"Medicine is a team sport"

[sliceofbread136]

Everyone is all about team work until you see in those stupid nursing notes "concerns raised to Dr. ****, not at bedside" or whatever crap they love to write that basically says "anything goes wrong it's definitely this guy's fault and not mine". It almost feels like the all of their training is not geared towards patient care but rather to avoiding liability, really grinds my gears.

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[WingedOx]

So what's your point exactly?

 

[sliceofbread136]

So what's your point exactly?

It's annoying and I'm ranting?

 

[operaman]

The not at bedside thing is a bit much because you may well have seen the patient while they were in another room and were not concerned. Documenting they made you aware of a potential issue is just part of their job.

And if something goes wrong because you failed to see a patient you should have seen, then it absolutely is your fault. The documentation prevents you from bs'ing your way out of it by pleading ignorance, but doesn't alter responsibility. Even if they never documented it, the pages would all be logged and discoverable later anyhow if things got to that point.

It also does not absolve them of responsibility either. If they are truly concerned, they can call code or rapid or whatever your hospital calls them. They could page the attending. Just paging the team does not wash their hands of the problem. My experience has been that the MD aware notes are typically for non-issues where there was little to no concern and possibly an NHO order to that effect, so the nurse note simply says they did their part but nothing else really happened. Nurses who are really concerned about a patient don't usually have time to sit and chart about; they're busy trying to get that person taken care of.

 

[sliceofbread136]

Yes we all know that if something goes wrong it's my fault, already understood so you don't have to have emr diatribes to make that more apparent. It feels really scummy to me, and I personally would not be finger pointing as hard in my notes. It doesn't just end at md not at bedside, there are sooo many other examples (quibbling over electrolytes, me making sure tasks are actually done).

And some nurses are better than others, but I have quite a few bad players are 24/7 on me about non-issues but are completely quiet with important things like vital signs changes

 

[Perrotfish]

Yes we all know that if something goes wrong it's my fault, already understood so you don't have to have emr diatribes to make that more apparent. It feels really scummy to me, and I personally would not be finger pointing as hard in my notes.

It's not scummy, it's not a diatribe, it's appropriate documentation. They called you, they documented that they called you. If they didn't call you and the patient died it would be their fault, so they need to document that they called you and if the patient dies it's your fault because you were aware of the situation


You do it too. When you write an order rather than giving it verbally you are not 'finger pointing' at the nurse/pharmacy in case they give the wrong dose of insulin, you are appropriately documenting that you ordered the right dose and that the ball is in their court to make sure the right dose gets delivered.. When you document your discharge instructions you are not trying to blame the patient for future complications, you are appropriately documenting what you said so that if the patient doesn't follow your advice they can't falsely claim it wasn't given. I'm not sure what you want here.

 

[sliceofbread136]

It's not scummy, it's not a diatribe, it's appropriate documentation. They called you, they documented that they called you. If they didn't call you and the patient died it would be their fault, so they need to document that they called you and if the patient dies it's your fault because you were aware of the situation


You do it too. When you write an order rather than giving it verbally you are not 'finger pointing' at the nurse/pharmacy in case they give the wrong dose of insulin, you are appropriately documenting that you ordered the right dose and that the ball is in their court to make sure the right dose gets delivered.. When you document your discharge instructions you are not trying to blame the patient for future complications, you are appropriately documenting what you said so that if the patient doesn't follow your advice they can't falsely claim it wasn't given. I'm not sure what you want here.

What I would appreciate is an "MD aware". I don't write notes explaining how my orders were written to a certain nurse followed by a paragraph about how worried I am.

 

[Crayola227]

"MD aware" is total bullshyte when they write some pt/nurse subjective there that is concerning, but they NEVER did anything besides write that

what makes you aware is the note that spans 4 hours

"Pt says they feel like something popped inside their stomach and that they might be dying. MD aware. Awaiting orders."

 

[sloop]

I don't really care much about the notes. I'm too busy to care about that stuff. I also have no problem with people voicing their concerns.

