Handling insubordination as House Staff

[ecCA1]

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For starters, I don't consider the nurse not jumping out of his chair or being unwilling to get you a cup of coffee insub. I am writing this thread because it's obvious that most of us here are House Officers, and fall into a "gray zone" if you will regarding the manner in which other members of the health care team treat us. Granted, there are plenty of nurses and the like I've run into who are perfectly respectable. However, especially in the units, there seems to be a pervasive idea that it is OK to be obnoxious and disrespectful to HS because they're "not really doctors yet." While it's true that we're not yet board-certified, we have (in most cases, anyway) unrestricted PHYSICIAN'S licenses for our respective states. We write ORDERS that the nursing staff have to follow. We take responsibility for judgement errors on rounds, not the nurses. There's nothing to stop a nurse from refusing to extubate a paralyzed patient because she also has a license to protect, but the opportunity to refuse the doc's orders comes very seldomly indeed.

I think that the most important thing to remember when dealing with the nurses is that we have the upper-hand, and they know it. Don't let them get you mad, as it only serves to loosen your hold on the other nurses who are watching the situation unfold. If you have someone who's acting incorrectly, just remind them that you wrote the ORDER, and that they need to follow it (or give a hell of a reason why not).

Don't argue with them. Don't get sucked into petty wastes of your energy while you try to "win them over." Some nurses are happy to be nurses; some are not so happy and will take every opportunity to deride those they view as vulnerable (HS) to such efforts. My wife is a nurse, and she's been frustrated many times with her co-workers who stymie residents merely because they have it in their heads that they're in a better position to decide what the patient needs. Don't give them the satisfaction of thinking they've got your number.

 

[toxic-megacolon]

Another excellent resource for housestaff is the floor nursing supervisor. There is a supervisor on call 24/7 for these kind if issues. Somtimes the nurse will know the H.O. is in charge but will play dumb. All you need to do is politely say "I understand you don't want to do this order. I'll have to page the nursing supervisor." This usually gets their attention RIGHT AWAY.

 

[ecCA1]

"All you need to do is politely say "I understand you don't want to do this order. I'll have to page the nursing supervisor." This usually gets their attention RIGHT AWAY."

Exactly.

And if you haven't demeaned them, which will hurt you more than their nastiness will hurt them, you will have nothing to worry about.

 

[f_w]

It is allways a good idea to double check your order to make sure you didn't order something outright dangerous. But once you have made sure that your order is correct, your patient has a right to see it carried out.
If not:
- a page to the nursing supervisor or the administrator on duty won't make you friends with the nursing staff, but if it gets the job done you might have to resort to this
- 'incident reports' including the words 'dereliction of duty' tend to get the message accross.

The downside of both of these confrontational approaches is that from that day on you have to make sure that your work is impeccable and that your responses to pages are quick. Also, you will have to completely eliminate any references to your or the staffs private lives from any conversation on the hospital grounds. Just as you can play the papertrail game, nurses can start to pelt you with complaints about breakdowns in care, bogus sexual harassment or 'unprofessional conduct' claims.

(personally, I have been through a couple of places. The ones where the staff sucked I figured I couldn't fix by trying to be on peoples case. At places where the staff is good and motivated you will never encounter this issue.)

I think that the most important thing to remember when dealing with the nurses is that we have the upper-hand, and they know it.

One thing to remember as an intern and resident is: The nurses allways win. They were there 10 years before you came, and they will be there 10 years after you are gone. Hospitals are systems entirely inert to change, you getting high blood pressure over something won't change a thing in their operation.

This doesn't mean you should allow people to get away with stuff that is dangerous to your patients, but you want to be very careful as to the fights you pick.

 

[Misterioso]

How one resident told me he handled insubordination from non-physicians was to whip out a official complaint form right there and then and fill it out in front of the nurse and anyone else who happened to be present. He'd then make a copy right then using the xerox machine on the ward, give one copy to the nurse and then go file the complaint with whoever it is they file complaints with. After he did this a couple times they got the message. He wasn't the most popular resident but his orders were never ignored.

 

[cchoukal]

My approach has been a little different. Typically when a nurse doesn't want to do something I ordered, it's for a reason (which may be flawed), not just out of laziness or obstinence. As an anesthesiology intern, the majority of my time is in the ICU, where nurses are pretty smart, so we'll often get into a discussion about why they don't want to do X or Y and, which a good explanation, they usually come around. Sometimes, though, they're correct. Of course, this more collaborative approach probably wouldn't work as well on the floor where, due to education and staffing levels that are inferior to those in the ICU, in depth discussions of physiology and research-based evidence are impractical.

 

[f_w]

It is less an issue of insubordination, more one of people not wanting to do their job.

If someone questions the wisdom of my order, within reason I am glad to explain it at least once. If an RN has a safety concern, I will be glad to double-check my dose or time of administration.

But at times, refusal to follow an order IS 'just out of laziness or obstinence'. When that is the case, you have to make a decision: Is this something I just want, or is it something the patient needs. If it is something the patient needs I will be the first one to pull rank and use whatever administrative sticks (or rather twigs) the hospital gives into my hands to get it done. If the refusal won't endanger the care of a patient, you have to decide whether it is worth the open field battle something like an incident report tends to generate.

You want to stay away from any sort of conflict that is based on the argument: 'I am the doctor and if I order it I expect it to be done'. It won't get you far and your attendings in all likelihood won't back you up.

