Posts Tagged nurse physician relations

A Matter of Hours

I was talking the other day to young, surprisingly old-school physician who bemoaned nurses “doing things” she thought properly done by duly authorized medical practitioners. (She also implied, by-the-by, that when physicians said “Go fetch,” the proper nursely response was a demure “Yes, doctor, and do you want your neck rubbed?)” Clearly, this physician thought, medicine was the senior and superior discipline, and nurses should defer at all times to their judgement, even on matters clearly within the sphere of nursing. Her basis for this line of thought was that physicians got “thousands and thousands of hours” of clinical and classroom education while nurses only had a “few hundred hours of  dubious training.”

My head almost nodded, subconsciously anyway, in agreement. Got us there. It’s a common theme, actually, when you see discussions of nursing versus medicine. Nurses just don’t have the education, it’s claimed, to make the really important decisions in patient care. But then I thought about it for a bit.

Leaving apart the obvious — that medicine and nursing are two different (if related) disciplines — in point of fact, I had 1950 clinical hours and about 2000 hours of classroom study to become a Registered Nurse — and this doesn’t include the hundreds of hours more of post-graduate education to gain speciality certification and also training for things like ACLS and TNCC. I know it doesn’t compare to the extensive/intensive training of physicians. But still, nearly four thousand hours of formal training as a minimal entry to practice is nothing to sneeze at either, and hardly the “few hundred hours of dubious training” imagined by some physicians. At any rate, it makes me wonder why, given our own expertise, education and experience, why some nurses continue to be cowed by claims of physician superiority?

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When Nurses Write About Physician Bullies, Don’t Shoot the Messenger

Theresa Brown has taken some heat for the op-ed she wrote for the New York Times last Sunday. When she wrote about her experiences being bullied by a physician and the detrimental effect bullying has on patient care, the reaction from MDs was angry and defensive. I am beginning to think, after reading though all the posts and comments, that her real sin was being a nurse challenging physician authority. Ford Vox, writing at The Atlantic took particular umbrage at a physician being called out at Brown’s work place. “Drawing and quartering your coworkers in the Sunday New York Times,” he wrote, might be run-of-the-mill for politicians. I’d like to see something better out of doctors and nurses.”  While making a very slight nod to the issue of  bullying behaviour among physicians, Vox’s principal objection to Brown’s article was the ethics of making an example of one particular physician; he went to an exceptional effort at demonstrating the physician could be identified — at least by his co-workers — by a Google search (and in the process outing Brown’s place of work, which at least one commenter construed as an act of bullying itself.)

Kevin Pho was somewhat more even-handed. But still, while acknowledging that bullying is a serious issue — which Vox trivializes as a “workplace spat” —  he accuses Brown acting in bad faith, of pandering to an anti-physician audience and “metaphorically” acting as a bully herself; he also engages in a tu quoque argument that nurses in general are bullies themselves. “Shouldn’t they [i.e. nurses],” he asks rhetorically, “bear some responsibility as well?” (Except that we do. Endlessly. Do physicians in the same way?)

The message, in any case, from our physician colleagues, is that nurses should shut up. We should not be airing our dirty linen in public. Any mention of physician bullying will only serve to exacerbate poor nurse-physician relations. It’s unfair to single out physicians. We aren’t bad actors ourselves, we treat nurses with the utmost respect, ergo, nurses should acknowledge the physician bully is a singular creature, as unique as a butterfly in a Toronto January. Et cetera.

I beg to differ.

I don’t think it’s quite true that physician bullying is rare and out of ordinary, even now, despite assertions to the contrary. When I thought about it, I realized without too much difficulty I could list dozens of examples of physician bullying, that I have been subjected to or witnessed, some dating from the dark ages of the late 1990s. These range from the utterly appalling — like the ED physician who unfairly and angrily blamed the primary RN for the death of a septic neonate, in front of the parents — to the half-humourous, some of which I have documented on this blog. I’m pretty sure nurses reading this could come up with a similar list.

Stating that some physicians bully, and that it is a more widespread problem than physicians themselves suppose, is not to take away from the respectful and collegial relationships I enjoy with the vast majority of the physicians I work with, but rather to address the reality of the complex power relationships in the hospital pecking order. It isn’t physician-bashing to point out the obvious. In any case both Vox and Pho ignore the central point in Brown’s piece: that when physicians bully, patient care suffers. It suffers because nurses are understandably reluctant to deal with a physician who will demean them. Who wants to call with a high blood sugar in the middle of the night, or question an inappropriate medication order, if you’re pretty sure you’re going to get reamed out in the process? It suffers because it’s a large factor in determining quality of nursing work life: poor nursing morale results in poor patient outcomes.

