Florence Nightingale stands as one of the most important reformers of 19th century medicine — a woman whose belief in the power of reason and statistical thinking would critically shape the both the fields of epidemiology and nursing. This episode discusses the fascinating story of Nightingale’s legacy — how modern nursing was born out of the horrors of war, medical theories about poisonous air, the outsize influence of the average man, the first graph in history, and how a woman who died over a century ago presciently foresaw some of the most important scientific and social issues in medicine that are still with us today. Plus, a new #AdamAnswers about the doctor-nurse relationship.

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• McDonald L, Florence Nightingale at First Hand, London and New York: Continuum, 2010.
• Oyler L, “It’s Really Sickening How Much Florence Nightingale Hated Women,” Vice Broadly, retrieved online at https://broadly.vice.com/en_us/article/kb4jd3/its-really-sickening-how-much-florence-nightingale-hated-women
• “Rank for Nurses,” The American Journal of Nursing, Vol. 20, No. 3 (Dec., 1919), pp. 241-24.
• Rowen L, The Medical Team Model, the Feminization of Medicine, and the Nurse’s Role. AMA Journal of Ethics, Virtual Mentor. 2010;12(1):46-51.
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• Young D A B. Florence Nightingale’s fever BMJ 1995; 311 :1697.

Transcript

This is Adam Rodman, and you’re listening to Bedside Rounds, a monthly podcast on the weird, wonderful, and intensely human stories that have shaped modern medicine, brought to you in partnership with the American College of Physicians. If you are a member of the ACP, you can get CME/MOC points for listening to this episode by going to www.acponline.org/BedsideRounds. This episode is called “The Lady with the Lamp,” and it’s about the life and legacy of Florence Nightingale, who in her productive career managed to not only critically shape modern nursing, but also became one of the most important figures in the development of biostatistics. Along the way, we’re going to talk about how modern nursing was born out of the horrors of war, medical theories about poisonous air, the outsize influence of the average man, the first graph in history, and how a woman who died over a century ago presciently foresaw some of the most important scientific and social issues in medicine that are still with us today. 

Before we get going, let’s have a little history lesson on Europeanb  politics of the 18th century. I can hear your collective “ugh” through the radio —  I’ll be brief. So the Ottoman Empire, with its capital straddling two continents in Istanbul, was one of the greatest empires the world had ever known, and by the late 17th century it controlled large amounts of territory in Europe, Asia, and Africa, ruling over a multicultural, multireligious empire, including the holy sites of the three Abrahamic religions. It was a power to take seriously — at its greatest extent, the Ottomans were besieging Vienna, tunneling deep into the cities inner defenses. But by the 19th century, the tides had turned against it for a number of reasons — technological change, stagnant government, the tides of nationalism that would basically take down every multi-ethnic empire — and it slowly lost territory in the Balkans and North Africa to various independence movements.

By the mid 19th century, the Ottoman Empire was known as the “Sick Man of Europe,” and its foreign affairs had largely been delegated to its voracious European neighbors who wanted to gobble it up, or at the very least carve out their own sp heres of influence.  In 1853, an obscure religious debate about the rights of Christians in the Holy Land blew up into an all-out war, with England and France siding with the Ottoman Empire against the Russians, who were eager to extend their territory.

The British were, to be generous, unprepared for war. It had been forty years since Waterloo. But it dutifully began to ship its young men off to the Crimean peninsula on the Black Sea. Death rates were horrific — 22.7 percent of all British soldiers sent died, and 30.9% of the French. The suffering of the Russian soldiers is unknown, but certainly equally large, if not larger. Compare these with modern wars — American deaths in Vietnam were 2.3 percent.  Looking retrospectively, these mortality rates were in line with the Napoleonic wars, and since that time period “total war” was the rule.