If the argument is: 'I ordered something that is medically reasonable and needed and adheres to hospital policy, yet this lazy_#% employee refused to carry it out' you are much more likely to succeed.

And NEVER, EVER get into a pattern of 'punitive ordering'. These q30 minute vital signs on a stable patient or water enemas on the most obnoxious patient on the floor will only serve to make you look like a complete fool (and represent malpractice).

 

[apma77]

the easiest way to deal with a nurse who doesnt want to carry out an order is to leave a note in the chart the time the intitial order was written and another followup time you again reminded the nurse to carry it out
no need to get into arguments.
when the attending asks in the AM why it wasnt done show him the chart with the timings
most good attendings will handle it from there

 

[jetproppilot]

the easiest way to deal with a nurse who doesnt want to carry out an order is to leave a note in the chart the time the intitial order was written and another followup time you again reminded the nurse to carry it out
no need to get into arguments.
when the attending asks in the AM why it wasnt done show him the chart with the timings
most good attendings will handle it from there

If you dudes are feeling control issues with an RN during your intern year, the year during which a seasoned ICU RN knows how to take care of a patient just as good (or better) than you,

youve got a LONG residency ahead of you.

 

[militarymd]

Hey, I was a fellowship trained double board certified attending with 5 years experience after fellowship when I was taking insubordination from RNs in the Navy...

I recommend you learn to deal with it with a smile on your face while keeping the patients safe.

 

[OldManDave]

Please take heed of the words of wisdom by MilMD & Jet. Being an @$$ to your co-workers, be they more or less educated than yourself, is commonly called "$hitting in your mess kit". It is never wise to $hit where you eat!

Your patients will benefit far far far far more from all of the medical providers learning to work together as an efficient team with effective inter-/intra-group communication. That mandates development of strong interpersonal relationship skills. That does NOT include developing a tough-guy, @$$hole-physician disposition & going on a conquest/power trip.

Believe me, the hardest job an RN or a Resp Therapist has, in a teaching hosp, is protecting their patients from well-intended, but highly inexperiences interns & residents. Med school fills your knoggin with a wealth of factoids & no paradigm into which you can congeal those concepts into an operable scheme - that is what residency does.

I tell every med student, pre-med & junior resident under my supervision that every person you encounter throughout the day (includes patients, family, nurses, resp terrorists, pt care techs & janitors) has something of value to teach you. Your job is to shut-up & invest the time to learn what they are offering up to you for free. In the long run, although listening in lieu of running your mouth may be less comfortable, it will make you a much more effective physician & better all around person.

Best of luck & success to you all!

 

[Gimlet]

(includes patients, family, nurses, resp terrorists, pt care techs & janitors)

Freudian slip, or subtle jab? Either way, it's funny!

 

[f_w]

Yep, the 'kumbayah lets all get along and work as a team for the best of the patient' thing is the right concept probably 98% of the time. But there is the occasional situation where staff doesn't do their job just because they are fat and lazy. That are the situations where an adversarial approach is sometimes the only fix.

If an RN has a safety or patient care quality concern, it is certainly correct to question the order and to get back to the prescriber for clarification. And except for some of the more immature interns, nobody will object to that.

 

[MacGyver]

Here's what I plan to do.

I'm going to scan a copy of my medical diploma into a small 6" x 8" index card format.

I'm going to carry it in my pocket, and when some lowly nurse tries to get up in my grill, i'm going to yank that card out and say "READ THE FINE PRINT BITCH, WHAT ARE THOSE 2 LETTERS AFTER MY NAME!"

Then I'll say "I AM THE DOCTOR AND THESE ARE DOCTORS ORDERS! YOU WILL FOLLOW THEM NURSE! NOW AFTER YOU GET DONE DOING THAT, GO GET ME A COFFEE AND BOW DOWN TO MY IDOL I HAVE ERECTED AT YOUR NURSES' STATION"

 

[militarymd]

Here's what I plan to do.

I'm going to scan a copy of my medical diploma into a small 6" x 8" index card format.

I'm going to carry it in my pocket, and when some lowly nurse tries to get up in my grill, i'm going to yank that card out and say "READ THE FINE PRINT BITCH, WHAT ARE THOSE 2 LETTERS AFTER MY NAME!"

Then I'll say "I AM THE DOCTOR AND THESE ARE DOCTORS ORDERS! YOU WILL FOLLOW THEM NURSE! NOW AFTER YOU GET DONE DOING THAT, GO GET ME A COFFEE AND BOW DOWN TO MY IDOL I HAVE ERECTED AT YOUR NURSES' STATION"

 

[Misterioso]

Here's what I plan to do.

I'm going to scan a copy of my medical diploma into a small 6" x 8" index card format.

I'm going to carry it in my pocket, and when some lowly nurse tries to get up in my grill, i'm going to yank that card out and say "READ THE FINE PRINT BITCH, WHAT ARE THOSE 2 LETTERS AFTER MY NAME!"

Then I'll say "I AM THE DOCTOR AND THESE ARE DOCTORS ORDERS! YOU WILL FOLLOW THEM NURSE! NOW AFTER YOU GET DONE DOING THAT, GO GET ME A COFFEE AND BOW DOWN TO MY IDOL I HAVE ERECTED AT YOUR NURSES' STATION"

That is over the top. Better to stand your ground, knowing that you are the doctor. Non-doctors can make suggestions and give their opinions, but it is you who ultimately decides. No need to try to prove anything to them, your M.D. speaks for itself.