So there are some very good reasons to point out this behaviour out. Should have Brown been so specific, even if anonymously so? Both Vox and Pho complain vigorously about Brown’s lack of discretion in her account of the incident. My only thought is that their reaction is a bit over-dramatic, because the only people witnessing the inappropriate behaviour were the care team and the patient — and they don’t have to be told who the bully is. Further, I guess if Brown is as careful as most health care bloggers, she’s disguised the identity of the physician in question by changing details and artful misdirection so that it would be difficult for even employees of her institution to make identification. And I’ll add a small artistic quibble: a direct, concise, personal example is worth a thousand words of exposition. In the event, I’m not clear where the appropriate place would be to deal with it, except publicly and openly.

Bullying is an exceedingly frustrating issue for nurses, mostly because of the sense of powerlessness. When you’re subjected to the bullying, you feel like a target, and helpless to boot — and you can only respond with difficulty because the power relationships within the hospital hierarchy. In short, physician-bullies, like bullies everywhere, get away with it because they can. Nurses have been complaining about bad physician behaviour since Florence Nightingale disembarked at Scutari. You would think, that after 150-odd years of politely asking physicians to pull up their socks, they might take the issue to heart and engage in some real collective self-reflection on the issue.

It was encouraging to see this in a few of the comments to all the posts, amid all the palpable anger toward Brown. But she only put to words what every nurse knows. The physician reaction to complaints of inappropriate behaviour has always been to minimize, to scorn, to condescend, to trivialize, to redirect, or to deny. Kevin Pho points out, correctly, that hospitals are beginning to address the issue through workplace respect programs. But in all seriousness, how many physicians have actually been called to account in any meaningful way by these programs? Pho writes, in another post on the subject that, “My issue is Brown’s methods, by pitting a wronged nurse against arrogant doctors. It’s a narrative that physicians will lose 100% of the time, no matter how they respond.” True enough. But despite this, it’s also true that nearly 100% of the time bullying physician behaviour will go by without serious consequences. The question I would like to pose to both Vox and Pho — and all the angry physicians out there — is this: have you ever witnessed a physician bullying a nurse, and what did you do about it?

Their answer, I would guess, would be, “Yes, and nothing.” I would be gratified to hear otherwise.

So physicians, stop complaining. We’re merely pointing out bad behaviour. It’s up to you to fix it.

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Framing the Discussion Around What’s Best for the Patient

There’s been some discussion around here and in other places about what nurses ought to do when they disagree with the physician. The general consensus among nurses, is that we are professional obligated to advocate — even aggressively — for the best possible care and treatment for our patients. Theresa Brown’s recent article in the New York Times about her own conflicts with physicians articulates this point of view well. But what to do when that discussion fails, as it often does? The traditional answer, as all good nurses were taught in school, is to advocate up the food chain, either on the nursing side or the medical side. But sometimes this is not an effective approach nor is it realistic. Nurses are constrained by power structures and institutional culture which devalue the opinion of the front-line — a chief of medicine once told me three nurses witnessing a physician error was insufficient for him to do anything about it, because the physician herself denied the error — or perhaps managerial indifference; there are constraints of time (the problem must be dealt with immediately) or timing (going up the food chain in the middle of the night is difficult). The system, in general, can make it difficult for nurses’ voices to be heard.

So when all attempts fail at persuasion, we resort to other tactics and stratagems . Some nurses, like Maha at Call Bells Make Me Nervous, exceed their scope of practice and put their licences at risk trying to do right by the patient. Another example: we have all heard of nurses who will give a “generous” 5 mg dose of morphine (or whatever) if the patient has insufficient pain control, rather than fight the physician to up the amount. Or you can be like me, the crusty old charge nurse who gets tired of confronting physicians, and does end-runs to get desired results. Trust me, it’s tiresome and demoralizing for us to act this, and in the end, it’s bad for nurses and nursing.

Nurses, being nurses, tend to put the blame squarely on the physicians for not listening or for failing to engage in more collaborative practice. I am not sure this is completely fair. To be sure, some physicians will insist that theirs is the absolute final word when it comes to patient care, which is patently false theoretically, and impossible in practice; I’ve had more than one physician insist I was practising nursing “under his licence” and should therefore shut up. However, it is equally true these physicians are a small minority. And I will say, I have worked with many physicians, even in the emergency department setting, who represent the ideal in collaborative practice, who will discuss treatment plans in a manner in which nursing input and perspective is essential for good patient outcomes.

Obviously, the key here is good communication, and if we’re going to be honest — and I’m as guilty of this as anyone — nurses don’t communicate their concerns as well as we might. We can be adversarial, blaming, or judgemental, or worse, passive aggressive. We tend to forget that we possess a unique body of knowledge related to nursing and to our patients. This should empower us greatly, to advocate effectively, but often it doesn’t.

