really delineate those different disciplines. In the past, those different disciplines were not delineated in the same way. And in many cases, it was not considered important to delineate them that way. However,
00:16:19
Speaker
the way that I looked back and tried to trace a history of nursing was to identify some, um, what I think of as, um, a definition of nursing, which is care, hands-on care for, for people with respect to, as I said, their full context, you know, thinking about them in their environment,
00:16:45
Speaker
with their families in their communities? What are the different inputs that are bringing them towards health or illness? And also thinking about nurses as really engaged in building those relationships. In addition, you know, I think about some of nursing practice is about, you know, first aid and nutrition.
00:17:13
Speaker
and some really fundamental sort of building blocks of providing healthcare that have been done for millennia, you know, before we had CAT scans and before we had antibiotics and before we had all of the sort of marvels of modern medicine, people have been, you know, trying to prevent infection and, you know, sitting up with someone who's dying, sitting up with someone who's giving birth, you know, all of these things,
00:17:41
Speaker
are practices that we think of often as nursing practice. But they are the basic fundamentals of health care. And those things have always been happening. And so if you look back even to Neolithic times, there's evidence in the fossil record of nursing practice. And whether or not that happened in the home or there was a community expert, a lot of times the evolution of this is that nursing perhaps started in the home with family members and then
00:18:11
Speaker
often there would be someone who developed expertise in the community. And so it was known as the person who was good at delivering the babies or who knew, you know, who had knowledge of, you know, herbs or infection control, things like that. And people have always been doing that kind of thing. They used honey, they used turmeric, back to the Egyptians, the ancient Indian empire. So we can trace those threads of nursing throughout
00:18:41
Speaker
really all of human history. In particular, I was really fascinated by the story of a skeleton that was found in a Neolithic village in Vietnam. So archaeologists were studying this, you know, this Neolithic village that they were digging up in Vietnam, what is now Vietnam.
00:19:05
Speaker
they came across a skeleton of a young man and from the skeleton they could tell that when he died he was in his mid-20s and he had been born with a congenital condition that had caused him to become progressively paralyzed so that he would have been a paraplegic
00:19:23
Speaker
Um, starting in his teens and nevertheless, you know, he had lived for another 10 years. That meant, you know, he would have had trouble chewing and swallowing. He would have had trouble with his, you know, positioning his body. So we would have needed help, um, moving to prevent pressure sores and infection. Certainly nutrition would have been, um, something he needed help with and
00:19:47
Speaker
We sometimes think of ourselves as a species for whom it's natural to just, well, survival of the fittest. Well, we'll just leave the vulnerable behind. He was someone who became disabled in a community that was so long ago that they didn't even really have metal tools, right? Nevertheless, somebody or many someones provided what they could for him and allowed him to live for another 10 years.
00:20:17
Speaker
as someone who couldn't move around on his own. And so when we think about that, we think that is nursing, that we have organized care for people who needed it throughout human history. And so I think about it that way. And then thinking about the ways that nursing has evolved, it's a really complicated story because nursing and midwifery has
00:20:47
Speaker
Certainly you can find it in every culture, in every time. When you think about it, it's actually quite logical because human societies can't function without that, right? Without nursing care, without some kind of organized health care, it's very difficult to have a functioning society. So for instance, you can often see evidence of nursing in military traditions.
00:21:16
Speaker
militaries have always needed health care. And when you think about the importance of military action in human history, unfortunately, for instance, the Roman Empire, because the Roman Empire was so far flung, they really needed to have military bases
00:21:42
Speaker
throughout their empire. And in order to maintain the fitness of those troops, they needed also to have hospitals there to care for the soldiers, not only from battle wounds, but also for all of the illnesses and ailments that come from living in a barracks, living in close quarters. And without the nurses taking care of the troops, that was what the Roman Empire's
00:22:08
Speaker
That was what the Roman Empire was supported by. So you think the Roman Empire, oh, they had such an advanced military. Well, actually, how did they have such an advanced military? They had very sophisticated health care for their military. And so, you know, you can think about this in all kinds of different ways. But nursing has always been key to the functioning of human society.
00:22:32
Speaker
With kind of all that in mind, kind of just bringing it back to present day, can you sort of elaborate on the current dynamic of like a healthcare team, like where nurses fit into that, like how it all works and perhaps things in that dynamic that you would like to see changed?