 

[jetproppilot]

Here's what I plan to do.

I'm going to scan a copy of my medical diploma into a small 6" x 8" index card format.

I'm going to carry it in my pocket, and when some lowly nurse tries to get up in my grill, i'm going to yank that card out and say "READ THE FINE PRINT BITCH, WHAT ARE THOSE 2 LETTERS AFTER MY NAME!"

Then I'll say "I AM THE DOCTOR AND THESE ARE DOCTORS ORDERS! YOU WILL FOLLOW THEM NURSE! NOW AFTER YOU GET DONE DOING THAT, GO GET ME A COFFEE AND BOW DOWN TO MY IDOL I HAVE ERECTED AT YOUR NURSES' STATION"

Geez Mac, thats kinda harsh. I dont agree with your managerial style, but heres an analagy where you're holding the short end of the stick, instead of the RN.

I'm going to scan a copy of my ABA board certification into a small 6" x 8" card format.

I'm going to carry it in my pocket, and when some lowly med student/intern/CA-1 attempts a procedure that I can do in my sleep, and said STUDENT -doctor has problems, i'm going to yank that card out and say "READ THE FINE PRINT YOU BOTTOM FEEDER!!! Whats that BOARD CERTIFIED certification mean after MY MD??? MY MOM CAN DO THAT BETTER THAN YOU!!!! GEEZ, WHERE'D YOU TRAIN?? IN HOBOCOE KANSAS, AT JOE'S MED SCHOOL/RESIDENCY? BY THE WAY, ONLY TWO THINGS COME OUTTA THAT PLACE...STEERS AND QUEERS!"

Then I'll say "I'M THE BOARD CERTIFIED PRIVATE PRACTICE STUD WHO'S FORGOTTEN MORE ANESTHESIA IN THE LAST TEN MINUTES THEN YOU'LL LEARN THIS ENTIRE YEAR!! NOW AFTER YOU GET DONE TOTALLY BASTARDIZING THAT PROCEDURE, GO GET ME A TRIPLE EXPRESSO AND BOW DOWN TO MY IDOL I HAVE ERECTED IN FRONT OF YOUR POVERTY STRICKEN, STUDENT-LOAN-LADEN DOUBLE-WIDE TRAILER WITH YOUR 1987 FORD PINTO PARKED OUT FRONT, AND KISS THE FEET OF MY IDOL, YOU INEXPERIENCED, ARROGANT PIECE OF S HIT!!!"

😀

nah, I'd never do that.

But you get the point.

Save your power trips for some other lifetime.

 

[bullard]

Misterioso and Macgyver, do you either of you guys even have MDs yet?

No? Then pretty please, with a cherry on top, shut the f up.

The title of the thread is "handling insubordination as house staff". You're not house officers yet, and I suspect your opinions about this stuff will change after the nurses (justifiably) make your intern year miserable.

 

[coccygodynia]

Geez Mac, thats kinda harsh. I dont agree with your managerial style, but heres an analagy where you're holding the short end of the stick, instead of the RN.

I'm going to scan a copy of my ABA board certification into a small 6" x 8" card format.

I'm going to carry it in my pocket, and when some lowly med student/intern/CA-1 attempts a procedure that I can do in my sleep, and said STUDENT -doctor has problems, i'm going to yank that card out and say "READ THE FINE PRINT YOU BOTTOM FEEDER!!! Whats that BOARD CERTIFIED certification mean after MY MD??? MY MOM CAN DO THAT BETTER THAN YOU!!!! GEEZ, WHERE'D YOU TRAIN?? IN HOBOCOE KANSAS, AT JOE'S MED SCHOOL/RESIDENCY? BY THE WAY, ONLY TWO THINGS COME OUTTA THAT PLACE...STEERS AND QUEERS!"

Then I'll say "I'M THE BOARD CERTIFIED PRIVATE PRACTICE STUD WHO'S FORGOTTEN MORE ANESTHESIA IN THE LAST TEN MINUTES THEN YOU'LL LEARN THIS ENTIRE YEAR!! NOW AFTER YOU GET DONE TOTALLY BASTARDIZING THAT PROCEDURE, GO GET ME A TRIPLE EXPRESSO AND BOW DOWN TO MY IDOL I HAVE ERECTED IN FRONT OF YOUR POVERTY STRICKEN, STUDENT-LOAN-LADEN DOUBLE-WIDE TRAILER WITH YOUR 1987 FORD PINTO PARKED OUT FRONT, AND KISS THE FEET OF MY IDOL, YOU INEXPERIENCED, ARROGANT PIECE OF S HIT!!!"

😀

nah, I'd never do that.

But you get the point.

Save your power trips for some other lifetime.

LOL! Exactly what I needed before heading to the hospital. Thanks for the laugh Jet.

 

[OldManDave]

Here's what I plan to do.

I'm going to scan a copy of my medical diploma into a small 6" x 8" index card format.

I'm going to carry it in my pocket, and when some lowly nurse tries to get up in my grill, i'm going to yank that card out and say "READ THE FINE PRINT BITCH, WHAT ARE THOSE 2 LETTERS AFTER MY NAME!"

Then I'll say "I AM THE DOCTOR AND THESE ARE DOCTORS ORDERS! YOU WILL FOLLOW THEM NURSE! NOW AFTER YOU GET DONE DOING THAT, GO GET ME A COFFEE AND BOW DOWN TO MY IDOL I HAVE ERECTED AT YOUR NURSES' STATION"

To quote the wise words of Shrek - yeah, the large green Disney character (congruent to this level of maturity) - "Do you think he's compensating for something?"

