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Say thank you to nurses. They deserve it.

(Seyllou / AFP)

The next time you have the chance, say thank you to a nurse. He or she near certainly deserves it.

In the American health care system (any health system, really) it's nurses who are on the front lines. We are seeing that right now in the Ebola outbreak. From Liberia to the United States, the brunt of the disease has fallen hardest on nurses.

The majority of Liberian health care workers who have become infected with Ebola are nurses, the country's government found in a late September report.

infections

A Spanish nurse became infected with the disease after caring for a patient there. And, here in the United States, two nurses in Texas — Linda Pham and Amber Joy Vinson — both contracted the disease.

It's not especially hard to understand why: nurses provide much of the world's hands on care. They're the ones who are checking in with patients, taking their temperature, administering medications and delivering lots of the hands-on care that makes the health care system works.

This isn't to undercut the important work that doctors do, everyday, helping to save lives and deliver medicine. But it is to draw attention to the fact that nurses are doing equally important work, also everyday, for less recognition and lower pay.

Nurses get paid less than doctors—even when delivering the exact same care

Our health care system values nurses less than doctors. Medicare pays nurse practitioners 85 percent of what doctors make for administering the exact same services. MedPac, a federal board that advises the government on Medicare policy, found that there was "no analytical foundation for this difference."

In other words: it's not that, in the situations that MedPac looked at, nurse practitioners provide worse care than doctors. It's just that we've made a decision we should pay them less for their services. The Affordable Care Act included a pay bump for doctors who provide primary care services — but not for nurses.

The Institute of Medicine has recommended upping nurses' reimbursement rates to match those of doctors. So far, it hasn't happened.

Nurses barely get leadership positions — not in TV dramas, not in real life

Nurses don't get as much popular attention. One 2002 study of four major medical dramas, like ER, found that nurses appear in 10 percent of all dramatized health care interactions. In the real world, there are more than twice as many nurses (2.6 million) as there are doctors (893,851). In the world of television though, nurses barely exist: the same study found they make up 4 percent of all characters.

"The shows portrayed doctors as dominating discussions around health policy issues," the report concludes. "Nurses, social workers, and other members of the health care team hardly existed in policy."

Nursing isn't glamorous; the title characters and ER and Grey's Anatomy all have M.D.s behind their names. The one television show that has a nurse as its title character is a comedy: Nurse Jackie.

This isn't just a challenge in the fictional world of Seattle Grace Hospital: real-life hospitals are less likely to have nurses in positions of leadership. Surveys of hospital boards find that nurses typically represent 2-4 percent of the board positions. Doctors claim 22 percent. Again, nurses vastly outnumber doctors in the overall health care system.

This should be worrisome: fewer nurses in leadership can mean less diversity of opinion— specifically, less opinion from nurses about what makes a hospital run best. Arthur Relman, a prominent physician and former editor of the New England Journal of Medicine, learned this lesson the hard way when he broke his neck. He spent 10 weeks in rehab in the care of nurses.

"I had never before understood how much good nursing care contributes to patients' safety and comfort, especially when they are very sick or disabled," Relmand wrote in an essay about his experience. "This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good."

So thank nurses. Try and do it sometime soon. They work important, sometimes dangerous and too-frequently thankless jobs. Our health care system just wouldn't work without them.

The 90-second case for deregulating nurse practitioners.

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