Modern Healthcare Team Dynamics
00:22:51
Speaker
Yeah. Well, of course it's difficult to say because the healthcare team dynamic I think is different in many settings
00:23:03
Speaker
and highly dependent on the setting and also the culture of the particular institution, all of that. But to generalize, of course, a healthcare team can be made up of physicians, nurses, like registered nurses, nurse practitioners. There are nurse anesthesiologists who provide anesthesia,
00:23:32
Speaker
Of course, other parts of the healthcare team can include certified nursing assistants, physical therapists, occupational therapists, respiratory therapists, and all of those providers have a particular discipline and a scope. And everyone is there, at least in theory, to use those skills to help the patient.
00:23:54
Speaker
I, in our current healthcare system, there is an emphasis, I think, on multidisciplinary care, which is a model that is geared more towards less of a hierarchy and more of a team-based approach in which everyone's discipline is valued as part of patient care.
00:24:21
Speaker
The bedside nurse has a certain expertise about this patient. Their pulmonologist has a certain expertise about this patient. The respiratory therapist as well. All of those people working together and adding their particular discipline towards the care of the patient. I think that that is a really good system in theory. I think that, unfortunately, it really
00:24:47
Speaker
often ends up being much more hierarchical than that. And some of that is based on the financial system that we have in our healthcare, in our healthcare system. So often it is the physician is seen as the most important. And part of that is because physicians bill and physician care is bills out at a more expensive rate. So makes more money for the facility.
00:25:17
Speaker
I think that that's unfortunate because the truth is that everyone's discipline is necessary. And I do not think that one is more valuable than the others. I have had, for instance, you know,
00:25:39
Speaker
of when I've been interviewing midwives about their practice in hospitals, I recently had a midwife tell me that midwives were barred from attending births because it was not a midwife birth bills out at a lower price than a physician birth. So even though midwives had that within their scope and within their training, they were not allowed to attend uncomplicated births.
00:26:08
Speaker
However, when the physicians are not available, the midwives do attend the uncomplicated births. If it's then they call it an emergent situation because the physician is not available. This midwife was describing how a physician might be doing a C-section in the OR.
00:26:25
Speaker
And another patient is about to give birth. So of course, the midwife, you know, is going to be there for the uncomplicated birth. But at the last minute, sometimes the physician has to run in the room and basically knock the midwife aside and catch the baby. Not because the physician is a terrible person, but because that's what the hospital has asked them to do because the physician attended birth bills out at a higher rate.
00:26:49
Speaker
Obviously, that's not about patient care, right? It's not. And I think a lot of the hierarchical aspects of our current system are really because of flaws in the financial model that we have. I actually think that the vast majority of people who go into medicine and nursing do it to help people and are trying their
00:27:18
Speaker
hardest within a really broken system to provide the very best patient care that they can so it's not that I don't think that most physicians are particularly into You know the idea that their their discipline is more important than everyone else's I think that there are pressures placed on everyone within this system that are really not about patient care at all and are about the financial system and the and and who bills out to payers and
00:27:46
Speaker
I'm sure you know this, but for instance, when you're in the hospital, your bedside nurse, the RN who takes care of you and who really is incredibly important, and we know this from research over decades, that the more time your nurse has to care for you in the hospital,
00:28:07
Speaker
the more likely you are to be discharged alive or to have a good outcome. And the reason for that is because nurses are an early warning system. I mean, they are the ones who catch signs of a stroke. They are the ones who catch signs of liver failure. They are at the bedside, and they have the expertise to know what's happening with their patients. However, when
00:28:33
Speaker
you get when your insurance company gets a bill for your hospital stay, the physician services are billed for, but the nursing services are wrapped up into room and board. So nursing services in the hospital are billed for kind of like meals or supplies or the bed itself. And that does not reflect the importance of nursing care to patient outcomes.
00:28:59
Speaker
And what that means is that when hospitals are looking at their balance sheets, they're saying, hmm, these physicians make us a lot of money, but these nurses are an expense. The more nurses that we have, the more we're paying for nursing care, but we're not getting money back from insurance companies based on that. So they're free to see nursing care as an expense. And what do we do to expenses? We cut them. So cutting nursing staffing, squeezing nurses to provide
00:29:29
Speaker
care to more and more patients. And that's not good for patient care. So that is the big picture problem that I really see with our current health care. Well, one of the big picture problems with our current health care system is that it forces people into this hierarchy based on the financial model. And that is not a reality in terms of what's important for patients.