But this time, the people back home were watching closely — probably the biggest difference in the Crimean War, as the conflict was being called. Reporters, photographers, and artists accompanied the troops, and daily updates were sent back to readers at home via the new invention of the telegraph. Take the famous Charge of the Light Brigade. In 1854, poor communication sent 700 British cavalrymen in a suicidal charge against t he wrong, very well-guarded artillery position. News immediately spread in an outraged Great Britain, and not six weeks later Lord Tennyson would write:

  “Forward, the Light Brigade!”
Was there a man dismayed?
Not though the soldier knew
  Someone had blundered.
  Theirs not to make reply,
  Theirs not to reason why,
  Theirs but to do and die.
  Into the valley of Death
  Rode the six hundred.”

This poem — and the visceral outrage imbedded in it — is still felt over 150 years later as it is taught to school children through the English-speaking world.

By 1854, the suffering of wounded soldiers had become a new target for public outrage. Traditionally, religious orders would send nuns — the Sisters of Mercy in Catholic countries — to care for wounded and dying soldiers. The chief medical officer of the War Office had declined this, however, not wanting to send women to  a war zone. The Times of Lo ndon wrote an article taking the government to task for not providing more for wounded soldiers, and pointing out that both the French and the Russians had nuns to care for their soldiers behind their lines. The War Office capitulated, and turned to the obvious woman for the job — who had in fact already made up her mind to go before she was even asked: 33 year-old Florence Nightingale. 

That Nightingale would so readily volunteer to travel to a war zone likely surprised no one who knew her. She was born in 1820 to a wealthy family — the money came from Mad Uncle Peter who had made a fortune quarrying lead. She was a precocious child, and particularly fond of math. As a young girl, she kept a detailed ledger of the size and distribution of plants in the family garden. Her parents gave her the education fitting an upper-class woman at the time — the Classics, musical instruments, sewing. But when she asked to be further trained in math, her father refused. As a girl and young woman, she was naturally drawn to nursing — she took care of sick family members and servants in the household. On February 5, 1837, when she was 16, she had a vision from God — her “call to service,” as she later called it. Nightingale became deeply religious, though with a particularly positivist spin. Her God had created a world ruled by constant laws that humans could understand by scientific and statistical study. And God did not want just prayer — He wanted humanity to understand and use His laws to make everyone’s lives better. Immediately after her Call to Service, she announced her intent to become a nurse, but her mother and older sister quickly stopped her. At this time, nursing was a profession for the lower classes, and the stereotypical nurse was a drunkard who stole from her patients. Instead, she was sent on a three year tour of Europe and North Africa. In 1850, she convinced her father to send her to Kaiserswerth in Germany, the originator of the deaconess movement and arguably the first modern — though religious — nursing school. On returning, her father agreed to give her a stipend so she could have a career without a husband, and she accepted a job as a superintendent at the Institute for the Care of Sick Gentlewomen.

So in late October, Nightingale and 38 volunteer nurses who she had personally trained shipped off to the Scutari Barrack Hospital, the main hospital for the British Army. Scutari, today called Uskudar, is located on the Asian side of Istanbul, many hundreds of miles and a long boat trip from the front in Crimea. The building was beautiful, perched on a hill overlooking the Bosphorus — and still is; today it remains a military hospital, and one of the towers houses a Florence Nightingale museum. But despite the lovely exterior and settings, what was inside the hospital horrified Nightingale and her nursing contingent.

She described it later,:

“There were very few beds . . . the poor soldiers were brought down with scarcely any clothes, their clothes having been worn off  their backs, [they] were placed upon palliasses [mats], and their clothes, or at least the remnants of them, [were] full of vermin . . . no washing had been performed in the hospital, nor the floor washed for six weeks . . . no washing of linen had been performed . . . there were no hospital dresses . . . neither cooking, nor comforts of any kind provided . . . the whole state of the hospital . . . was pestiferous and infectious, the privies being in such a state that nobody could approach the place.”