If you're even actually stupid enough to pull that, you can guarantee that you will never, ever sleep again on call - period. Second, you might get 1/3 to 1/2 of that tirade out of your mouth before some crusty old-school RT or RN pulls your stress-induced hemorrhoids out right through your mouth and sends you packin like a whipped pup to go count corn kernals in Mr. Smith's last BM. Finally, if you were under my supervision & I learned that you had been such a prick to another medical professional - you would definitely wish to hell all you had to do was count the corn in the old man's stool.

Medicine has more than enough a$$holes in it &, just in case you have not noticed, medicine is fighting a battle with well organized, intelligent opponents. At risk is our stature, respect & the trust our patients have in what we recommend to them. May I suggest that in lieu of trying to the "playground stud", maybe keep your eye on the real game & learn to work well with others who are equally invested in providing high-qulaity, safe & effective patient care.

 

[OldManDave]

Freudian slip, or subtle jab? Either way, it's funny!

Fully intentional! We, RTs, frequently referred to ourselves as Resp Terrorists or the other favorite - Snot Jocks.

 

[f_w]

Another McGyver classic.

Every day I see this parade of well-adjusted quiet non-descript medstudents coming through our department. I allways wonder which one of them at night releases his repressed agressions on SDN under the McGyver nick.

 

[Danger Man]

Medicine has more than enough a$$holes in it &, just in case you have not noticed, medicine is fighting a battle with well organized, intelligent opponents. At risk is our stature, respect & the trust our patients have in what we recommend to them. May I suggest that in lieu of trying to the "playground stud", maybe keep your eye on the real game & learn to work well with others who are equally invested in providing high-qulaity, safe & effective patient care

.

Old Man, that diatribe is filled with some wisdom. Dude, I am catchin' what you are throwin'.

 

[hoop_jumper]

I have to laugh at people like you because the intials JD always trump MD, and when you piss off the nursing staff and make an error which you will, guess who is gonna let the family know it? After the family get's done reaming you out so a soup can will fit nicely in your rectum that lawyer is going to bend you over in court, see the soup can and say "hey look, a virgin".

Here's what I plan to do.

I'm going to scan a copy of my medical diploma into a small 6" x 8" index card format.

I'm going to carry it in my pocket, and when some lowly nurse tries to get up in my grill, i'm going to yank that card out and say "READ THE FINE PRINT BITCH, WHAT ARE THOSE 2 LETTERS AFTER MY NAME!"

Then I'll say "I AM THE DOCTOR AND THESE ARE DOCTORS ORDERS! YOU WILL FOLLOW THEM NURSE! NOW AFTER YOU GET DONE DOING THAT, GO GET ME A COFFEE AND BOW DOWN TO MY IDOL I HAVE ERECTED AT YOUR NURSES' STATION"

 

[jetproppilot]

I have to laugh at people like you because the intials JD always trump MD, and when you piss off the nursing staff and make an error which you will, guess who is gonna let the family know it? After the family get's done reaming you out so a soup can will fit nicely in your rectum that lawyer is going to bend you over in court, see the soup can and say "hey look, a virgin".

Know whats black and brown and looks good on a lawyer???

A doberman.

 

[OldManDave]

Know whats black and brown and looks good on a lawyer???

A doberman.

Hey now...hold on a minute! That is not fair to lawyers! Surely you realize that a mere 99% of lawyers tanrish the image of the 1% who are actually worth a $hit!

 

[hoop_jumper]

What's green and white and looks good on a trial lawyer?

An MDA's money

Hey now...hold on a minute! That is not fair to lawyers! Surely you realize that a mere 99% of lawyers tanrish the image of the 1% who are actually worth a $hit!

 

[Danger Man]

What's green and white and looks good on a trial lawyer?

An MDA's money

That is less than humorous...

 

[Misterioso]

Doc May Have Been Drunk in Operating Room
Mar 09 1:05 PM US/Eastern

The chief of neurosurgery at Highland Hospital was wrestled to an operating room floor by deputies and arrested after allegedly throwing a drunken fit when a nurse refused to let him operate, authorities said.

Federico Castro-Moure, 45, was arrested Monday night on suspicion of being under the influence of alcohol and interfering with the duty of officers, said Alameda County sheriff's Lt. Jim Knudson.

Castro-Moure became belligerent after insisting on operating on a man who broke his ankles and fractured his spine in a two-story fall, according to the sheriff's department.

Two other surgeons had determined the injuries were not life- threatening, but Castro-Moure insisted the man would die if he did not receive immediate attention, the report said.

He "threw a fit" and began yelling and cursing at staff when they told him equipment for the procedure needed to be transferred from another hospital, according to the report. When the surgical instruments arrived, a nurse refused to allow Castro-Moure to operate until they could be sterilized.

Castro-Moure threatened the nurse by punching his fist in his hand. He took a swing at deputies after they were called to intervene.

"Do you know that I am a (expletive) doctor, and I'm going to do what I want," he said, according to a witness.

He was booked into Glenn Dyer Detention Facility in Oakland and was released several hours later in lieu of $4,000 bail, a jail official said Thursday morning.

Castro-Moure was placed on leave while the hospital investigates the matter, hospital spokesman David Cone said.

A woman who answered the phone at Castro-Moure's home Thursday morning said the doctor had no comment.

