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Surgeon General Richard Carmona Relies on His RN Roots

Monday April 19, 2004
Photo by Keith Wellerr
Photo by Keith Wellerr
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Many may not know that the Surgeon General also used to be a registered nurse. Vice Admiral Richard H. Carmona, RN, MD, MPH, FACS, was sworn in as the 17th Surgeon General of the United States Public Health Service on August 5, 2002. During an exclusive interview with Nursing Spectrum, Dr. Carmona clearly expressed his respect and admiration for the nursing profession and stressed the value of nursing experiences in his life and how they impact his role as Surgeon General of the United States.
According to your bio, you are a registered nurse. Where did you attend nursing school, how long
did you practice, and in what capacity?
A. My nurse training was in the Army. I was licensed in California as a registered nurse, approximately 1974 or 1975, and worked as an RN for seven years as I was finishing college and going to medical school. Halfway through medical school, I put my license on inactive status because I didn't have time to work anymore, as I was doing clinical rotations and working full-time as a student physician.
While I no longer did clinical nursing, I continued teaching, worked with a number of registries, and did continuing education. In medical school I collaborated with two other RNs to put together a nursing elective for first- and second-year students to learn about nursing and bedside care - the nursing approach to care: what it's like to be a nurse, vital signs, patient communication, compassion, and so forth. The elective was well received and was fully subscribed every semester at the University of California, San Francisco. Most first- and second-year medical students have no clinical experience and they really liked working with the nurses. We put together a nursing skills lab and taught a broad range of skills, from caring for bedridden patients to vital signs and invasive procedures.

What led you into the nursing profession?

A. I served as a medical specialist in the Army and took the exam and additional training in critical care nursing, or what was also called mobile intensive care nursing. I combined my paramedic skills with working on the ambulance and transporting patients. It seemed like a logical extension for career development and enhancement. I already had the skills, so a lot of things came together. I needed a job, loved working in the health profession, and liked working with patients. It worked well for me because I needed to support myself while I was going through college.
Did your nursing background make you a better physician? If so, why?
A. No question about it. Talk with any of my colleagues in medicine, the medical students, and residents I worked with over the years. It's something I've said for 25 or more years. Being a nurse has better prepared me to be a physician because I really understand what caring means - the compassion side. As I used to tell my medical students and residents: We physicians pass by the bedside for five minutes. The nurse is the true caregiver. They're the ones at the bedside 24 hours a day in the traditional nursing role. Now nursing, of course, has expanded tremendously and there are so many different roles. I believe there is no better definition of a true patient caregiver than a nurse.
As a former practicing nurse and practicing physician, what solutions would you offer to help the nursing shortage?
A. First of all, I think there has to be greater recognition of the importance of the role the nurse plays on the team. When I was a nurse, nurses were treated more or less in a subordinate fashion with the doctor as the captain of the team. That's changed. I grew up in an era where doctors would come into the nursing station and the nurses would get up and give them their seats, go get them coffee. It was a different world, a different culture. And now, I believe nurses are an equivalent partner in the team because we all apply some skill set to the patient whatever that may be. The doctor may do an intervention or make a diagnosis - the nurse, the physical therapist, the social service people do their special things, and I really do look at it as a collaborative team.
Of course, what we always thought of in nursing was collaboration - collaborative teams. The recognition of the importance of nursing has to be brought to the forefront. I think we need to be much more innovative in how we use our nurses. Nurses need to be used in positions commensurate with their abilities. Where we can divide out supportive activities that aides and technicians can do and that nurses can supervise, I think that's helpful. We have to make a healthier, positive and productive work environment. We have to treat nurses fairly and justly for what they contribute to the team. And we have to create an environment for which young women and men really feel a passion, that they want to work there. I think it's all of those things. The problem we're facing in nursing today is not just one issue. It's multifactorial and we have to approach it on all those levels.
What new roles might be assigned to nurses in the future?