And that’s intentionally an understatement. In her private correspondence, Nightingale paints a graphic picture of a wave one-inch high of liquid feces flowing down the halls from the uncapped sewer, with the soldiers stricken with typhus and cholera walking through barefoot in order to relieve themselves. Her nursing staff did what they could. With their donations from the public, they had brought clothes, towels, food, brandy, dressings, and medications. Her nurses were placed under the orders of the medical officers. But she did not just take an organizational role — she spent hours with her patients, providing nursing care, yes, but also helping them to write letters back home, comforting the dying, and helping notify their families when they passed. She opened a cafe, reading rooms, a parlor for card games. And probably most importantly, she did math. The military was collecting detailed information about diseases and deaths of their soldiers — but doing nothing with them. When Nightingale sat down to analyze the data, the raw numbers of the statistics spoke even louder than what she was seeing in person — that first year, at Scutari, there were 19,000 deaths from illnesses, and only 4,000 from wounds.

In order to understand Nightingale’s interventions, I need to talk a little bit about the miasmatic theory of disease. Miasma is the idea that bad air causes disease. It dates back to the ancients, and was used to explain epidemics in particular. Disease, after all, was caused by humoral imbalances. How, then, could smallpox and the plague wipe away entire populations? By the nineteenth century, however, as humoralism had died out and pathological anatomy had become the standard explanatory model in medicine, miasma theory had gradually broadened to, in some cases, explain ALL disease. For example, a Professor H Booth asserted in 1844, “From inhaling the odor of beef the butcher’s wife obtains her obesity.” There had been challengers to miasma, of course. The most notable was contagion, originally advocated by Fracastoro in the 16th century, which held that epidemic disease was spread by “germs,” which he visualized as small chemical substances that traveled from person to person. But by the 19th century, contagion was certainly a minority view, and several scientific studies — most notably by William Farr, now the superintendent of statistics at the General Register Office — had shown that disease decreases with increasing elevation. Miasma was so mainstream that Edwin Chadwick had successfully argued to Parliament to adopt a policy of draining away sewage — into the drinking water I should add — by saying, “All smell is disease.” Of course, while Nightingale was in Crimea, the seeds of miasma’s death were already being planted. John Snow was almost at that exact moment removing the handle on the Broad Street Pump, and Friedrich Henle had published his essay “On Miasma and Contagia,” arguing that “contagium vivum” or living contagion was the cause of disease — what we would later call “germ theory”. But that is a story for another time.

My point is, that Nightingale was completely within the scientific mainstream when she began to agitate for changes mostly along a miasmatic model — especially closing the sewer, but also providing good ventilation, fresh air, the highest standards of cleanliness including hand-washing, frequent cleaning, and better food.  In fact, the soldiers were given their rations raw and expected to cook it themselves, leading naturally to a fair amount of spoiled food. Nightingale worked nonstop to meet these aims, and clashed frequently with medical officers, though her tirelessness won her supporters as well. She worked throughout the day and night, and would often make her rounds on her wards late at night, earning the admiring nickname from her patients, “The Lady with the Lamp.” She did this all at great personal risk to herself; she nearly died from typhus and she contracted “Crimea fever,” likely brucellosis, which would render her essentially disabled for a large proportion of her life. But her agitation paid off — in March, the sewers were covered. Soon after, the death rate dropped dramatically. 

When the war ended, Nightingale returned to London — though in what would become characteristic later in life, she declined government transport so she could return with as little fanfare as possible. No matter. She was hailed as a national hero, the Lady with the Lamp. 45,000 pounds were raised in her honor — almost 3 million dollars today. She declined her many society invitations and used her fame to push for a single goal — the formation of a Royal Commission to determine what had gone wrong with the Army’s medical care, and to make reforms such that it would never happen again.

To do this, she faced a hostile military medical establishment.  But she was a public hero, so she planned to make her case the best way that knew how to — using the power of math. Her new prominence allowed her to work with some of the most important doctors, engineers and statisticians of the day, a small group of volunteers who would become her lifelong friends. The most prominent for the purpose of this story was the aforementioned William Farr. 

So let’s talk about the state of epidemiology in 1855, when Nightingale starts her work. In Episode 37 and 38, I told the story of Pierre Louis and the first population study in history, which showed the overall inefficacy of bloodletting in pneumonia. Louis was not immediately influential — physicians largely carried on as they had before, publishing case reports and case series to justify their treatments. But he was a respected member of the Paris Clinical School, and students from around the world came to hear him lect ure about his “numerical method.” One of those was the young physician William Farr, who would later create an office of vital statistics in Great Britain, essentially inventing epidemiology along the way.

