Theresa Brown unfairly blames doctors for hospital bullying

Theresa Brown unfairly blames doctors for hospital bullyingBullying is a problem within health care.

Stung by a physician’s rebuke, Theresa Brown, an oncology nurse, takes to the op-ed pages of the New York Times to address the issue.

In it, she cites several vignettes that paint doctors poorly:

But while most doctors clearly respect their colleagues on the nursing staff, every nurse knows at least one, if not many, who don’t.

Indeed, every nurse has a story like mine, and most of us have several. A nurse I know, attempting to clarify an order, was told, “When you have ‘M.D.’ after your name, then you can talk to me.” A doctor dismissed another’s complaint by simply saying, “I’m important.”

Clearly, there is no excuse for the behavior described. Nurses are essential to the health care team, and on KevinMD.com, there have been numerous pieces praising nurses, and how doctors can’t function without them.

But does Brown goes too far, when she blames the entire medical profession as the root cause of health care bullying?

… because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

I’m not sure that physicians, although certainly not guilt-free, should bear the sole responsibility for a corrosive culture that pervades some hospitals. For instance, it’s well-known that bullying is prevalent within the nursing culture. Shouldn’t they bear some responsibility as well?

Instead, blame should be directed towards the physician education system, rather than doctors themselves.  The hierarchical culture that perpetuates bullying goes back as far as medical school, when as students, future doctors are trained in a pecking order not unlike the military. It’s no wonder that some carry that attitude into the workplace. Of course, that’s no excuse, but changing physician behavior needs to start at the beginning, not in the hospital after they’ve been indoctrinated.

And finally, a comment on the piece’s inflammatory tone. Theresa Brown is a contributor to the Times’ Well blog, which, if you read the comments, has an audience generally less than friendly to physicians. The op-ed panders to the hostile physician sentiment of Well’s core readers, and while sure to be popular, is regrettable.  Brown has a prominent media platform in the New York Times, and in a way, she wields it here to metaphorically bully the entire physician profession. Perhaps her workplace environment is particularly toxic, but the doctors I know harbor nothing but the greatest respect for nurses and the rest of the medical staff. They don’t deserve to be painted with such broad strokes as was done here.

Bullying in health care is a real problem, and needs to be addressed. But this vicious column strikes me as angry, and is also unfair to many of Brown’s fellow nurses, who have collegial relationships with doctors.  Attacking physicians so personally only serves to drive a bigger wedge between doctors and nurses, when in fact, we need to be working together to solve this issue common to both professions.

Update:
I wrote a follow-up piece, on Doctor bashing, and confronting physicians in the media.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitter, and LinkedIn.

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  • http://passionsforthesoul.typepad.com Vicki

    I am not a part of the medical culture, except in my role as a patient, from time to time. But I know something about personal accountability, and to blame doctors for bullying among nurses violates that concept.

    A TV program like ER also portrays the medical culture as one in which bullying occurs and is to be endured by those bullied. That doesn’t help. Your statement about where blame should be laid and change should begin seems valid, but part of the re-indoctrination should include firm reminders that even those who are bullied have the choice: They can bully others, in turn, or they can treat those around them with respect.

    I have not read, nor do I expect to read Theresa Brown’s column. To use a major media source to vent and to paint all doctors with a broad brush is unfair, and I would only raise my blood pressure, if I read it. And that’s problem enough, these days.

  • rrptl

    Hospital bullying goes both ways. I will never forget the verbal berrating/abuse I was given by an infusion nurse for orders that I didn’t even write for a patient. Being a team player, I re-wrote new infusion orders that a colleague had inaccurately written, but was that necessary for the nurse to verbally berate me?
    There are bullying, abrasive and unprofessional nurses out there who go after docs as well.

    • Primary Care Internist

      if anything i would say that the verbal abuse is worse the other way, with nurses bullying doctors, especially residents. And especially female nurses bullying female doctors. Perhaps there’s a jealousy there? On the other hand, the male nurses i have dealt with have been extraordinarily respectful and easy to work with.

  • Chris

    Blame should be assigned to both the physicians who engage in such behavior as well as the educational apparatus. Blaming only the educational system and not the individual, autonomous adults who engage in the kinds of behavior that I think we both find problematic misses a key point. The doctors in question still have the ability to treat nurses (and others) as colleagues rather than the help.

    In the piece in the Times, Ms. Brown noted that not all physicians act this way. The main point is that while not all doctors engage in these behaviors, it is a systemic problem. One that needs to be addressed from both the individual and systemic levels.

  • http://www.parentingintheloop.com Lorette Lavine

    I have not read Theresa Brown’s entire piece…but I agree that there is plenty of doctor bashing going on…it brings followers and readers to those that bash the medical profession.
    I am a nurse and have practiced with many physicians some of whom were arrogant and difficult to practice alongside. But most were more than willing to answer questions and share information especially when it was directly related to patient care. Those that work in the medical field have strong personalities and sometimes they get in the way when dealing with members of the healthcare team.
    There are policies and procedures for everything in patient care but unfortunately there are none that cover manners and general respect for your co-workers. Respect , I have found is earned in the medical field by performance…so if you want respect then give respect and work hard at your job.
    For some reason in the current medical care climate doctor bashing is popular…there is an effort to knock them off a make believe pedestal. They are human beings trying to help other human beings…there are good doctors and not so good doctors…find one that you like and respect…take some responsibility for your own care and stop bashing …as pretty soon there will be fewer and fewer good doctors available given the current medical care crisis.
    Hold other workers to the same high standards that you hold the medical profession and see how they measure up and then bash that group and leave the doctors alone.

    • Primary Care Internist

      thanks Loretta, what a refreshing reaction by a nurse to Theresa’s clearly inflammatory piece. Shame on the NY Times for publishing it, and i can’t wait to see the reader responses.

    • Anders

      Loretta, I agree with you fully. I would add that while the doctor pedestal is most likely the source of much of the bashing, there was a time when it was not “make-believe.” The concept is a relic from times gone by and while change has eroded it for the most part, it still exists in the minds of doctors and nurses alike, which leads them to assume a contentious relationship from the start. Hospitals and even educational systems are not necessarily trying to quell this and may indeed turn a
      blind eye to this now misguided belief.

      In addition, the current economy has brought a great influx of new nurses, making it easier for hospitals to simply fire nurses and bring in new ones. If a nurse and a physician get into an argument, who do you think is considered more valuable to the company? This has made nurses vulnerable and in some cases, insecure enough to become bullies.

  • Laura

    Kevin, I completely agree with you. I work as a nurse, and the primary source of bullying that I have witnessed has come from a few, very destructive, nurse bullies. On the other hand, the majority of nurses and doctors that I know are supportive and professional toward one another.

  • http://www.wjhb.de William

    Writing a column in the New York Times is just as much a fighting technique as a soflty-spoken, but thoroughly destructive, insult in the OR. Clearly there is an on-going battle. Rather then getting snagged on the fighting technique of bullying, it would make more sense to get to the root of these conflicts between individuals and stop pushing the responsibility off on the “circumstances” the “health care system” or the “educational system”. This is the thinking of state socialism.