A. We've already seen it with nurse practitioners. We've seen the role of the nurse expand. When I was practicing nursing, nurses typically had no assessment authority. Almost every nursing school curriculum now is packed with nursing assessment and nursing skills. In the old days, nurses did bedside care and limited observation and no real assessment. We've seen a new trend in the past 30 years. Nurses are at the bedside doing assessments. They're active participants in the care of the patient. I used to tell my medical students and residents, "You have to look at those nurses as part of your team. They are your eyes and ears when you're not at the bedside." Especially in the ICU where I ran a trauma system and intensive care. I told the residents you need to get to know the nurses well; they will teach and train you. They will have you understand what real critical care at the bedside is about and they will protect you because they will see subtle changes in the patients that you as students and residents won't pick up and they'll alert you. That's nursing assessment because they know that patient. They're right there, minute to minute. They see those variables changing.
What part of your nurse's
training has stayed with
you as Surgeon General?
A. The strongest part is compassion and patient advocacy. I have a daughter who is a registered nurse and a graduate of the University of Arizona. She's a trauma/critical care nurse and we often have these conversations. As a young nurse, she comes home frustrated because she's trying to fight for something for a patient. I love that because I see the advocacy part. When you're in bed, sick, and can't make good decisions for yourself, nurses need to be in positions of advocacy for the patient, assuming that responsibility as well as the care. For me, it's that unique role as a patient advocate and as a very compassionate caregiver.
Why is the concept of health promotion and disease
prevention a hard concept to "sell" to the American public?
A. A lot of it is our culture and the media. Having been a nurse, a public health officer and a trauma surgeon, when I ran the trauma program I never had any problems finding reporters who wanted to spend the night in the trauma center and witness the gunshot and stab wounds and film a story about it. But if we called them to film a story about nursing care or public health or prevention, it would have to be a really slow news day before you got someone interested in something like that. I think it's just what sells - the acuteness, the trauma center, the police, the rescue squad - those are the shows. No one makes shows about a nurse or public health person.
One of the things I tell my staff - and I have a lot of nurses in the Public Health Service - is that you are brilliant and wonderful. My one criticism of people in public health, including my nurses, is that they do everything so well, but they do it anonymously and everyone takes it for granted. I think public health is like nursing in that respect. You turn on the water and you expect clean water. You have sanitation, immunization, on and on and on, but then when things fail you want to know why certain things didn't happen. Who didn't do their job? Nursing is the same way. The doctor gets all the credit at the bedside for doing this great operation, when in fact, it's the team that kept the patient alive after the operation and nursed the patient through all the wounds, injuries, mental problems, etc. The nurse is the one with the holistic approach. The doctor, especially today, is often involved in a complex system, unless you have a primary care doctor caring for you. Disease prevention and health promotion are not sexy, don't sell; they're not headlines.
You have stated that domestic preparedness is an important issue for our country and requires
collaboration among many different government and health entities. Is that an achievable goal? What role might nurses play in that collaboration?
A. Absolutely there's a role for nursing. It is an achievable goal, but it's going to take time because we have to break down our silos to relate better to one another. A lot of what we're doing in this transformation requires more people skills. We have assets, relationships, and resources. We have to figure out how to put that local, state, federal network together in a seamless fashion that provides research capacity when needed but doesn't create redundant systems that are costly and are not used. We have to be very creative and think differently than we have in the past. Definitely achievable.
Some of the first groups I went to when I was charged with this responsibility on the local and state levels, and now as the Surgeon General, were the nurses - nurses locally, nurses in state organizations, as well as nurses nationally. A few years before I was the Surgeon General, I sat on a committee that was the predecessor of preparedness today - the national FEPO, sponsored by the FBI and the Office of Emergency Preparedness - and it included people like myself who had been involved in emergency preparedness for years. It was pre-9/11 and, other than those of us who did this for a living, no one paid much attention to it. I worked with a nurse with the FBI, and she and I and a number of others formed a national network of nurses so that we had a listserv to help us communicate with nursing organizations and nursing schools and let them know what was going on in preparedness. We used the nursing network to reach the communities and educate them and tell them what was going on.
Obesity has been cited as a major public health problem in this country. Why has that happened and what is your office doing to address the problem? What can nurses do to augment your efforts?