But probably the biggest influence on Nightingale came from Adolphe Quetelet and his “social physics.” Quetelet was a Belgian astronomer by training, but when he turned his attention to biometrics — in particular, the chest measurements of 5.378 Scottish soldiers — he noticed something remarkable. Astronomers had long recognized the Law of Error in measuring celestial objects — that there would be a normal distribution of measurements surrounding the true “average” value. When Quetelet graphed out the distribution of these recruits’ chests, he noticed the same thing — a normal curve, surrounding an “average”. He looked at other objective measurements of people, and each time he discovered the same thing — a normal distribution surrounding an average. 

If you’re listening to this in 2019, I expect you probably have a collective “duh”. But from an early 19th century perspective, there was nothing obvious about this finding. Why should the measurements of humanity cluster around an average, like the movements of the Heavens? Quetelet developed all this into the idea of  bL’Homme Moyen — the average man. Of course, in the 21st century, “average” is something of an insult– milquetoast, boring, something to be avoided at all costs. But not to Quetelet. Average was the way to understand the architecture of God, or to the eugenicists who would run with these ideas half a century later, Natural Selection. The average man was the ideal man — in both the physical and moral sense. 

So when Nightingale sat down to analyze thousands of pages of army data, she could count among her influences Quetelet’s social physics, Louis’ numerical method, and of course William Farr’s vital statistics. She and Farr spent the better part of a year tabulating by hand all the deaths in the entire army by cause, lumping them into general categories — death from war wounds, deaths from preventable and “zymotic” causes, and all other non-preventable deaths. While the numbers on the page spoke to Farr and Nightingale, they realized a thousand pages of tables wouldn’t convince anyone else. Therefore, they created what she called a “coxcomb” and what we would call a polar area chart. This was, arguably the second graph ever produced in history, and probably one of the most influential graphs at that. It goes without saying that you’re going to have to take a look at this on my Twitter feed, because I’m about to go all “graph on the radio” on you. 

Imagine flower petals, 12 of them, one for each month, extending from a center stigma. Each petal shows shows the three categories of death — red for war wounds, blue for preventable causes, and black for all other deaths — startings in the first year in Crimea in 1854  up to March of 1855, when the sewers were covered and many Nightingale interventions went into effect. The larger the petal, the more death. The vast majority are preventable blue, spiking during that first horrible winter. Figure two starts in April of 1855, after the interventions. The blue wedges grow smaller and smaller, almost disappearing in the second winter. 

But Nightingale did not stop with this arresting figure. She also produced a graph showing the peacetime death rates in military hospitals around London, as well as a graph showing the civilian hospital deaths in the city of Manchester, which she chose as a control.  Industrial Manchester, with its foul smells, was considered one of the least healthy cities in England. You could clearly see, then, that Nightingale’s interventions had brought the death rate below London military hospitals, and essentially down to the civilian level in Manchester — a young soldier would be better off treated in Scutari than in London. 

She used these facts to deeply criticize the army Army — “Our soldiers enlist to death in the barracks,” she told Parliament , and she drew the analogy that the poor conditions in peacetime military hospitals was the same as if the military marched out 1100 men t o Salisbury Plain each year and shot them. But her overall tone in her report was hopeful — statistical data could be leveraged to improve lives. In the end, Nightingale got her Royal Commission, as well as the formation of a statistic report on the health of the army which used forms that Nightingale herself designed to track the health of soldiers and disease outbreaks. And while certainly not everything can be credited to Nightingale herself, the army followed many of her recommendations, especially in regards to setting up military hospitals and the presence of professional nursing. And these reforms worked — when British troops were sent to China to counter the Taiping rebellion less than a decade later, deaths were 90 percent lower than in Crimea, the vast majority of that driven by decreases in transmissible disease. Nightingale’s forms would be used well into the 20th century.