    These fights can proably only be resolved on the spot by staff themselves or immediate supervisors. And all the commentaries on the web, including this one, are not going to help one bit. This reminds me a little of the Israel/Palestinian conflict: if the parties really want to go after each other’s throats, there is not much a third party can do.

    There was once a theory that violence between ethnic communities was liable to continue even more stubbornly when the parties involved believed that the police would always interfere in case things got out of hand.

    In any case, just calling doctors or other nurses bullies does not seem to put an end to the practice. It is therefore a bad fighting technique. It is time to move on to something else and forget the charge of bully. It apparently does not work.

  • http://thedogatemycareplan.wordpress.com IsntSheLovlei

    I believe that bullying, in healthcare, in the schools, and just about everywhere else is due in large part to our competitive culture in general. Success is judged by who has the highest grades, the most medals or money, or whatever helps distinguish ourselves from the rest of the pack. Unsurprisingly, this oftentimes out of control competitiveness promotes aggression towards others.

    • http://www.wjhb.de William

      Yes. There’s competition all over. Not just in “our competitive culture”. The questions for each of us are: If I am not for myself, who will be? If I am only for myself, what am I?
      Each of us faces the choice of how we stand up for ourselves. Some even do it by going passive, playing dead. But it is helpful to think of us all as being in the thick of it, i.e. in the thick of life.
      With this perspective it is possible to puncture the windbags and bring everybody back down to earh. The participants are all overinflated:
      Underneath most of them are pushovers. We don’t have a culture of competition, we have a culture of buckling under. And then blaming that on the other guy.
      Again: staff have to resolve their own specific conflicts themselves or resort to an in-house or other mediator. Blaming a competitive culture d o e s n o t h e l p.

    • http://www.confutata.com Squillo

      I suspect that it’s less due to a competitive culture than to the pressures of the environment. Of course, workplace bullying occurs across all professions, and some companies are attempting to address it. However, hospitals are not like other workplaces because the responsibilities are so much greater than in most other workplaces, so measures that may be effective in other environments may not work as well. A number of medical/nursing schools are beginning to stress inter-disciplinary training models, which I hope will go some way toward ameliorating the culture that fosters bullying. Part of the problem is that, ultimately, the attending physician is responsible for the hospitalized patient, and, as in the military or in other command-and-control environments, some people respond to the stresses of this responsibility inappropriately. Inter-disciplinary training, in which team approaches are stressed, may or may not improve this, because the chain of responsibility is not going to change. There is a great deal of interest in the way bullying–both physician-on-nurse or -resident, and nurse-on-nurse, negatively effects quality and safety, and in the end, I expect quality-improvement initiatives will drive the change.

  • inchoate but earnest

    “Vicious”, really?

    You’re overreacting. Brown dwells on the systems problem, as you encourage – but for some reason your primary reaction is to feel defensive.

    • sktaz

      I agree Kevin is overreacting. For Ms. Brown to point out that a few doctors bully – and that it is detrimental to patient care – even in as public a forum as the New York Times – is not “doctor-bashing.” Should she remain silent?

      It would seem to some that to point out any flaws or faults in physician behavior is doctor-bashing. Is the preference to sit quietly and let the misbehavers figure it out for themselves – sometime after an incident comes to light where the behavior results in the death of a patient? I doubt that such individuals, as bullies, are capable of acknowledging their own responsibility in such events. It’s the nature of bullying in general to justify the behavior – so I doubt that a bully can change his/her behavior without outside intervention.

      Ms. Brown makes the point, quite strongly I believe, that these disruptive behaviors exist in very few doctors. She also states that the bullying culture is present in nurses as well. She states that most of the doctors she interacts with respect the concept of teamwork and do not bully. The fact that she points out that there is still more work to do – all in the name of patient care, the true North Star, the only reason doctors and nurses are working in the first place, seems laudable. It’s not about doctors and nurses. It’s about patients. Always. Always. Always. The doctors, as the acknowledged leaders, have an opportunity to lead the way to change.

      For those that are uncomfortable that this was written in such a widely-read and highly respected publication – ask yourselves – why – why are you uncomfortable that something that is true (some doctors and nurses bully – it can be detrimental to patient care) has been published in the New York Times. It is not a lie. Ms. Brown is more fortunate than most. She has a very public forum to reveal this truth. Is that your problem?

      • Primary Care Internist

        yikes did you even read the title of her piece??? to me it sounds like it was written very one-sided, then edited to make it less inflammatory.

        And anyone who does not see the exponentially-growing culture of physician-bashing and debasement, vs. nursing-praise and elevation of status (even prescriber status), has their head in the sand

        • Katie

          Ah, therein lies the problem: “nursing-praise and elevation of status (even prescriber status).” I suspect someone is worried that he’ll become less relevant if nurses gain the respect they deserve and continue to have a wider scope of practice – the more educated ones at least.

          Part of the problem with “physician-bashing” is that too many physicians have given the medical profession a bad name over time through extremely long office times, a lack of policing their own, which has at times resulted in patients’ deaths, and a perceived notion that most physicians care more about the almighty dollar than the patients. I’m not bashing you or your profession, but as a civilian, I can tell you what we see.

          A few years ago, I started seeing a new OB/GYN and had to wait 2 hours to be seen for 5 minutes! First of all, there was a sign in the waiting room that stated if I canceled my appointment with less than 24 hours notice, I would be charged $100; however, I was on my lunch break during a very busy work day. If they knew they were behind, why not call and ask me to reschedule or tell me to come later instead of wasting my time? Then to charge my insurance $535 for a visit that took 5 minutes? I don’t think I need to tell you that 5 minutes for a new patient is not sufficient time to deliver get one’s medical history (which she didn’t inquire about) and perform my exam. The following year, I saw a different physician, and she was worse! Not only did she fail to introduce herself, but she was condescending and rude until I barked back at her, at which point she became sickeningly sweet.

          I’m sure you’re well aware of the fact that physicians suffer retaliation if they police one another for poor care. My mother’s friend was blacklisted for being a whistleblower and reporting a fellow physician’s lack of medical ethics and poor care. And a family friend was killed during surgery by a physician who has had a career full of medical mishaps, yet never seems to lose his license – I’m sure this helps drive up everyone else’s medical malpractice and, by extension, health care costs.

          While in corporate America, I’ve worked with some fantastic physicians, but I’ve also worked with some divas. I also have good friends who great physicians and even have them in my family, so I realize that physicians are human just like everyone else. But please realize that “physician-bashing” did not magically appear – there are a number of reasons it exists, though it certainly does not apply to all physicians. There is truth in both your and Ms. Brown’s columns. Somewhere in between lies the solution.

          • Primary Care Internist

            nursing elevation of status to prescriber status is very often unwarranted and dangerous. yes i have heard the countless arguments on this blog about increased years of training etc. but what i am seeing are new NPs prescribing dangerous drugs that they know nothing about, and perhaps hadn’t heard of before. there is a reason medical students can’t prescribe, and even interns don’t get a medical license (in NY) until completing their internship year and the USMLE Step 3.