Collaboration in Patient Care
00:29:57
Speaker
Yeah, like the, the commercialization of medicine is definitely something we've, I've, I've tried to talk a lot about on the show. And it's, it's just, it's, it's sort of squeezing everybody that the patients, the physicians, the nurses. Um, you mentioned a lot of the men, members of the healthcare team, but like just zoning in on the nurses and the physicians for a second, like, what do you think?
00:30:21
Speaker
Like how do they kind of, what is their interplay like? What can they do for the patient? And what, you know, how do they work as like a team? I think that there is a really important exchange of information that happens between physicians and nurses. Physicians are attending usually to someone's a particular, say a particular organ system or a particular pathology that the patient presents with.
00:30:52
Speaker
and figuring out what's going on with the patient, what's going on with them physiologically, running the tests, doing the exams that the physicians do, and really trying to solve the mystery of what's happening with this patient and what do they need, what is the treatment that they need.
00:31:15
Speaker
So that, of course, has to be communicated to the nurse. And the nurse then has a lot of insight also that can be communicated back to the physician. So for instance, if a patient is having a lot of anxiety about going home, why is that?
00:31:43
Speaker
If a patient's mental state suddenly deteriorates, why is that? That could be a side effect of the medicine that was unexpected. It could be a sign that something else is going wrong, that needs to be checked into.
00:32:01
Speaker
Or say, you know, is there a conversation that the nurse has had with somebody's spouse? And there's some really important piece of information in there about, you know, that relates to their illness or relates to their ability to be discharged home. So I think that you can think of the physician as
00:32:30
Speaker
And again, these things are overlapping, right? It's not that physicians never have these relationships or don't have these conversations. They do. And also nurses do have tremendous biomedical knowledge, and they often have a lot of insight into the physiology of the patient. But I think if you think about the physician being most expert in the physiology and the nurse being most expert in
00:32:56
Speaker
gathering information from the patient both related to the physiology and related to their entire context and how much back and forth there can be there can be really powerful actually and can can really provide excellent care when when those relationships sort of are are functioning as as they should. There's just there's a no one person could
00:33:25
Speaker
provide everything a patient needs. And I think it's really important to sort of honor both kinds of expertise.
00:33:34
Speaker
So I think what I'm hearing is like you feel that nurses can kind of really like lean into that art of medicine while still having, you know, a broader knowledge of, of biomedical concepts, physiology, et cetera. And the science and the doctors can kind of be like more like the science of medicine, but still have those, you know, relationships with patients.
00:33:57
Speaker
You know, I always thought of, as somebody who's a medical student, I look at like the amazing knowledge that all these nurses have and kind of thought like, would it make sense for a lot of these nurses to move on to like, or move on to be a physician or something? In your eyes, is it more that you want to see nurses kind of stay on the nursing track? Or like, should more nurses be going to medical school?
00:34:24
Speaker
So here's the thing, I think the problem with that line of thought is thinking that going to medical school is a step up or is sort of a natural progression when in fact it's just a different discipline, right? And actually, so interesting, many nurses will tell you that, I mean, nurses get very prickly about that idea, the idea of like, oh, you could have been a doctor. And many of them find that a little bit offensive where they would say, like,
00:34:49
Speaker
I wanted to be a nurse. It wasn't a second class or a second choice to me. Like it wasn't because I couldn't be a doctor, I became a nurse. Maybe in the past for women, that might've been an aspect of it, you know, when it was much, much more difficult for women to be accepted and to go into medical school. But today, you know, bringing that, that did come up actually in my reporting and this idea that nurses find it,
00:35:19
Speaker
Um, nurses, um, chose to be nurses and they didn't, they often really do not see it as like, Oh, I should progress to become a doctor. Sometimes they will progress or, um, you know, move on to be a nurse practitioner, something like that. You know, if they want, um, additional training and an, and a sort of a bigger scope, if that's something that they're interested in. But, um, no, I do not think that nurses should become physicians. Um,
00:35:48
Speaker
because I think that nursing is actually just as complex and difficult and crucial as medicine. I think they are equally complex, crucial. And people who go into nursing often have an affinity for nursing as a discipline. I mean, I guess that's obvious, but I think that instead of thinking about
00:36:14
Speaker
you know, these excellent, excellent nurses who do have so much expertise. And you're right, you know, they especially, and I've heard this from residents a lot. And I've heard, you know, I've heard about training residents from nurses. I've heard about it on both sides. I know that that's a really important relationship. And nurses, nurses do often have similar expertise
00:36:44
Speaker
Or I should say, people have been working with patients in hospitals for years and years and years. They have tremendous expertise. I mean, they have tremendous knowledge from their experience, from their training, but also from their experience. And that expertise can stay in nursing. That's really important because that's not like extra knowledge for nurses. That's actually nursing knowledge. Do you know what I mean? It's actually
00:37:12
Speaker
quite of a piece with their discipline. So yeah, no, I don't think that more nurses need to become physicians. I wish that some of this, I think that perhaps more collaboration between physicians and nurses would be great.