So here’s where we talk about some of the historical controversy. Basically starting in Nightingale’s own time, she was treated as a saint and a legend. In the 1980s, however, two de-mythologizing scholars claimed that Nightingale herself was largely responsible for the high death rate at Scutari that first winter, and that her guilt over this had led her to have a nervous breakdown when she realized what she had done. This has trickled into the lay press; the BBC produced two documentaries with these accounts, and actually called Nightingale the “liability with the lamp.” This has led Lynn Macdonald, anti-tobacco activist, former Canadian MP, and probably the foremost Nightingale scholar — she published 16 volumes of Nightingale’s correspondence — to fight back with a ferocity that earned one reviewer to call her “Nightingale’s bulldog,” referencing another often-maligned scientist — Charles Darwin, who, for the record, I happen to adore. Macdonald, for example, agrees that the death rate at Scutari skyrocketed Nightingale’s first year, and didn’t go down until March when the sewer was covered. But this is to some degree blaming the messenger — the army chose the location for the hospital, and Nightingale was the biggest agitator to get it covered. More importantly, it doesn’t take into account the French data, which shows a considerably higher death rate in French hospitals during the same period. Moreso, French doctors analyzing the data themselves saw this discrepancy as due to Nightingale’s sanitary reforms. But probably what offended Macdonald the most was the idea that Nightingale had a nervous breakdown after returning from Crimea. Because, as befitting someone who has literally read every letter Nightingale either sent or received, during the period of her alleged nervous breakdown, Nightingale was furiously working with William Farr to produce their report for the Royal Commission. I think it’s clear where my sympathies lie — when historiographical debates comes down between someone who has read and published 16 volumes of correspondence, and analyzed 19th century French army mortality records, versus  an analysis of secondary sources, I know where I stand. 

But back to the story. By 1858, Nightingale was revered across the country, had changed military medicine, and had even, at William Farr’s insistence, become the first female member of the Royal Statistical Society. On top of this, she was sitting on a healthy sum of cash that the British public had raised. So what to do next?

When you hear Florence Nightingale’s name today, she is most associated with being a founder of modern nursing. And that is because she put her 45,000 pounds towards founding a secular nursing school at St. Thomas’ hospital in London, called the Nightingale School. It was, in many ways, the first modern nursing school. So a very brief history of nursing. Nursing of course, has existed since time immemorial. In Catholic Europe, nuns, especially the Sisters of Mercy, took care of the sick and dying in crowded hospitals. In the poor houses of England, the inmates themselves would be designated nurses. But up until the 19th century, these were not professional roles — they were either branches of religious orders, and those that were not were poorly paid, looked down upon, and in some cases largely janitorial jobs. 

During the early 19th century, there were several parallel movements to professionalize nursing, concentrated mainly in religious order. The most notable was the protestant Deaconess movement, women who would be professionally trained in a variety of religious and lay activities, including nursing.  The first deaconess training center was founded, in fact, at Kaiserswerth, where Nightingale had studied, and by the time Nightingale was starting her school had already spread throughout Germany, England, and to the United States. Half of my own hospital — Beth Israel Deaconess, was founded as part of the Deaconess movement in the late 19th century as New England Deaconess. 

So I need to be clear that Nightingale certainly did not invent nursing, nor was she the first modern reformer. But she was the first to position nursing as a lay, or non-religious, profession. And she likely stands out the most for two major reasons.

The first was for her role in defining what a nurse should be. It’s true, if you read her Notes on Nursing today, the job will seem almost completely alien, largely providing fresh, clean air, good food, and cleanliness, and getting patients out of the hospital as quickly as possible. But she fundamentally envisioned nursing as a profession that would keep up with scientific advances; she wrote:

“Nursing is, above all, a progressive calling. Year by year nurses have to learn new and improved methods, as medicine and surgery and hygiene improve. Year by year nurses are called upon to do more and better than they have done”

And indeed, quickly the purview of nursing education at the Nightingale School expanded.. Nurses took temperatures, cleaned and dressed wounds, passed urinary catheters, gave injections, and when germ theory finally became ascendent, not only emphasized cleanliness, but also antisepsis.

