Don’t Question the Doctor Part 2

I posted last week about my friend Lois’ run in with a nasty doctor soon after she graduated nursing school in the 60s.

Here is my story about working with a difficult physician that took place in the mid 80s.

The medical director, Doctor X, sat me down in her office on my first day as a nurse practitioner in a home care program at a large VA Medical Center and said, “When the doctor and nurse disagree, the doctor WINS.” She repeated this twice with a glare to discourage whatever protest I might be considering.

I can still see her fleshy face framed by cropped curly hair and a white lab coat stretching over her heavy shoulders. We sat in two chairs in her warm office facing each other without a desk between us. Did she know something about me that prompted this confrontation? Or was she always so caustic with nurse practitioners? She was a rising star in the organization. I didn’t expect this intimidating behavior.

I nodded my head as if I agreed with her dictum. What good would it do to argue since I hadn’t a clue what kind of disagreement we would have? What could happen in a health care setting that would be black or white, right or wrong, a doctor wins and a nurse loses?

What reassured me that Dr. X and I might never have a run in was that I would have autonomy when I made home visits. And I would call another doctor on the team if I needed advice, not the medical director.

One day, while visiting a patient his wife stated, casually, that Dr. X had stopped by on her way home from work. She felt flattered that the medical director would take the time to see how she and her husband were doing. What reason did Dr. X have to visit and not tell me? Not wanting to involve the patient’s wife in a conspiratorial alliance, I smiled and said nothing.

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Dr. X visited a second patient. The scenario was the same: wife mentions the visit, I smile and say nothing. An uncomfortable sense of being under surveillance hounded me. What was Dr. X looking for?

Shortly after, Dr. X was promoted to a leadership position and left the home care program. There was no fallout from her clandestine visits to my patients. Would there have been if she stayed with the home care program and continued her unorthodox conduct?

I am grateful that I didn’t need to confront her—for surely I would lose.

Don’t Question the Doctor

My friend Lois and I were talking on the phone the other day. We both graduated from diploma nursing schools in the early 60s. It was a time when the nurse was considered the “handmaiden” of the physician. We played the Doctor-Nurse Game* and even stood up when a doctor entered a room. Feeling powerless to confront their authority, not surprisingly, caused us to harbor much resentment towards the medical profession over our long nursing careers.

I told Lois that my volunteer work at a local hospital has exposed me to the improved interactions between nurses and physicians. Of course, having more female physicians has leveled the playing field somewhat and the emphasis on “team” encourages the professionals to respect and work together to care for the patient. I have fresh insight into the challenges physicians face in the health care delivery system that restrict their practice and autonomy. While I do feel more sympathetic toward physicians, I cannot forget the unbalanced relationship nurses once endured.

 

Here is an example from Lois’ book, Caring Lessons.411isrlw3gl-_ac_us320_ql65_

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.18064403-angry-doctor-in-glasses-with-notebook

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

 

 

* Doctors and nurses: new game, same result

Mark Radcliffe, deputy features editor

BMJ. 2000 Apr 15; 320(7241): 1085.

“In the beginning the relationship between doctors and nurses was clear and simple. Doctors were superior. They had the hard knowledge that made ill people better. The nurses, usually women, were good but not necessarily very knowledgeable. They were in charge of folding pillowcases and mopping brows. . . .

In 1967 Dr Leonard Stein first outlined the doctor-nurse game. He said that the interactions between the two were carefully managed so as not to disturb the fixed hierarchy. Nurses were bold, had initiative, and were responsible for important recommendations. While being bold, however, they had to appear passive. In short, nurses were able to make recommendations as long as they made it look as if they were initiated by doctors. So the nurse was responsible for the wellbeing of her patients and the nourishment of the doctors’ sense of professional self.”

INVISIBLE Part 3 of 3

I trudged into the nursing station. The phone sat on an empty desk. Mary, the stocky, dark-haired charge nurse, faced the chart rack at the other end of the room. I avoided acknowledging her presence, keeping my eyes on the floor. Any word from her might shake my resolve. I stood by the desk and picked up the receiver with a trembling hand. I dialed the operator. When she answered I said, “Please page Doctor J. I’ll hold.”

From the corner of my eye, I watched Mary’s head bend in my direction as she leafed though one of the patient records. My body jerked when I heard a gruff voice say, “Dr. J here.”

I took a long breath and plunged in. “I’m Marianna Crane, one of the staff nurses on 2 West. You just left your patient, Ms. O, telling her she could go home today.” My heart drummed so loud in my ears that I barely heard the words coming out of my mouth. “I just want you to know that her lungs sound full of fluid. She has a productive cough, two plus pedal edema and is having problems urinating. I obtained 300 cc’s when I cathed her.” I gulped and raced on. “I don’t think she’s ready for discharge.”