            That’s what i’m talking about – an unwarranted elevation to prescriber status. it’s not about socioeconomic status, as it seems that’s how you took it.

            but just like in an average public school there’s a tendency to gravitate everyone toward the mean ie. very very hard to get an a+ but also very very hard to fail.

            nurses, of course, deserve tremendous respect for the very very difficult job they have. i have the utmost respect for med-surg floor nurses, but NPs have been a mixed bag. And certainly neither should consider themselves equal to the doctor in medical decision-making.

        • Anne-Marie

          PCI has engaged here in the same form of profession bashing that she/he accuses Ms. Brown and society at-large for engaging in. I would encourage the author to first research the data before making such inflammatory remarks about NPs that appear to be based on a personal anecdotes. Numerous studies have demonstrated that NPs provide excellent clinical care. Even the IOM is calling for the removal of barriers so that NPs can practice to the full extent of their training. Nurses and NPs provide a different, but equally important form of care so stop trying to create a hierarchy over who should be in charge. We all have to come together if we are truly going to solve today’s healthcare crises: an aging population, obesity, and skyrocketing healthcare costs.

          • stitch

            “Numerous studies have demonstrated that NPs provide excellent clinical care.”

            A wise person once pointed out to me that those studies were, in fact, conducted by nurses and nursing organizations; this person pointed out that nursing research is about nursing, whereas research conducted by physicians is about medical conditions and medical practices. It’s all about what you want to study.

            This person is, in point of fact, a nurse practitioner, one whom I respected and trusted thoroughly. I have said before, I have known some wonderful NPs and PAs and thoroughly enjoyed working alongside of them, but the fact is they knew the limitations of their training, even those with many years of experience. That’s really the critical point for anyone in healthcare.

            And the IOM has their own agenda.

            Medicine needs to be practiced in a team manner, but what has to be understood in that approach is the nature of medical, and I mean physician, training, which is critical clinical decision making based on deep understanding of pathophysiology. Nurses such as Ms. Brown are trained in this; nor are, frankly, advanced nurse practitioners. Their input is important but it is only part of the picture. The final decision making, as well as the final responsibility, lies with the attending physician.

            Most current clinicians in any discipline recognize the collaborative nature of medical care. Yes, physicians can be imperious. Nurses can also be, shall I say, “attitudinal” if they feel their viewpoints have not been adequately taken into account, sometimes whether or not that is actually true. And frankly, the often militant push towards “empowered nurses” can be an impediment to collaborative care rather than a contribution.

          • Primary Care Internist

            why do you consider my position that NPs should not be given such rapid and easy prescribing authority “bashing”?

            why is it that doctors have to jump through umpteen hoops to prove they are fit to prescribe meds, but NPs are held to a much lower standard? and you feel that my questioning this is “bashing”? what if LPNs had a lobby that published a study of a limited scope of, let’s say, young healthy women with fever and dysuria seen in an outpatient clinic, and the LPNs had correctly identified those having a UTI, as well as an RN or an NP or an MD. And they treated them with a choice of either cipro or bactrim. Then they would have proven their care equivalent to all of us, and their lobbying group could push for their prescribing authority.

            Would you have a problem with that? If so, why?

          • Anne-Marie

            To PCI
            My sincere hope is that you have taken these “perceived” cases where the new NPs were supposedly “prescribing dangerous drugs that they know nothing about” and have reported them to your local State Board of Nursing for investigation. You might want to also ask your State Board of Nursing how many cases have been opened against NPs and how many resulted in disciplinary action. In the end, aren’t we all trying to provide safe, quality care to our citizens?

  • Brad

    Bullying goes on from the more powerful to the less powerful, from the stronger to the weaker, or from the many to the fewer. It’s a repetitive thing, and the purpose is to make the victim miserable. If you’re an observer, it’s hard to believe what you see. You might think it’s a one-off, that the person is acting angrily, that the victim deserved it, or you just don’t believe what you see. If you see repetitive events, and start to get the pattern, then the fact that you let the prior events go by and didn’t call attention to them will be a problem. I can also mention that adult bullies are usually very good at following the rules. In fact, if they can use the rules to bludgeon their victims, so much the better.

    That’s what bullying is.

    • http://www.thenerdynurse.com The Nerdy Nurse

      bullying is also standing by and allowing others to be bullied. if you aren’t part of the solution…. well, you know.

  • Vicki S

    As a physician, I have certainly seen docs treating nurses and other health workers badly. I make an effort to always be courteous though I will say something to a person who has made an egregious error.

    However, I have also seen nurses treating doctors badly. I have seen them call someone (not me) all night over nothing because they were mad at him. I have had nurses refuse to carry out my orders because “I haven’t worked with you and don’t know if I can trust you.” Goes both ways and the one who truly suffers is the patient.

    I move most of the responsibility for the recent increase I have seen in hospital tension/bullying upstairs to administration. With the constant push to have fewer nurses for sicker patients and with the constant pressure on the physician to discharge early, we are all under stress and that affects our working relationships.

  • SarahW

    ” changing physician behavior needs to start at the beginning, not in the hospital after they’ve been indoctrinated.”

    Wherever the beginning, I don’t care. It needs to stop wherever it is going on, and “indoctrination” is no excuse.

    The nurse in the piece might have hinted the problem flows down from the top, but she doesn’t except behavior of nurses and particularly singles out those who bully young, starting-out physicians.

  • Larry Whitlock

    I have read nurse Brown’s column and will not since it is in the NY Times. In my 35 years of practice, I have seen problems with both doctors and nurses. I have found that most nurses and docs respect each other and the handful that don’t are the problem. Sounds like Brown is in the latter group.

  • Nurse Sharon

    Kevin, you make some valid points in your piece about the lateral violence perpetuated by nurses but as an RN for the past 20 years, I can assure you that Theresa’s piece was spot on. I have worked in several different settings over the past years, and it is absolute truth that many physicians view nurse abuse as their right and a perk of their profession just as the physician in the piece clearly does. This culture is most pervasive in the hospital environment.

    When you are on the front lines, it doesn’t matter that the root causes lay in the medical education system because the physician is being a vicious jerk just because he can. I can cite so many examples of rude and hostile behavior from physicians it brings me to tears sometimes at the memories. I’m always amazed when physicians feign ignorance at the bullying behavior of their colleagues but then again I guess they don’t need to know.

    Fortunately, I have fared better in the past 7 or 8 years or so as I no longer work in the hospital setting. Physicians in general tend to act out less in the acute care arena which does not mean that they are not condescending and dismissive in other settings. I can assure you some of them are, it’s just less vicious.

    The nursing professon itself can take some of the credit. Nurse leaders are rarely advocates for their staff and in fact, sometimes encourage the behavior. Other staff nurses work overtime at socializing new nurses and staff into a submissive role so that when a nurse is tempted to stand up for herself they find themselves standing completely alone. Eventually one learns to just take it or even better, work to make sure you don’t upset the offending doc. “Make sure you do it this way because Dr. So-and-so doesn’t like it”. Yeah. That’s reality.

