My project on Angola entered its final phase last week when my partner and I submitted a copy of our thesis to our advisors at the Kennedy School! The 60-page document, targeted towards policy-makers in Angola, makes a case for training mid-level providers (such as Nurse Practitioners) to do cesarean sections in rural hospitals. We believe that the extraordinarily high maternal mortality rate in the Angolan periphery can be reduced by getting nurses to provide essential care where there are no doctors.
My partner and I learned dozens of lessons in putting together our case: We realized how difficult it is to gather basic data from rural hospitals, how complicated the flow of money is from the Treasury to the Ministry of Health to the country-side, and we realized just how many logistical details go into medical education. We also learned that simple politics would trump all these other very tangible concerns. The greatest obstacle to starting a pilot program in Angola will not be data, money, or logistics. The greatest obstacle will be the politics of doctors.
The final product
I don’t mean to pick on the politics of just Angolan doctors. (I can’t fairly say how they will react to our proposal). Doctors in the U.S, in South Africa, and in Angola have received the idea that nurses can do surgery with skepticism and even defensiveness. And the defensiveness doesn’t seem to be limited to the issue of surgery.
In the US there is reasonably strong opposition to allowing nurse practitioners to work more independently in the primary care setting (an example). In Australia, it is arguably worse. And in Boston hospitals, I have heard numerous snarky comments about something as petty as nurses or physical therapists wearing white coats. It seems that at some point in our training, we as doctors come to believe that we have a monopoly on providing high quality care to our patients. In fact, we set up professional organizations (such as the American Medical Association) to try to formalize this monopoly and advance our interests.
Certainly, our intentions aren’t entirely bad. Doctors correctly believe that it takes a certain level of training, oversight, and approval to carry out some medical tasks safely. After all, we wouldn’t want anybody with a sharp knife doing caesarean sections (“kill two, save one” as it was put to me in Angola). But the problem with our professional organizations is that they are designed to take care of people in the club (i.e. doctors) and not to think creatively about how to improve patient care.
Of course,our professional organizations have an important role. They help us continue our education and protect us from potentially unfair policies. But groups like the AMA can do better. As doctors, we need to demand that our profession be flexible in how we advance the well-being of our patients. Sometimes this means allowing more people into the club. Sometimes it may require rethinking what the purpose of this club is. In a crisis such as extraordinarily high maternal mortality (as in Angola) or an extraordinarily low supply of primary care doctors (as in the US), our professional organizations can be leaders in patient care if they are able to let go of old dogma on who does what, when and where.