Even though I had only glanced at his large frame as he exited Ms. O’s hospital room, I visualized his face turning crimson with anger at the audacity of a nurse questioning his judgment. An ominous silence planted itself at the other the end of the phone. The fact that my words couldn’t be taken back set my skin on fire. Was he still on the line? Finally, his voice pounded into my ear: “I’ll send the resident up to check her.” Click.

I stood with the phone pressed to my head. Then the realization hit. He had listened to me. I had accomplished what I wanted. I didn’t feel elated as much as relieved. Ms. O would get the work-up she needed. I hung up the phone.

Mary turned to face me. “Wow,” she said.

“The resident will come up to check on Ms. O,” I told her. I didn’t plan to stick around to discuss what had just happened. I marched out of the nurses’ station and up and down the hall twice until my heart no longer galloped. I barely talked to Ms. O while I gave her a bed bath. I feared I would blurt out that I had initiated a course of action that might delay her discharge.

While I was taking care of my other patients, the resident sauntered into her room and later an attendant whisked her down to radiology. I left before Ms. O returned to the floor. Before she received a diuretic to get rid of the fluid in her legs and lungs. Before the insertion of a Foley catheter to keep her bladder draining. And before the discharge order was cancelled.

When I returned to work three days later, Ms. O, dressed in a polyester pantsuit, sat at the side of the bed finishing her breakfast. She had taken the time to rouge her cheeks and apply a rosy lipstick. She smiled in recognition when she saw me. “I’m going home today,” she said with a chuckle that didn’t this time produce a paroxysm of coughing. She took the last bite of sausage and drained her coffee cup. Pushing the empty tray away, she shimmied off the bed on trim ankles. Her step, although slow, was steady. She settled into the wheelchair.

I pushed Ms. O through the hospital exit. The summer sun had yet to heat up the asphalt parking lot. A cab waited at the curb. I held her arm as she carefully stepped out of the wheelchair. She tried to press a couple of dollar bills in my palm. “Oh no.” I said, “Nurses are not allowed to take tips.” I stressed the word nurse.

To Ms. O I was just another hospital worker. As far as I knew, she had never asked why the resident appeared, examined her and delayed her discharge. She was unaware of my concern or the part I, a nurse, played in her recovery. And why would she know? I never told her. And surely her doctor hadn’t.

 

INVISIBLE Part 2 of 3

“When did you urinate last?”

Ms. O looked at me blankly.

“I’m going to press over your bladder,” I said. I reached under the hospital gown and pushed over her pubic area. My fingers felt a soft swelling. Ms. O winced. “I think you’d feel better if I passed a tube into your bladder and got rid of the urine.” I didn’t need a doctor’s order for a straight catheterization—in and out. Ms. O nodded her head.

Back in her room with the supplies, I raised Ms. O’s bed so I wouldn’t have to bend over, draped her with a sheet and placed the catheterization tray between her spread legs. My hands, encased in sterile gloves, guided the thin, rubber tube into Ms. O’s urethra. Dark amber urine flowed from the catheter into the specimen container.

As the last of the urine trickled out of the tube, Ms. O sighed and said, “That’s such a relief.”

“Let me get rid of this,” I said as I gathered up the soiled equipment. “Be right back.”

In the dirty utility room, I sorted out the recyclable parts from the cath tray and tossed the disposable items. I measured the amount of urine before flushing it down the toilet. I tried to sort out what to do about Ms. O. What could be going on with her? She could have congestive heart failure, pneumonia or some other illness that would get worse without treatment. And no one would be home to notice her deterioration. She might become so weak that she could fall, maybe break a hip and then lie on the floor for days—be found dead. If she were lucky, a neighbor would find her in time and call an ambulance. If Ms. O survived hip surgery, she might not recover fully and off to a nursing home she would go.

I leaned against the cool tile wall. What was Ms. O’s doctor thinking? How could he have known Ms. O was retaining fluid? He ran in and out so quickly? Had he even bothered to listen to her lungs? Ms. O needed to stay in the hospital for a work-up to find out what was wrong and treat the problem. She shouldn’t go home until she was well enough to care for herself. What should I do?

Since I was employed as a staff nurse and reported to the nursing department, I should inform Mary, the charge nurse of my findings. She would go up the chain of command, relating my concerns to the nursing supervisor. The nursing supervisor would contact Ms. O’s doctor. What if the doctor dismissed my concerns? Would the nursing supervisor back down and let Ms. O to be discharged?

I could always bypass nursing altogether and call the doctor myself. Surely there was nothing wrong in that. I would report my findings and let him decide what needed to be done. That way it wouldn’t seem as if I was telling the doctor what to do.