    I’m pleased that you and some of your peers respect nurses. However, I encourage you to do some honest research for your blog and do a survey of working nurses. (Make sure it’s anonymous or they will never be honest).

  • soloFP

    I’ve seen bullying since med school.. On many rotations med students would have walking rounds. Routinely scut work was delegated to the students and teachers routinely ripped apart students who they did not feel were doing a good enough job. Some of the most abusive rotations for med school and residency were ob and surgery rotations, where it often seemed like a testosterone contest of one up manship.

    In med school, residency, and in current practice I have witnessed doctors throw charts, throw instrument trays, throw suture needles during operations, throw instruments, use condescending and often abusive language to students, residents, nurses, and anyone the person feels is low on the totem poll. The best procedure is not to engage or encourage this behavior.

    My local hospitals had to implement ethics codes rules, which have greatly cut down on the abusive behavior. I still see the med records workers get abusive language and screaming from docs who don’t get their records done on time, but it is less frequent. I have a lot of nurses as patients and view docs and nurses as team members who have a common goal of helping the patient.

    Nurses can be your best friend or your worst enemy. The few specialists who are still condescending and abusive are mostly older in my area. If I find out a doc is poorly behaving toward nurses, staff, or patients, I no longer send referrals to the person. The nurses often tell me stories of OR abuses or simply refuse to see a certain specialist for personal reasons. Abusive behavior discourages teamwork, increases errors, and can lead to poor patient outcomes. Many of these docs are employed by the local hospitals and bring in millions in procedure revenue, which means many of them have God complex and are almost untouchable.

  • http://www.wjhb.de William

    Isn’t there a film comedy which shows a frustrated traveller who cannot get all his clothes into his suitcase and so finally take an enormous scissors and cuts off all the bits hanging out at the edges?

    Excuse me, but there is something a little more than fishy about a blog site about conflicts among medical staff where humour is completely absent. If everyone is really so serious all the time this may be a part of the problem.

  • http://emergency-room-nurse.blogspot.com girlvet

    You never fail to amuse me Kevin. A little sensitive are we? Perhaps this column hits home a little too closely. There is nothing “viscious” or “angry” about this column, it is simply stating facts fo situations a lot of nurses experience.. The suggestion that there should be training doctors to treat coworkers decently in medical school is ridiculous. Why should that even have to be talked about? Treated people with respect is common decency. Anything less shouldn’t be tolerated. Doctors shouldn’t have to be taught this.
    I would bet that if a bunch of doctors across the country started being fired, this kind of behavior would disappear.
    Here’s the thing: As far as I am concerned everyone in the hospital, office, etc. is of equal importance from housekeeping to the CEO. Everybody plays an important role in patient care. The days of doctors being more important than anyone else is done. Doctors haven’t caught up with that idea yet, but they will.

  • http://Ssdd@Hofmann.com Resident

    Wait until you are sitting in the sick bed before you declare that everyone is equal. Everyone is special and deserves a medal! The people who dole out abuse are older nurses. It is my life so I know. Just keep my eyes down bc they can cause more trouble for my career then I could ever hope to for theirs…

  • Joe

    No matter the setting, no matter the issue, no matter the parties involved or their relative stature or hierarchy, no matter the validity of the statement – any time you have an individual of one group (nurses, in this example) stating that individuals in another group (physicians, in this example) should or must do something – that statement will likely not be accepted or appreciated. That the NY Times willfully neglected to appreciate this demonstrates at least a partial intention to inflame.

  • Nora Mitchell

    I usually understand where Ms. Brown is coming from, but in this case I think she got it wrong. The patient jokingly asked whom he should be angry with, and my feeling is that the physician replied in jest. And when he defended his response later on, he was stating fact but not that he truly believed the nurse should be blamed. I am an RN. Early in my career I was genuinely dressed down by a physician in public because I questioned an unclear order. I asserted myself and it never happened again. It’s unfortunate that Ms. Brown feels she was publicly bullied. I know that the treatment of nurses can become demoralizing at times but if she thinks that relatively mild comment was humiliating, she needs to either sharpen up her sense of humor or learn to give as good as she gets.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    I thought the piece was doctor bashing and it was in the wrong venue. If Ms Brown is upset with relationship between staff then let her work within her own institution to improve behavior and relationships not in an op-ed piece in the NY Times. I wrote a letter to the editor about it. I come from a different point of view. I am not anyone’s employee. I am an advocate and caregiver for my patients in a dysfunctional hospital environment where systems and communication between hospital employed personnel including administrators , nurses, labs and imaging departments is mediocre to poor especially with a medical staff made of independent contractors. The level of clinical experience and bedside skills exhibited by much of our young nursing staff has declined dramatically the last ten years despite the improvement in technology. Faced with larger patient to nursing ratios, sicker older patients and longer shifts their jobs have become much more difficult. They no longer go to the bedside with the doctor to make patient rounds citing too few nurses and too many physicians making rounds at the same time. To reach the nurse you must call the extension of her portable in hospital phone. They turn it off often. Unfortunately the nursing staff is the most accessible and visible representative of the hospital administration. When things go wrong they receive the criticism and complaint to correct the problem. I am not necessarily certain that valid criticism is distinguished from bullying in her article. Whenever someone is criticized they claim the physician is unprofessional and if they do it in private they claim they were abused. As for the health care team being an essential unit? I haven’t seen one in my community hospital in years. Even if there was a team there would be those with more experience ,education and leadership skills and in most health care environments despite what many on this board think, it is the physician. There are many wonderful dedicated nurses and health care workers in my community hospital. The systems created by a dysfunctional and profit motivated administration are the main problem. If anyone is bullying and ramming things down peoples throats it is the hospital employed chief medical officer and the administration.

    • Joe

      Maybe the UPMC administrators bully thte docs, and the docs bully the nurses. She may have no where to go that will support her there.

      • Melissa

        Why is it that everyone is so upset because she took advantage of a platform that many have used so many times. I have been in healthcare since 1997; this has been an ongoing issue. So to me, please bring it to everyone’s attention. I personally would have done the exact same thing. We always want to hush things up. Keep it queit so everyone does not know.

        One incident I will never forget as a nursing student was when I was observing a bypass surgery. The lead surgeon had two medical students with him to assist that day. He asked one student to take an instrument and hold open the rib cage of the patient so that the heart would be better exposed for all to see. I guess the student was not doing it to his satisfaction. After asking the student twice to change the position of the instrument the surgeon snatches it out of the student’s hand while saying “I said like this”. While the surgeon was viciously jurking the instrument around in the chest cavity of patient, the patient coded. Although it was very exciting as a student to see the surgeon revive the patient by manually pumping his heart, I believe without a doubt it was the surgeon’s fault in the first place.