00:37:40
Speaker
And I do think that part of the tension between nursing and medicine sometimes is about nursing wanting to be understood as an expertise and a discipline that is just as complex as medicine, which it is. And so I wish that we could kind of do away with that altogether and really
00:38:06
Speaker
focus on what each discipline really brings to the table, as opposed to trying to always set them off in relation to each other.
00:38:16
Speaker
Yeah,
Medical Field Hierarchy Issues
00:38:17
Speaker
sure. I think what you're getting at, what you're saying is basically, you know, there's this hierarchy that exists in medicine. And we kind of have this notion of like, almost like military ranks. And you know, nursing, nursing, you know, you can have a five star general nurse and a five star general doctor who worked together to kind of provide adequate patient care to somebody who's in need. So I think how do you how do you kind of destabilize that hierarchy, I guess?
00:38:47
Speaker
or kind of change that hierarchy. I think it's kind of like a power struggle within medicine for who's sort of doing things. So how do you kind of put those people on equal footing, I guess? So I have two sort of thoughts about this. One is that it makes a difference when individuals in a system start to interact differently. So I think
00:39:15
Speaker
the more that nurses and physicians can individually collaborate with each other and really see it as a team that is there for the good of the patient, that that's really good. But I do think that a lot of this hierarchy and the sort of the push-pull
00:39:37
Speaker
sort of a little bit of turf wars is related to, again, the financial system that we have for paying for health care in this country. And I think that if we change that, it might go a long way towards ending these really false and harmful hierarchies. I will mention, for instance, that the American Medical Association
00:40:07
Speaker
you know, is really, really aggressive about lobbying state legislatures not to allow for the practice of nurse practitioners. So whenever we have these conversations, I just want to say, you know, no one is saying that any provider should be providing care that they are not trained and licensed to provide.
00:40:30
Speaker
You know, so the sort of hyperbole around like, oh, do you want a nurse taking out your gallbladder? Well, of course, I don't want anyone taking out my gallbladder who is not trained in license to take out my gallbladder, right? But nurse practitioners in many states must work under the supervision of a physician. And in large part, that is because of the lobbying of the American Medical Association, which really seeks to
00:40:57
Speaker
keep billing flowing through physicians. So this is really an issue of, it's not about patient care. There's so much evidence that nurse, for instance, getting your primary care from a nurse practitioner is just as safe and appropriate as getting your primary care from a physician.
00:41:24
Speaker
There's plenty of data to that. So what is this about? It's really about maintaining the financial status quo of billing flowing through physicians. And as long as health care is
00:41:53
Speaker
engaged in making money, as long as the financial incentive in healthcare is at odds with providing the best evidence-based care for patients, we're gonna continue to see this kind of turf battle. I actually don't think that it is any individual's
00:42:22
Speaker
fault. I think that it's a product of the system that we have.
Nursing's Political and Community Impact
00:42:29
Speaker
I know you've said that nursing is inherently political. Can you kind of touch on sort of the relationship between politics and nursing?
00:42:44
Speaker
Yeah, actually, I think all health care is political. But because nurses are so provide often the most hands-on care and the most community-based care, I think nursing is particularly political. So for example, say, I'll give you an example of actually a nurse scientist out of Emory. Her name is Roxanna Chicas.
00:43:15
Speaker
And Roxanna Chikas, Dr. Chikas is a nurse PhD and she also has a postdoc in nephrology. And she does research with the Farm Workers Association of Florida. She researches farm workers in Florida to assess their kidney status and how working outside in the heat and the humidity
00:43:41
Speaker
impacts their kidney health because there is a lot of evidence that in particular agricultural workers are at increasing risk of kidney disease and kidney failure as a result of rising temperatures and rising humidity. So you could say that Roxana is
00:44:08
Speaker
She's engaged with the community there. She is following these workers for longitudinal studies for the last one, I think, was for two years. So she has them come in. She collects data on their kidney health, and she tracks it with the weather and with their working conditions. On the face of it is that political? I suppose not. But when you start to think about the context in which she's doing this research, it becomes quite obvious how it's political.