 

[miamidc]

Doc May Have Been Drunk in Operating Room
Mar 09 1:05 PM US/Eastern

The chief of neurosurgery at Highland Hospital was wrestled to an operating room floor by deputies and arrested after allegedly throwing a drunken fit when a nurse refused to let him operate, authorities said.

Federico Castro-Moure, 45, was arrested Monday night on suspicion of being under the influence of alcohol and interfering with the duty of officers, said Alameda County sheriff's Lt. Jim Knudson.

Castro-Moure became belligerent after insisting on operating on a man who broke his ankles and fractured his spine in a two-story fall, according to the sheriff's department.

Two other surgeons had determined the injuries were not life- threatening, but Castro-Moure insisted the man would die if he did not receive immediate attention, the report said.

He "threw a fit" and began yelling and cursing at staff when they told him equipment for the procedure needed to be transferred from another hospital, according to the report. When the surgical instruments arrived, a nurse refused to allow Castro-Moure to operate until they could be sterilized.

Castro-Moure threatened the nurse by punching his fist in his hand. He took a swing at deputies after they were called to intervene.

"Do you know that I am a (expletive) doctor, and I'm going to do what I want," he said, according to a witness.

He was booked into Glenn Dyer Detention Facility in Oakland and was released several hours later in lieu of $4,000 bail, a jail official said Thursday morning.

Castro-Moure was placed on leave while the hospital investigates the matter, hospital spokesman David Cone said.

A woman who answered the phone at Castro-Moure's home Thursday morning said the doctor had no comment.

That Must be your role model huh?

 

[excalibur]

Doc May Have Been Drunk in Operating Room
Mar 09 1:05 PM US/Eastern

The chief of neurosurgery at Highland Hospital was wrestled to an operating room floor by deputies and arrested after allegedly throwing a drunken fit when a nurse refused to let him operate, authorities said.

Federico Castro-Moure, 45, was arrested Monday night on suspicion of being under the influence of alcohol and interfering with the duty of officers, said Alameda County sheriff's Lt. Jim Knudson.

Castro-Moure became belligerent after insisting on operating on a man who broke his ankles and fractured his spine in a two-story fall, according to the sheriff's department.

Two other surgeons had determined the injuries were not life- threatening, but Castro-Moure insisted the man would die if he did not receive immediate attention, the report said.

He "threw a fit" and began yelling and cursing at staff when they told him equipment for the procedure needed to be transferred from another hospital, according to the report. When the surgical instruments arrived, a nurse refused to allow Castro-Moure to operate until they could be sterilized.

Castro-Moure threatened the nurse by punching his fist in his hand. He took a swing at deputies after they were called to intervene.

"Do you know that I am a (expletive) doctor, and I'm going to do what I want," he said, according to a witness.

He was booked into Glenn Dyer Detention Facility in Oakland and was released several hours later in lieu of $4,000 bail, a jail official said Thursday morning.

Castro-Moure was placed on leave while the hospital investigates the matter, hospital spokesman David Cone said.

A woman who answered the phone at Castro-Moure's home Thursday morning said the doctor had no comment.

relative of yours, Misterioso?

 

[SilverStreak]

I think that the most important thing to remember when dealing with the nurses is that we have the upper-hand, and they know it.

Perhaps the reason you are getting what you perceive as insubordination in response to orders you want carried out is because of your condescending and superiority attitude towards nurses that the above statement implies. Nurses are not your beck and call *itches, and often, if an order is questioned, there may (I know this may come as a shock since you have probably never written anything other than an absolutely necessary perfect order) a reason. Granted, I admit and respect that you have more education, your training is more in depth and intense than the education of nurses, but YOU ARE STILL LEARNING!!! And just because you have more education does not mean nurses are stupid. None of you know everything, and if a nurse questions an order, keep in mind the NURSE is JUST as LEGALLY ACCOUNTABLE to carrying out a bull**** order you write as you are. Sometimes, nurses are not being obstinate or putting a resident in their place. Sometimes, they may simply being trying to protect your best interests, the nurses best interests, and most importantly the PATIENTS best interests. You can get your point across without demeaning the importance of the RNs place in the healthcare system. Don't lord over the unit/floor you're working on and expect all the nursing staff to respond in a positive way.

Now, I'm not saying there aren't nurses who are *itches and deserve your frustration and need to be dealt with for purposely being difficult just because they think they can with a resident. Some nurses may treat you in a way they never would an attending. But, don't let the attitudes of those nurses cloud your view of the other nurses who want to be helpful, learn from and with you, and give the best care to their patients. Just as I don't let some of the appalling attitudes I've read on here cloud my view of the good interns. You should be ashamed of yourselves for wanting to carry around a diploma to rub in it my face that you have MD behind your name and I have RN. I could go to med school, but I chose not to. I'm not secretly yearning to be an MD or jealous of you for your accomplishment. I think there's one class that should be required from all of you in med school- How to be Humble 101. The best docs I know are not the loud know it all bossy ones, but the thoughtful, understanding docs who are willing to consider different perspectives other than their own. How do you think patients would respond to some of the comments you've made on here? Or does medical school place you so far above the common humans you treat that you don't care?