The one thing that will annoy me is people who haven't gone to medical school refusing to stop questioning my medical decisions after they have raised a concern and I have explained my thought process. I have no problem with people bringing up a concern, but when I give them a legitimate medical explanation for why their concern does not worry me while assuring them that I appreciate their communicating this with me, they should back off (especially if the topic has already been discussed with the attending). Earlier this year, I had to argue with a nurse who was insisting I not replete a patient's magnesium through the IV because "it burns the patient" despite explaining that "no, you're thinking of potassium. The IV mag will be painless and if I give it PO it will cause the patient to have diarrhea," she wouldn't let up about it. Such a waste of time. I also once had an allied health professional tell me that they were concerned that a patient's symptoms I had diagnosed as a conversion disorder were actually "real"—that is, due to a physical illness—despite me explaining how I had considered medical/primary neurological causes, reactions to medication, etc. and why none of them made sense as explanations for the patient's symptoms while there was a clear major psychological stressor that was temporally related to onset. I really wanted to just respond "So what do you think is causing this, then?" but I figured that would have been too snarky and gotten me in trouble.

 

[CherryRedDracul]

I would have contacted the nurse personally about that "MD not at bedside" thing if I were you. Chances are, the nurse was just trying to document and didn't mean any harm by it. I've unintentionally done something similar to an attending consultant which led me to get mildly reamed out, but we quickly resolved the issue with a bit of dialog and were back to good terms.

 

[DiagnasaurusRex]

It's a tricky situation. The nurse has to balance the fact that she made the MD aware, documenting that she was concerned/did everything she can and what transpired afterwards. Let's be clear though: all EMR data pertaining to patient can be requested by the patient, the medical board or - if there is a trial - by the courts.

In situations like this I make sure to clearly document what I did.
"Made aware by RN that x occured at 1300; saw patient at 1312...."
Then sum it up with what transpired. Ultimately the physician documentation trumps RN notes anyways.

 

[jm192]

Not at bed side is weak because you just cant get there immediately sometimes for a patient that isnt dying.

Also, nursing freak out=\= Dr freakout. If the patient does ok, it doesn't matter.

In residency, I'd get called overnight for a-fib in the 120's--patient sound asleep. This was obviously not the cardiac floor. But me saying it's ok, doesn't mean the nurse isn't going to freak out.

I leave a note: patient in 120's, aymptomatic, asked nursing to monitor and call for these perameters. And that's reasonably all you need to do.

I had a 35 year old with Down Syndrome who I knew was a difficult patient. Nurse called me at 3 AM saying he was hard to arouse and his CO2 was 80--it was 90 on admission. They wanted to send him to the unit, and I said I'd like to come see him first that I think he's just a big child mentally and probably wants to sleep. They said they were close to calling a rapid, and in fact did so before I got to the room. Everyone is there and now my patient is very awake and very mad. He tells me about his dogs. I send him to the ICU because I'm done with dealing with the BS from the floor. The ICU nurses laugh when we get to the unit that a rapid was called.

The floor nurse turned me into quality--said they had to call a rapid because I didn't take her concern seriously and I didn't respect her nursing judgement. N

 

[DiagnasaurusRex]

Not at bed side is weak because you just cant get there immediately sometimes for a patient that isnt dying.

Also, nursing freak out=\= Dr freakout. If the patient does ok, it doesn't matter.

In residency, I'd get called overnight for a-fib in the 120's--patient sound asleep. This was obviously not the cardiac floor. But me saying it's ok, doesn't mean the nurse isn't going to freak out.

I leave a note: patient in 120's, aymptomatic, asked nursing to monitor and call for these perameters. And that's reasonably all you need to do.

I had a 35 year old with Down Syndrome who I knew was a difficult patient. Nurse called me at 3 AM saying he was hard to arouse and his CO2 was 80--it was 90 on admission. They wanted to send him to the unit, and I said I'd like to come see him first that I think he's just a big child mentally and probably wants to sleep. They said they were close to calling a rapid, and in fact did so before I got to the room. Everyone is there and now my patient is very awake and very mad. He tells me about his dogs. I send him to the ICU because I'm done with dealing with the BS from the floor. The ICU nurses laugh when we get to the unit that a rapid was called.

