We are all so equal...

[EMIM2011]

I am just wondering how we got here. When did nursing propaganda become so effective? Every time I hear nurses say that "every team member is equal, the nurse is as important as the doctor, we just have different roles" I cannot grasp why there is no outcry, why people actually appear to believe this BS? Who in their right mind would believe that a 22 year-old RN with 3 years of training is "equal" to a physician with 10-15 years of training? That's like saying the intern at the electrical company is equal to the electrical engineer, who would buy into that? I am not saying we don't need nurses, not at all. They help us do our job, they are important for good patient care if they do their job diligently and so on. But where did this idea of them being equal to the physician come from? Because at the end of the day, they have received a tenth or less of a physician's education. They want to call themselves doctor after becoming an NP, wear a white coat, take an H&P, but oh no, they don't want to be equal anymore when it is about being sued, or living with the knowledge of having made the wrong call that caused a patient to have a bad outcome. Then they'll chart "MD aware of xyz.". And, I hate to say it, I can wash a patient if I have to, I can draw up drugs, I can hang antibiotics, I can start an IV. Can they intubate, place a central line, discuss a DNAR decision, reason through a difficult MDM, prescribe the right dose of an antibiotic?......

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[Birdstrike]

It's part politically correct nonsense and part brought on by ourselves. So many doctors have been such arrogant jerks, to so many people, for so long, everyone's sick of it. So it's forced them to develop these politically correct, feel-good slogans, that you did not necessary being on yourself, due to the action of a few stage 4 arseholes. Treat everyone with respect and you'll get yours in due time. Also know that some nurses like to rub your nose in these mantras, especially if you're a resident or intern, the more they realize it irritates you. Realize it for what it is, but play the game at the same time.

 

[EMIM2011]

Completely agree with birdstrike, but I'm really looking at it less on a personal-interaction level, but more of a system-wide level. At some point this got to be corrected. It is just dangerous. We as physicians really need to speak out against it, for the sake of our patients. The worst thing that could happen is that physicians actually buy into it, and really just become another "team member" with the mindset of an employee who does what he is being told to do, without any sense of personal investment and responsibility. I guess this may be quite common in EPs already....I see too many colleagues who have this "just keep on smiling, at the end I'm making bank and just give a f++k about everything else" approach that is gonna bite as in the longterm

 

[Birdstrike]

The worst thing that could happen is that physicians actually buy into it, and really just become another "team member" with the mindset of an employee who does what he is being told to do, without any sense of personal investment and responsibility.

I think a lot of people are already there. But yes, as long as there's a extra zero in each paycheck, most people are going to smile and say, "Yes ma'am" and let them have their equality slogans. Ultimately, if you work for administrators, you're beholden to their imposed corporate culture and pet projects. If the paychecks start looking equal, then I suppose you've got a much bigger problem at that point.

But to answer your question, "How did we get here?" Doctors got there by selling out their independence, flocking to hospital based and/or employed-practice models and by giving up any responsibility or risk involved with independent practice. Now they don't dare to bite the hand that feeds them.

 

[Arcan57]

Completely agree with birdstrike, but I'm really looking at it less on a personal-interaction level, but more of a system-wide level. At some point this got to be corrected. It is just dangerous. We as physicians really need to speak out against it, for the sake of our patients. The worst thing that could happen is that physicians actually buy into it, and really just become another "team member" with the mindset of an employee who does what he is being told to do, without any sense of personal investment and responsibility. I guess this may be quite common in EPs already....I see too many colleagues who have this "just keep on smiling, at the end I'm making bank and just give a f++k about everything else" approach that is gonna bite as in the longterm

A team approach is best for the patient. A physician who is only able to rely on themselves is a physician that can't effectively take care of their patients in the ED. If nurses aren't part of the team then they're not responsible for relaying to you changes in patient condition, carrying out your orders with alacrity, etc. As such, cultivating a good working relationship with the nurses is a core competency in EM. When you're getting pissed about the idea of "equal but different roles" what exactly are you pushing back against? Are the nurses ignoring your orders or performing interventions you didn't authorize? If so then they're practicing medicine without a license and the nursing board is not such a big fan of that. Is it that they want to be treated with respect and want to understand some of your reasoning? Well, that makes you sound like kind of an a--hat for denying them that. It feels really damn good the first time you get to say "because I'm the doctor" but if it's a common phrase in your interactions then you are so completely hosed. Think about what happens when the offensive line gives up on a quarterback.

 

[EMIM2011]

Again, I'm not talking about personal interactions at work, which are good. I'm really more interested in discussing what allowed the nursing propaganda to get to this level, where it is almost being accepted as truth, despite its completely nonsensical nature.

 

[gman33]

Depening on what you mean, every team member is equally important.
Some roles might take less training, but they are very important.
The days of the physician centered healthcare model are long gone.
You can maybe have this in a single doc private practice, but that's not the world of EM.

I do have issue with the thinking that someone with less training can do my job.