I want to back up a bit to the point where the nurse disagrees with the physician about the treatment plan, and bring in a recent interview in the New York Times with Dr. Peter Pronovost, the medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore. He speaks about flattening hierarchy and egos to maintain good patient care, about creating an institutional culture where patient safety is paramount and where management empowers and (more importantly) tangibly supports nurses to speak up. “In every hospital,” he says, “patients die because of hierarchy. The way doctors are trained, the experiential domain is seen as threatening and unimportant.”

He spoke about a situation where he knew a patient was going into anaphylaxis  from a latex allergy, and having to confront the surgeon (even physicians have this problem!) to get him to remove his latex gloves:

“I said to the surgeon, “I think this is a latex allergy, please go change your gloves.” “It’s not!” he insisted, refusing. So I said, “Help me understand how you’re seeing this. If I’m wrong, all I am is wrong. But if you’re wrong, you’ll kill the patient.”

This, I think, is exactly the way to approach it. Show me how I’m wrong, because if I’m wrong, than all I am is wrong,and I hope so, because being right about this may harm the patient. Suddenly it isn’t about externalities. It isn’t about nursing judgement, or physician qualifications or ego. All of that is off the table. It’s about patient safety and about providing the best possible care.  The next time I disagree with a physician, I promise to ask this: when disagreeing with physicians, nurses must be prepared to be wrong in order to best advocate for their patients. But then, so must physicians.

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The Title Is About The Power

When I was young and worked at Sticksville General Emerg, we had exactly one dental surgeon on call. I secretly called him Dr. Fabulous, because in his esteemed and respected opinion, he was fabulous. He was fabulously good-looking, and lived in a fabulous house with fabulous wife and children; his practice was fabulous, and of course, his ego was fabulously huge.

As I’ve mentioned before, Sticksville Gen was somewhat reactionary in attitude: the physicians were all men and the real leaders and heroes, and the nurses followed them like meek lost puppies. We had one nurse — Suzanne — however, who didn’t quite fit the mold: she was, truth be told, dangerously mouthy.

One day, Dr. Fabulous made his triumphal entrance, all pomp and self-regard, into the emergency department to look at the smashed mandible of an 18 year-old hockey player.

“Jim,” said Suzanne, “Your patient is in Minor Trauma.”

Dr. Fabulous screwed up his eyes and made a great show of looking at Suzanne’s name tag.

“Suzie,” he said, “You will please address me as Dr. Fabulous!”

Without missing a beat Suzanne screwed up her eyes and looked at Dr. Fabulous’s name tag.

“In that case, Jimmy,” she said, “You may call me Nurse Assertive or Mrs. Assertive. Only the people I like get to call me Suzie!”

I was reminded of this story when I saw this article: Doctorate in nursing causes confusion, resentment.

Shirato, a nurse practitioner, just got her doctor of nursing practice degree at Thomas Jefferson University.

[snip]

Most newly graduating physical therapists now have doctorates, too. Pharmacists and psychologists already made that move. Audiologists, physician assistants, and occupational therapists can also get doctorates.

As nonphysicians with doctorates proliferate, the potential for confusion has grown, and physicians aren’t happy about it. A 2008 survey by the American Medical Association found that 38 percent of patients believed that nurses with doctorates were medical doctors.

The American Medial Association has produced model “truth in advertising” legislation that requires health professionals, including physicians, to wear badges that clearly spell out their credentials.

Yeah, well, yawn. Just do normal practice and identify yourself when you meet the patient. In any case, I’ve come around to the opinion that titles of any sort are antiquated expressions of professional authority. Physicians acquired the title “doctor” — and remember it was originally, and still is, an academic title — over the course of the 18th Century to establish their credentials on par with the traditional professions (and gain entrance to the middle-class). They then spent a good part 19th Century trying to deny the same title to surgeons who were, in their opinion, “mere barbers.”

Titles, in short, are about establishing status and power. Why else worry about them? They are utterly irrelevant to actual patient care and one’s ability to do the job. Insisting on their use can create an atmosphere of professional intimidation that suppresses the free exchange of information. Health care professionals expressing power over patients is definitely not a good way to create therapeutic relationships. Implicitly saying (or believing) the title makes you a better person or supplies you with definitive or superior knowledge about patient care is dangerous as well as destructive to collaborative relationships with other health care professionals. In the end, it results in bad care of our patients, and of each other.

Some physicians really resent the loss of power. Don’t believe me? Check out why the defensiveness of this physician.

James Goodyear, a Lansdale, Pa., general surgeon and president of the Pennsylvania Medical Society, said health care workers who are not physicians should immediately tell patients what they do.

“I am a physician. They are not,” he said. “They trained for hundreds of hours. We trained for thousands of hours.”

And, he said, physicians should still be in charge. “We think that those in the allied health fields that get a doctorate such as in nursing are a very, very important component of a physician-directed … team,” he said. [Emphasis mine.]

Not about power and status? Fer sure. When this guy says, “I am physician” you can almost hear the sub-vocal “I am God”.

Oh, and thanks for the condescension too.

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