00:44:38
Speaker
In the United States, farm workers in particular don't have any workplace protections against the heat. There are a handful of states that have implemented requirements for employers to provide water, shade, and rest, which protects, is protective from heat-related illness. But in most cases, including Florida,
00:45:04
Speaker
Employers are not at all required to provide access to water, provide access to shade. So you have farm workers working in 100 degree heat in 80% humidity. And because they don't have access to water or shade breaks, they are
00:45:24
Speaker
33% of them, according to Dr. Chikas's research, 33% of them are incurring a kidney injury every day. On any given day that they are tested, 33% of those workers have incurred a kidney injury. And when you add up enough kidney injuries, you end up with a chronic kidney disease and with potentially kidney failure.
00:45:48
Speaker
The layers of this are, you know, why don't farm workers have these protections that actually many other, many other workers have more protections than farm workers do.
00:46:03
Speaker
Farm workers tend to be undocumented immigrants, especially in Florida. They are often afraid to ask for what they need at work for fear of losing their job or fear of retribution in terms of immigration status. So when Roxana is doing this work with the Farm Workers Association, she's not just really focusing on
00:46:32
Speaker
these workers kidney health. She's also saying, well, what does OSHA need? What kinds of standards do we need to protect people? And that's a political issue. Why aren't these people in particular getting protection? That's a political issue. And all of that context is completely inseparable from these rates of kidney disease in agricultural workers.
00:47:00
Speaker
So it's that kind of thing. It's sort of engaging in the why and then the how and what needs to change. I think that's really the key. Like what needs to change so that everyone has access to health and safety. Because everyone doesn't have access to health and safety at all.
00:47:28
Speaker
I think that that's, that's what makes nursing political is, you know, when, for instance, um, when someone needs an abortion and can't get one, when someone is at risk of an infection because their water broke at 16 weeks, but their fetus still has cardiac activity and they can't get the healthcare they need. That's a political issue. Um, all of these things are, are
00:47:55
Speaker
inextricably linked to how we care for each other and how we decide we're going to organize our communities. And that's what politics is, right? People think of politics as like this thing over here. Politics is just how we decide to organize our communities, how we decide to take care of each other.
00:48:14
Speaker
I definitely, as someone who's getting into healthcare, I'm trying to lean in to this idea of both nurses and physicians being advocates for people, not just staying isolated within a hospital or healthcare setting, but saying, hey, we can also go outside these doors and throw our weight around to get things we want to make society work better, and that'll make healthcare better.
00:48:41
Speaker
Yeah, because you have that expertise. You have expertise and knowledge that other people don't have. When I see legislators passing laws about healthcare topics that they clearly don't have any expertise or insight into, your expertise is so necessary, both physicians and nurses, because the people making laws often do not have this context at all. And so even when you think about gun violence,
00:49:08
Speaker
There have been a lot of physicians who have been very vocal about ending them, because physicians are the ones who are trying to mend these bodies, right? It is so tied up in all of these issues. Nothing is in a vacuum.
Balancing Politics with Advocacy
00:49:29
Speaker
I want to go just a little deeper on like the politics thing. It's something I kind of struggle with just like politics and healthcare because on one hand, you know, recently I heard a speaker talk about, uh, she had been in Gaza and she was talking about the healthcare system there and how it's like.
00:49:46
Speaker
Inevitably, you can't not think about health care, you know work on health care in Gaza without discussing politics but at the same time it's like, you know, I just did an episode that I'm gonna post soon about Civil War medicine and to hear about Confederate and Union physicians and health care providers working together and like sharing ideas to like help each other that's also like freaking beautiful, you know, so it's like I
00:50:14
Speaker
It's like where that spirit of just unconditional love that transcends politics, that can go beyond that division that often politics creates. So where do you think, what's the place for politics and what's not the place for politics in health care? That's a great question. Here's what I think. I think that health care is about seeing the humanity in every single person and seeing yourself in them, seeing your family members in them, everybody. Everybody has
00:50:44
Speaker
everybody has innate human worth. And that's what I think is so beautiful about healthcare is that that's what draws me back to it again and again is sort of this, this endeavor that people go into to, to help people, you know, to like mend their bodies as best they can, you know, you, I had a, my daughter was born at 28 weeks.
