Asking the Nurse First

I built a curriculum out of one sentence.

The sentence is the founding argument of this publication: ask the nurse first. The curriculum is the structured operational answer to the question, what does it look like to actually teach this to family medicine residents.

The answer is concrete. It is not a teamwork module. It is not a communication skills workshop. It is not a sentimental session about respect. It is three specific changes to what residents do, what residents read, and how residents reflect — implemented in my residency program as a formal curriculum component. The changes are small. The changes work.

This essay is what they are.

The Pre-Round Protocol

The first change is structural. Before a resident enters a patient's room on rounds, they find the nurse and ask for the nurse's clinical assessment. Not "any updates?" Not "anything I should know?" The protocol is: ask the nurse what they think is happening with the patient, and write down what they say before you walk into the room.

The phrasing of the question matters. "Any updates" produces a status report. "What do you think is happening" produces an assessment. The first is data transfer. The second is solicitation of the nurse's clinical model. Most residents have never been asked to ask the second version. Most have been trained, implicitly, to assume that the nurse will report what is needed and otherwise stay out of the diagnostic frame.

The act of writing down the nurse's answer is the second part of the protocol. It does two things. It signals to the nurse that the answer was heard, recorded, and will inform the clinical reasoning. It also forces the resident to engage with the answer as content — to take it seriously enough to commit to paper.

In didactics I tell residents the same thing every cycle. The nurse you are asking has been with this patient for twelve hours. You have been with this patient for the duration of the physical exam you are about to perform. The nurse's model has more inputs than yours does. Use it.

The Reading List

The second change is academic. Residents in this program read selected nursing texts during the interprofessional epistemology component of didactics. Not the whole BSN curriculum. Five readings.

Patricia Benner's chapter on caring from From Novice to Expert. The chapter that frames the practice of caring as a clinical act with informational content, not as a sentimental complement to the technical work of medicine.

Sister Callista Roy's chapter on the Adaptation Model. The framework that gives the clinician a structured way to think about biological, psychological, and social inputs as a single coherent clinical picture.

Mark Risjord's article on standpoint epistemology in nursing. The philosophical argument that nursing's position generates clinical knowledge unavailable from the physician's position. This is the article that founded the publication you are reading.

A short paper by Donna Diers on clinical scholarship — what it means for a clinical profession to take its own knowledge seriously enough to study it. This is the corrective for the assumption that nursing is task-focused; Diers shows the discipline studying itself.

A 2014 Lancet paper by Linda Aiken on nurse staffing and hospital mortality across nine European countries. The empirical anchor. The paper that makes the philosophical argument operational.

Residents do not read these passively. They read them and write a one-page response that I read and discuss with them. The responses change over the course of residency. By the third year, residents come into didactics quoting Benner without prompting. That is the metric.

The Reflective Practice Session

The third change is methodological. Once per block, residents present a case from the previous month and examine it through the framework of the theory-practice gap. The structure is borrowed directly from nursing education's reflective journaling tradition, adapted to a fifty-minute didactic.

The resident describes the case. They name what they were taught about the clinical situation. They name what they encountered. They identify the gap. They consider what model the nurse on shift might have been using, and whether that model would have closed the gap faster.

This is not a Morbidity and Mortality conference. It is not about error. It is about the structural distance between what medical education delivers and what clinical practice requires. Some sessions are dramatic. Most are not. The point is not the drama. The point is the practice of recognizing the gap as a gap, and using the recognition as a tool.

Schön's reflective practitioner is the theoretical scaffold. The residents do not need to know it by name. They need to know that the activity of reflecting on the distance between formal preparation and clinical reality is itself a skill, that it can be improved with practice, and that medicine has not historically taught it.

What Changes on Rounds

The outcome metrics I care about are not satisfaction scores. They are behavioral.

By the end of the first year, residents in this program ask the nurse before entering the room. By the end of the second year, they document what the nurse said. By the end of the third year, they identify when their differential diagnosis does not match the nurse's clinical impression and treat the mismatch as data, not as conflict. These are observable changes. The attending physicians on the floor notice them. The nurses on the floor notice them more.

The residents themselves describe the change as small. None of them experience it as a curriculum revolution. They experience it as a slight reorientation of attention — toward a clinical actor they had been peripherally aware of and trained to consult only when something specific was needed. That smallness is the point. Curriculum reform that requires every resident to feel transformed produces less behavioral change than curriculum reform that quietly reorients a single habit on rounds.

The clinical outcomes are harder to measure in a community program of this size. I do not have the population to detect failure-to-rescue differences. What I have is qualitative report from nursing leadership that this program's residents engage with floor nurses differently than residents from comparable programs, and that the difference is recognizable enough to be remarked on.

That is enough. The curriculum is the operational version of an argument. The argument is that nursing's standpoint produces clinical knowledge worth accessing. The curriculum teaches residents to access it. The rounds are where the access happens.

This is not philosophy. This is what philosophy looks like when it is enrolled in residency, taught in didactic, read in PDF, and practiced at the bedside on Tuesday morning.

It is a curriculum, not a courtesy.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.