The floor nurse turned me into quality--said they had to call a rapid because I didn't take her concern seriously and I didn't respect her nursing judgement. N

Never fight with individual nurses. It's a battle that always makes you seem like the bad guy. You have to get them on your side. My strategy:

1) Make friends with nursing admin and charge. As an attending it's easier to do I understand, but you can still try. I did this as I served on several committees where nurses admin also served
2) Give them positive feedback, doesn't have to be cloying or kiss-assey but a simple "hey thanks for your help today"
3) Ask how they are treated and if they feel supported by hospital - makes it seem like your looking out for them
4) always be calm, they feed off of your tone. They want to be told it will be ok.
5) educate them, walk them through your reasoning, not in a condescending way but make them feel included

Pretty soon they will be your eyes and ears and provide invaluable intel. I was able to hustle my way up as a junior attending and accomplish much more because I had a lot of rank and file people helping me out.

 

[cd14+]

It almost feels like the all of their training is not geared towards patient care but rather to avoiding liability, really grinds my gears.

You have hit a raw nerve. It is savage isnt it?

So what's your point exactly?

speaking of savages

Arent you just a bundle of joy, or is it C. diff?

Never fight with individual nurses.

.... people helping me out.

This. A thousand times yes!

Until we make rank, please everybody because you need them. put up with the beachy nurse because she/he might very well save your arse one day.

 

[FrkyBgStok]

Like someone said, leave your own note. When I see a note about “concerns raised with resident” i put a note in saying my whole thought process and why we didn’t do anything. But if they want me to come see the patient (or I think they are calling because they want me to), I do.

 

[sliceofbread136]

Like someone said, leave your own note. When I see a note about “concerns raised with resident” i put a note in saying my whole thought process and why we didn’t do anything. But if they want me to come see the patient (or I think they are calling because they want me to), I do.

Those would be lovely if I had the time for that, but between admissions and putting out fires I rarely do

 

[KnuxNole]

It doesn't have to be a long note, something short and to the point works.

Medicine IS a team sport, and I'm thankful for that every day. No way in hell I could survive inpatient medicine without great nurses. Usually, if a nurse raises a concern, I give them some sort of plan, that either ends with a medication or parameters for him/her to monitor and assess, or what parameters would need a call back. If they lead the question with "Do you mind taking a look at him?", that triggers to me that they are concerned about potentially crashing, so I usually take the time to head at bedside to at least ease the fear or confirm the suspicion they have. Of course, it can't always be immediate, but if they request a physician at bedside, letting them know an estimate helps.

IMO, rapids are helpful if nursing staff needs someone to make a decision ASAP but the doctor is off-site or busy in a procedure or in the midst of another crashing patient, but can be abused if used incorrectly.

 

[sliceofbread136]

It doesn't have to be a long note, something short and to the point works.

Medicine IS a team sport, and I'm thankful for that every day. No way in hell I could survive inpatient medicine without great nurses. Usually, if a nurse raises a concern, I give them some sort of plan, that either ends with a medication or parameters for him/her to monitor and assess, or what parameters would need a call back. If they lead the question with "Do you mind taking a look at him?", that triggers to me that they are concerned about potentially crashing, so I usually take the time to head at bedside to at least ease the fear or confirm the suspicion they have. Of course, it can't always be immediate, but if they request a physician at bedside, letting them know an estimate helps.

IMO, rapids are helpful if nursing staff needs someone to make a decision ASAP but the doctor is off-site or busy in a procedure or in the midst of another crashing patient, but can be abused if used incorrectly.

I don't where you are working where the only time you are asked to come to bedside is when the nurse is concerned they are going to crash, but I want to start working there

 

[KnuxNole]

I don't where you are working where the only time you are asked to come to bedside is when the nurse is concerned they are going to crash, but I want to start working there

*shrug* usually that seems to be the case in my experience. Most of the calls I would field are usually handled with verbal orders. The only time I would be asked to come to bedside besides rounds is if the patient is acutely decompensating and the nursing staff wishes for a physician to make a quick decision. I usually have structured rounds with the charge nurse, and each individual nurse, and go over the plan and talk with family. Nurses know how valuable my time is and for the most part, I have great nurses where I work. Some of the newer ones might be unsure of some things, but a lot of the more seasoned and/or strong nurses are helpful. Just out of curiosity, what other reasons are they asking you to come by? The only other reason I can think of is if family wants to speak with physician. Usually, with group rounds, that tends to cut that down, and usually myself and the nursing staff emphasize that the doctors rounds from XX-to-XX, or a phone number to call the POA during downtime, which makes things easier.

