How do doctors keep from becoming dinguses?

[michaelrack]

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Case in point: I remember an ED nurse refused to discharge a patient because she was too hypertensive. The ED physician was stuck arguing with the RN, her superior RN, the charge nurse, and finally the administrative ARNP before finally getting the patient discharged. The whole affair took 2 hours.

That's odd, the usual way an ED doc would handle this situation is to give up and call medicine to admit.

 

[Promethean]

Easier move for the doc would have been to discuss with the nurse why it was safe to discharge, and if the nurse was still uncomfortable with it, do the discharge without that nurse.

Much more acceptable.

If you want to do something to a patient which I feel is dangerous, and don't want to give me a better explanation than "I am more educated and experienced than you," I have the right and responsibility to refuse to participate. If you don't try to compel me to put my license on the line, then it is your lookout. I won't stop you.

We have told a surgeon who wanted to do something unnecessary and potentially lethal to a patient in our OR that he was welcome to do so if he could find an anesthesiologist willing to induce and a surgical nursing team willing to assist. He left and came back with a safer plan.

I am not holding up one or two events as my shield against all the times I was wrong, and I am not inventing a new aspect of my job as a nurse, as someone above suggested. This is actually the most important part of my role in the OR. They have trained unlicensed technicians to hand surgeons instruments, but circulators must still be RNs. Why is that? Do you really think it is because the person who runs to get you the things you forgot to tell us upfront that you would need requires professional licensure to be your step-and-fetch?

My duty in the OR is not to the surgeons or the anesthesiologists, although I do support both teams as a matter of professional courtesy. Circulating RNs are there to ensure patient safety. It is a hazardous environment, and the physicians have specific goals that can narrow their focus. We are there to be thinking about the patient's interests because they are too unconscious to do so for themselves. I have hundreds of anecdotes about times that I had to speak with one doctor or another, to point out to them implications of their decisions and ask them to either convince me or else work with me to find another plan. That is what I am really being paid to do. Otherwise, they would just replace me with another cheaper technician.

I know that there are some really evil OR nurses out there. You will have to take me at my word that I am not one of those, that I am truly seeking collaborative approaches and mutually acceptable solutions.

Or you can take the usual SDN approach and assume the worst of me so that you can discount all my points as invalid and coming from "just" an uppity nurse.

 

[username456789]

I am wondering how we, as physicians, can walk that line between being the leader of a healthcare team and take ownership of our extensive training, without looking down upon other health-care workers (nurses, NP's, PA's, etc.) for their less complete understanding

You're in luck! Hospital/medical systems are all about pushing for the "pit crew" analogy now, where everyone is on equal footing when working towards a common goal. The physician is no longer the leader any more than the janitor is!

 

[NickNaylor]

You're in luck! Hospital/medical systems are all about pushing for the "pit crew" analogy now, where everyone is on equal footing when working towards a common goal. The physician is no longer the leader any more than the janitor is!

Excellent.

 

[dadaddadaBATMAN]

I've heard of doctors developing a "God complex" (inflated egos, thinking they know best, etc.) and it seems easy to see how that happens. There is a recent ongoing thread about how it can be offensive when people assume you are a nurse, not a doctor, and why it is wrong for NP's to call themselves doctors. To be clear, I'm not arguing for or against those arguments.

I am wondering how we, as physicians, can walk that line between being the leader of a healthcare team and take ownership of our extensive training, without looking down upon other health-care workers (nurses, NP's, PA's, etc.) for their less complete understanding (even if they think they know better). Basically, after I am done my 7-9 years MD/PhD and 4-7 years residency+fellowship, how to I keep myself from turning into a pretentious jerk?

I'll apologize for the confrontational tone, but I'm too lazy to edit.

first bold:
That thread is more about sexism than titles.

second bold:
Welcome to SDN.

third bold:
sounds like a passive aggressive attack on other posters, hence the trolling accusations. It also sounds grossly politically correct, except the bit where you accuse physicians of looking down on other health care workers.

The solution? Don't be a d***.

 

[tdram]

You're in luck! Hospital/medical systems are all about pushing for the "pit crew" analogy now, where everyone is on equal footing when working towards a common goal. The physician is no longer the leader any more than the janitor is!

If we're all on equal footing can we all divide up the blame and liability equally too?

 

[link2swim06]

That's odd, the usual way an ED doc would handle this situation is to give up and call medicine to admit.

