The Physician Supports the Nurse 

I am following a physician’s blog: Suneel Dhand.

Reading his post for the first time, I had a gut feeling I would like this guy. I think he represents a new and steadily growing wave of physicians who are becoming more aware of the effects that good communication has on patient outcomes and improvement in health team collaboration.

After I read his blog today: Doctor, I am just double-checking that you spoke with the nephrologist before I give that? September 4, 2018, I was moved to write this comment:

Thank you for this very timely and important post. We older nurses have many unfortunate memories of altercations with physicians who were more concerned over their status than the welfare of the patient and the benefits of team collaboration. With a renewed interest to improve the patient experience and prevent medical errors your post shows what physicians can do to improve communication with co-workers, especially nurses.

Here is Dr. Dhand’s post:

(I highlighted what he said that so impressed me)

I was recently seeing a rather complicated medical patient in the hospital. We were treating both a heart and kidney condition, and things were not going so well. To spare anyone non-medical who is reading this the scientific details of the bodily processes involved, we were essentially balancing hydrating, with the need to get rid of excess fluid. After seeing the patient, I spoke with the nurse, went over the clinical dilemma, and mentioned that I would speak to the kidney specialist before making the decision—and would perhaps order an additional medication if appropriate. I went back to my desk, entered a note onto the computer, spoke with the nephrologist, and we decided to go ahead and order the medication. A few minutes later, the nurse came back to me and asked: “Dr Dhand, I saw your order and just wanted to double-check that you spoke with the nephrologist before I give that medication?”.

The way the question was asked, may have come across to some as slightly condescending. I could tell some of the other doctors in the room were surprised with such a direct question. After all, I’m a reasonably experienced physician—why would I order a medicine I didn’t want to give? And how dare I be asked so bluntly if I’ve double-checked with another colleague, after I’ve already said that was part of the plan? Did this nurse not trust me?! It wasn’t even a particularly strong or toxic medicine, but one that we use everyday on the medical floors.

I paused for a bit, and said: “Yes, I’ve double checked, and it’s fine to give, no problem”. The nurse, sensing this question may have come across in the wrong way, then said: “Oh, I just wanted to check because you said you were going to speak with the nephrologist…and I looked at your note, and you didn’t even mention the medication”.

Indeed, that was correct—I wrote my note just before I had the conversation.The nurse was spot on. Whether or not the question could have been phrased differently is irrelevant, and I actually found the fact that this nurse sought to clarify the issue with me, highly impressive. I passed on that compliment. Not to mention the fact that the question was based on the conscientious act of actually reading the physician’s note!A more junior doctor colleague in the room afterwards commented on how what was asked to me sounded like a bit of an affront. Actually, I said it was the opposite, and explained why. There’s no room for ego in healthcare, and that’s frequently how mistakes happen, and what the nurse did was outstanding.

That interaction interested me, because as someone who teaches communication, I know I myself would have handled that situation very differently 10 years ago. Indeed, many doctors would have snapped right back at the nurse or taken offense that they were being so directly questioned. Perhaps even with a sarcastic response. “Of course I have, do you think I would have ordered the medication if I didn’t want it?!” “Yes I’m a doctor too, and wouldn’t order a medicine for no reason (you dare question me like that!)”. Imagine if that had happened, what the effect would have been on the nurse of being chewed out, possibly leading to not double-checking an important clinical issue in the future if they felt like something wasn’t right. A bad thing to happen to a well-meaning professional! Many doctors I’m afraid to say would have responded very differently to how I did, and chosen the latter approach during a hectic day when they already felt overloaded with questions and issues. I’m sure if you ask almost any nurse, they will tell you about countless times when they’ve been needlessly talked to in a terse manner by doctors. That’s not to say these don’t represent a small minority of interactions, but certainly enough to remember.

The one thing I feel most proud of as I’ve (hopefully) matured over the years, is how I handle situations like that. I may have always had a relatively calm demeanor, but I was definitely much more of a hot-head around the time when I finished medical school. Not confrontational, but definitely more somebody who could get into needless conflict over things like this. For anybody not working in the high-paced and frequently emotionally charged healthcare arena, you may not realize that run-ins, disagreements and personality clashes are part and parcel of the job (frequently between physicians too). They happen every day, everywhere. I remember after one negative interaction I had with a colleague many years ago, I was talking to another group member, and was given some great advice. She said: “You know what Suneel, always remember the saying: Great Minds, Don’t Mind”. That saying, Great Minds, Don’t Mind, has always stuck with me. It’s so very true, in all aspects of our lives, and something I strive for every day. The very best of us don’t take offense, become hyperreactive, or needlessly be petty and escalate situations, when we could easily interpret something as a personal insult. Especially when we are all doing our best for our patients at the frontlines of healthcare.