But more than the content, the Nightingale School laid the foundation of what nursing should be, which has largely persisted to today — a completely independent profession, separate from medicine, with its own training; nurses would take instructions from doctors, but not unquestioningly — intelligent discretion was the rule. Above all, they served the patient. And nursing would be its own department and have its own hierarchy within the hospital, completely parallel to the medical hierarchy. Nurses ultimately answered to their own. And finally, and likely most importantly — nursing was a career, and a respectable one at that. It would pay well, have pensions, holiday time, and sick leave.

And the second reason was for the incredible influence and guidance that she offered to other young reformers throughout the English-speaking world. Nightingale School nurses — they were actually called nightingales — quickly spread through the British Isles, Australia, and Canada, to establish systems and training schools of their own. Nightingale would keep lifelong correspondences with many of these women. In the new United States, she was particularly influential. Linda Richards, the first trained nurse in the United States, corresponded with Nightingale throughout her lifetime, and even went to visit her with another group of American nursing leaders in London in the 1870s. She would go on to form training programs at Massachusetts General Hospital, in my neck of the woods, Philadelphia, Hartford, Worcester, Michigan, and later in Kyoto where she would start Japan’s first nursing school. 

I don’t want to downplay the rest of Nightingale’s career — she studied and advocated for the “aboriginal” members of the British Empire, especially children. She did groundbreaking work on hospital statistics and disease reporting, and her contributions, along with Farr, were essential to the founding of the International Classification of Disease, which is still used and in it’s 10th version. In fact, when I worked in Botswana, I had to file monthly mortality reports that still used a version of Nightingale’s original form. She used this data to advocate for rational hospital design; in fact, when her own data suggested higher mortality rates in her own midwifery program, she stopped deliveries in favor of delivering at home. And probably most remarkably — she advocated for what we would today call “evidence-based medicine,” or even evidence-based policy, a century before that term even existed. Towards the end of her life, she became obsessed with innumeracy — that public misunderstanding of statistics was harming public policy. Should would try to have a chair at Oxford endowed to study “social physics,” and wrote to Francis Galton, the founder of Eugenics:

“Our chief point was that the enormous amount of statistics at this moment available at their disposal (or in their pigeon holes which means not at their disposal) is almost absolutely useless. Why? Because the Cabinet ministers…their subordinates, the large majority of whom have received a university education, have received no education whatever on the point upon which all legislation and all administration must—to be progressive and not vibratory—ultimately be based. We do not want a great arithmetical law; we want to know what we are doing in things which must be tested by results.”

All of her accomplishments are remarkable on their own, but even more remarkable for her living condition. Like I mentioned earlier, after she returned from Crimea, she was stricken with a disease that left her bedridden for the remainder of her life, w ith various neurological symptoms, fatigue, muscle aches, chest pain, and difficulty walking. During her own time she was considered to have neurasthenia. But with the benefit of a century of more medical knowledge, it seems like that she probably contracted brucellosis in Crimea. The disease, which was then called Malta Fever, was first identified, in fact, in soldiers during the Crimean War. The initial infection presents with a flu-like illness, but like Lyme disease, chronic infection can have a myriad of neurological symptoms. But that it was caused by a gram negative coccus would not be discovered until 1887 by David Bruce.

And, of course, she was a single woman in Victorian London, and considerably constrained by her sex, despite directing groups of male physicians, statisticians, and engineers who would become her lifelong friends. She complained bitterly of the limitations of Victorian society in her own lifetime, and her essay “Cassandra” would later become an essential text to early-20th century feminists. She intentionally nev er married, even though she had suitors, knowing that doing so could strip her of her freedom. But her interaction with other women, and the suffrage movement, was complex, and she was initially vociferously AGAINST giving women the right to vote — ultimately, she was still a product of her time and held regressive stereotypes about the faculties of women, though she recanted and gave money to suffragists in her later years. 

One of the reasons I make this podcast is to view medical history in the context of its time, and I feel the same about Nightingale. But there’s clearly still wide disagreement today, since the top 2 google hits for “Florence Nightingale feminism” give a Vice article entitled “It’s Really Sickening How Much Florence Nightingale Hated Women,” and the second from a foundation dedicated to increasing the number of women in leadership positions entitled “Florence Nightingale: One of the World’s First Feminists.”

