A September 12, 2019 Wall Street Journal op-ed titled “Take Two Aspirin and Call Me by My Pronouns- At ‘woke’ medical schools, curricula are increasingly focused on social justice rather than treating illness” exposed the problem with including politically popular courses at the expense of hard science.

This was preceded by an August 23, 2019 MedPage article titled “A Radical Change to Nursing Board Exams” that exposed a “A lack of situational teaching in clinical settings has led to inadequate skills in critical thinking and decision-making on the part of novice new graduate nurses” resulting “in an epidemic of poor clinical judgment among novice nurses, preventing them from making the best decisions for their patients and incurring huge costs to the institutions where they work for longer orientation periods and malpractice lawsuits.” (Emphasis added)

It is hoped that this new nursing board exam will force nursing schools to make clinical judgment and clinical experiences a central part of nursing education.

I was shocked but not actually surprised by these two disturbing articles.

NURSING EDUCATION

I started to notice the problems some new nurses were having several years ago after the traditional 3 year nursing diploma education in hospitals was  phased out in favor of 2 year associate degree programs (ADN) and 4 year bachelor degree programs (BSN) with less clinical experience.

Many of our new nurses had trouble with decision-making and couldn’t function well in the hospital. Many were demoted to nursing assistant or left after their trial period. I tried to personally help some of these new nurses who were obviously dedicated and wanted to do their best for their patients but many froze from the fear of making a wrong decision.

These new nurses needed more continuous help than I could give so I talked to nursing supervisors but the situation did not change much.

In the meantime, my hospital announced that every nurse now must have a bachelor degree in nursing (BSN) by 2021. This started at many hospitals after a 2010 Institute of Medicine paper recommended a goal that 80% of nurses have a BSN by 2020. RN to BSN programs then proliferated, eventually even online.

Most of my fellow nurses who took these BSN courses on their own time while working full-time complained to me that these courses were not especially helpful clinically and more geared to management preparation and community education. They also complained about exhaustion and difficulty managing family, work and study. Several wound up getting sick themselves.

Although the hospital helped with the expense of the BSN degree, the hourly salary increase for a BSN only went up to 10 cents more an hour when I was there.

MEDICAL EDUCATION

In the September 12, 2019 Wall Street Journal op-ed “Take Two Aspirin and Call Me by My Pronouns”  by Dr. Stanley Goldfarb, a former associate dean of curriculum at the University of Pennsylvania’s School of Medicine, highlights  another but similar problem. He asks “Why have medical schools become a target for inculcating social policy when the stated purpose of medical education since Hippocrates has been to develop individuals who know how to cure patients?”

He complains that:

“These educators focus on eliminating health disparities and ensuring that the next generation of physicians is well-equipped to deal with cultural diversity, which are worthwhile goals. But teaching these issues is coming at the expense of rigorous training in medical science. The prospect of this “new,” politicized medical education should worry all Americans.” (Emphasis added)

He also states that:

“The traditional American model first came under attack by progressive sociologists of the 1960s and ’70s, who condemned medicine as a failing enterprise because increased spending hadn’t led to breakthroughs in cancer treatment and other fields. The influential critic Ivan Illich called the medical industry an instrument of “pain, sickness, and death,” and sought to reorder the field toward an egalitarian social purpose. These ideas were long kept out of the mainstream of medical education, but the tide of recent political culture has brought them in.” (Emphasis added)

He concludes:

“Meanwhile, oncologists, cardiologists, surgeons and other medical specialists are in short supply. The specialists who are produced must master more crucial material even though less and less of their medical-school education is devoted to basic scientific knowledge. If this country needs more gun control and climate change activists, medical schools are not the right place to produce them.” (Emphasis added)

After an apparent avalanche of criticism, the Wall Street Journal wrote an editorial defending Dr. Goldfarb’s op-ed stating:

“Patients want an accurate diagnosis, not a lecture on social justice or climate change. Thanks to Dr. Goldfarb for having the courage to call out the politicization of medical education that should worry all Americans.” (Emphasis added)

CONCLUSION AND SOLUTIONS

I became an RN fifty years ago in what I now call a “golden age”.

Before we could even be admitted to nursing school, we had to submit a character reference. My fellow nursing students were as excited and dedicated as I was to become the best nurse possible for our patients. We regularly saw programs like “Marcus Welby, MD” and “Medical Center” where doctors and nurses worked tirelessly and bravely to help their patients.

When my preferred hospital changed its nursing program from a 3 year diploma program to a 2 year ADN program, I was worried but decided to trust the hospital. However, I felt somewhat unprepared after graduation and found a 1 year nursing internship program at another hospital that gave me supervised clinical experience in every area.

Not only did that increase my competency, it changed my mind from specializing in pediatrics to critical care. I think that such programs should be encouraged at every hospital for new nurses to help solve the problem of poor decision-making and clinical judgement. Nothing substitutes for actual clinical experience which is in short supply  in many ADN and BSN programs.

Also 50 years ago, rigorous ethics were an important part of our nursing education with “do no harm” to patients, report our mistakes, never lie, advocate for our patients regardless of age, socioeconomic status or condition, etc. incorporated as standard requirements. We happily took the Nightingale Pledge.

However in the 1970s, I saw ethics slowly become “bioethics”. The tried and true Hippocratic Oath principles requiring high ethical and moral standards for doctors including prohibitions against actions such as assisting suicide and abortion gave way to “bioethics” with essentially four principles:

1. Respect for autonomy (the patient’s right to choose or refuse treatment)

2. Beneficence (the intent of doing good for the patient)

3. Non-maleficence (not causing harm)

4. Justice (“fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation”)

Unfortunately, those principles are malleable and then used to justify actions and laws that would be unthinkable when I graduated. That bioethics mindset slowly changed not only medical and nursing education but also the principles that informed our work.

While we cannot recreate the past, we can reform our medical and nursing education and practice to return these professions-and our medical and nursing associations-to positions of trust. This is crucial not only for our professions but also for our patients and the public.