A. Well, we've defined the problem. We've got 9 million children who are overweight and obese, and 300,000 deaths a year related to obesity at a cost of $117 billion per year. We've established that we have an epidemic and that it is growing. And, if we don't break the cycle - especially for our children, not to mention the two-thirds of adults who are overweight or obese - what we're doing is breeding an overweight, dysfunctional, middle-aged population that in 20 years will have type 2 diabetes, higher rates of cancer, and higher rates of heart disease, laid on a disease burden and economic burden that we already can't afford.
That's the future. So we must act now. What do we do? Well, we have to increase health literacy, that is awareness. People have to understand that this is a problem and grasp the seriousness of it. Much like we mentioned earlier with public health and the issue of nursing contribution, the problem of obesity is kind of assumed or taken for granted. And so, how do you address an issue such as this in our society, that I've come to call the "terror within" and worse than any terrorist event? With 300,000 lives a year lost from obesity-related disease, and now growing a future culture, in twenty years, of middle-aged people who will have all these diseases and all these problems, what does it say for the work force? For education? Where will our policemen, firemen and soldiers come from when we don't even have people who can walk safely? Nursing has a vital role in this because nurses have much more contact with patients than do physicians. Nurses are educators and leaders, and what I'm trying to do is work with nursing organizations to raise the level of health literacy and educate the public about the problems of being overweight and obese.
Your predecessor published a major report about mental health and the fact that it gets less attention in the health arena than physical health. What are your plans for addressing the concerns raised by the report?
A. I met with some of my predecessors, Dr. David Satcher, Dr. C. Everett Koop, and Dr. Antonia Novello, both before and after I took the job. I wanted to be certain there was some continuity in programs that Dr. Satcher had initiated and that were important. One of those was mental health. Having had many positions in healthcare, including nursing, but also having been a CEO of a county hospital and a health system, I am acutely aware of the deficiencies we have in mental health in the US. I would go so far as to say it's not a mental health system we're trying to repair or build on, because we've really never had a mental health system in this country. We have a number of well-intentioned people who have practiced and programs that have come together. But as far as a system, I think it's pretty tough to define a system when you have about a fifth of the people in the country every day who have mental health needs that are going unmet.
Following up on Dr. Satcher's work, I have actually taken it another step forward and we're now looking at a Surgeon General's Report on mental health issues in women. We're also looking at mental health issues in preparedness - that is, how we deal with the mental health consequences of terrorism. We have a working group at NIH and CDC and other stakeholders right now looking at those issues. I agree with my predecessor, Dr. Satcher, that this is a very important area and one that hasn't received as much attention as it should get. And I'm trying to also keep it on our radar screen and dealing with nursing as well as other organizations nationally to come to a consensus on a lot of these issues and how we should deal with them.
You served in the Army's special forces and are a Vietnam veteran. Has your experience as a combat surgeon affected your approach to domestic preparedness?
A. No question. I got my first education in terrorism and nuclear, biological, and chemical warfare back in the late '60s and early '70s. I've been dealing with this pretty much my whole life both in the military and in civilian EMS, law enforcement-I was a police officer - and as a paramedic. Just about every job I have had has intersected with, or been involved in emergency preparedness or what we used to call emergency management, or EMS systems. I'm very comfortable in that environment because for 35 years it's been pretty much my life. That early education has helped me a great deal.
Since 9/11, the importance and role of public health has increased substantially. How will you as the Surgeon General ensure that that attitude will continue?
A. I'm doing everything I can to keep public health in the forefront. I think after 9/11, it's difficult to take public health for granted anymore, whether it's bioterrorism or it's sanitation and health. But in an everyday setting, we're dealing with prevention and wellness activities. That involves public health, too. So everything I do is a public health message. My portfolio includes prevention, preparedness, health disparities, and in all of those areas I talk about health literacy, increasing the knowledge base for all citizens, and strive to keep public health in the forefront of all we do.
Any final words you would like to say to the 1 million readers of Nursing Spectrum?
A. I am very happy and I'm lucky that I have had the opportunity to be a nurse and add that dimension to my ability to be a better physician and Surgeon General. I draw on those skills every single day, including not just the knowledge base but also the networks and the nursing friends I've kept and maintained over the years. And it's trickled down right to my daughter who is a critical care nurse today.