Nightingale leaves a complicated legacy for the 21st century — founder of nursing, pioneering statistician, complicated feminist. But I think she would also want to be remembered for her passionate advocacy and belief in “evidence-based medicine,” and more fundamentally evidence-based public policy. She believed in the power of science and statistics to make everyone’s lives better, and that the way to do that was education. We live in a more cynical age now, where there are, as Mark Twain put it, lies, damn lies, and statistics, where statistical thinking about human morality and capabilities have been taken to its extremes in the eugenics movement, and where p-hacking, publication bias, and any other number of methodological tricks can be used to justify pretty much conclusion.

But ultimately — I still think Nightingale was right. It’s just going to be a little harder than she thought. Well, that’s it for the show! But wait, it’s time for a #AdamAnswers.

#AdamAnswers is the section of the show where I answer listener questions about pretty much any medical topic that comes to mind. For this episode, I solicited questions about nursing in particular — and I got the most questions I’ve ever had for an episode! I’m going to answer two — and start with the easy one.

First, Zaven Sargsyan asks, “In many English-speaking countries, the word for nurse is “sister.” Same with many other Indoeuropean languages. Why?”

Like I talked about earlier, one of the sources of modern nursing is from Catholic religious orders, in particular the Sisters of Charity. The Deaconess Movement at Kaiserswerth, where Florence Nightingale had trained, explicitly adopted many of the trappings of the Sisters of Charity — Deaconesses would train in the “Motherhouse,” and they were called by the title Sister. This terminology was deeply ingrained enough that by the time Florence Nightingale started the Nightingale School, sister was used as an official rank — a ward sister, for example, is what we Americans would call a charge nurse. And this terminology is still used throughout the world, including where I worked in Botswana, where we had a male “ward sister,” as strange as that sounds.

So why aren’t nurses called “Sister” in the United States? I don’t really know the answer to this question, but I found a fascinating series of letters published in the American Journal of Nursing in 1919 complaining about treatment of Navy and Army nurses during WWI. The women writing these letters talk about the contrast with their Canadian counterparts, who were treated with considerably more respect, and talk about them being called “Sister” as if it were rather surprising. So it’s presumably not a recent phenomenon — but if anyone knows more, please let me know.

So like I said, I’m going to tackle a far more difficult question for the second. Tali Cahill asks on Twitter, “I want to know how much discussion of the role/scope of nurses is incorporated into med school curriculum…sometimes I feel like we’re playing two different games on the same field at the same time.” 

Tali’s question was just one of many that addressed in a fashion the same overall theme — why does there seem to be so much nurse-physician conflict?

This is a sensitive subject, and I suspect there are some interesting sociological and anthropological takes on the relationship. In fact, I’d love to hear from other perspectives. But I’m going to be quoting from nursing and medical literature — and explicitly from a U.S. context. All of the studies I quote are in the show notes if you want to read them.

Professional nursing as advocated by Nightingale placed nurses in their own hierarchy separate from physicians, but very much in a subservient position — so much so that in living memory, nurses would have been expected to stand when a physician enters the nursing station, and could potentially be subjected to verbal or even physical physical abuse. And the relationship was constrained by traditional gender roles — physicians were men, and nurses women. Even today, 28% of physicians are female, and only 9% of nurses are male.

The first literature that I can really find on nurse-physician relationships comes from 1967 by Dr. Stein, who along with his colleagues interviewed young doctors, nurses, and nursing students.  He, like Tali, describes the  doctor-nurse relationship as a “game” — nurses would give feedback by “tricking” the doctor into thinking the correct course of action was their idea all along. This was an idea Florence Nightingale would have approved of,  who once wrote that, “the bad woman, the clever nurse, must be an idiot if she cannot hoodwink the doctor.” 

