T

he longstanding hierarchy in medicine — mostly male doctors at the top of the heap and mostly female nurses below them — often gets in the way of patient care. We need to change that structure for the good of the profession and our patients.

Emerging trends in medicine and nursing may lead to “flattening the hierarchy” as women move into traditionally male roles, sociologist Anne V. Bell recently told attendees at Rosalind Franklin University’s second annual symposium on the gender divide in health care professions. But despite these gains, women still struggle to establish themselves as equals in health care professions.

A reminder of this divide tore through social media recently when a Florida anesthesiologist with ties to a major medical school posted demeaning and inflammatory comments about nurse practitioners.

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“Nurse practitioners are not, I repeat, not physicians. They lack the education, IQ and clinical experience. There is no depth of understanding. They are useful but only as minions,” Dr. David Glener ranted on Doximity, a medical social media network. His comments were posted to Twitter, where many people reacted swiftly, calling for physicians to take a team-based approach and promote unity among health care professionals.

Nurses have long realized that membership in a female-dominant profession means having their competence questioned despite extensive training. The comments by Glener, who is on the board of Florida State University, as well as one by Dr. Wendell Perry, an emergency physician, speak to a broader issue of disparity in the health care professions that is connected to gender and the hierarchy of medicine.

As policymakers work to reform health care, aided by professionals who provide patient care, the Glener rant provides a well-timed reminder of the ethical obligations of physicians and nurses to build collegial relationships with each other and with all health care professionals.

The American Medical Association prioritizes the importance of this inter-professional relationship. In a chapter of its code of ethics, these efforts are described as part of a “common commitment to patient well-being” which “should be based on mutual respect and trust.”

With looming physician and nursing shortages, predicted to produce up to 104,000 and 1.2 million vacancies in the coming decades, this trust and commitment will be put to the test. The health of the public depends on its success.

Improving inter-professional relationships is one approach to help advance gender parity in health care. Women in STEM fields have been historically undervalued. As Angela Saini points out in her recent book, “Inferior: How Science Got Women Wrong — and the New Research That’s Rewriting the Story,” researchers such as Charles Darwin have made claims deeming women inferior in science and medicine dating back to at least 1881. This could not be farther from the truth.

As IQ scores have risen over the past 100 years, women’s gains have outpaced men’s. Furthermore, in a test of abstract, logical reasoning women again matched or exceeded scores of male counterparts of equal educational level.

Yet despite overwhelming evidence of the contributions women make in advancing science, women in academia experience persistent gender bias. Men have often received credit for women’s work, a phenomenon that has become known as “The Matilda Effect.” One study, for example, showed that the same research abstract was rated higher in scientific quality if the author was a man rather than a woman. Such bias and other gender differences, such as women contributing more time to teaching and mentoring colleagues, mean that women publish less frequently than men, limiting this as a gateway to career advancement and promotion.

Economic disparities persist as well. Despite accounting for 91 percent of the nursing profession, women still experience a gender pay gap, earning between $4,000 to $17,000 less per year than men, depending on specialty area.

Similarly, though the percentage of female physicians has grown to account for 50 percent of the profession, on average they earn 8 percent less (about $20,000) than their male colleagues.

These gaps will not shrink overnight. The onus will be on higher education to deconstruct the hierarchy of science and medicine. It must do this by recruiting a diverse faculty and student body that mirrors the U.S. population by gender, race, beliefs, sexual orientation, and socioeconomic backgrounds. It must also cultivate a culture of respect for the contributions of these diverse bodies.

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Faculty members of every discipline will be asked to model behaviors that foster inter-professional collaboration. One essential component of their approach must be to equally value the contributions of all health care providers — and the providers themselves — and not see one group as superior to others

In my experience as a nurse, patients usually don’t prioritize a health care provider’s gender, title, or degree. They want to know you are competent. And that you care.

With all of the controversy in health care, we need to put emphasis back on the caring. Flattening the hierarchy is an important way to do this.

Melissa D. Kalensky is an assistant professor in the College of Nursing at Rush University, a family nurse practitioner, and a Public Voices Fellow through The OpEd Project.

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  • Hey G,
    I agree with you. you seem to be the only one who understands this article is based on personal view and really just pointing out facts about the differences between a nursing education and a physician’s 8 to 12 years of education that they go through before fully becoming a doctor. The IQ part was redundant. There are plenty of nurses that demeans med students, interns, doctors sometimes. where is the mentioning about that? Where’s the article about nurses having cliques and gossiping at work? Nurses such as RN someone with more experience demeans LPNs, MA’s all the time. So, please don’t try to turn it around and say only doctor’s do this. A company’s upper-level management is going to have the upper hand sometimes and because they earned it. NP or PA is adequate enough that is a fact. You can’t replace physician with nurse’s care, it is impossible. There are plenty of patients who want to be seen by an MD than an NP and of course, if there is none then they will take next to nothing.