        Yes, bullying happens in all professional environments, but healthcare it poses a serious threat. We are not dealing with a “product”. So for Ms. Brown to put in out in the forefront in the manner in which she did in my opinion was necessary. See how many feathers got ruffled. I was always taught that those who take offense obviously partake in the matter. I could probably understand others reaction better if what Ms. Brown stated was not true. It seems everyone agreed to what she had to say but was upset because she made it so public. Really??

  • Jens

    I read Brown’s column, this one, and the one over on the Atlantic site, which regarded the NYT column as unnecessarily vindictive towards physicians.

    As people have said before me, Brown did note that nurses can behave badly too, and that abusive acts are rare. But more to the point, Brown accurately points out that abusive doctors do what they get away with it. That’s their game. Bedside, these doctors also act condescendingly to patients. In the workplace they target people “lower on the totem pole”, but behave well in front of other doctors.

    These “abusive” doctors in turn model to younger docs that this is ok, and there you get the pervasive “culture”. Doctors get their clinical training from other doctors. If the workplace is now so unbearable (I’m not arguing care providers have it easy) the healthcare team needs to be more cohesive, not less. And true enough, care environments are definitely distinct, but as Brown said, doctors take the lead in hospitals.

    If bad behavior is rare (I actually think it’s fairly common) it poisons widely. The attitude of “abusers” (found too in business, finance, technology, academia, politics etc), that they’re more talented/important than anyone else therefore don’t need to be civil, is dangerous. People who are beyond civility and never get reprimanded for stepping out of line often flout other rules as well (from billing to operating procedures).

    And who will reprimand doctors? Patients won’t say anything and they have no status anyway. Other doctors often don’t see it. As for nurses like Brown, she wrote that at the workplace, she will avoid this doctor. He has more power. Most likely that’s what everyone else already does. In other words, no one dares stand up to him.

    So. Kudos to her for pointing it (I thought her example tame) out in a place she feels safe.

    Some people felt she unnecessarily targeted a doctor in his workplace (see Atlantic). But why this attitude? Doctors who put nurses and others down create a hostile workplace for many others and for patients. Maybe other doctors don’t recognize this because they’re not privy to the abuse, and/or when their patients, they’re privileged. But perhaps docs should pay more attention, b/c patients who’ve met with this surliness can’t help but harbor a fear and distrust that extends to other doctors. (And probably seeps out at The Well.)

    As Brown pointed out, doctors often act this way when no one of import can witness it. But by what standard does one judge it fair for him to be secretly nasty, undermining work and care of many people, while it’s not fair for those he abuses to defend themselves while simultaneously standing-up for better healthcare? In other words why SHOULD Brown follow the rules of HIS little power game and say nothing? Doesn’t that just propagate the harm being done to everyone?

  • http://www.wishfulthinkinginmedicaleducation.blogspot.com Anne Marie Cunningham

    I’m a doctor but working in the UK rather than the US. I read this column and didn’t think it was doctor-bashing. Instead it recognised that we all have responsibility to tackle the hidden curriculum that allows the behaviour that Brown has described to be tolerated.
    Medical schools have responsibility of course, but step up to the plate and accept responsibility for the behaviour of your profession. That is all that she asks.

  • http://www.innovationpartners.com Loretta

    Rather than give an opinion, I am going to share grounded research that I conducted in 2009 at a very fine hospital with Press Ganey scores above the 95th percentile. I interviewed and conducted focus groups with everyone from the CAO, CMO, VP Nursing and VP of HR and dozens of nurses, dietitians, technicians and managers. There is a fear of physicians – the hospital administration does not want to confront disruptive behavior because of the patients they bring. Clinical and non-clinical staff fear retaliation if they disclose the physical and psychological harm they inflict. Sorry, Kevin, this is the physicians fault. We each were exposed to education and prior work environments that were less than spectacular in human kindness. As an Emotional Intelligence coach, I know the shortcomings that cause bullying and that they can be overcome. Accountability is a personal issue. Theresa’s message may sting, however, she is telling the truth and we must confront it.

  • http://josephineensign.wordpress.com Josephine Ensign

    Dr. Pho,
    Surely you must know that you can’t judge an ‘audience’ to a blog by the quality of the posted comments? If I were to judge your blog’s audience by the comments on your post claiming Theresa Brown is ‘doctor bashing,’ I would assume they all had hypertension and never read primary sources…

  • Medstud4

    As a 4th year medical student, I was verbally attacked by an ICU nurse during the middle of rounds. It was a minor error, and yet she didn’t feel like talking calmly to me. She claimed that it was people like me who are the reason errors propogate in the hospital. She had a bone to pick and made sure to demonstrate her power over me. Fortunately the senior resident called her out, as the mistake was secondary to HER mistake and a JHACO violation. I can say that I have been held in high regard by every resident, attending, and most ancillary staff. I’ve found that some nurses feel they can and should take out their issues on the medical students since they are lower on the totem pole. Interestingly, I don’t get this as much from physicians.

    • http://www.wjhb.de William

      In situations like the one you describe why is it that so many of us (me included) are so inhibited that we don’t just laugh at accusations like this, especially the glaringly false or hugely exagerated ones. Why do we not just laugh them off?

  • http://paynehertz.blogspot.com Payne Hertz

    I’m really amazed at the people who refuse to read the article yet feel comfortable passing judgment on Nurse Brown. Having actually read the article, it is clear some people are inordinately threatened by what is at most a fairly tame discussion of a very serious problem that according to studies Nurse Brown cited may lead to death and injury to many patients. But let’s keep our priorities in order lest we forget the real issue here is not the death of patients, but failure to pay due deference to doctor sensitivities. It’s hard to accept she is making a broad-brush attack against doctors when she says “most doctors are kind, well-intentioned professionals, and I rarely have a problem talking openly with them,” but you’d have to read the article to catch that.

    I am not so amazed at the fact that so many who preach the doctrine of “personal responsibility” even to the point of punishing patients for being sick make no such demands of doctors. Personal responsibility, like taxes, is for the little people. No matter what behavior a doctor engages in, he is sure to find a sizeable number of his colleagues willing to blame the system for it, rather than hold him personally responsible for his own conduct. While the elitist, authoritarian culture of privilege, impunity and cover-up that pervades the medical system fosters and even encourages abusive behavior, it doesn’t force doctors, nurses, or anyone else to behave in a hostile manner to their colleagues or patients. The failure to hold medical professionals even morally accountable for their actions let alone discipline and fire them where necessary is a major part of the problem.

    Nurse Brown is to be commended for having the courage to go against the White Wall of Silence and speak openly in her own name in a public forum like the Times, rather than play the bully’s game of complaining in-house, where her problem would likely be ignored, and where she might find herself blacklisted for speaking out. I’ve been there as a patient. She is clearly someone who understands the concept of moral responsibility, and we have all been given a lesson here how those who speak out against abuses in this system are treated.