 

[Arcan57]

Again, I'm not talking about personal interactions at work, which are good. I'm really more interested in discussing what allowed the nursing propaganda to get to this level, where it is almost being accepted as truth, despite its completely nonsensical nature.

Three things :

1) There's a huge gaping hole in healthcare delivery that the current pipeline supplying MDs can't fix. The system can't pay for everyone to see an MD (either from a price standpoint or from a cost of training up sufficient numbers of docs). So it's sort of in politicians best interest not to poo-poo the providers that are going to be taking care of the majority of the newly "insured".

2) Aside from price, NPs and CRNAs have been available and willing to work in BFE which has allowed them to get opt-out status because otherwise there'd be no healthcare in significant portions of the West.

3) They've mainly stuck to low risk areas of medicine in these areas allowing them to claim success without facing the media attention they'd be getting in more populous regions. Also, having moonlit in small towns, there is just a generalized lowering of expectations regarding the efficacy of medical care.

 

[Birdstrike]

Honestly, I wouldn't over think this one. We all know that if you define "equal" as "the same," then it's absurd. But I really think what they're getting at is equal defined as deserving of equal respect, and that all team members are equally as "important." Although that sounds initially a little questionable, it actually is true, in a sense.

Think if it this way. If all staff went on strike other than doctors, and you had the ability to call in an unlimited number of doctors to fill everyone's roles, could your ED or hospital function? Absolutely not.

No physician would be able to jump in and run the lab CBC machine. Despite your ability to do some nursing tasks, would you really be able to jump in and run nipride drips, do the nursing charting, get meds out of the machine all as fast and efficiently as a nurse? Would you be able to do the unit clerk's job?

Not really, if you think about it. So, any link in the chain is equally important on some level and deserving of the appropriate amount of respect.

Are they all the "same" or "highly skilled" or have the same level of training? No.

Does that mean that the physician is not the team leader, with the most years of training, highest paid and maybe hardest to replace?

No, because the physician is all those things.

I think they're just looking for docs not to be arrogant and not treat other team members without respect. A lot of hospitals have had disruptive physician issues, and had to institute these corporate sensitivity programs which can seem insulting to those who do treat others with respect.

Now, that doesn't mean nurses need to get in your face and start refusing to give meds you've ordered or refuse to do their job because they were told some slogan in some corporate-sensitivity focus group, and start disrespecting you. If so, then you do have a more significant problem that needs to be dealt with.

 

[EMIM2011]

Birdstrike, nurses don't follow "orders" anymore anyways: http://www.truthaboutnursing.org/faq/nf/orders.html

 

[Birdstrike]

Birdstrike, nurses don't follow "orders" anymore anyways: http://www.truthaboutnursing.org/faq/nf/orders.html

Oh, I'm so old fashioned. Silly me. Certainly, the day has come that the term "order" be replaced with something less offensive such as "suggestion" or "recommendation." (/end sarcasm font)




My favorite part about that link, is that they propose to rename "order" as "prescription." Then, they define "prescription" as, well.....
an "order."

Hmm...

"Prescription = Orders, interventions, remedies or treatments ordered or directed by an authorized health care provider."

Great stuff. Doesn't get much better than that.

 

[Arcan57]

Birdstrike, nurses don't follow "orders" anymore anyways: http://www.truthaboutnursing.org/faq/nf/orders.html

The last time I lost that most time down an Internet wormhole was when I found a site touting the medical and spiritual benefits of trepanation. While it makes a good hate read, I've never encountered someone in real life who had the nerve to actually repeat any of the website's suggestions to me.

 

[EMIM2011]

Arcan, lucky you. One of my colleagues who in fact is the nicest and least arrogant person ever once got a comment on a "360 evaluation" from a nurse that "he makes it sound as if he is expecting me to take orders instead of suggesting a treatment plan to the nurse"....

 

[deleted480308]

Arcan, lucky you. One of my colleagues who in fact is the nicest and least arrogant person ever once got a comment on a "360 evaluation" from a nurse that "he makes it sound as if he is expecting me to take orders instead of suggesting a treatment plan to the nurse"....

Utopian bullcrap...it's not a suggestion

 

[Arcan57]

Utopian bullcrap...it's not a suggestion

Sadly given nurse staffing ratios and rise of useless EMR documentation, at times it can feel exactly like you are issuing suggestions. Sometimes placing an order in the computer has only a vague and confusing relationship with what actually happens to the patient. Specifically with regards to collecting the liquid gold we call urine.

On a more related note, it's actually deleterious to patient care to think of the instructions we give nurses as suggestions. The problem with calling them suggestions is that there is no expected feedback loop when you disregard a suggestion. I'm under no obligation to report back that despite your endorsement I decided to go with the black beans rather than the pinto or that I decided the guacamole wasn't worth the money. When an order is not executed, there is a clear expectation that something should have happened and that the person giving the order needs to be involved in why it was not executed and whether the plan needs to be changed. I have no problem discussing orders that the nurse feels are not appropriate for the patient, but that discussion must happen. Hence, orders.

 

[Daiphon]

Utopian bullcrap...it's not a suggestion

I would strongly "suggest" to complete the orders as written or I may "suggest" to the nursing office & unit manager that refusals negatively impact patient care and thus flow.