 

[OldManDave]

Perhaps the reason you are getting what you perceive as insubordination in response to orders you want carried out is because of your condescending and superiority attitude towards nurses that the above statement implies. Nurses are not your beck and call *itches, and often, if an order is questioned, there may (I know this may come as a shock since you have probably never written anything other than an absolutely necessary perfect order) a reason. Granted, I admit and respect that you have more education, your training is more in depth and intense than the education of nurses, but YOU ARE STILL LEARNING!!! And just because you have more education does not mean nurses are stupid. None of you know everything, and if a nurse questions an order, keep in mind the NURSE is JUST as LEGALLY ACCOUNTABLE to carrying out a bull**** order you write as you are. Sometimes, nurses are not being obstinate or putting a resident in their place. Sometimes, they may simply being trying to protect your best interests, the nurses best interests, and most importantly the PATIENTS best interests. You can get your point across without demeaning the importance of the RNs place in the healthcare system. Don't lord over the unit/floor you're working on and expect all the nursing staff to respond in a positive way.

Now, I'm not saying there aren't nurses who are *itches and deserve your frustration and need to be dealt with for purposely being difficult just because they think they can with a resident. Some nurses may treat you in a way they never would an attending. But, don't let the attitudes of those nurses cloud your view of the other nurses who want to be helpful, learn from and with you, and give the best care to their patients. Just as I don't let some of the appalling attitudes I've read on here cloud my view of the good interns. You should be ashamed of yourselves for wanting to carry around a diploma to rub in it my face that you have MD behind your name and I have RN. I could go to med school, but I chose not to. I'm not secretly yearning to be an MD or jealous of you for your accomplishment. I think there's one class that should be required from all of you in med school- How to be Humble 101. The best docs I know are not the loud know it all bossy ones, but the thoughtful, understanding docs who are willing to consider different perspectives other than their own. How do you think patients would respond to some of the comments you've made on here? Or does medical school place you so far above the common humans you treat that you don't care?

Very well said SilverStreak! Before I became a physician, I invested ~10 as a respitory therapist; so I can relate first hand to the arrogance of physicians in training. Fortunately, those who fit this description are very much in the minority. But, they are a loud, obnoxious minority!

Personally, I think the arrogant / @$$hole disposition is actually a defence mechanism secondary to insecurity. Many new-grads from med school are scared $hitless when they realize that they cannot anser all of the questions they are asked. Many of them truly feel that immediately upon graduation that they should already know it because they have graduated. The easiest way to prevent getting asked questions you cannot answer? Act like a complete turd & folks just won't ask.

Fortunately, most of those who are obnoxious eventually come around. But a few persist...

 

[ecCA1]

Dave and Silverstreak,

I assume you did not read most of my post when you wrote your self-righteous tirades. I was quite reasonable in my approach to dealing with nurses. This was not triggered by a rash of insubordination episodes; rather, it was because I've seen threads discussing such problems and thought I'd lend a hand. If anything, I was very fair in my advice.

 

[OldManDave]

Dave and Silverstreak,

I assume you did not read most of my post when you wrote your self-righteous tirades. I was quite reasonable in my approach to dealing with nurses. This was not triggered by a rash of insubordination episodes; rather, it was because I've seen threads discussing such problems and thought I'd lend a hand. If anything, I was very fair in my advice.

ecCA1;

You ass/u/me incorrectly. I read, more than once, your post - while you are not nearly as condescending in your disposition & you seem to be genuinely concerned over maintaining/forging relationships with nurses, there is still a profound level of "they are beneath me" therein. Furthermore, I think you bring out some excellent points that need to be discussed. And, I think your continued above-the-level involvement in this thread has demonstrated that you are not among the group that my post above was directed towards.

My tirade, as you referred to it, was solely meant to add to the post by Silverstreak & was not directed specifically at you, but more towards the more militant remarks that have been made here. Now, I can certainly see where you may have felt 'pointed out' as Silverstreak's post was a reply to comment you made. But, I think the overall message contained within the text of Silverstreak's reply has worth, meaning & needed to be expounded upon.

As someone who has enjoyed a long allied health professions career prior to becoming a physician. Having worked in allied health since 1983 - started when I was a senior in HS - I have a somewhat unique caste to my perspective & feel that having lived no on both sides of the fence, those perspectives need to be offered up to everyone.

 

[ecCA1]

"You ass/u/me incorrectly. I read, more than once, your post - while you are not nearly as condescending in your disposition & you seem to be genuinely concerned over maintaining/forging relationships with nurses, there is still a profound level of "they are beneath me" therein."

Dave, they are beneath us in the hierarchy. That's why we write the orders that they execute. It's really pretty simple, until someone like yourself, with a 10-year history of being scolded by doctors as a RT, comes along with an axe to grind, looking for an "overbearing" physician to take to task.

Notice that I was the first to point out that nurses have some form of license that they must preserve; hence the need for them to question orders as they see fit, too.

We're all in this together, but that the attending is "above" us, too, in the health care hierarchy. I know you would prefer not to have it phrased that way, but that is an issue for you to resolve yourself.

As for self-esteem issues, please, Dave. It's hard to imagine an intelligent man gleaning that from what I've been writing, but if you think it strengthens your moral highground, by all means, "ass/u/me" away.

 

[f_w]

You seem very preoccupied with this issue of 'hierarchy' and 'respect', whatever they meaning they have in a healthcare setting. Worry a bit more about practicing in a safe manner and maintaining a collegial attitude in your organization which will allow your 'inferiors' to bring patient related issues to your attention.

 

[ecCA1]

The hierarchy system is a fact of life. Look at Military MD's responses when provoked for further support of that.