    • http://www.thenerdynurse.com The Nerdy Nurse

      I agree. I am proud that there are people like Mrs.Brown who will stand up on soapbox when so many others would just bow their heads and say “yes doctor”

  • Jade Black

    As a physician, I still haven’t fully recovered from the bullying done to me while in training at the hands of my residency program director. Bullying is devastating, especially when done by a physician who is supposed to be training you, but instead abuses his workplace power. It caused me to lose trust in ALL superior physicians for awhile and to take on a certain amount of callousness. While we need not paint one group with broad brushstrokes, we do need to acknowledge the hurt out of which she was likely writing. And I agree we need to fix the system. There was no one in place to check the wrongs of my program director, but there was someone there keeping the broken current system in place. One may not experience bullying personally, but it is not an uncommon phenomenon.

  • http://patients.about.com Trisha Torrey

    Theresa Brown’s piece focuses on bullying and condescension, but what it is really about is lack of respect and problems within hospital pecking order. The victims are all those on the receiving end of disrespect – whether they are doctors or nurses or patients – anyone.

    This disrespect has gone on for decades – it’s nothing new. Every single nurse who reads this knows of a bullying and caustic nurse. Every single doctor knows of physician colleagues who think their you-know-what doesn’t stink – and isn’t afraid to throw around his or her considerable status to the detriment of others.

    But here’s the problem: by not confronting this behavior, it becomes the accepted way to do business. And pecking order IS important because only “like” can adjust “like.” Only other doctors can make other doctors see the folly of their bullying ways. Only other nurses can adjust the attitudes of other nurses.

    If you are a physician who has taken offense at Theresa’s piece – then do something about it! Pull your guilty colleagues aside, or work with hospital administration to develop some sort of communications correction course. If you are a nurse who has observed your nursing colleagues bullying anyone else – residents, patients or even doctors – then YOU must take the bull by the horns and figure out how to straighten it out.

    If you don’t? Then the continuation of such a venomous culture will be on your back. You will be as responsible for that person’s poor behavior – and possible negative outcomes for patients – as the person who bullied to begin with.

    Trisha Torrey
    Every Patient’s Advocate
    See post: A Call to Physicians: It’s Time For You to Weed Out Those Rotten Apples

  • Joe

    She will likely lose her job during the next purge at UPMC.

  • http://www.womeninpainawareness.ning.com carol

    I do not know about bullying of nurses. I do know that when there was a medical malpractice case against a very powerful doctor, nurses refused to testify stating “I will lose my job.”
    The bullying is built-in. From my perspective as someone who worked in a teaching hospital for years (and as a non medical person in the ER), did some training as a P.A. and has been an active patient for over 30 years, the hospital culture a dysfunctional family where docs are at the head of the food chain and the institution in the long run more important than the empolyees or patients.
    Carol
    ( http://apainedlife.blogspot.com/ )

  • http://newworkplace.wordpress.com David Yamada

    I’ve been researching and writing about workplace bullying for over 10 years, and the Brown op-ed and responses to it have grabbed my attention.

    I blogged about it here:
    http://newworkplace.wordpress.com/2011/05/09/nurse-writes-about-bullying-by-doctors-and-other-doctors-respond/

    David Yamada
    Professor of Law and Director, New Workplace Institute
    Suffolk University Law School, Boston

  • Pam Charney

    Bullying happens in healthcare. Nurses are probably more responsible for arrogant, aggressive behaviors than physicians. I’ve seen bullying carried out more often by nurses with the “I’m with this patient 24/7 and you don’t have a clue” attitude. I’ve seen nurses do the passive-aggressive act of taking their time carrying out orders (I’m sorry they’re called orders. Perhaps we should change the name to “suggestions”, since too many nurses second guess. Sometimes they’re right, sometimes not, but they’re never willing to have a grown-up discussion with the provider.). I’ve seen nurses decide to wait until 1 am to call a physician regarding questions because “If I’m up at that hour, he/she should be up, too”.

    As a Registered Dietitian with the ability to stand up for myself, I’ve also been the victim of nurses who refuse to weigh patients, refuse to accurately complete I/O for fluid sensitive patients, and more. I’ve also had physicians behave poorly; once a neurosurgeon grabbed a chart from my hands as I was writing! Another time, an internist walked over to where I was sitting (in a shared office space) and insisted that I move because he wanted that chair.

    So, to blame the physician alone for this is just further evidence that bullying happens and it’s not just the physician who is the bully.

  • doctor1991

    I stopped reading the NYT many years ago, so can’t comment directly on her piece. I also think the term “bullying” is overused. But in any organization doing significant work- in medicine, in the military, in sports, in law, in politics, in business- there is always rank and a pecking order and people looking to use their rank or impress those of higher rank by trashing another. There isn’t one doctor practicing who wasn’t set up by a nurse at some point in his/her career; I agree many female nurses are particularly hard on female doctors. There also are arrogant doctors whose arrogance not only affect nurses, but also other doctors (and other staff as well). There are also plenty of channels in the hospital environment that were not available a generation ago to address these wrongs. As far as rank, I think many nurse administrators now believe they outrank doctors- and make more money as well.

  • Jo

    As Medical Manager who has been around doctors, nurses, patients and a patient and most recently a daughter of a patient in the hospital and the SNF.

    I can attest to hosptial physicians not only bullying nurses, but also specialists bullying those in primary care physicians. Also hosptialists being arrogant toward PCPs rounding in the hosptial. I have also experienced nurses who not only spoke rudely to physicians, who did not carry out their orders and were also very condecending to patients as well. I have personally had a nurse actually hurt me unneccessarily. I counted up to a “bad hair day’ and never reported her even though there was actual physical suffering involved.

    Then through it all there are those shining stars, those physicians and nurses who are “called” into their profession and it is obvious they love to learn, they understand that the more they learn the more there is to learn, they love their job and they give and receive respect and cultivate around them an awesome aura of care. Then I have seen some sucomb to the pressure of the job and their light begin to dim.

    There is such sensitivity in our culture that leaves no room for anyone to have a one-time bad hair day and we wear our heart on our sleeves and are petulant and pouty when someone says anything that can be taken as “offensive” which is very different than someone who is chronically abusive and should be strongly corrected.

    One must seperate someone’s “bad hair day” or bad attempt at humor from a truely power-mad person who boosts their own self worth from making other people cower.

    • stitch

      I asked my office manager recently, on a particularly “bad hair day” (I always have bad hair days, if you want to be literal about it) if being in a foul mood was sufficient for an excuse from work. Sort of joking, but I played it out and it was a relatively good day at work (wasn’t ’til I got back in traffic that it got bad again.)

      All people, including people in healthcare, and even docs, have bad days, days when we wish we could just take a day off. For docs, however, it’s a major hassle for many people just besides the doc: the office staff, the patients, everyone else down the chain, and the work doesn’t go away, it just gets pushed to the next day or couple of days which negates any benefit of the “mental health day.”

      So we go to work. We go to work when we know when we got out of bed that morning, it was a bad idea. We go to work when we are sick, even though for any number of reasons it’s a bad idea (prolonging illness, passing it to the patients, making us less efficient.) We tell patients to take 4 to 6 weeks off from surgery and then go back to work ourselves after one (if that.)

      Need we wonder why physicians have among the highest rates of substance abuse and of suicide?