    • Sam, This isn’t an article comparing nurses to doctors. It is comparing Advanced Practice Nurses with doctors. Advanced Practice nurses act as Nurse Anesthetists, Nurse Practitioners, Clinical Specialists, Nursing professors, and also specialized roles life Certified Midwives. They have a minimum of a Master’s Degree(6 years of education) or a doctorate (7 years of education). You seem to be confused about their role, and their academic preparation. Moreover, NPs do not wish to cut out or supersede physicians, they are not meant to replace the doctors, but extend from the doctor’s role. Patients need to understand that research shows that NPs have excellent track records and outcomes similar to their physician colleagues. Interestingly, NPs have been shown to have greater job satisfaction than physicians, and the job opportunities keep growing for both NPs and PAs as shortages of medical doctors persist. I hate the tone of your letter; most doctors are happy to work with NPS and to mentor and advise them.

  • The crux of the article is the statements by Dr. D Glener who commented “Nurse practitioners are not, I repeat, not physicians. They lack the education, IQ and clinical experience. There is no depth of understanding. They are useful but only as minions.”

    To call your colleague a “minion” and lacking in IQ, these are condescending, inflammatory words that show little respect for another’s profession, whether or not a woman or man is the nurse practitioner.

    What does Glener hope to achieve with such statements? The medical profession is difficult enough with long hours and is one that takes a toll on your physicality.

    How about some respect for the nurse practitioners who are on the front line of caring for patients?

  • This article really doesn’t make sense, it’s based out of gender discrimination. Regardless of personal views, consider the “devil’s advocate” position.

    1. The comment about NPs has nothing to do with gender and everything to do with nurse vs. physician education. You can’t possibly say a nursing education is equal to that of a physician education. Yes, they serve different functions, but medicine can NOT happen without physicians to diagnose and provide treatment plans – it can without nurses, just highly inefficient. Sorry if that’s a flaming comment.

    2. For that mat matter, regarding the pay gap in medicine, last I checked BCBS doesn’t pay more for a lap choly to a male surgeon vs. a female surgeon. There is obviously another reason for the pay gap. We know from studies that male physicians work more and see more patients per hour. That would result in more money. Male physicians are more likely to choose lucrative specialties like cardiology or surgery. So why not continue to encourage woman to pursue these specialties? Funny how there’s no push to equalize the gender gap in the female dominated specialties like pediatrics or OB-GYN. Sure these aren’t the highest paying specialties — so is money the only thing that matters in life? Where’s the push to have men enter general nursing, which is relatively well paying compared to average American jobs. Where’s the push for male NPs? Oh that’s right, none of this fits the agenda.

    • G-nurse practitioners in my state of MA can and do set up private practices where they do diagnose and treat patients in primary care settings. They are expected to make referrals when appropriate to their MD colleagues. They have excellent outcomes and efficacy. You are overstating their dependency on physicians. Nurses do not develop practice standards based simply upon the physicians”orders”. Standards of wound care and prevention, infection control practices, best methods of practice for procedures such as placing lines, giving chemo, assisting the patient’s rehabilitation, post natal family care, to name just a few, are all arenas in which nursing research has led to standards of nursing care. Such practices are not taught to nurses by physicians but by nursing educators. In short, busing is a distinct profession, governed by nursing leadership, with many of the same general aims as medicine. It is not subordinate to medicine, it stands shoulder to shoulder with it, and other related fields.
      Might I say you sound as if you are, like Gen John Kelly, afraid we will forget our history, and haven’t moved on from the 1860s, when your view of nursing as handmaiden to the MD was enshrined. Time you were woke.

  • The very best patient care emerges when ALL healthcare professionals work together. Docs, nurses, laboratory scientists, radiology and imaging, pharmacy, rehabilitation, etc. All these people should function like a well-oiled machine. One discipline can’t possibly know everything!

  • Nurse Practitioners who graduate from highly regarded programs such as Yale, Penn and Duke are very bit as intelligent as their physician colleagues, and those programs are probably harder to get into than some lower tiered med schools. Are they equivalent in practice? No, and i don’t know any NPs or Pas who claim to be equivalent or aspire to be equivalent. Physicians are trained to diagnose illness. Nurse practitioners/Physician Assistants act as physician extenders, diagnosing and treating less complex problems, and making referrals to physician/specialists when warranted. Both disciplines follow algorithms based upon best practice research. Its discouraging to read the disparaging comments made by a few rogue Mds who apparently are misogynists, they certainly don’t represent the vast majority of physicians who treat their nursing colleagues as colleagues. When I was a practicing NP I knew my limits and sought out physician guidance when I needed it.

  • Women have always been made to feel inferior and have accepted that a fact. My granddaughters as being raised with self respect and the ability to make anything they want of themselves

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