Admit for what? There is no acute problem to be treated here...

 

[dadaddadaBATMAN]

Or you can take the usual SDN approach and assume the worst of me so that you can discount all my points as invalid and coming from "just" an uppity nurse.

I was going to write a longer response, but I've spent way too much time on here today already.

So I'm just going to point this out: the way you phrased this last sentence is kind of confrontational. It makes it sound as though anyone who disagrees with you *must* be saying that you're invalid and an uppity nurse. This is a false argument, and a distraction from an otherwise valid point.

I agree that people should have justification for their decisions, and should be ready to defend them (they may very well have to later). I also applaud your desire for justification, and to protect patients.

But from an outside perspective, it sounds a little odd. Imagine a LPN telling a RN what you just said. Think of how that makes you feel.

Yes, the RN should know why he's choosing to do what he wants, but the LPN should have a lot of trust in the RNs judgement. A RN should not have to have a long conversation with every LPN over every order. He also may not have a lot of time to argue with the LPN about why he wants something done.

 

[username456789]

If we're all on equal footing can we all divide up the blame and liability equally too?

Not only can you not have your cake, but you can't eat it either.

 

[dadaddadaBATMAN]

Not only can you not have your cake, but you can't eat it either.

You should also be punished for wanting the cake. Cake is vile and unclean. It's unprofessional to think of cake.

 

[tdram]

Much more acceptable.

If you want to do something to a patient which I feel is dangerous, and don't want to give me a better explanation than "I am more educated and experienced than you," I have the right and responsibility to refuse to participate. If you don't try to compel me to put my license on the line, then it is your lookout. I won't stop you.

We have told a surgeon who wanted to do something unnecessary and potentially lethal to a patient in our OR that he was welcome to do so if he could find an anesthesiologist willing to induce and a surgical nursing team willing to assist. He left and came back with a safer plan.

I am not holding up one or two events as my shield against all the times I was wrong, and I am not inventing a new aspect of my job as a nurse, as someone above suggested. This is actually the most important part of my role in the OR. They have trained unlicensed technicians to hand surgeons instruments, but circulators must still be RNs. Why is that? Do you really think it is because the person who runs to get you the things you forgot to tell us upfront that you would need requires professional licensure to be your step-and-fetch?

My duty in the OR is not to the surgeons or the anesthesiologists, although I do support both teams as a matter of professional courtesy. Circulating RNs are there to ensure patient safety. It is a hazardous environment, and the physicians have specific goals that can narrow their focus. We are there to be thinking about the patient's interests because they are too unconscious to do so for themselves. I have hundreds of anecdotes about times that I had to speak with one doctor or another, to point out to them implications of their decisions and ask them to either convince me or else work with me to find another plan. That is what I am really being paid to do. Otherwise, they would just replace me with another cheaper technician.

I know that there are some really evil OR nurses out there. You will have to take me at my word that I am not one of those, that I am truly seeking collaborative approaches and mutually acceptable solutions.

Or you can take the usual SDN approach and assume the worst of me so that you can discount all my points as invalid and coming from "just" an uppity nurse.

The whole point of the person with more education and experience is that person can call the shots and keep things moving without having to explain every decision to everybody else. If you knew more about how to perform surgery safely than a surgeon, you'd be a surgeon. You're not being paid to question the decisions of a profession you have no training in. That would make no sense. It would be nice if the surgeon explained her decisions to you, but is by no means necessary.

If the surgeon makes a lot of mistakes, the corrective action should come from another surgeon, not a nurse. A nurse is just in no way qualified to question a surgeon's decisions in the OR. Neither is any other doctor who's not a surgeon.

Edit: This whole thing sounds like much more of an ego issue than a patient safety issue.

 

[DermViser]

You're in luck! Hospital/medical systems are all about pushing for the "pit crew" analogy now, where everyone is on equal footing when working towards a common goal. The physician is no longer the leader any more than the janitor is!

I to you, sir. Oh, and you now owe me a new monitor.

 

[DermViser]

If we're all on equal footing can we all divide up the blame and liability equally too?

Nope. The malpractice risk goes to physician since all of a sudden he's the leader. Team based care: None of the credit, all of the blame©.

 

[tdram]

Nope. The malpractice risk goes to physician since all of a sudden he's the leader. Team based care: None of the credit, all of the blame©.

Why don't physicians just say NO. I'm not a physician, so I can't answer that question. Maybe some of you who are can?

