August 18, 2007, 9:23 pm

Newsflash: The Physician is Not the Enemy

yoko

Yeah, that’s Yoko over there. I’ll wait for everyone to roll their eyes.

I’ve always had a soft spot for Yoko. Maybe because I “got” bagism back when I was an impressionable youngster. I always seemed to know what she was trying to say.

That doesn’t mean I didn’t cover my ears when she sang.

So I was pleasantly surprised and intrigued when I saw this CD on iTunes.

Maybe the world is ready for Yoko – she definitely fits into the techno scene. Who else could manage that in their 70’s?

******************************

Thank goodness I brought headphones with me. If I hear one more reggae song at Starbucks I am going to scream.

Never mind that I feel like running around calling everybody “mon”.

I like channeling my inner “Jamaica” as much as anyone but enough is enough.

So I’m listening to Journey the Band-That-Shall-Not-Be-Named. And Yoko.

In about five minutes I’ll be listening to the Browns vs. Lions game via the internet.

*****************************

tshirt

I really hate this T-shirt.

How is this supposed to promote collegiality between the professions?

My sense of humor is as good as that of the next person.

This isn’t funny.

*****

As a nurse and patient advocate, I’m supposed to question any order by a physician that I believe detrimental to my patient. I can refuse to carry it out, respectfully letting the doctor know that they can give the drug/do the procedure, but in good conscience I cannot.

I have never once done that. I’ve never had to.

Once I had to explain to an intern that an order of Toradol 60 mg BY MOUTH was probably not what she meant. She was rather stern in her insistence that her order was correct. I called the hospital pharmacy to verify the PO dosing range – I was right.

On rare occasions I have to verify an illegible written order or I spot an incorrect dosage and I am responsible for informing the physician.

Should errors happen?

No.

Are any of us perfect?

No.

My point here is that I don’t “question” a doctor’s judgement.

Nursing heresy, you say! Hardly.

It does not mean I blindly accept everything written. I do not question, I ask for clarification. There is a big difference here. If I don’t understand why an order is written, I’ll ask for the reason behind it. That’s asking a doctor to clarify something for me. If it is a blatant error in dosing or treatment, I’ll ask the physician to rectify it. The patient benefits if the order needs changing and/or I learn from understanding the thought process behind the order.

Think about it. The difference between “WHY are you ordering THIS (you idiot)?????” vs “Would you explain the rationale behind this order for me?” or “Did you really mean to write for 250 mg of Atenolol”? vs. “WHAT do you mean by THIS?

I always have my patient’s welfare foremost in my mind. I like to think that the doctors I work with know that I have their back, too. That I am on top of orders that are wrong or just seem out-of-place. That I will follow up with them to clarify any order that seems problematic (or is just plain wrong).

I know nurses who firmly believe in the motto on that T-shirt. I’m sure it shows in their attitude toward physicians, too.

Call me crazy, but in my world the nurses work for the good of the patients with the physicians, not in spite of them.

In our haste to demand respect commensurate with our professional status, let’s not forget that we need to give the same respect to those we work with.

Including physicians.

26 Comments

  • Mama Mia
    Mama Mia

    August 19, 2007 at 5:34 am

    Really good post, Kim. That slogan has always rankled me too, but you were able to explain why so clearly. Thanks!!


  • TBTAM
    TBTAM

    August 19, 2007 at 6:26 am

    My brother is a pilot, and tells me that they are REQUIRED to question or confirm ot whatver we want to call it, and order that seems wrong to them. There are scripted words that they use on both sides of the convesation to avoid it becoming personal, and there is never an implication of accusation or wrongdoing. It is all part of the teamwork safety that is religion in the airline industry.

    We are slowly moving in this direction in medicine, but the movement is indeed slow.

    T-shirts like this one, as you rightly point out, don’t help anyone.


  • rlbates
    rlbates

    August 19, 2007 at 6:38 am

    I appreciate the checks and balance system. I appreciate good nurses and pharmacist who “catch” my errors. Thank you.


  • Vitum Medicinus
    Vitum Medicinus

    August 19, 2007 at 7:14 am

    I’ll definitely be hoping nurses act as a buffer if – when – I screw up on the wards.

    Then again, I’ve heard stories of doctors who need to learn to take the criticism. A nurse friend of mine told me she asked a doctor if he really meant to give an ACE inhibitor to a patient who already had extremely low blood pressure. “It will be okay,” he responded, and PATTED HER ON THE HEAD. She was furious… as she should be.


  • Jenn
    Jenn

    August 19, 2007 at 7:15 am

    I always would ask for clarification too, but often it would be met with insistance that they were correct. Two incidences come to mind. I called an intern for an order for a laxative in a post-op patient. He told me to give her Percocet. I asked, Percocet for a laxative? Are you sure? Yes, just give her percocet! I then proceeded to explain she was already on percocet for, you know, pain control and that was probably part of the reason she was constipated in the first place.