In the context of 1967, Stein sees the game as regrettable; he calls it a “transactional neurosis” and cautions physicians that expecting it to continue in this fashion is “disastrous”. But he respects clearly respects the game as well, in that it gives a socially acceptable way for nurses to give feedback to physicians, in a society that would never tolerate direct confrontation. Nurses were steeped in this “hidden curriculum” — since the time of the Nightingale school through roughly the 1970s, nursing education was focused in hospital-based diploma programs, and from their first day as a student nurses would have encountered the game. Stein describes this education: “[student nurses] are told [the doctor] was infinitely more knowledge than they, and thus he should be shown the utmost respect… the inevitable result of these practices is to instill in the student nurse a fear of independent action [which is] most marked when relating to physicians.”

By the 1980s, nursing education started to shift to universities and academic centers and away from diplomate programs — in 1988, less than 15% of new graduates were diplomates, compared to 90% in 1955. These new academic nursing schools introduced many new ideas into nursing education, but for the purpose of this answer, they promoted a new sort of nurse-physician relationship that stressed collegiality and equality, similar to the “allied health” professionals like physical and occupational therapists. And while this is way beyond the scope of this answer, the same period saw the gains of second wave feminism change both professions — including an increasing number of female physicians, to the point that over half of students who matriculate to medical school are now women. 

Enormous cultural and societal changes — even those for the better — can cause a phenomenal amount of stress, and over the past two decades a number of qualitative studies in both nursing and medical literature have catalogued changing perceptions of both nurses and doctors. I have a few review articles in the show notes, but I’ll quote one that I find particularly interesting since it  focuses on a setting that I work in — an academic hospital. Weinberg and her colleagues interviewed and coded in-depth interviews with 20 medical and surgical residents on their relationships with nurses. As you can imagine, there’s a lot of heterogeneity to how residents viewed their relationships with nurses, but many still viewed the primary role of a nurse to carry out orders, and had a lack of understanding on how much education nurses had to understand the medical plan. A similar study looked at nurse-doctor relationships from the nurse perspective. Kramer and Schmalenberg in 2003 interviewed 279 staff nurses at Magnet hospitals, chosen because they have high levels of nurse job satisfaction. They found that nurses viewed the most positive relationships with physicians as either “collegial” — in which nurses and doctors are both experts in “separate but equal” domains of knowledge, and “collaborative,” in which nurses and doctors share knowledge and power. Most of the nurses reported that they did not view their professional judgement as “subservient” in any way to the physician.

And Tali — this gets to your question; I didn’t actually find any literature of the scope and roles of nursing in medical education; I know that I didn’t get anything in medical school (though got a heavy dose of the “hidden curriculum”). But essentially e very article I read ends by concluding that both nurses and doctors need better education on each other’s roles and responsibilities as part of a health care team — even more importantly because it appears that good physician-nurse relationships improve patient outcomes.

I don’t want to sound overly pessimistic here. Things actually appear to be changing for the better, and social changes often come with a significant amount of stress. Dr. Stein, who wrote the original 1967 article describing “the game,” wrote a follow up in 1990, and even almost 30 years ago he saw many of the conflicts that authors are recognizing in the teens. But despite this, he sees nothing but positivity in a new relationship; “Subservient and dominant roles are both psychologically restricting,” he writes to close his article. “When a subordinate becomes liberated, these is the potential for the dominant one to become liberated too.”

Okay, thank you so much for the question Tali, and the many other people who wrote in as well. Let me know what you think — the nurse-physician relationship is, for lack of a better word, complicated — but the two fields are inextricably linked together, and beyond the nurse-patient and doctor-patient, the nurse-doctor relationship is about as important as it gets in health care.

And if you, dear listener, have a question you want to submit to #AdamAnswers, please tweet at me @AdamRodmanMD.

Okay, that’s really it for the show! I have some incredibly exciting news — I will be giving a talk at the American College of Physicians annual meeting this year in Philadelphia! The title is The French Disease at 500: A History of Syphilis, on April 11th at 11:15 AM to 12:45 PM, along with King of Med Twitter Tony Breu. I posted the event page on Twitter, but stay tuned for more details as they come, but I’d love to see you there!

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All of the sources are in the shownotes. 

And finally, while I am actually a doctor and I don’t just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes, and should not be construed as medical advice. If you have any medical concerns, please see your primary care provider.