What are they going to do? Fire every physician?

 

[Jabbed]

You should also be punished for wanting the cake. Cake is vile and unclean. It's unprofessional to think of cake.

The cake is a lie.

 

[evilbooyaa]

Much more acceptable.

If you want to do something to a patient which I feel is dangerous, and don't want to give me a better explanation than "I am more educated and experienced than you," I have the right and responsibility to refuse to participate. If you don't try to compel me to put my license on the line, then it is your lookout. I won't stop you.

We have told a surgeon who wanted to do something unnecessary and potentially lethal to a patient in our OR that he was welcome to do so if he could find an anesthesiologist willing to induce and a surgical nursing team willing to assist. He left and came back with a safer plan.

I am not holding up one or two events as my shield against all the times I was wrong, and I am not inventing a new aspect of my job as a nurse, as someone above suggested. This is actually the most important part of my role in the OR. They have trained unlicensed technicians to hand surgeons instruments, but circulators must still be RNs. Why is that? Do you really think it is because the person who runs to get you the things you forgot to tell us upfront that you would need requires professional licensure to be your step-and-fetch?

My duty in the OR is not to the surgeons or the anesthesiologists, although I do support both teams as a matter of professional courtesy. Circulating RNs are there to ensure patient safety. It is a hazardous environment, and the physicians have specific goals that can narrow their focus. We are there to be thinking about the patient's interests because they are too unconscious to do so for themselves. I have hundreds of anecdotes about times that I had to speak with one doctor or another, to point out to them implications of their decisions and ask them to either convince me or else work with me to find another plan. That is what I am really being paid to do. Otherwise, they would just replace me with another cheaper technician.

I know that there are some really evil OR nurses out there. You will have to take me at my word that I am not one of those, that I am truly seeking collaborative approaches and mutually acceptable solutions.

Or you can take the usual SDN approach and assume the worst of me so that you can discount all my points as invalid and coming from "just" an uppity nurse.

This reminds me of that "I was told I would be good at pathology" thread. If you need to define yourself as NOT something, it doesn't help your internet argument.

Are you insinuating that you believe that your rate of speaking up and telling the operating surgeon that he's doing something wrong results in you being right (let's say) more than 50% of the time?

It's a very simple question and I'll phrase the rest of my response based on your answer.

I'm all for checks and balances (especially on orders and stuff), and I appreciate that nurses check orders before blindly giving doses with an extra 0 at the end. However, if a nurse tried to question my assessment and plan for a patient, I would listen, and if her initial statements didn't at least make me pause and think, I would continue with my plan if I felt strongly enough about it. I would not expect it to be OK for a RN to be practicing medicine by altering the plan that I (the physician in this hypothetical) had formulated.

 

[DermViser]

Why don't physicians just say NO. I'm not a physician, so I can't answer that question. Maybe some of you who are can?

What are they going to do? Fire every physician?

Now you know why some of us head for specialties where we are still able to be leaders when it comes to that care. Most of us (I'm sure the MD/MBA and MD/MPH/Public health crowd disagree) went into medicine to do actual patient care and be the leader in that care.

 

[tdram]

Now you know why some of us head for specialties where we are still able to be leaders when it comes to that care. Most of us (I'm sure the MD/MBA and MD/MPH/Public health crowd disagree) went into medicine to do actual patient care and be the leader in that care.

Which specialties are those?

 

[DermViser]

Which specialties are those?

Well this is only my opinion but: Radiology, Ophthalmology, Anesthesiology (but becoming less so, due to scope of practice laws changing), Dermatology, Psychiatry, Pathology, PM&R, Radiation Oncology, Surgery and all its subspecialties. I'm sure I'm missing some more, but those are the ones I can think of for the moment.

 

[Pisiform]

My cousin is in general surgery and before even getting residency he was the biggest a-hole. So the question is, does only a-holes apply for surgery coz I would be applying to one and I am not an a-hole I think? Ok maybe a bit

 

[tdram]

Well this is only my opinion but: Radiology, Ophthalmology, Anesthesiology (but becoming less so, due to scope of practice laws changing), Dermatology, Psychiatry, Pathology, PM&R, Radiation Oncology, Surgery and all its subspecialties. I'm sure I'm missing some more, but those are the ones I can think of for the moment.

Do you think Psych is in there? When I was doing my psych rotation, the social workers and psychiatric nurse practitioners were basically running the show. The docs didn't have a lot of control.