      Physicians are known not only for their imperious manner and their bullying sorts of ways (kidding) (sort of) but also for having very strange, gallows senses of humor. It appears that in this day and age, relieving stress with such a gallows sense of humor can get one dressed down in the most public of forums.

  • http://www.thenerdynurse.com The Nerdy Nurse

    I think this is a subject that deserves the attention Mrs. Brown gave to it. I started blogging because I was bullied. Doing so has brought me more courage and has empowered me to be a much stronger nurse for my patients. It is important that people speak up about issues that effect the practice of healthcare, and bullying certainly falls into that category.
    Physicians should be held accountable to the same standards that everyone else within a healthcare organization are, and that includes policies regarding code of conduct. But the fact is, they aren’t. Hospitals are all too consumed with stroking egos and keeping the MDs happy that they may turn a blind eye to the treatment they sometimes give nurses.
    However, as you have mentioned, not all MDs do it, and yet the harshness of medical school should not but a justification for these actions. If anything, this suggests a strong need for higher education to reevaluate how they are preparing their physicians to care for us. Doctors are leaders and because of this they should lead by example. An example of professionalism and respect for their colleagues, nurses falling into this category.
    As a nurse I have met some of the most charismatic, considerate, and respectful doctors. I am proud to say I know and help them to provide care. I have met others that were not so friendly, and have gotten the occasional hang-up, rough words, and aggravation from them. That being said, I have gotten the very same poor treatment and lack of respect from other nurses as well. So it isn’t doctors that deserve the blame.
    We, all of us, nurses and doctors, need to be accountable for our actions and words. We need to treat others with respect and professionalism and work to support each other and not tear each other apart.
    Nurses eat their young. Doctors eat their young. Can we please just stop eating each other and have a great big-ole potluck and break bread rather than feelings?

  • http://www.theatlantic.com/ford-vox Ford Vox

    Incisive observations on this Op-Ed are being posted over at the Well blog:

    http://community.nytimes.com/comments/well.blogs.nytimes.com/2011/05/09/belittling-the-nurse/?sort=recommended

  • Jack

    As an internist with over 25 years of clinical experience and 12 years as a physician leader (medical director, CMO, etc.) I can say that physican behaviors do occur that are bullying and disruptive. Ms Brown is right to both say it and to publish it. Why, because it negatively affects patient safety and patient care. My only dissappointment with the article is that many physicians and medical staff have taken this on successfully. It’s worth mentioning that many physicians have championed team-based care, Just Culture, and TeamStepps – all programs designed to improve culture and safety through respect and accountability. Unfortunately not all physicians have gotten the message so Ms Brown’s article is welcome. Ultimately we physicians need to hold ourselves as accountable as she has.

    • Primary Care Internist

      as increased acuity in hospitals and other settings have forced nurses and doctors alike to take on more (and more difficult) tasks over the last 5-10 years, it isn’t surprising that administrative types continue to “take the high road” and preach to all us awful practicing physicians that we have to do better.

      and i don’t think nurse brown has held herself accountable. publishing this in the ny times is cheap and only serves to inflame an already tense environment.

      • Maria

        I can’t begin to imagine the experience that led you to this Dickensian view of medical practice. Poor, poor Dr. Twist, no power and everyone is mean to you.

        This blog post and a number of the responses are galling. Brown’s article may have taken a joke out of context (I honestly believe that), but she really does portray the reality for many nurses and offer solutions for whole organizations and not just doctors. Some of these overly defensive responses only make it seem like doctors think there isn’t a problem and Brown is just targeting them. Please, get over yourself for a moment and let’s actually talk about bullying.

        Can any MDs or DOs, without taking sides or whinging about this blasted article, tell me what the bullying situation is for doctors? What do you do when you see your colleagues being aggressive toward each other or toward nurses? Have you found yourself being aggressive? How do you deal with conflict?

        • ninguem

          “……I can’t begin to imagine the experience that led you to this Dickensian view of medical practice…….”

          No, you can’t. Maybe you should, but I have a strong feeling you don’t want to, your mind is made up.

          “…..Poor, poor Dr. Twist, no power and everyone is mean to you……”

          But your admitted lack of knowledge of the matter…..didn’t stop you from throwing rocks it seems. Maybe you should learn something before you take your little swipes.

          The stories of the bullying going the other way, are posted all over the place, here and in the newspaper that originally carried the column. Maybe you ought to read it.

          Actually, I’m impressed how many of the stories revolved around interns. Not surprised, I had my own intern-bullied story.

          The real key, which no one has touched on…..more than any other intervention……don’t abuse the interns.

          Doctors are smart. Yes, so are a lot of other people, but we’re talking about doctors here. They’re smart.

          That means they learn their lessons well. You might want to be careful what lessons you teach them.

          • Maria

            1. The comment to which I was replying was tragically removed. By whom, I do not know. The original poster made the claims that doctors are the “least powerful entities in the hospital” and becoming a doctor meant “painting red circles on your back.” I’m certain you can agree that this is self-pitying hyperbole rather than fact.

            2. Before you go jumping to conclusions about me, read the rest of my previous comment. I am looking for the MD’s side of the story. I’ll add this though: What does it look like when you are bullied by your peers? Is it different from the scenarios nurses describe? Will anyone respond or should I just go watch an episode of Grey’s Anatomy to find out?

      • stitch

        agree. Enuf said.

        • Primary Care Internist

          thanks, good to know i’m not totally nuts

  • http://www.womeninpainawareness.ning.com carol

    A lot of these posts sound to me like a ‘kill the messenger’ rather than willingness to look at the issue.

    • Maria

      Exactly!

  • http://paynehertz.blogspot.com Payne Hertz

    What we are witnessing here is a public demonstration of the White Wall of Silence in action. There is no legitimate or logical reason for anyone in the medical system to keep problems in house rather than exposing them to the public other than a refusal to face reality and a misguided sense of loyalty. Anyone serious about dealing with workplace bullying or any other problem under the sun would want that problem to get as much exposure as possible.

    http://patient-safety.com/white_wall_of_silence.htm
    http://patient-safety.com/bullying_and_mobbing.htm

    Education is not a solution. We are great believers in the magical power of education in America. If only BP executives had been given classes on the environmental consequences of oil spills, or the guards at Abu Ghraib had been given sensitivity training, things would have been different. No doubt a 4 hour class on interpersonal relations in medicine will nip bullying in the bud.

    But the fact is that anyone who is still so poorly socialized by the time they reach medical school they need a class to tell them it is morally unacceptable to abuse and humiliate people in an environment where human life is at stake, is not likely to benefit much from such a class. Human behavior is notoriously difficult to modify. Medical school is a poor place to give remedial education in morality.

    The solution to bullying is to get rid of the bullies. People who acquire a track record of bullying at their workplaces need to be given the choice of either shaping up or shipping out. No bullies = no problem with bullying.