With this decision made, the tightness in the back of my neck relaxed. I returned to Ms. O’s room. “Close your eyes and rest for a while.” I told her. I dimmed the lights and left the door slightly ajar.

Heading towards the nursing station to make the phone call, I reflected that hospitals had not changed that much since I graduated in 1962. Long corridors with patient rooms on either side, dirty and clean utility rooms and a nursing station at the end of the hall. What had changed was nursing education. I had attended a three-year nursing diploma program in New Jersey run by the Grey Nuns. Formally known as The Order of Sisters of Charity of Montreal, they “trained” me along with forty-three other females in my class to be subservient to physicians, all males at that time. When a doctor sauntered into the classroom to teach, we stood up, chanting in unison: “Good Morning, Doctor.” In the hospital, I would rise from my chair if a doctor entered the nursing station. Besides enforcing nightly curfew, weekly dorm room checks, and pressing us to attend daily mass, the nuns sent an implicit message: never question a doctor’s authority.

My first job after graduation was at a large inner-city medical center. I can only imagine how surprised—and maybe delighted—the physician felt when I stood as he lumbered into the small lounge off the nursing station. He happened to be a resident not much older than I. After he left, the other staff nurses encircled me. Never stand for a physician.

In the mid 70s I returned to college for a baccalaureate in nursing. An innovative professor at the university, who started her own home health agency, had quite an impact on our large group of mostly seasoned nurses. “Nurses see the whole patient, not just the disease entity,” she said. “You don’t exist just to follow doctor’s orders, After all, nurses spend more time with the patient than doctors do. You must serve as the patient’s advocate.”

We were also primed by the women’s rights movement to take responsibility for our practice, to challenge the blind authority of doctors and hospital bureaucrats. At that time I worked in a small branch of a Health Maintenance Organization (HMO) near my suburban home. Spurred on by my professor I asked the administrator if we nurses could schedule our own patients for education and monitoring. “I believe we could resolve patients’ problems and reduce visits,” I told him.

He agreed. We negotiated a fee of five dollars for a nursing appointment since this was an extra service not covered by the HMO. One middle-aged obese, diabetic schoolteacher came to see me every two weeks for a half-hour visit. I suggested she pack a lunch to avoid the school cafeteria and take evening walks with her husband. She lost weight and so did her husband. Eventually, her diabetic medication was discontinued. The experience of having patients make an appointment to see me, and their willingness to pay for the visit, prompted me to become a nurse practitioner. So there I was back in school again. One year done and one to go before I would graduate and be eligible to sit for the NP certification exam.

Now, thinking about my desire for autonomy and independence, I realized I was about to fall into old habits. How in the world could I permit the doctor to interpret my information and make his own decision? There was no way around it. I had to give this doctor a clear message: Ms. O shouldn’t be discharged. At the thought of confronting him, my neck felt like an icy hand was gripping it. I slowed my usual brisk gait as if by dawdling I could put off making this call. I knew I had no choice.

INVISIBLE Part 1 of 3

“Invisible,” by Marianna Crane, originally appeared in the Examined Life Journal.

 

 

The cardinal rule of the game is that open disagreement between the players must be avoided at all costs. Thus, the nurse must communicate her recommendations (to the physician) without appearing to be making a recommendation statement. – – – The greater the significance of the recommendation, the more subtly the game must be played.

– 1967, Leonard I. Stein, M.D.

 

 

I left my patient, Ms. O, dozing in her hospital bed. Heading towards the nursing station, I clenched and unclenched my fists, steeling myself to make a call I didn’t want to make.

When I first ambled into Ms. O’s private room that morning, she was sitting up in bed with a breakfast tray in front of her. Her knobby fingers put down a half eaten slice of toast. The eggs and sausage were untouched.

“I’m done. I just want to keep the coffee.” I removed the tray and slid it onto the food cart standing in the hallway. Back in the room, I noticed a stale, musty odor. Sunlight filtered through the only window highlighting Ms. O’s greasy and matted hair. “How about washing up?” I said.

Ms. O’s pale face lit up with a smile. “I’d just love a shower.”

“Sure. Finish your coffee while I get the linens.”

It was the summer of 1980. I had just completed the first year of a two-year master’s degree program in nursing. I had taken this part-time job, working a couple of days a week, in a small community hospital near my home. When classes started back up, I figured, I would juggle being a full-time student with doing what I loved—caring for patients.

Outside of Ms. O’s room, my arms laden with sheets, towels and a hospital gown, I was aware of a tall man as he breezed by me, his copious belly encased in a dark suit. Over his shoulder he shouted back into Ms. O’s room, “See you in my office next week.”

“My doctor just told me I’m going home today,” Ms. O said, as I unfolded the fresh towels. Her chuckle, which trickled up her throat, exploded into a racking cough. When the episode was over, she sank back into her pillow, breathing deeply. Had her doctor heard that cough? He couldn’t have been in her room more than a minute or two.