 

[DermViser]

Do you think Psych is in there? When I was doing my psych rotation, the social workers and psychiatric nurse practitioners were basically running the show. The docs didn't have a lot of control.

Except in Psychiatry, you have the ability to have your own private practice. You're doing a rotation at an academic medical center.

 

[tdram]

Except in Psychiatry, you have the ability to have your own private practice. You're doing a rotation at an academic medical center.

That's true. But is private practice for psych economically viable anymore?

 

[evilbooyaa]

Social workers are critical in psych and stop you as a resident/attending from having to deal with them personally. The place I did my inpatient psych rotation was in a hospital had residents but no NPs. Docs ran the show there.

Well this is only my opinion but: Radiology, Ophthalmology, Anesthesiology (but becoming less so, due to scope of practice laws changing), Dermatology, Psychiatry, Pathology, PM&R, Radiation Oncology, Surgery and all its subspecialties. I'm sure I'm missing some more, but those are the ones I can think of for the moment.

Agree with this list, although apparently as a surgeon you should expect to have your plan questioned at times by the circulating nurse (according to that other thread in this forum, I believe).

Although I will state that this idea that physicians (at least as attendings) are not the leaders of care is generally overblown. Yeah, if you're the R1 or R2 in the MICU, you might get some crap from the nurses (maybe even up to a fellow). But I hope that if you're an PCCM attending (maybe even a fellow gets crapped on) you should be the clear leader for these immensely sick patients, and delegate out tasks to the nurses working under you.

That's true. But is private practice for psych economically viable anymore?

If you do a cash practice, absolutely. Otherwise, it may be a little difficult to get sufficient volume in the hours of the day.

 

[DermViser]

Although I will state that this idea that physicians (at least as attendings) are not the leaders of care is generally overblown. Yeah, if you're the R1 or R2 in the MICU, you might get some crap from the nurses (maybe even up to a fellow). But I hope that if you're an PCCM attending (maybe even a fellow gets crapped on) you should be the clear leader for these immensely sick patients, and delegate out tasks to the nurses working under you.

You know there are ICU NPs, right?

 

[DermViser]

That's true. But is private practice for psych economically viable anymore?

Of course, it is. There are many psychiatry physicians who see patients all day who have private insurance.

 

[tdram]

You know there are ICU NPs, right?

Yeah the NPs in the ICU fight with the attendings all the time. They are always trying to "one up" them and prove they're just as good.

 

[DermViser]

Yeah the NPs in the ICU fight with the attendings all the time. They are always trying to "one up" them and prove they're just as good.

Yup, I can't imagine not only the stress of having to be a PCCM attending but also having the stress of having your orders challenged while your patient is actively dying on you.

 

[evilbooyaa]

You know there are ICU NPs, right?

I knew there were programs in the works, but I figured they were reserved for the rural areas that can't get physicians to work out there in significant enough numbers.

They are not in the MICU at the hospital my rotations are at. I believe there are PAs and NPs in the SICU, neuro ICU, and TICU at times, but I've never heard or seen those PAs and NPs disagree with an attending.

All this being said, I couldn't imagine having anyone besides a physician managing my (or any relatives) ICU care. It's one thing to see me for a yearly physical or evaluate whether I should be on Abx (oh who are we kidding, the answer to that is always yes) for my URI/sinus infection/pneumonia/UTI.

 

[DermViser]

I knew there were programs in the works, but I figured they were reserved for the rural areas that can't get physicians to work out there in significant enough numbers.

They are not in the MICU at the hospital my rotations are at. I believe there are PAs and NPs in the SICU, neuro ICU, and TICU at times, but I've never heard or seen those PAs and NPs disagree with an attending.

All this being said, I couldn't imagine having anyone besides a physician managing my (or any relatives) ICU care. It's one thing to see me for a yearly physical or evaluate whether I should be on Abx (oh who are we kidding, the answer to that is always yes) for my URI/sinus infection/pneumonia/UTI.

If I just want a healthcare service and want an Abx (assuming I'm that hardheaded to believe that all my colds require an Abx) I'll go to a NP.

If I'm going to the ICU of one of my family members, you can be darn sure I'll be wanting to hear the plan from an attending not an NP. After seeing how academic medical centers and VAs operate as a medical student, you can be sure I'll be watching everyone like a hawk, when it comes to my family.

