1. Masson, Veneta MA, RN

Article Content

It's 1997, and the 76-year-old patient sitting before me in apparent good health is feeling miserable. She reports that her breasts are sore and hard "as rocks" and that she's noticed some spotting "after all these years." She tells me that the physician she last saw had put her on hormone replacement therapy (HRT)--"for my bones and heart," she says, "and to keep me from getting Alzheimer's." In so doing, the physician has standard practice and published research studies to support him, but while I believe that HRT can be effective for the relief of menopausal symptoms, I question its preventive value. I have read everything I can on the subject and know that experts share my view. At the very least, I think, this woman should be taking a lower dosage.


But I'm a nurse practitioner, and because my patient doesn't know me well and trusts her physician, I must be circumspect. I suggest that because she is older, has a small frame, and is experiencing breast and uterine changes, she might do better taking a lower dosage-if she wishes to continue HRT at all. "Remember, we're not all the same," I remind her. Wary of the suggestion, she replies, "He told me this is the standard dose. If I take less, I won't get the benefits." I ask her to consider the option and to return for a follow-up visit. According to current practice, an endometrial biopsy is indicated if spotting persists. I'm troubled and quite doubtful.


It's 2002. Early study results of the Women's Health Initiative have made newspaper headlines, in apparent confirmation of the validity of my doubts about HRT, and women are spitting out their hormone pills as though they were wormy apples. At the same time, my mailbox is stuffed with letters from Wyeth, the manufacturer of the formulations tested in the study, in an attempt to cast the best possible light on the research findings.


I'm old enough to remember when patients were immobilized with sandbags after cataract surgery and treated for myocardial infarction with oxygen and bed rest. I also recall the milk-and-cream "Sippy" diets prescribed for peptic ulcers, and the rushed radical mastectomies for breast cancer. At the time I accepted the validity of all of these treatments, but they have long since passed from favor. Even as recently as a decade ago, I prescribed antibiotics for otitis routinely and believed that bypass surgery, mammograms, and cancer chemotherapy save lives. Now I doubt the validity of all these practices, sensible of certain limitations intrinsic to medical scientific research, in which there is concern with reputation and profit, considerable competition, and the self-aggrandizing advancement of "pet" theories. Science doesn't possess the tools to explain and heal all of what ails us human beings, and I expect that many of you share this view.


How, then, can we nurses reconcile doubt about current practice? We learn early that there is safety in conformity and that the so-called gold standard of diagnosis and treatment of any condition is sacrosanct until supplanted by a new one. To challenge an outright mistake-the wrong procedure, technique, or dose used-is one thing, but for a nurse to question conventional wisdom--well, that's quite another. Yet we are obligated, to ourselves, to the profession, and to our patients, to provide the best possible care.


I've come to embrace rather than suppress my doubts about medical practice, and they indicate that my mind is at work, weighing conventional wisdom against 35 years of experience. I ask myself, "Are these doubts well founded? If so, on what?" I'm not a researcher, but I know how to read and evaluate research reports. I can tap colleagues and experts for their experience, through conversation, lectures, and publications. If I'm convinced that my doubts are well grounded, I can express them at staff meetings and professional conferences and in letters to an editor. To be the best advocate of my patients and of the public, I must take an informed and principled stand. Doubts that don't dissipate in the light of new information may in the end prevent harm or even save a life.


I've come to embrace my doubts about medical practice.