The Theory of Everything

A few weeks back I mentioned nurse practitioners. These are nurses who have gone on to get a Master's Degree so they can work alongside or independently of physicians as higher-level providers of medical care. Nothing wrong with nurses wanting to get more education and advance their career, of course, and more power to them for doing so. What I didn't realize, however, is that much of the class time in spent in nursing research. This strikes me as kind of a fluffy topic (no traditional nursing-based pillow tasks pun intended), because I can't figure out what nursing research is. If we're trying to figure out what clinically works for patients in the real world, we're dealing with the same issues, and the same set of facts, whether the research is done by doctors or nurses. That’s why it’s called clinical research. It’s not doctor research.  So I don't quite get what nursing research is if it's not research into clinical care. And if it's not, then that means it's not fact-based, and risks getting lost in rubrics of good feeling and a cornucopia of psychobabble. This is not really a criticism; it's the nature of the beast when you try to quantify that which is inherently subjective. It's a problem when subjectivity becomes confused with fact, and extrapolations are made on unfounded assumptions. You know, like pain scales and patient satisfaction measures.

(For the record, research that is fact-based does not mean that it's useful or even worthwhile finding out. It's like those studies that appear from time to time as a Waste of Government Dollars, like the one in England a few years back that showed that the girls really do get prettier at closing time. Mickey Gilley knew that years ago, as did his cousins Jerry Lee Lewis and Jimmy Swaggert.  As well as anyone who went home at two with a ten and woke up at ten with a two. Not sexist; it works both ways.)

I was talking the other night with one of my nursing friends who's just finishing up her nurse practitioner degree, and she was telling me about their class research project. (This particular nurse is also savvy about why nursing research is so prominent in her curriculum. "The professors have us do a project, write it up, stick their names on it, and submit it to see if they can get published." Yet another way nursing academics are exactly like their physician peers.)  She and her classmates have spent the better part of a year trying to figure out why patients with emphysema (more specifically known as Chronic Obstructive Pulmonary Disease, or COPD) don't get the care they need. They've come up with the usual suspects: lack of access to health care, lack of financial resources, lack of health education, and the like. In the end, it seems like in health care, like everything else, it always seems to come down to money...money that drives access to care, to medications, to resources, to education, and even to time to devote to health care and maintenance.  But as we discussed her project, we realized that in our rush to blame the system and absolve individuals from accountability...not a specifically medical issue, but a systemic one...we simply ignore all those factors that result from individual free will. There are those who quite actively choose to continue to smoke, to not take advantage of free health care resources, to not use their prescribed medicine as directed, to refuse home oxygen when suggested by the physician. In the shorthand of the ER, we term these behaviors as idiocy.

It seemed to me as we talked that we could make this problem a lot easier if we focused on money and idiocy as driving forces for healthy behaviors.  And we could do so in a diagram:

IDIOT?

Yes No

Yes Bad Hooray!

MONEY?

  No Bad Bad

In brief, if you're an idiot, bad things happen.  If you're not an idiot, but don;t have money, bad things happen. If you're not an idiot and you have a few bucks, you'll be fine.  That's all of health care behavior in a nutshell. And depending on how high up the food chain we consider the idiot, probably explains a lot about the healthcare are system as well.

See how easy this can be?  

(In reflecting upon this solution, I recognize that I have now personally put any number of nursing, social science, and economics journals out of business, have destroyed tenure for countless academics, and have simplified doctoral theses for any number of graduate students.  The only thing left now is to define the extent and the operational mechanisms of idiocy, which in itself remains an expansive topic of study, one that women have been trying to figure out in men since the first Australopithicus said, "Hey, I can walk upright!  Guess that lion can't eat me now!"  And I have distilled the collected works of Will and Ariel Durant, Jared Diamond, and Yael Noel Harris, all excellent scholars of civilization, into a Cliff Notes version.  You're welcome.)