Monday, March 18, 2013

Healing the hospital hierarchy: A different view

The other day, Theresa Brown, an oncology nurse who has somehow finagled a quasi-regular column in the New York Times, wrote about, you guessed it, another unpleasant encounter with a mean doctor.

Her patient was about to undergo a stem-cell transplant when he developed what she called "textbook symptoms of a heart attack." A cardiogram had been done and while awaiting the arrival of a cardiologist (apparently a myocardial infarction can only be ruled out by a cardiologist at her hospital), the patient's doctor, a big bad oncologist, arrived on morning rounds.

He took a quick look at the EKG and said “This does not concern me.” In the hallway, Nurse Brown challenged him in front of his team of doctors and he had the temerity to ask her why in an intimidating way. 

After another 600 or so words about collaboration, blah, blah, teamwork, blah, blah, we come to find that the cardiologist confirmed the oncologist's impression that the EKG did not show a heart attack and the patient went for the procedure.

OK, I'm not saying that doctors don't intimidate nurses. And I'm not saying that it's all right to do so. I realize that some physicians can be annoying, overbearing and even disruptive. I just blogged about this myself today on another site. But was this really the best anecdote that Nurse Brown could come up with about how she rose to the defense of a poor patient?

When I was in practice, I had no problem with nurses questioning my actions if the question was based on a legitimate concern and (this is important) the nurse knew what she was talking about.

Unfortunately, the latter feature was often not present in the discussion. This is because as Nurse Brown points out, "Doctors and nurses are trained differently." 

She also says, "Some nurses reject the whole idea of doctor’s orders; they think the term makes nursing sound subservient." Excuse me? What would be the alternative? Nurses deciding what should be done? Anarchy?

Maybe it would have been better if she had said to the oncologist, "Can I have a word with you in private?" 

How do you think a nurse would feel if I confronted him in front of all of his colleagues at the nurses' station? 

Nurse Brown laments that there are no protocols to resolve disagreements between doctors and nurses. I disagree. Since the overwhelming majority of orders are not of a life-or-death nature, one can simply go up the chain of command. When this has happened to me, I have spoken to the nurse's supervisor to help sort things out. It works in reverse too. The nurse can talk to her boss who can talk to the doctor's chief of service. It's called "communication," one of the very things Nurse Brown says is lacking.

One of the reasons so many doctors are depressed and burnt out is the seemingly endless supply of articles like Nurse Brown's blaming us for everything that is wrong with medical care in the United States.


pilocarpine said...

well said.

Anonymous said...

I was surprised at your snarky tone vis-a-vis Theresa Brown, "an oncology nurse who has somehow finagled a quasi-regular column in the New York Times"... I've read her column; she provides an insider's view-point that often focuses on the human aspects of the acute-care experience. Relevant stuff, since we are human and will likely be at some point, patients. But, regarding the incident where she utilized a confrontational approach with a physician; in my experience, that approach may thwart not enhance communication efforts.

Communication between patients and providers (and between providers ) affects pt outcomes. Is there an optimal approach that nurses/physicians should use when dealing with each other? Yes--be polite and show mutual respect for the work each provider contributes toward the shared goal of healing. Nothing new or high-tech about that.

Anonymous said...

I suspect it is reactions like this that get nurses' frustrated with doctors. There is an arrogant tone and is not constructive. It's an old turf war in which doctors have felt they had the upper hand. Now many nurses are highly qualified and challenge doctors.

The concept of doctors "giving orders",inherently carries a militaristic hierarchy requiring obedience.

The doctor may be responsible for certain treatment decisions, but it is very disrespectful to refer to another clinician and say, "After another 600 or so words about collaboration, blah, blah, teamwork, blah, blah...".

Skeptical Scalpel said...

I guess it was a bit snarky, but this isn't the first time she has trashed physicians. It's just the first time I finally decided to comment about her column.

I'm glad you agree that confronting the oncologist in front of his team was inappropriate.

I agree that mutual respect would help.

Skeptical Scalpel said...

Second anonymous, I didn't think Brown's comments were particularly constructive either.

My point was, she was wrong to confront the oncologist the way she did. She disrespected him by openly challenging what proved to be his *correct* interpretation of the EKG.

If you don't like the term "orders," what would you use instead? Suggestions? Hints? Requests?

Bob said...

Possible "simple communications problem".

"This doesn't concern me";
Would this mean:
A) This is not part of my care of the patient, call the cardiologist.
B) This EKG is unremarkable, I'm ruling out the probability of an MI.

The difference in interpretation is alas, the attitude that the Listener is taking into the conversation, but also the relationship that has been forged over the past months with this physician.

Skeptical Scalpel said...

Bob, that's a good point and I did consider the two interpretations of that statement.

I decided that it must have meant that the oncologist felt that the EKG did not show an MI. Otherwise even if he were the most arrogant doctor in the world, you would think he would have wanted to wait for the cardiologist's input. Most of us would not send a patient for a significant procedure like a stem-cell transplant if he was evolving an MI. I'm surprised the cardiologist didn't order (request?) an echocardiogram. :-)

I agree it sounds like the oncologist and Nurse Brown had had some bad encounters in the past.