 

[fab4fan]

The whole point of the person with more education and experience is that person can call the shots and keep things moving without having to explain every decision to everybody else. If you knew more about how to perform surgery safely than a surgeon, you'd be a surgeon. You're not being paid to question the decisions of a profession you have no training in. That would make no sense. It would be nice if the surgeon explained her decisions to you, but is by no means necessary.

If the surgeon makes a lot of mistakes, the corrective action should come from another surgeon, not a nurse. A nurse is just in no way qualified to question a surgeon's decisions in the OR. Neither is any other doctor who's not a surgeon.

Edit: This whole thing sounds like much more of an ego issue than a patient safety issue.

Maybe I'm misunderstanding what you're saying here, but actually nurses are paid to question orders when they feel there is a problem (e.g. medication ordered incorrectly). It's not about an ego issue, it is, as Promethean stated, about patient safety. I've spoken to surgeons over issues from time to time. Sometimes the mistake was on their end, sometimes it was a problem with communication. But let me clear: Nurses have a duty to speak up if they feel the patient's well-being is compromised for one reason or another. We work as a team. Yes, the physician is the leader of the team, and I respect that. A good team leader appreciates the members of the team for what they bring to the table. Doctors don't operate in a vacuum.

 

[tdram]

I knew there were programs in the works, but I figured they were reserved for the rural areas that can't get physicians to work out there in significant enough numbers.

They are not in the MICU at the hospital my rotations are at. I believe there are PAs and NPs in the SICU, neuro ICU, and TICU at times, but I've never heard or seen those PAs and NPs disagree with an attending.

All this being said, I couldn't imagine having anyone besides a physician managing my (or any relatives) ICU care. It's one thing to see me for a yearly physical or evaluate whether I should be on Abx (oh who are we kidding, the answer to that is always yes) for my URI/sinus infection/pneumonia/UTI.

Yeah, I would be really pissed off if anyone other than physician was taking care of me in the ICU.

 

[DermViser]

Maybe I'm misunderstanding what you're saying here, but actually nurses are paid to question orders when they feel there is a problem (e.g. medication ordered incorrectly). It's not about an ego issue, it is, as Promethean stated, but patient safety. I've spoken to surgeons over issues from time to time. Sometimes the mistake was on their end, sometimes it was a problem with communication. But let me clear: Nurses have a duty to speak up if they feel the patient's well-being is compromised for one reason or another. We work as a team. Yes, the physician is the leader of the team, and I respect that. A good team leader appreciates the members of the team for what they bring to the table. Doctors don't operate in a vacuum.

Can you please tell this to NPs? I don't think they got the memo. That being said, the MICU nurses I interacted with were awesome. After a call night the next morning, the MICU nurses told me to sign for the Protonix renewal from last night - bc that they didn't want to call and wake me up at 3 AM in the morning for something so ridiculous. That being said, we all knew when we got a call from a MICU nurse to come see the patient, it was always for something serious.

Wish I could say the same for floor nurses.

 

[fab4fan]

If I just want a healthcare service and want an Abx (assuming I'm that hardheaded to believe that all my colds require an Abx) I'll go to a NP.

If I'm going to the ICU of one of my family members, you can be darn sure I'll be wanting to hear the plan from an attending not an NP. After seeing how academic medical centers and VAs operate as a medical student, you can be sure I'll be watching everyone like a hawk, when it comes to my family.

Several years ago my father had a cardiac incident. I gave him a huge harangue about going to his doctor; he told me to go ahead and call for the appt. I called, and the receptionist said she was putting him in with "John," who I knew was a PA. I said that was unacceptable; he had no history of cardiac issues and should be evaluated by a physician. She hemmed and hawed and then said she would put him in with "Jane Doe." I asked her if "Jane" was a physician and she said "Jane" was one of Dr. X's partners. I asked if she was an MD or DO. The receptionist finally said she was an NP. I told her (a whole lot more forcefully) that this was a new onset of symptoms, and he needed to be seen by a physician.

We finally got him that appt. with a real doctor, but man, it shouldn't have to have been that hard.

 

[fab4fan]

Can you please tell this to NPs? I don't think they got the memo. That being said, the MICU nurses I interacted with were awesome. After a call night the next morning, the MICU nurses told me to sign for the Protonix renewal from last night - bc that they didn't want to call and wake me up at 3 AM in the morning for something so ridiculous. That being said, we all knew when we got a call from a MICU nurse to come see the patient, it was always for something serious.