Decreased flow = less hospital dollars = bad performance review for manager = fired nurse ).

 

[da8s0859q]

Arcan, lucky you. One of my colleagues who in fact is the nicest and least arrogant person ever once got a comment on a "360 evaluation" from a nurse that "he makes it sound as if he is expecting me to take orders instead of suggesting a treatment plan to the nurse"....

I can't help but feel like much of the whole 360 evaluation idea is nice in theory but **** in practice.

 

[Arcan57]

I can't help but feel like much of the whole 360 evaluation idea is nice in theory but **** in practice.

It's basically adding a popularity contest into the job eval. Although my first one was useful for discovering that nurses that I thought sucked were not big fans of me. This revelation allowed me to practice getting better at disguising my disgust with their inability to function in the ED. This has been a useful skill for staying employed long-term at a single hospital.

 

[GeneralVeers]

After going through those evals with my prior employer I can say they are rubbish. I got chastised because one of the nursing comments was: "He needs to smile more while giving orders".

At least the nurse acknowledged that they are "orders".

 

[oldiebutgoodie]

My theory (and I am a CNS, like an NP in my state) is that the old bat nurses who run nursing schools went and got PhDs in some esoteric nursing "theory", and were just pissed that they had to kowtow to MDs for so many years, and now they are getting revenge. Seriously. I went to nursing school when I was in my "golden years", after 30 some years in the corporate world, and was amazed at the stuff they spouted.

 

[da8s0859q]

Have talked to quite a few fellow residents who are in programs where they have to do 360 evals on each other. Drama waiting to happen.

In other news, this whole thread makes me want to be a radiologist.

 

[gutonc]

In other news, this whole thread makes me want to be a radiologist.

You know, everyone talks about going into path or rads so you don't have to deal with patients. But the real bonus is not having to deal with nurses.

 

[The White Coat Investor]

Nurses are great, couldn't do my job without them. But I'll tolerate a lot of the rah-rah "we're all equal" as long as my unequal paycheck keeps hitting the bank account each month...

We all have different training. We are all necessary. We're all part of the team. But if we were all equal, we'd all be paid the same, no?

 

[deleted480308]

Nurses are great, couldn't do my job without them. But I'll tolerate a lot of the rah-rah "we're all equal" as long as my unequal paycheck keeps hitting the bank account each month...

We all have different training. We are all necessary. We're all part of the team. But if we were all equal, we'd all be paid the same, no?

I think things like oregon mandatingprivate insurance pay docs and nps the same rates for office visits concerns some docs

 

[EMIM2011]

Nurses are great, couldn't do my job without them. But I'll tolerate a lot of the rah-rah "we're all equal" as long as my unequal paycheck keeps hitting the bank account each month...

I guess this tolerance is part of why they get away with it, and may ultimately hurt the profession

 

[The White Coat Investor]

I guess this tolerance is part of why they get away with it, and may ultimately hurt the profession

Choose your battles wisely, for you cannot win them all. Like today, the nurses at the psych unit I was transferring a patient to insisted we wait another 45 minutes before they'd take report because the patient's BAL had to be under 200 before they could take him. This is a guy who drinks 24 beers a day and did not seem inebriated at all at 320. I ended up having to give him ativan for withdrawal symptoms before transfer. In the grand scheme of things, a patient sitting in my bed for an extra 45 minutes wasn't worth 10 seconds of thinking about, much less a phone call to the psychiatrist or even the nurse being an idiot. My nurse thought it was worth 10 minutes to write up the other nurse. Not for me it wasn't. I've got better things to do with that ten minutes.

 

[filhodeinferno]

You know, everyone talks about going into path or rads so you don't have to deal with patients. But the real bonus is not having to deal with nurses.

There are always the rad/CT/MRI techs there do disagree with you and give you crap.

 

[Arcan57]

After going through those evals with my prior employer I can say they are rubbish. I got chastised because one of the nursing comments was: "He needs to smile more while giving orders".

At least the nurse acknowledged that they are "orders".

Perhaps its a unique character flaw for me, but I'm deeply distrustful of people that are smiling as they give me work to do.

 

[Siggy]

I think there's also a couple of other issues at play.

1. There's a lot of routine in medicine. See x, give 1. See temp of 101.4 in a patient with sepsis (criteria sepsis, not necessarily severe sepsis or septic shock)? Pan culture, UA, x-ray, ABx. Things like this makes it pretty easy over time to recognize and "suggest." Unfortunately, this can breed a false sense of competence.

2. There's a lot of things that nursing suggests that aren't worth the time to fight over. "I don't really care about a potassium of 3.4, but if you want to throw K-dur 20 at the patient, sure... why not."

3. Just because we don't spend every second of our shift with the same few patients (there's no patient to physician ratio in medicine... unlike nursing), therefore we must be worth less. Never mind it isn't our job to assist with the patient's activities of daily living (which is a pretty important job, even if nurses don't want to own that what their actual job is is pretty important).