“Are you okay?” I asked. The night nurse had recorded that Ms. O slept well and hadn’t indicated any problems. Ms. O gave me half a smile but didn’t speak.

“Well,” I said, “let’s get you up, showered and dressed.”

Pushing off the covers, Ms. O inched her legs toward the edge of the bed until they dangled over the side. Her bony hand pulled on my arm as she swiveled to a sitting position. This effort set off another coughing fit. What’s going on here?“ How long have you had that cough?”

“A couple of days. Seems to have gotten worse.”

Bending down, I pressed the skin over her thick ankle. My finger left a half-moon print on her leg.

“Do you usually have swelling in your legs?”

Ms. O glanced down. “No.”

“Who will be home with you?”

“I live alone.”

Something wasn’t right. I pulled out my Littmann stethoscope, a gift to myself after successfully completing the last class of the semester: physical assessment. In that course, my fellow nurse practitioner students and I learned how to take a patient’s history. We used each other to hone our diagnostic skills: we probed bellies with our fingers, placed stethoscopes over lungs, and tapped elbows and knees with a rubber hammer. We hadn’t practiced on patients yet. Instead, we listened to tapes in the computer lab of heart valves leaking, lungs wheezing and large intestines gurgling.

“I want listen to your lungs.” With my hand on Ms. O’s shoulder, I nudged her forward and placed my stethoscope on her scrawny back. What filled my ears were not the same clear blowing reverberations of my classmates’ young, disease-free air passages. What was I hearing? Rales? Rhonchi? Wheezing? The names of abnormal sounds jumbled in my head. “Cough, please,” I said, trying to sound like I had done this for years. We had learned that semester that coughing would clear mucus from airways, resulting in normal breath sounds. After coughing, Ms. O’s lungs were still waterlogged. I straightened up and pocketed my stethoscope.

Ms. O interrupted my thoughts. “I need to go to the bathroom.”

I didn’t like the pasty color of her face or the way her chest rose and fell with each breath. Better she stayed in bed. “Let me get you a bedpan.”

After helping her lie back, I raised her hips and slipped a blue plastic bedpan under her bottom. When I retrieved the bedpan a few minutes later, it was empty.

SILENT NO MORE

When will nurses cease to be invisible? The web site The Truth About Nursing discusses an article about Hillary Clinton’s hospitalization in which the author did not make one reference to nursing hospital room(MatthewLee, “Hillary Clinton hospitalized with blood clot,Bloomberg Businessweek, December 31, 2012 *). The Truth About Nursing suggests if Clinton needed to be hospitalized then she needed nursing care or she could have received treatment at home. Think about it. Can hospitals function without nurses? Instead doctors were the only ones mentioned that monitored and assessed her condition while she was an in-patient.

Do you think doctors stay at the bedside of their patients 24/7? No, they go home for dinner. If there were a problem, most likely they would be paged by the nurse on duty—perhaps at 2 a.m. Or they would hear how the nurse independently solved the problem when they made rounds the next day. Or not.

Unfortunately, to our detriment, we nurses avoid seeking attention for what we do that improves patient outcomes. Because we are so self-effacing, is it any wonder the media rarely mentions us and therefore “reinforces the damaging misimpression that physicians provide all the health care that matters.”?

Isn’t it time we spoke up for ourselves, demanding recognition for what we do? It is a sad fact that the media have long ignored nurses and nursing practice. Nurses continue to shun publicity as if calling attention to what we do is a sign of hubris. I’ve mentioned in the past that I had asked nurses in a hospital where I worked to write stories about what they did that made a difference in a patient’s life. I received few submissions. The most common reason for not writing was they didn’t want to sound as if they were bragging.

I have been guilty of not taking credit for my nursing actions in the past. The story I wrote for The Examined Life Journal, Invisible, tells of a time back in the early ‘80s when I told a doctor that I believed the patient for whom he just wrote a discharge order should remain in the hospital. The challenge there was to avoid the old doctor-nurse game. But, and this is the big but, I never told the nurse with female ptpatient I was worried about the fluid in her lungs, her labored breathing and lethargy. So she never knew a nurse made a difference in her care when a few days later she went home without those troubling symptoms. Now, years later I wrote my story.

Let’s all of us nurses start speaking out by following a suggestion from The Truth About Nursing:  email authors Mathew Lee and Marilynn Marchione at mlee@ap.org and mmarchione@ap.org, stating our concerns about omitting any reference to nursing in their article. And send a copy of your email to: info@truthaboutnursing.org

I plan to do that. I hope you will, too.

*A P Chief Medical Writer Marilyn Marchione in Milwaukee contributed to this report.