Wish I could say the same for floor nurses.

Yeah, I wish some of my colleagues would think first, page later.

As far as NPs go, I think I've made my feelings clear on them.

 

[DermViser]

Several years ago my father had a cardiac incident. I gave him a huge harangue about going to his doctor; he told me to go ahead and call for the appt. I called, and the receptionist said she was putting him in with "John," who I knew was a PA. I said that was unacceptable; he had no history of cardiac issues and should be evaluated by a physician. She hemmed and hawed and then said she would put him in with "Jane Doe." I asked her if "Jane" was a physician and she said "Jane" was one of Dr. X's partners. I asked if she was an MD or DO. The receptionist finally said she was an NP. I told her (a whole lot more forcefully) that this was a new onset of symptoms, and he needed to be seen by a physician.

We finally got him that appt. with a real doctor, but man, it shouldn't have to have been that hard.

You can bet this will happen much more frequently once Obamacare rolls thru. I'm not surprised with the receptionist bc many of them try to pull one over on patients - they may even be directed by the practice/hospital to do so.. I've seen it as a med student, and wondered how pissed I would be if they tried to pull that over on myself or a family member.

I like the ones that complain when a patient/patient's family has a physician/nurse in the family. I guess we don't want them to be too smart for their own good. 🙄 You can imagine if the NP had a DNP, the receptionist would have said she's a doctor.

 

[tdram]

Several years ago my father had a cardiac incident. I gave him a huge harangue about going to his doctor; he told me to go ahead and call for the appt. I called, and the receptionist said she was putting him in with "John," who I knew was a PA. I said that was unacceptable; he had no history of cardiac issues and should be evaluated by a physician. She hemmed and hawed and then said she would put him in with "Jane Doe." I asked her if "Jane" was a physician and she said "Jane" was one of Dr. X's partners. I asked if she was an MD or DO. The receptionist finally said she was an NP. I told her (a whole lot more forcefully) that this was a new onset of symptoms, and he needed to be seen by a physician.

We finally got him that appt. with a real doctor, but man, it shouldn't have to have been that hard.

This is terrible. Thank you for being one of the informed patients who doesn't put up with this sort of thing. We need to get more and more informed patients to be vocal about their preference for a physician to be always involved, especially in complicated cases.

 

[Promethean]

I'm all for checks and balances (especially on orders and stuff), and I appreciate that nurses check orders before blindly giving doses with an extra 0 at the end. However, if a nurse tried to question my assessment and plan for a patient, I would listen, and if her initial statements didn't at least make me pause and think, I would continue with my plan if I felt strongly enough about it. I would not expect it to be OK for a RN to be practicing medicine by altering the plan that I (the physician in this hypothetical) had formulated.

I agree that it isn't my role to practice medicine by unilaterally changing the plan. It is my role to question it when that is called for. If the physician does feel strongly enough about it, they do move forward. Usually my relationship with the physicians in question is such that they do take what I have to say into consideration. By the same token, my respect for them is great enough that I listen to them and take their concerns seriously as well.

Again, we are talking OR. Most of my anecdata have to do with novel problems and attempts to innovate around them. An example: Surgeon says, hey, there isn't an instrument that does exactly what I want, so I will modify another one to fit the need. Sometimes that is reasonable. Sometimes it isn't. When you decide to get crafty with materials and end up with a piece of a catheter broken off in someone's vena cava, that was maybe one of those times when checks and balances might have been useful.

EDIT: I realized I didn't answer your question. Am I right at least 50% of the time? It isn't about being right or the doctor being wrong. It is about taking a moment to consider whether what we are talking about doing is right for the patient. I would say that 25-50% of the time, my objection results in a variation on the plan. The other 50-75% of the time, the doctor addresses my concern and we proceed without a change, because I am satisfied that the plan is safe. I don't question every single order. I would say that I have a minor issue every couple of weeks and something really serious every 6-12 months.

 

[DermViser]

I agree that it isn't my role to practice medicine by unilaterally changing the plan. It is my role to question it when that is called for. If the physician does feel strongly enough about it, they do move forward. Usually my relationship with the physicians in question is such that they do take what I have to say into consideration. By the same token, my respect for them is great enough that I listen to them and take their concerns seriously as well.