Just to reinforce what older nurses experienced when we were considered the handmaidens of the physician, I’ve included this previous post of mine: Don’t Question the Doctor,February 19, 2017, describing my good friend Lois Roelofs’ altercation with Dr. Jericho:

 

One afternoon while making rounds, I dashed in to see, Mr. Barnes, my last patient, in 236-1, the triple ward next to the nurses’ station. He smiled when he saw me. “I’m going out for dinner tonight. Dr. Jericho is picking me up at five.”

“Oh? I didn’t know. He didn’t tell us at the desk,” I said, scanning his Kardex card in the vertical file positioned on my left arm. “I’ll check on it.”

Back at the nurses’ station, I checked the doctor’s order sheet for Mr. Barnes. Hospital policy dictated that patients could leave hospital grounds only with written orders from their attending physician. Dr. Jericho was not the attending physician; he was a personal friend. And there was no written order.

I faced a potential explosion. Dr. Jericho’s capacity to be short-tempered was well-known to the nursing staff.  We’d each had our experiences. None of us liked it, but we felt powerless to do anymore than endure. And I didn’t need the problem right then: I wanted to give report on time and get home on time, once.

I dialed his office. “Hello, Dr. Jericho, this is Mrs. Roelofs on Hall Two. Your friend, Joseph Barnes, told me you were picking him up for dinner.” I swallowed hard and took a breath. “I see no written order covering this leave. I’m calling to see if you’ve run this by his attending, Dr. Acorn.”

He barked into my eardrum. “I don’t need to check anything out with anybody. Do you hear me? It’s none of your business….who is this again? What’s your name?”

“Mrs. Roelofs. Head nurse. Hall Two.” I forced my voice to sound strong.

“I’m coming right over to clean your clock,” Dr. Jericho yelled into the phone.

My head and heart spun wildly into one big tuft of fear that settled in my throat. I raced to a friend working on the ward at the other end of my floor. We schemed to hide me on that ward when Dr. Jericho arrived. Then we stationed lookout nurses. Minutes later I got the message. I ducked into Room 214, a five-bed room on East, and hid behind curtains drawn around a vacant bed. When Dr. Jericho arrived, my cohorts told him I was off the floor on an errand. He strode into my nurses’ station across from Room 201, parked himself on my desk chair, and bellowed, “I’ll wait.”

When I was a student nurse a few years before, I had scrubbed to assist Dr. Jericho in surgery. He became irritated with something and kicked a metal wastebasket across the room. Anesthesia saved the patient from being startled off the operating table. However, my nerves, as a novice, vibrated with the intensity of the metal clanging against steel and tile. Now my nerves were vibrating once again.

Suddenly, my friend peeked around the curtain, wearing worry on her face. “He won’t leave until he sees you. He’s camped out. Slicked back hair, black suit, green paisley tie, and all. You better come.”

I returned to the utility room on my ward with its steel cabinets, stowed commodes and IV poles, soaking instruments and thermometers, and corner hopper – a large square toilet-like bowl for rinsing bedpans. Standing in the doorway to the adjacent nurses’ station, I said as confidently as possible, “Dr. Jericho, I’m back. I understand you want to see me?”

Dr. Jericho launched to a standing position. “You bet I do. Who do you think you are to question what I’m doing? To tell me I need a doctor’s order to take my friend out for dinner?” His words torpedoed through the nurses’ station and up the ramp to pediatrics.

He stomped toward me. I backed away, inch-by-inch, until I was flush with the hopper. One more step and I’d plop into hopper water. I was trapped. Only the smothering smells of disinfectant separated us. “It’s my responsibility to see that hospital policy is followed, sir,” I said. My breath stopped momentarily.

“Who are you to tell me what hospital policy says? You, young lady, are never to question me again. Do you understand?”

His words slapped my face like sleet on a winter walk. I could have punched him – he was close enough – but I thought better of it. “Yes, sir.” I held back a salute that he seemed to demand. He turned, clicked his heels, and marched out, as if on a military drill.

My meds nurse, LPN, and aides crowded into the small nurses’ station. “What happened? What’d he say? I’ve never seen him so mad. At least not this week.”

“Oh, the usual Dr. Jericho stuff. Nothing new.” I said, trying to sound nonchalant with a heart rate of over a hundred.

Reaching for the desk phone, I glanced at a list of phone numbers and dialed Mr. Barnes’ attending physician. He gave me the order. Why hadn’t I called him in the first place?

I determined never to let a doctor’s behavior intimidate me again.

Caring Lessons: A Nursing Professor’s Journey of Faith and Self, Lois Hoitenga Roelofs, 2012, pp 49-50