Anonymous said...

Nurse Brown lacked respect for the oncologist's medical interpretation of the EKG. And portrays herself as the only thing standing between her patient and death at the hands of the oncologist. When the reality was: patient has sx of MI, EKG was ordered, oncologist ruled out MI. The problem in this story was caused by the nurse. So how she twists this into a doctor bashing story is amazing.

Anonymous said...

It sounds like Nurse Brown and other like minded nurses would favor minimizing the hospital hierarchy. Let's say this happens. It should then also entail a shift in who is ultimately responsible for outcomes. I recall a previous post discussing counting of lap pads and the leaving of objects in patients. The response was overwhelmingly that the surgeon was ultimately responsible for everything that happened in the OR. In order for everyone to work together harmoniously, one party (in this case doctors) can not be the only ones taking the blame for what everyone does.

Skeptical Scalpel said...

First anon, I agree.

Second anon, I didn't think about my previous blog about retained surgical objects. How good of you to bring it up. Excellent point.

Anonymous said...

It's all about power without responsability. They (nurses) struggle for decision power all the time BUT when it comes to such sensitive topics such as who should be held responsible for the overall patient's outcome they like to vanish in the haze. Strange and worldwide behaviour that (along with the stacks of paperwork they love to invent) serves little to any patient benefit.

Skeptical Scalpel said...

Nice comments. The "paperwork" has gone digital here in the US. Nurses spend so much time documenting unnecessary information on the computer that they don't know what's going on with the patients.

Anonymous said...

Don't blame the nurses for excessive documentation. EMRs are set up as billing systems, and that documentation is for billing purposes, not for conveying relevant information about the patient and his/her condition. The other issue is having to document "negatives" (not necessarily only pertinent ones), to demonstrate that nothing was left out.

young frustrated surgeon said...

I must agree with your blog but my bigger concern is that medical support staff are being educated to question ( as a nursing educator told me "police" the doctor) anything a physician/ surgeon orders or says, or performs is fare game. Yet There is an entire labor force on the floor termed nurses with a wide range of knowledge ranging from LPNS, to 14 month RNs to 2 years RNS to BSNs on the ward managing our patients. Most general floor and general surgery wards have very young nurses with limited experience. Yet in the face of all these variables affecting patient care the administration sees no difference. These "nurses" can drop the ball, question a doctor but god forbid you ask why or how come then heads would role. They can hold up our cases, our procedures our days because they think something is wrong but If one asks for an explanation or a thought process one is labiled a bully,mean or even disruptive. We are victims to modern health care. We are outsiders, if not part of the adminsitration ( ie MEC) we are not a part of the hospital system. When things go wrong or mis managed or the nurses complain the hospital will protect itself and therefor the nurses. They rather lose a doctor then get hit with a law suit for an unsafe or " bullying" enviornment.

Henna said...

I am so glad to hear of someone else who does not like Theresa Brown. I was forced to read her book "Critical Care" in nursing school. It's poorly written and the hostile tone you noted in the NY Times column is present throughout.
I agree with Anonymous just above. Nurses hate the amount of time we're required to spend at the computer ticking a thousand finicky boxes rather than being at the bedside.

Skeptical Scalpel said...

Good comments all. I agree that it's not only billing but also Joint Commission and other groups driving the electronic charting madness.

Young frustrated surgeon, your frustration is palpable and I agree with what you said. While Nurse Brown calls for collaboration, the nurses do what you describe and react by reporting you if they are questioned.

Henna, I appreciate your support. Thanks.

artiger said...

This is something that just doesn't happen in my rural hospital. If the nurses do see something that doesn't look quite right, they know how to approach the physician in a tactful and respectful manner to discuss it.

Skeptical Scalpel said...

Having worked at large city and small rural hospitals myself, I agree that communication is better at the smaller places.

cynthia said...

I’ve noticed that an increasing number of hospital CEOs got their start as RNs, even if they worked only briefly as clinical nurses. This has resulted in a power shift in the hospital industry, IMO. More power has shifted away from physicians and towards nurses. This may explain why Nurse Brown and other like-minded nurses have become so pumped up with hubris that they will never apologize for questioning a physician's judgement even after they are clearly in the wrong.

Even though I'm a nurse, I don't have many good things to say about nurses running hospitals. They tend to reward managerial skills over clinical skills. They create wasteful white elephant like "The Center of Nursing Excellence," which is nothing more than corporate welfare program for master's and doctorate prepared nurses. And most of all, they deserve most of the blame for hospitals becoming way too top heavy, which is causing administrative costs to outstrip the cost of providing care.

If I had my way, I'd turn the hospitals back over to the physicians. They tend to be less bureaucratic in the way they manage things. And they don't believe that it's beneath them to put their clinical skills to use from time to time. Nurses in middle management, much less the ones in the corporate suite, would never, ever stoop to doing clinical work!

Skeptical Scalpel said...

Cynthia, thanks for your thoughtful comments and for agreeing with me. How do you feel about "Magnet" nurses?

