Non-physicians trained to recognize the smoke, not the cause
by E. Jeanne Kroeker, MD —
As I was driving north on I-135 recently, just north of Hesston, a distant gray-white plume of smoke came into view straight ahead. Across the northern horizon, the haze of smoke stained the lower portion of the sky and this plume was in the midst of that haze. Turning west onto K-4, I realized there were multiple plumes dotting the northern horizon, contributing to the haze visible through the passenger window as I headed to Kanopolis Lake.
Turning north on K-141 and going over the lake dam, I vaguely noticed that the plumes were now to my east and briefly wondered if the smoke was coming from the Smoky Hill Bombing Range. Then I decided it must be smoke from controlled field burning. It was less windy that Saturday compared with the days of intense winds we had earlier in the week, so field burning seemed most likely. I did not see any fire equipment heading that direction.
Driving home five hours later, backtracking my route, I had forgotten about the plumes and haze until charred, actively burning and smoking hills came into view just north of Marquette. Instead of distant smoke, now there were visible swaths and tiers of hills burned and burning, extending several miles in each direction.
I marveled at the speed at which this fire had traveled. I then thought about the devastating wildfires Kansas has seen in recent months and years, and had a better understanding of how quickly these fires engulf and destroy everything in their path when uncontrolled. The fire I was watching was clearly a controlled burn, hemmed into particular fields and sections of land.
As physicians, we see many illnesses, diseases and conditions that are initially perceived only as a hazy, smoky horizon with occasional, barely visible plumes of smoke. The source of the symptoms/smoke is not known. In fact, we may not even know if the symptom is mildly concerning or truly problematic.
Throughout our training, we are challenged, over and over, to notice and address symptoms and signs, create a differential diagnosis of the possible causes, predict the likelihood of an outcome, and act accordingly. We are introduced to this method of thinking in medical school, and it is refined further in residency and fellowships.
As practicing physicians, this is what we do every day. Our “see one, do one, teach one” training is augmented by our “read about it before and read more about it after the encounter” practical training.
We are taught to think about more than one cause for each problem and more than one way to try to address it. We do not learn by reading instruction sheets or order sets; we learn by viewing the patient with eyes trained by classic reference books, current journals, practice through mentorship and experience. We are ultimately tested in Step exams and Board exams with patient vignette questions that test our ability to figure out if the “smoke” is productive or destructive and demand that we define when and how to intervene.
Once again non-physicians have been striving to change how the Kansas Legislature defines medical care in Kansas. This session, they succeeded in getting the Legislature to approve a bill, which Gov. Laura Kelly signed this month, permitting APRNs to prescribe drugs without a collaborative practice agreement with physicians.
We have all seen the many cartoons that juxtapose the hours of classwork and patient-care training of physicians and other non-physicians, showing an incredible disparity. These listings of hours, however, do not address the very important, primary difference in the focus of education of nurses, physician assistants and physicians.
While non-physicians are trained to skillfully recognize smoke, they are not fundamentally trained to initially and critically think about the cause of the smoke and the many factors that influence its production. The non-physicians’ focused and abbreviated training sessions (online or in person) do not allow for the same critical-thinking approach, influenced by multiple clinical experiences and hundreds of hours of mentored learning.
Our semesters of physiology, pathology, pharmacology, immunology and every other “ology” of medical school, added to our undergraduate studies, laid a framework of basic facts and knowledge. But our clinical experiences in medical school and our residencies and fellowships provided the ability to perfect the studied nuances of differential diagnoses and differential treatment, recognizing that decision trees do not allow for patient or case variations. We learned to predict when the fire was expected to race over the hills and when it was only going to smolder. We learned that treatment planning depends on this prediction.
Through our unique training system, physicians learn to recognize the “smoke,” predict if it is going to be uncontrolled, think about its origin, strive to prevent it when it is detrimental, and provide the most appropriate patient care in that exact setting.
Our non-physician care team members can contribute to this process, but they do not have the training needed to work without physician collaboration or supervision.