    The second time was when we had a transfer from another facility and the doctor was writing orders based on what the patient was taking there. She wrote for five GRAMS of aspirin PO QD. I questioned it, she said yes that’s what she meant. I said, are you sure you don’t mean grains? No, quite certain she was taking 5 grams at the other hospital and that’s what she’d be taking here. I said I was pretty sure it was 5 grains which is close to 325 mg. She said she’d never heard of grains and was writing it for 5 grams. I said that would about 15 aspirins a day and asked her to please call a pharmacist. Eventually after a more drawn out argument that there was no such thing as grains, she called the pharmacist and wrote for 325mg ASA PO QD.


  • beastarzmom
    beastarzmom

    August 19, 2007 at 7:58 am

    a good grand rounds post if ever I’ve read one. I’d never seen that T shirt before, but had the same reaction. Not good. This is one of the reasons I enjoyed working in the teaching hospitals. I found the environment much more friendly to cooperation and sharing of concepts and new treatments than the private hospitals and their general “ego wars”. We all questioned and we all learned. Sometimes it was frustrating, but mostly it was good for us and better for our patients.
    Nice post.


  • Doctor Anonymous
    Doctor Anonymous

    August 19, 2007 at 8:38 am

    Great post! There are just some people out there who just want to make things advesarial – not just nurses and docs – just wanting to pick a fight anytime and anywhere. I’m glad that we’re on the same side.


  • Bemused
    Bemused

    August 19, 2007 at 9:23 am

    We have a new computer system that I will blame this on.
    I accidentally wrote for 750mg Levaquin TID. I wanted 750mg QD. When the prescription printed, it printed 250mg QD. I clicked around and did one thing right but added another wrong between reprintings and it came out to 750mg TID. By the time I had gotten it to finally print the 750mg, I only looked at 750.

    The nurse caught it and asked, “Are you sure you want 750 TID?”
    Eek no!

    We’re all a team. Everyone makes mistakes. We all have different jobs and each one is equally as important because our end goal is the same.


  • atyourcervix
    atyourcervix

    August 19, 2007 at 9:36 am

    I have (politely) refused to give a medication direct IV push that RN’s are not allowed to give IV push, and kindly told the physician that I’m not allowed to give it in that method. I told him I would gladly give it subQ (the usual method we give it), or he could give it IV push himself.

    He just didn’t get WHY I couldn’t give it IV push.

    #1 – it’s against hospital policy to give it IV push
    #2 – no where in the most current Davis Drug Guide did it say you could administer it IV push

    In the end, he changed his order to give it sub Q.


  • Zagreus Ammon, the Physician Executive
    Zagreus Ammon, the Physician Executive

    August 19, 2007 at 9:42 am

    Amen!

    Nurses can be as hard-headed and dumb as doctors, or the other way around if you prefer.

    When I used to teach, July was always interesting to see which of the new interns would give nurses grief. With almost 100% certainty the month would end with a nurse having saved some poor intern’s ass more than once. Usually the one mouthing off the most.

    It’s an interesting evolution, one which must be experienced to be learned. You can print T-shirts until you turn blue, but it won’t make a difference until you demonstrate how working together respectfully makes a better situation for all.


  • Mousie
    Mousie

    August 19, 2007 at 3:07 pm

    I love the idea of asking for clarification and I’ll always try that first, but sometimes the “clarification” you get is absolute nonsense and one needs to be a little more assertive.

    I have, unfortunately had to question, then refuse outright on several occasions when a doctor has tried to insist I administer some treatment which would be downright dangerous.

    So, whilst I agree that such a t-shirt should only ever be worn in private, I have to say that sometimes it’s the truth.


  • Ali
    Ali

    August 19, 2007 at 5:59 pm

    I may be over simplifying things and being a little idealistic… but aren’t we all working on the same team towards the same goal? We want to keep the patient healthy and for them to get better. I have a hard time understanding why some people feel justified when they pick fights with others within their profession, and with other professions they work with. Such as the ER nurses vs floor nurses, or nurses vs doctors. We each have our jobs to do, and it is easier on all of us when we work together, not against each other. I would think that as a patient, it would be horrible to think that the nurses and doctors who are caring for you are enemies….


  • TofuLou
    TofuLou

    August 19, 2007 at 8:50 pm

    i really enjoyed the way you put this post together – the wording and explanation of your rationale is great. i guess i’ve done a bit of doctor-bashing since i’ve become part of the birth scene… but just because you’ve had a bad experience with one or two doctors doesn’t mean they’re ALL bad. i try to keep that in mind… i went to meet with some perspective doula clients once and john came with me; it was at a starbucks and i didn’t introduce him until we were done with the meeting. but, before i could get too far they began the doctor-bashing… i was just thinking “oh god, don’t let john think that i support this with ALL of my clients.” i ended up our meeting with “this is my boyfriend, john. he’s an ob/gyn *insert TOTAL EMBARRASSMENT from them* but he’s one of the ‘good ones'”. i guess the same could be said about nurses; just one bad experience can’t become a blanket statement for everyone in the profession.
    oh, btw, thanks for the kudos on my skin cancer post. i emailed it to mother jones… we’ll see what happens!


  • Richmond
    Richmond

    August 19, 2007 at 11:58 pm

    I thought you hate the shirt because of the color. I hate pink.


  • Mary J.
    Mary J.