DD said...

I will weigh in on what "frustrated young surgeon" accurately pointed out, there IS a problem in nursing--The lack of consistency in educational preparation (i.e. LPN, RN, BSN) are all considered "nurses". Some research shows that "In hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates" (

I am an advocate of BSN as entry level for nurses (I am a nurse practitioner who started as a diploma RN and went on to get my MSN). Part of the underlying problem is that a four-year nursing degree costs more than a two-year program so many future nurses elect the less costly option. Compensation and nurse-to-patient-ratios could also be better.

The nursing profession uses things like "Magnet" programs to attract and retain BSN prepared nurses;and I like the more collaborative, "learning" culture that results.

One additional comment about surgeons--I worked for many years, in a general surgery practice and I learned that when it comes to clinical management, decision making and patient care, surgeons are at the top--Because they have to be. Few other specialties involve such a broad scope of practice.

Skeptical Scalpel said...

DD, I appreciate your comments. There is a more recent paper about the impact of BSN nurses by same author as the one you cited. It's in Health Affairs this month. ( It reached a similar conclusion.

It has not been my experience that BSN nurses are clinically better than diploma nurses. I note that many hospitals have established "nursing internships" lasting several months to teach BSN's how to take care of patients.

It is unclear by what mechanism the presence of more BSN nurses affects mortality and failure to rescue. Association does not prove causation. The Health Affairs paper also claims that years of experience of nurses did not matter, a concept that defies logic.

It is an interesting issue to ponder.

cynthia said...

Magnet claims to empower nurses who work at the bedside, but in actuality, it only empowers nurses who work nowhere near the bedside. In fact, the further a nurse is from the bedside, the better off he or she is in terms of empowerment. This is why I would classify the Magnet program as a shell game.

The hospital I work for has an entire department dedicated to all the prep and follow-up work involved in maintaining its Magnet status. And believe you me, the jobs there don't come cheap! Most of the nurses who work in the "Magnet Preparedness" department, or whatever it's called, are pulling down six-figure incomes. Tell me, how in the world can hospitals justify paying these nurses such enormous salaries when none of them ever have to put their license on the line to do what they do, nor do any of them ever have to experience the enormous stress and strain of having to deal with life and death situations. They don't even provide a billable service to patients. In fact, if any of them ever tried to bill a insurance provider for the services they provide to patients, they probably would be investigated for fraud! Patients don't base their choice of a hospital on the competency and skills of the armchair nursing staff, they base it on the competency and skills of the clinical nursing staff. So tell me, again, how in the world can hospitals justify paying their armchair nurses significantly more than their clinical nurses?

There also appears to be an incestuous relationship between the Magnet folks and the folks in nursing management, which includes the "Magnet Preparedness" department. Such a relationship creates a revolving door between these two entities, which breeds corruption and cronyism -- a kind of corruption and cronyism you'd find spinning through the revolving door between Wall Street and Pennsylvania Avenue. This is why I would also classify the Magnet program as a racket -- perhaps not on par with the war on drugs, but a racket nonetheless.

I suppose there is one thing hospitals can do with their Magnet status -- they can always use it as an advertising gimmick. That's assuming the public is dumb enough to fall for it, which I doubt.

Skeptical Scalpel said...

Cynthia, your comments are spot on. Does anyone think that a patient would choose a hospital because it has "Magnet" status?

Your point about the incestuous relationship reminds me of HealthGrades, which runs a consulting business on the side. If your HealthGrades scores are bad, HealthGrades will help you improve them. I've blogged about this.

Anonymous said...

am i the only nurse who sees thru the cottage industry that is theresa brown? she hasn't been a nurse long enough or done anywhere near enough for the profession to be considered the "expert" she passes herself off to be. when you come right down to it, she is an empty-suit rookie who parlayed her PhD in english into an instant out from the oh-so-mundane tasks of developing as a nurse. look at her website..she has more agents and handlers than years in nursing. she sits on more panels, and gives more lectures, than anyone with so little actual background in the field. her sole asset is that she can write snarky, fear mongering tomes that play into people's legitimate concerns and come up with "answers" that amount to editorializing. what shames nursing more than ms. brown herself is how our supposed nursing "leaders" have bought into her self-serving sideshow.

Skeptical Scalpel said...

97, thank you for an interesting perspective on this topic. Opinions about her seem to be divided. I wish others would speak up.

Lets all get together and push said...

This is an interesting discussion, however from a quality management perspective that would be applied in a manufacturing setting, key data is being ignored, 100000 deaths due to medical mistakes per year. Even if this was 50% off, that is a broken system. The article by Brown addresses this problem, and proposes a constructive solution, while the discussion above ignores it.

Skeptical Scalpel said...

I was going to let your comment go because the post is old, but I just can't. I don't understand what you are driving at. I wrote that there is already a perfectly good way to resolve conflict between doctors and nurses. See the next-to-last paragraph of my post. It doesn't involve confronting the doctor in front of other people, especially when the nurse in the scenario she described was wrong about the EKG.

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