Again, we are talking OR. Most of my anecdata have to do with novel problems and attempts to innovate around them. An example: Surgeon says, hey, there isn't an instrument that does exactly what I want, so I will modify another one to fit the need. Sometimes that is reasonable. Sometimes it isn't. When you decide to get crafty with materials and end up with a piece of a catheter broken off in someone's vena cava, that was maybe one of those times when checks and balances might have been useful.

I've never seen a Surgeon (at least one that cares about his malpractice) altering surgical instruments. Ever.

 

[PL198]

Much more acceptable.

If you want to do something to a patient which I feel is dangerous, and don't want to give me a better explanation than "I am more educated and experienced than you," I have the right and responsibility to refuse to participate. If you don't try to compel me to put my license on the line, then it is your lookout. I won't stop you.

We have told a surgeon who wanted to do something unnecessary and potentially lethal to a patient in our OR that he was welcome to do so if he could find an anesthesiologist willing to induce and a surgical nursing team willing to assist. He left and came back with a safer plan.

I am not holding up one or two events as my shield against all the times I was wrong, and I am not inventing a new aspect of my job as a nurse, as someone above suggested. This is actually the most important part of my role in the OR. They have trained unlicensed technicians to hand surgeons instruments, but circulators must still be RNs. Why is that? Do you really think it is because the person who runs to get you the things you forgot to tell us upfront that you would need requires professional licensure to be your step-and-fetch?

My duty in the OR is not to the surgeons or the anesthesiologists, although I do support both teams as a matter of professional courtesy. Circulating RNs are there to ensure patient safety. It is a hazardous environment, and the physicians have specific goals that can narrow their focus. We are there to be thinking about the patient's interests because they are too unconscious to do so for themselves. I have hundreds of anecdotes about times that I had to speak with one doctor or another, to point out to them implications of their decisions and ask them to either convince me or else work with me to find another plan. That is what I am really being paid to do. Otherwise, they would just replace me with another cheaper technician.

I know that there are some really evil OR nurses out there. You will have to take me at my word that I am not one of those, that I am truly seeking collaborative approaches and mutually acceptable solutions.

Or you can take the usual SDN approach and assume the worst of me so that you can discount all my points as invalid and coming from "just" an uppity nurse.

I agree with some of your points, but you're getting all sensationalist and pulling the safety card is basically an unfair trump card. I'm pretty sure the doctor, that is up to his/her eyeballs in debt (at least at the start) and has all of their assets liable to taken away if they exhibit negligence probably also cares about the safety of the patients too...

 

[DermViser]

My cousin is in general surgery and before even getting residency he was the biggest a-hole. So the question is, does only a-holes apply for surgery coz I would be applying to one and I am not an a-hole I think? Ok maybe a bit

1/10 for that trolling performance.

 

[Promethean]

But from an outside perspective, it sounds a little odd. Imagine a LPN telling a RN what you just said. Think of how that makes you feel.

Yes, the RN should know why he's choosing to do what he wants, but the LPN should have a lot of trust in the RNs judgement. A RN should not have to have a long conversation with every LPN over every order. He also may not have a lot of time to argue with the LPN about why he wants something done.

My closing statement was not intended to shut down legitimate debate. It was directed at the people who have essentially said that nurses need to know their place and just follow orders. If that doesn't apply to you, it wasn't meant for you.

As for your argument above, there are few issues I have with it. First is that I don't question every order that the physician gives. Most of the time, we run as a well oiled machine, based in mutual respect and mutual goals.

How would it make me feel if an LPN called me on a decision that put a patient at risk? Proud of him! I don't work with LPN's, but I do work with surgical techs, which is a very similar level of training and scope, and they do speak up when they see something that isn't right. The scrubs will tell me quick if I have contaminated something, or if I am doing something boneheaded that could hurt the patient. Some will speak up to the surgeons, some will come to me and ask me to raise their concerns, but it takes all eyes to keep our patients safe.

This thread has mightily derailed from the original question of how to not be a jerk, but I think it is still talking around the point. Never feel too important to let someone else question your decisions. Big egos and patient safety don't mix.

 

[DermViser]

My closing statement was not intended to shut down legitimate debate. It was directed at the people who have essentially said that nurses need to know their place and just follow orders. If that doesn't apply to you, it wasn't meant for you.

As for your argument above, there are few issues I have with it. First is that I don't question every order that the physician gives. Most of the time, we run as a well oiled machine, based in mutual respect and mutual goals.