    August 20, 2007 at 2:25 am

    My how the world of nursing has changed. When I was a “new” nurse, I was expected to rise and give up my chair when a doctor entered the nurses station and to carry his charts for him as he made rounds. Of course I also wore white and a cap. It was a brave nurse who questioned the doctor.
    To show how things have changed. One night a senior resident(third year emergency) was escorting a new resident around the ER, introducing him to the nurses. He introduced three of us older nurses as “representing 40 years of ER experience” and he should listed to us if we question.
    I thought that was just wonderful and also true. At the same time, there are ways to question and then there are ways.
    As a lovely lady from a Southern state once told me: A southern lady can get away with saying anything derogetory about some one if she precedes or follows her statement with the phrase “Bless his(or her) heart”. As in “Bless her heart, she is as ugly as a mud fence.”

    Just imagine your are new on a job, your mind is stuffed to overflowing with information, but now you have to apply it. We were all there once and a little tact smooths the water a lot.
    I prefer the shirt that says: “I am the nurse who helped train your doctor.”


  • Vand
    Vand

    August 20, 2007 at 6:48 am

    I bet you have a lot of doctors who just love to work with you. Using tact is so much better than confrontation.


  • Trisha Torrey
    Trisha Torrey

    August 20, 2007 at 9:05 am

    Kim — another excellent post.

    Demanding vs. commanding are two different things, and you’ve described them here. The same will be true for any professionals: those who “demand” respect won’t be responded to nearly as positively as those who “command” respect.

    It’s not about showing up the other person. It’s about working together for the patient.

    Trust but verify.

    Trisha Torrey
    EveryPatientsAdvocate.com/blog


  • Disappearingjohn
    Disappearingjohn

    August 20, 2007 at 10:51 am

    I’ve never seen that shirt either, and I hate the message, too.

    Especially in the ED, I find the doctors to be very interactive, and open to answering any question I may have about an order, although I tend to use the “could you explain this to me” approach as well, so I am “getting on the same page” rather than questioning an order… I think tone of voice has a lot to do with it, too…

    Great post, Kim!


  • mcewen
    mcewen

    August 20, 2007 at 2:19 pm

    Well that was a very interesting viewpoint. I admire your train of thought. Not so keen on hearing that Yoko is 70 though.
    Best wishes


  • Candy
    Candy

    August 20, 2007 at 3:04 pm

    I concur — wonderfully put, Kim! And I love what you DIDN’T say — it’s our responsiblity to make sure we’re current with meds, new therapies and treatments and hospital policy. I heard about an old doc who routinely wrote for 20 of dilaudid. The nurses knew he meant 2 and covered his butt. When the hospital went to EMR and an electronic med distribution system, it wouldn’t let him write the scip. He was really mad until the nurses showed him that he’d been writing it wrong for years. He said, “Why didn’t you ever tell me?”


  • New Nurse Jane
    New Nurse Jane

    August 20, 2007 at 5:07 pm

    Very interesting reading, since I am a new nurse I have never really had this experience or attitude of being on the opposite side of the the fence with MDs. It is still nice and fresh in my mind that when it comes to our patients we are all on the same team. I am learning which physicians like to teach and am using them as well as the experienced nurses to my advantage.
    Hopefully I will not have any negative experiences to damage my optimism to persevere in this rewarding/demanding profession. Sometimes I feel embarrased and get tired of asking questions all the time, but I have to know what I need to know, and even though I was on the Deans list every semester at school, I feel as though I know nothing! (hopefully everyone will just have patience with me for the next year or so at least!)


  • Markie
    Markie

    August 21, 2007 at 5:54 am

    Another spot on observation.

    For this, and your other frequent insights I’ll forgive the whole Yoko thing. 😉


  • Trisha Torrey
    Trisha Torrey

    August 21, 2007 at 6:00 am

    Candy — your story about the nurses covering for that doctor is scary. What happened when they were out sick or on vacation? What happened when that doctor was in his office and wrote a script those nurses didn’t see? What happened when he was at a family party and wrote a script without the nurses around? And what happens when someone gets 10x the amount of delaudid they are supposed to get?

    Is it malpractice on the nurses’ parts that they never pointed it out before?

    Kim’s point about tactfully calling the error is great — but repeatedly covering a doctor’s butt is unforgivable, IMHO.

    Trisha Torrey
    EveryPatientsAdvocate.com/blog


  • beajerry
    beajerry

    August 21, 2007 at 8:05 am

    I’ve never seen that shirt before, either.

    The slogans I hate even more are “Nurses are Heroes” ones. Calling oneself a “hero” or wearing a hat saying it is very wrong to me.


  • Candy
    Candy

    August 22, 2007 at 7:52 am

    Trish, I agree 100 percent. ‘First do no harm’ applies to all medical professionals and requires immediate “education,” if you will — if the nurses on the floor had corrected the doc the first time and every time after that until he “got it,” it wouldn’t have been an issue.


  • NPs Save Lives
    NPs Save Lives

    August 22, 2007 at 4:53 pm

    Yet again another great post Kim! You are right on the money regarding that shirt. We all tend to get so busy bashing each other that we forget who we are supposed to be taking care of.


About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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