 

[Crayola227]

I don't where you are working where the only time you are asked to come to bedside is when the nurse is concerned they are going to crash, but I want to start working there

lol, believe me, you don't

that's when those nurse notes can really make you look bad

 

[jw3600]

Never fight with individual nurses. It's a battle that always makes you seem like the bad guy. You have to get them on your side. My strategy:

1) Make friends with nursing admin and charge. As an attending it's easier to do I understand, but you can still try. I did this as I served on several committees where nurses admin also served
2) Give them positive feedback, doesn't have to be cloying or kiss-assey but a simple "hey thanks for your help today"
3) Ask how they are treated and if they feel supported by hospital - makes it seem like your looking out for them
4) always be calm, they feed off of your tone. They want to be told it will be ok.
5) educate them, walk them through your reasoning, not in a condescending way but make them feel included

Pretty soon they will be your eyes and ears and provide invaluable intel. I was able to hustle my way up as a junior attending and accomplish much more because I had a lot of rank and file people helping me out.

While you are correct about the reality of the situation, it says a lot about the power that the nursing union/lobby has. Basically: suck up to them and live in fear. I'm all for being cordial to everyone but you wouldn't say this about any other group.

 

[Tenk]

MD Aware.

 

[Lexdiamondz]

I always skim nursing notes. One of the easiest ways to get fxcked in court is when the nursing notes state a problem hasn't been resolved (pt complaining of pain, continued SOB, whatever) and there's a discrepancy with their documentation and yours.

While you are correct about the reality of the situation, it says a lot about the power that the nursing union/lobby has. Basically: suck up to them and live in fear. I'm all for being cordial to everyone but you wouldn't say this about any other group.

It's like any other job - the people "below" you on the totem pole can still fxck you over if you aren't careful. Better to just be nice to anyone you meet.

 

[Crayola227]

life isn't just about what notes will **** you over in court - it's also about what ones can make your life a nightmare at work, with hospital admin or your own program

just because you're a doctor doesn't mean that in the hospital even other doctors will take your side

sometimes the side taken is, "we know, we believe you, but it looks bad in the notes. So you are in trouble for not dancing to the beat of this note-writer's drum" which is a totally fun way to practice medicine, even if nothing further bad happens

 

[Mad Jack]

While you are correct about the reality of the situation, it says a lot about the power that the nursing union/lobby has. Basically: suck up to them and live in fear. I'm all for being cordial to everyone but you wouldn't say this about any other group.

It is just good practice to get along with the people actually providing care, shocking as that sounds, because your orders aren't just entering a void.

 

[jw3600]

It is just good practice to get along with the people actually providing care, shocking as that sounds, because your orders aren't just entering a void.

I agree with your sentiment. But there's no thread about advice for dealing with conflict with respiratory therapists, radiology technicians, etc.

 

[WingedOx]

I agree with your sentiment. But there's no thread about advice for dealing with conflict with respiratory therapists, radiology technicians, etc.

uhhh, you should probably also follow that advice with them too.

The extent to which medical students in this forum display this condescending god complex toward other health professions is creepy. It also shows a cluelessness to how a hospital actually operates.

"The nursing lobby"? C'mon bro.

 

[KnuxNole]

uhhh, you should probably also follow that advice with them too.

The extent to which medical students in this forum display this condescending god complex toward other health professions is creepy. It also shows a cluelessness to how a hospital actually operates.

"The nursing lobby"? C'mon bro.

I doubt most people nowadays have a god complex...at least I hope not. I mean, we are physicians, not even close to a god, I probably would burst out laughing if a physician claims to be the "top of the food chain". Nurses are our friends not food. I fear as if some people think nurses are a bunch of idiots, which question the quality of nurses at their place if that really is a true statement.

How to deal with conflict with Respiratory and radiology? same as with other people. It's easy to avoid conflict in a professional setting by far.

bigger question is why are you having conflict to begin with? I can't fathom a scenario where someone is always getting into conflict unless there are some anger issues going on. I usually get along with everyone, and have never had a conflict since working in the hospital. I get along wonderful with nurses, dietary, physical therapists, CNA, janitors, with cracking small talks, eating lunch with them, etc. When someone said "basically suck up to them or live in fear", that's a poor mentality to have. You shouldn't have to suck up. Just be yourself, I usually talk 10% medicine with them and 90% about other things anyway. Nurses respect physicians easily who are humble and easy to talk to, and same with physicians. It has nothing to do with their nursing lobby. After all, we are all on the same team, working the same hospital to make a living and focus on healthcare.