How would it make me feel if an LPN called me on a decision that put a patient at risk? Proud of him! I don't work with LPN's, but I do work with surgical techs, which is a very similar level of training and scope, and they do speak up when they see something that isn't right. The scrubs will tell me quick if I have contaminated something, or if I am doing something boneheaded that could hurt the patient. Some will speak up to the surgeons, some will come to me and ask me to raise their concerns, but it takes all eyes to keep our patients safe.

This thread has mightily derailed from the original question of how to not be a jerk, but I think it is still talking around the point. Never feel too important to let someone else question your decisions. Big egos and patient safety don't mix.

 

[Promethean]

I've never seen a Surgeon (at least one that cares about his malpractice) altering surgical instruments. Ever.

Well, I have seen it. Those are the kinds of things that I am saying that I speak up about.

I'm certainly not telling them where to make their incisions! They are the doctors, not me. I get that.

But I am refusing to plug their bovies in when they want to bovie inside the mouth with a 100% FiO2. I used to trust them not to start cauterizing without confirming that the O2 was turned down... but after that one airway fire, I just don't give them the option anymore. That is the kind of thing I am talking about. That kind of obstructionism is absolutely my job.

 

[dadaddadaBATMAN]

My closing statement was not intended to shut down legitimate debate. It was directed at the people who have essentially said that nurses need to know their place and just follow orders. If that doesn't apply to you, it wasn't meant for you.

It does not.

As for your argument above, there are few issues I have with it. First is that I don't question every order that the physician gives. Most of the time, we run as a well oiled machine, based in mutual respect and mutual goals.

Context helps in these statements. I know nothing about you, so I only had your previous statements to go on.

How would it make me feel if an LPN called me on a decision that put a patient at risk? Proud of him! I don't work with LPN's, but I do work with surgical techs, which is a very similar level of training and scope, and they do speak up when they see something that isn't right. The scrubs will tell me quick if I have contaminated something, or if I am doing something boneheaded that could hurt the patient. Some will speak up to the surgeons, some will come to me and ask me to raise their concerns, but it takes all eyes to keep our patients safe.

This is perfectly reasonable. The issue is when catching another person's mistake is misconstrued as a sign of superiority or superior knowledge. It is neither. I think we're in agreement here.

This thread has mightily derailed from the original question of how to not be a jerk, but I think it is still talking around the point. Never feel too important to let someone else question your decisions. Big egos and patient safety don't mix.

Answers above.

 

[fab4fan]

You can bet this will happen much more frequently once Obamacare rolls thru. I'm not surprised with the receptionist bc many of them try to pull one over on patients - they may even be directed by the practice/hospital to do so.. I've seen it as a med student, and wondered how pissed I would be if they tried to pull that over on myself or a family member.

I like the ones that complain when a patient/patient's family has a physician/nurse in the family. I guess we don't want them to be too smart for their own good. 🙄 You can imagine if the NP had a DNP, the receptionist would have said she's a doctor.

Which is why you have to specify "Doctor as in MD/DO."

 

[DermViser]

Which is why you have to specify "Doctor as in MD/DO."

Right. What I'm saying that a patient, even the most educated, who isn't in healthcare, won't know to ask. They'll assume (rightfully) that when they say they want a doctor, they're getting an MD/DO.

 

[fab4fan]

This is terrible. Thank you for being one of the informed patients who doesn't put up with this sort of thing. We need to get more and more informed patients to be vocal about their preference for a physician to be always involved, especially in complicated cases.

The only reason I knew to ask was because of being a nurse. In the background of that convo., my Dad was saying, "That's OK, I can see the PA," and I was like "NO!!!"

 

[DermViser]

The only reason I knew to ask was because of being a nurse. In the background of that convo., my Dad was saying, "That's OK, I can see the PA," and I was like "NO!!!"

Parents can be so frustrating sometimes (even though we still love them). Maybe it's bc they don't want people making a a fuss over them or something, as many times you have to drag them to see a doctor in the first place. My Dad is the same way. He just wants the person to give him the prescription that he already wants. I would have reacted the same way you did. He's like the Traffic School episode on the tv show Everybody Loves Raymond where the father attends and keeps saying, "Sign my thing!!" (re: signing his traffic ticket saying he went to a Defensive driving course).

 

[tdram]

Which is why you have to specify "Doctor as in MD/DO."

What are nurses thoughts on NPs/PAs in terms of going to them solely for care? Would most nurses trust that option? (to clarify I mean nurses that are not NPs).