As far as my dealings with "underlings" go, I'm one of the guys who's very well liked by the nurses, scrub techs, etc. I address them by name, go out for beers with them, and have their respect. Not because I lord my "MD status" over them but because I respect them, treat them as I would want to be treated, etc.

It's really interesting to see you guys chastising me for what I've written here. Are there some deep-seated issues you have to grind with authority?

Finally, it is curious that Dave would bother to list his titles, including a fellowship that begins years from now, given his strong interest in "leveling the playing fields." I don't even call myself "doctor" to my patients, for God's sake, though my title would allow me to do so.

 

[SilverStreak]

Dave and Silverstreak,
I assume you did not read most of my post when you wrote your self-righteous tirades. I was quite reasonable in my approach to dealing with nurses. This was not triggered by a rash of insubordination episodes; rather, it was because I've seen threads discussing such problems and thought I'd lend a hand. If anything, I was very fair in my advice.

ecCA1,

I was not specifically pointing a finger at you, even though I did use your quote in my post as an example of why some of you may have problems interacting with nursing staff. I also made reference to other posts that encourage the bad attitude/working relationship with residents/nurses (the comment about copying my degree because I have MD behind my name). I apoligize to you for my post coming across as self righteous or an attack on your very fair question on how to deal with a problem.

I should have offered my oppinion on how to deal with these issues as someone on the other side so to speak. I know you realize by now there are those ICU nurses who think they know everything, who belittle other nurses for the care they've given on their shift, and treat co workers like they are stupid. Keep in mind these are probably the nurses the house staff has problems with (and fellow nurses don't like their attitudes either).

However, the best way to deal with these trouble makers is not to "pull rank" so to speak and take the attitude "I'm above you, you do what I say because I'm the doctor and you're the nurse". What kind of results do any of you get when taking this approach? I think the best way to handle these disputes is to involve the nurses as part of the inter disciplinary team and ask their oppinion. If they don't agree with a treatment, why? They may have a good reason you have not considered, or they may truly not know why you've ordered something, and you could teach them something. I am much more willing to do something I thought was a bogus order if you are patient with me and explain to me why it is good for my patient. Most nurses always have their patients' best interests at heart and want to do good for them.

Now, some nurses will be difficult no matter what, they may resent they've been a nurse for 30 years and this twenty something year old kid with little hands on experience comes in and runs the show. Realize that's their problem, not yours, and nothing you or any other person does or says will change that type of mentality. You just have to smile, suck it up, and get through that part of your training, because when it's all said and done, that nurse will still be there after you're gone tormenting the next group that comes through.

If you truly want to solve the problem of insubordination, endear yourself to the nurses. I'm not saying kiss *ss, we can't stand that either, but being friendly and open to our suggestions, polite in your requests, please and thank you go a long way too. In the ICU I work at nurses are RESPECTED by the doctors, and as such we have a wonderful working relationship. Even our head cardiothoracic surgeon will say "I'm thinking about trying this, what do you think?" Or, "Is there anything else WE need to address for this patient that you can think of?" It makes me much more open and receptive to him as a physician when I know he listens and takes my concerns in to account.

One other tip, for those nurses who seem to give your grief. Try to talk to the charge nurse (hopefully the nurse being a butt is not the charge nurse), have a frank conversation, "you know, so and so really seems to have a problem with me, is she always that difficult?" You would be surprised when other nurses start hounding her for being awful to you what a change you might get. In return, as someone else mentioned, your behavior must be above reproach in return, always answering pages timely, being polite and respectful to staff. If you are that way, people will see it is the nurse who has the attitude and the problem, not you.

 

[SilverStreak]

The hierarchy system is a fact of life. Look at Military MD's responses when provoked for further support of that.

As far as my dealings with "underlings" go, I'm one of the guys who's very well liked by the nurses, scrub techs, etc. I address them by name, go out for beers with them, and have their respect. Not because I lord my "MD status" over them but because I respect them, treat them as I would want to be treated, etc.

It's really interesting to see you guys chastising me for what I've written here. Are there some deep-seated issues you have to grind with authority?

Finally, it is curious that Dave would bother to list his titles, including a fellowship that begins years from now, given his strong interest in "leveling the playing fields." I don't even call myself "doctor" to my patients, for God's sake, though my title would allow me to do so.

Realize, I don't know you, or your interactions with other healthcare staff. I just wanted to point out some of the attitudes prevalent on this board perpetuate "insubordination" as you refer to it (whether it is justified by nurses or not). I see after reading this post you are probably one of the few who does interact well with nurses, and treat them as EQUALS- not from an education standpoint, but from their vital contribution to the functioning the healthcare system standpoint. I have my place, you have yours, both of which are equally important in treating patients. Please don't take my post as chastisment, I know it came across that way, but honestly it rubs my nerves raw to read the garbage some of you all think about yourselves.

 

[toughlife]

Realize, I don't know you, or your interactions with other healthcare staff. I just wanted to point out some of the attitudes prevalent on this board perpetuate "insubordination" as you refer to it (whether it is justified by nurses or not). I see after reading this post you are probably one of the few who does interact well with nurses, and treat them as EQUALS- not from an education standpoint, but from their vital contribution to the functioning the healthcare system standpoint. I have my place, you have yours, both of which are equally important in treating patients. Please don't take my post as chastisment, I know it came across that way, but honestly it rubs my nerves raw to read the garbage some of you all think about yourselves.

And how should we feel when we read the garbage that nurses or midlevels think about themselves such as believing they are equal to docs? That makes my nerves raw too.