00:51:09
Speaker
And I don't think you can go through that experience without seeing tremendous beauty in healthcare. I mean, the fact that, you know, a baby can be born like my daughter weighing one pound 13 ounces and the level of care and technology and just attention to every detail
00:51:36
Speaker
what was possible for her through her medical care. She is a healthy, happy fourth grader. I mean, in the past, she would have died within minutes of birth, right? So I see tremendous beauty in that because I think that within caring for each other, there is no place for division. You know, everyone has the right to be cared for with equal dignity and worth.
00:52:03
Speaker
And so that I think is a power that healthcare has that actually then can enable healthcare providers to act on political issues where they see that promise not being lived up to.
00:52:29
Speaker
I think that when people are engaged in caring for each other and when we are engaged in voting for different health care laws or advocating for different health care laws, I think the guiding star always needs to be that everyone deserves to have the health care that they need.
00:52:59
Speaker
and that truly we all deserve that. But where it does get political is where that promise breaks down and where you see it break down and where nurses see it break down. And I think that's where it's appropriate to be political. And you can call it politics or you can call it advocacy for patient safety or care.
00:53:27
Speaker
People think of politics as a dirty word because this idea that it's somehow corrupt or divisive. I think maybe we can better think about it in terms of advocacy for human rights or advocacy for evidence-based care because it's OK to disagree, right?
00:53:55
Speaker
it's okay for people to have different opinions about things. Um, what I would say is it's not okay to legislate based on, um, legislate medical care based on your opinion, right? It has to be based on the evidence. So just using the example of abortion, you know, if women need care to be healthy, that they can't get, um,
00:54:23
Speaker
That's not good for patient outcomes. You can say, oh, that's bringing abortion politics into health care. Or I could say, that's advocating for appropriate health care to be available to everyone. You may not want to get an abortion, and that is fine. But appropriate health care should be available to everybody. And so you could think about it as advocacy for evidence-based health care.
Rapid-Fire Q&A with Sarah
00:54:50
Speaker
With that, it's time for a lightning round, a series of fast-paced questions that tell us more about you. So what are your early morning and late night beverages? Early morning coffee, coffee, coffee, coffee. And late night, I really like tension tamer tea, old school, and also red wine.
00:55:19
Speaker
Who's your favorite writer? Oh, God. Oh, boy. Oh, God, I don't know if I can pick just one. Oh, that's a hard one for me. You can give us two or three if you really want to. OK, this is going to sound pretentious, but I studied theater in
00:55:45
Speaker
college so I have a real soft spot for Shakespeare like I love love love Shakespeare and I just I just do so for for on that front I'll say Shakespeare and then let's see I love Kate Atkinson there's a book that she wrote called
00:56:14
Speaker
Sorry, I know I have to. This is not the point of a lightning round, is it? But I. OK, Life After Life by Kate Atkinson. I love that book. And I also will say Angela Garbus, who wrote Essential Labor as a nonfiction writer that I just love. Growing up, who is your celebrity crush? Oh my gosh.
00:56:44
Speaker
Oh, this is, this is a little weird. I actually thought as a like a six year old, I thought that me and Michael Jackson were going to get married. What's your favorite outdoor activity? Oh, um, I love going for a run. I love, um, I, I, I've tried to run every day and I live near, um, the Veranzano narrows, which is like the straight that goes into, um,
00:57:11
Speaker
New York Harbor. And so I love to run down to the pier. And every day I get to look out on the Manhattan skyline and it's always different, but it's always the same and it's just lovely. All right. And lastly, what's one change you'd like to see in healthcare? I would like to see, I would like to see the money taken out of healthcare and the focus be put on evidence based patient centered care that that should be the
00:57:41
Speaker
that that should be the reason for everything and that we need to find some kind of different financial model, whether it's Medicaid, I'm sorry, whether it's Medicare for all or some other way of figuring out how we can refocus healthcare onto patients, which I think will also make
00:58:08
Speaker
a really big difference in the lives of physicians and nurses so that they can feel fulfilled and less squeezed in their occupations. All right. Sarah de Gregorio, thanks so much for joining the show. Thank you so much for having me. I really appreciate it.
00:58:40
Speaker
Thanks for listening to The Wound Dresser. Until next time, I'm your host John Neery. Be well.