After all, work is supposed to be enjoyable, and being in a friendly environment with cordial people help. After all, I wouldn't want to go to work and feel like I'm in a war zone or on an episode of Real Housewives ready to snatch edges.

 

[kb1900]

I doubt most people nowadays have a god complex...at least I hope not. I mean, we are physicians, not even close to a god, I probably would burst out laughing if a physician claims to be the "top of the food chain".

Hahaha have you met older surgeons? Especially ones in subspecialties. It’s hard to even taken them seriously sometimes. The god complex definitely exists and permeates to some degree to other fields

 

[KnuxNole]

Hahaha have you met older surgeons? Especially ones in subspecialties. It’s hard to even taken them seriously sometimes. The god complex definitely exists and permeates to some degree to other fields

True, which is why everyone and their dog laughs at them. In our generation, it shouldn't exist unless you want me and everyone to poke fun at them for life. It's ok, they are phasing out for more normal human beings

 

[Goro]

uhhh, you should probably also follow that advice with them too.

The extent to which medical students in this forum display this condescending god complex toward other health professions is creepy. It also shows a cluelessness to how a hospital actually operates.

"The nursing lobby"? C'mon bro.

I suspect that there is a decent amount of misogyny built into this as well.

 

[WingedOx]

I suspect that there is a decent amount of misogyny built into this as well.

You're likely not wrong.

Though @KnuxNole, my above comment came more from the fact that it's M3-4s who are the ones espousing those attitudes on here rather than anyone with any clinical experience. One would hope that such a thing gets extinguished quickly, but it's still a sh-tty attitude regardless. (there have been a few regular posters who are greater offenders than others in the last few years) And unfortunately, I've met enough students for which "be yourself" would be awful advice out of the gate. Sometimes those interpersonal skills haven't actually developed yet.

 

[jw3600]

uhhh, you should probably also follow that advice with them too.

The extent to which medical students in this forum display this condescending god complex toward other health professions is creepy. It also shows a cluelessness to how a hospital actually operates.

"The nursing lobby"? C'mon bro.

The method in which I interact with anyone in the hopsital from janitor to security to nurse is the same. Be polite and cordial. Understand it's a team effort and no one usually has bad intent even if there is an issue.

As far as nursing lobby? Are you living under a rock with regards to advanced nurse practitioner pushes towards complete autonomy and independence?

 

[WingedOx]

The method in which I interact with anyone in the hopsital from janitor to security to nurse is the same. Be polite and cordial. Understand it's a team effort and no one usually has bad intent even if there is an issue.

As far as nursing lobby? Are you living under a rock with regards to advanced nurse practitioner pushes towards complete autonomy and independence?

I'm not sure what any of that has to do with Dignasaur's original post, but ok...

 

[jw3600]

I'm not sure what any of that has to do with Dignasaur's original post, but ok...

To be honest I'm not really following your responses to me in this thread. Do you think I was asking for advice about dealing with conflict with these different professional groups? I'm not even sure what we disagree about here. Except the existence or non existence of a "nursing lobby."

 

[CherryRedDracul]

To be honest I'm not really following your responses to me in this thread. Do you think I was asking for advice about dealing with conflict with these different professional groups? I'm not even sure what we disagree about here. Except the existence or non existence of a "nursing lobby."

I'm in diagnostic radiology now so I have lot more contact with radiology techs now compared to nurses. The "nursing lobby" seems to be more of a thing among medicine folks because the majority of the non-physician staff they're going to be in contact are going to be nurses. The radiologists could certainly start a thread on how to deal with conflicts with rad techs. As a matter of fact, there's a thread in the Radiology subreddit on called "Rads of reddit, what are you major pet peeves you see from techs? Conversely, what do rads do that drive techs crazy?".

The fact is that interprofessional conflicts are not solely a nurse vs. physician thing. They happen in all fields, including and outside of medicine. Dialogue is the first step to resolve these conflicts.