 

[ecCA1]

The whole CRNA=MD(A) issue has been addressed in multiple threads and I will not re-examine it here.

"If you truly want to solve the problem of insubordination, endear yourself to the nurses. I'm not saying kiss *ss, we can't stand that either, but being friendly and open to our suggestions, polite in your requests, please and thank you go a long way too."

I endeared myself in the ultimate way: I married one!

 

[SilverStreak]

And how should we feel when we read the garbage that nurses or midlevels think about themselves such as believing they are equal to docs? That makes my nerves raw too.

Touche. I agree with you that there are the good, the bad, and the ugly on both sides. But, of course when I hear comments negative towards my profession, I will stand up for my chosen career, as I would expect you to do.

 

[NYCDawg81]

.

 

[Lizard1]

i have a feeling that most of you are full of crap. you couldn't do more of a foolish thing than escalate a situation of "insubordination" by pulling the MD rank. it's amazing how simple & pleasant your job/education can be if you are just nice and smile. yeah you might get that one malignant person take advantage of that but you come out on top. as i finish this year, it's easy and fun because of all the unsolicited help that i'm given with transports, ICU pickups, lunch breaks, calls, etc...

off sopabox 😀

 

[Misterioso]

Some of you are coming across as clueless about this issue. As a physician YOU will be held responsible for decisions made about patient care and the consequences of those decisions. Despite what non-physicians would like you to believe, lawyers come after the person with the M.D. Thus why you shouldn't hesitate to pull-rank if need be: because ultimately it's YOUR butt on the line and you got to take care of yourself. That's how the real world works: everyone looks out for themselves in the end when push come to shove.

You think the nurses and other non-physicians who were involved in the patient's care will all come running to your defense if something goes wrong, even if you followed their "suggestions" that caused/contributed to it? Get real. Those same non-physicians who were once proudly claiming they were "looking out for the patient's best interest" will run and hide and let you absorb the legal consequences as the doctor.

So if you have to pull-rank so be it. They're not likely to be there to back you up if things go sour regardless of how "nice" you were to them. Who cares what people think about you. You look out for yourself.

 

[militarymd]

Some of you are coming across as clueless about this issue. As a physician YOU will be held responsible for decisions made about patient care and the consequences of those decisions. Despite what non-physicians would like you to believe, lawyers come after the person with the M.D. Thus why you shouldn't hesitate to pull-rank if need be: because ultimately it's YOUR butt on the line and you got to take care of yourself. That's how the real world works: everyone looks out for themselves in the end when push come to shove.

You think the nurses and other non-physicians who were involved in the patient's care will all come running to your defense if something goes wrong, even if you followed their "suggestions" that caused/contributed to it? Get real. Those same non-physicians who were once proudly claiming they were "looking out for the patient's best interest" will run and hide and let you absorb the legal consequences as the doctor.

So if you have to pull-rank so be it. They're not likely to be there to back you up if things go sour regardless of how "nice" you were to them. Who cares what people think about you. You look out for yourself.

Ahhhh...the single voice of reason and sense in all this.

 

[SilverStreak]

Some of you are coming across as clueless about this issue. As a physician YOU will be held responsible for decisions made about patient care and the consequences of those decisions. Despite what non-physicians would like you to believe, lawyers come after the person with the M.D. Thus why you shouldn't hesitate to pull-rank if need be: because ultimately it's YOUR butt on the line and you got to take care of yourself. That's how the real world works: everyone looks out for themselves in the end when push come to shove.

You think the nurses and other non-physicians who were involved in the patient's care will all come running to your defense if something goes wrong, even if you followed their "suggestions" that caused/contributed to it? Get real. Those same non-physicians who were once proudly claiming they were "looking out for the patient's best interest" will run and hide and let you absorb the legal consequences as the doctor.

So if you have to pull-rank so be it. They're not likely to be there to back you up if things go sour regardless of how "nice" you were to them. Who cares what people think about you. You look out for yourself.

I hate to disagree with you because I see how part of your point is accurate. But, if a case goes to court, anyone whose name is on that chart is going down with the MD. If I make a "suggestion" for an inappropriate treatment or med, I am going to be held just as accountable as you for carrying through with the treatment or pushing the med.

As far as pulling rank, yeah there may be times when it is appropriate, but I would say those times are few and far between. Don't get the big head and think every situation in which you encounter a little hesitance to follow an order you write needs to be blown out of proportion. That was my point.

 

[Misterioso]

I hate to disagree with you because I see how part of your point is accurate. But, if a case goes to court, anyone whose name is on that chart is going down with the MD. If I make a "suggestion" for an inappropriate treatment or med, I am going to be held just as accountable as you for carrying through with the treatment or pushing the med.

Do you have to pay thousands of dollars for malpractice insurance? Will the rate of your malpractice insurance skyrocket if there's a decision against you? Will insurers refuse to insure you anymore if you lose big or have too many claims against you, effectively ending your career?

How many times have you seen lawyers go after the nurse because her/his "name was on the chart"?
How many times have you seen lawyers drop the doctors from their case and go after the nurse?

Stop trying to put yourself and the the responsibility you carry for your decisions (or should I say "suggestions") in the same league as physicians.

 

[toofache32]

This is hilarious. Insubordination?!?! Residents are employees just like the nurses. You didn't hire them and you can't fire them. When you get out of residency, it doesn't change.

Get over yourself. Did your med school have a graduation or a coronation? Doctoring is just a job....just like nursing.