    • http://www.womeninpainawareness.ning.com carol

      The problem is they are taught to keep up that wall of silence no matter what they see. When there was visible evidence of negligence and malpractice in a suit I had against a major neurosurgeon, I was tld outright “I will not testify against him (because of who he is).” from doctors. From nurse, “If I coome forward I will lose my job.”
      You can’t have a wall of silence for one thing and not expect it to spill over to other areas of hospital care.
      (I have to say as a patient, although I had a lot of good nurses, I was bullied by more than one of them. If you complain the result is often even worse care; you complained about one of ours, now you pay.)
      Carol
      ( http://apainedlife.blogspot.com/ )
      http://www.womeninpainawareness.ning.com

    • http://www.wjhb.de William

      One of the better comments. More important, however, are standard procedures for dealing seriously and effectively with conflicts between staff. How else to avoid an inflation of “bully” accusations? It’s the face-to-face, local resolution of such conflicts – firing if necessary – that counts. Nothing else, not even blags, will help.

  • ninguem

    There’s your problem. You think medical practice is like Grey’s Anatomy.

    “………The original poster made the claims that doctors are the “least powerful entities in the hospital” and becoming a doctor meant “painting red circles on your back.” I’m certain you can agree that this is self-pitying hyperbole rather than fact……..”

    Uh…..no. The author has a point. Use the hospitalist as an example, or the emergency medicine doctors, they are usually independent contractors, they can be fired on a whim, with no recourse, and they are hit with noncompetes that will exclude them from large areas. Being let go means they have to pack up the spouse and the kids, sell the house in a rush, and move the kids to another community. And you wonder why the families break up.

    Hospitals don’t do that to nurses. Heck they don’t do that with the janitors. You’re fired, and by the way, you can’t sweep floors anywhere else in town.

    Not fair to say the docs have “no power” or “least power”, but the doctors have far less power than you think.

    Actually, speaking of people who think real medicine is like the TV shows. When “St. Elsewhere” first came out, I thought it was fairly realistic. It was also very bleak. It was killing their ratings, so they lightened it up by the second season.

    When Samuel Shem’s “House of God” came out, a medical student friend said it was funny. He was just entering medical school. I told him, wait until you’re an intern, and re-read the book. You will find it quite sad.

    Yes, I’m jumping to conclusions, and you’ve done nothing to change them. You think medicine is like the TV shows. You claim you want to hear doctor’s side of the story.

    The doctor’s side of the story, specific cases of bullying far worse than the nurse described, where the doctor is on the receiving end. Those stories have been posted all over this site, the New York Times, and elsewhere.

    For Pity’s sake, read them.

    Specific constructive suggestion. Stop beating up on the interns, they’re getting taught the wrong lesson.

    • Maria

      Sigh, the Grey’s Anatomy comment was sarcasm, but I’ll accept that I’ve been too subtle. You’ll note that I never said that I thought medical practice was like television; I don’t even watch medical shows. You make assumptions; I think you think I’m a bitter nurse of some sort. That’s interesting. Anyway.

      You agree with me that the commenter exaggerates, but you qualify it. Fair point, though I can’t imagine that the scenario you describe is a threat that all doctors constantly face. As an aspiring medical student, I admit naivete and maybe I should avoid the specialties you share.

      I agree though, that the problem starts when the experienced beat up on novices. They learn to perpetuate abusive behaviors.

      In addition, I was asking the fine people of this forum to respond with their own experiences and still ask you for yours. I’m not so ignorant as to make this my one stop for all things medical. Maybe I should just rely on my Google-fu for future inquiries.

    • stitch

      Bingo.

      But there are way, way too many nursing groups out there that are on the bandwagon that the way nurses are portrayed in the media is “killing” their profession, and they get on their high horses about it. Grey’s Anatomy is one they often cite, and is House. Like either of those shows are even remotely realistic in their portrayal of docs and their roles? Really? But they provide those with and agenda a target to which to point.

      Sad, really.

  • http://patients.about.com Trisha Torrey

    Stitch,

    You say, “The final decision making, as well as the final responsibility, lies with the attending physician.” How very arrogant that sounds in your “tone of type.”

    In a participatory model, the final decision making, the responsibility – and most certainly the outcomes – lie with the patient.

    As you all argue among yourselves as to whom is on the receiving end of the worst bullying, consider that the person paying the ultimate price for it all – is STILL the patient.

    Trisha Torrey
    Every Patient’s Advocate

    • stitch

      Absolutely, the patient’s desires remain paramount; if I was not clear about it I was speaking of the role of the professionals in the decision making process.

      And what I want to make clear about this is that the nurse’s perceptions of the patient’s concerns have a significant role in that medical decision making. But it is only one perspective and one part.

      Successful medical care occurs when the patients, and their families, are fully involved. Communication is key, as is a good medical team. And the patients and their families depend upon a functional team, which is achieved when everyone is on the same page.

      Having read several other of Ms. Brown’s posts, now, as well as in my personal experience, there are unfortunately more than a few nurses out there who get their knickers in a twist at any perceived slight or if their position does not take primacy among all others. This is damaging to the members of the team and certainly does not contribute to optimal patient care. Period.

  • http://pikesvillepsychologist.com Michael Heitt, PsyD

    I think both this blog and Brown’s op-ed painted accurate perceptions of the concept of disruptive professional behavior among health care providers. As a psychologist who consults to hospitals, medical practices, licensing board and professional associations, I hear all sides of the story – - from the administrator, the perceived bully, the perceived victim and the bystander. If you listen closely enough to all parties (and if you read this blog and the op-ed piece) I think you can find more commonalities than differences in individuals’ experiences with disruptive behavior. Surely everyone is agreeing that the root cause of bullying in the workplace is a systemic issue. This does not, of course, absolve the disruptive individual. Just my $0.02.

    • http://www.wjhb.de William

      “Surely everyone is agreeing that the root cause of bullying in the workplace is a systemic issue. This does not, of course, absolve the disruptive individual.”

      I am quoting here so that readers see these sentences at least twice. They bear repeating.

      I interpret what you write to mean that it is important to perceive conflicts in context and, extrapolating from this, that it is important to differentiate between highly affective defensive behaviour and low-key aggressive (destructive) behaviour. The soft voice can deliver a venomous message.

      • http://pikesvillepsychologist.com Michael Heitt, PsyD

        Thanks for highlighting my statement.

        What I meant is that the problem is multifactorial: there is more than one cause (and cure) to the issue. I don’t think I need to talk much about the systemic issues as they’ve been addressed nicely here. I will note that implementing cultural change (which is what is being proposed) is very difficult, requires buy-in at all levels and takes a long time to occur. Despite the challenges, cultural change is occurring and will continue to occur (see the Joint Commission sentinel event memos).

        I do agree that there is a broad range of of disruptive behaviors (“highly affective and low-key aggressive”) but it should be noted that disruptive behaviors are disruptive. Whether we’re talking about a professional yelling, threatening and throwing things, or a professional who refuses to answer questions or cell phone calls, the end result is often the same: communication breakdown. When professionals are afraid to talk with one another openly, bad things happen – - staff burnout and turnover, potential medication errors are not confronted, etc. This claim is well-supported in the patient safety literature. There are also some great articles out there about the financial costs of disruptive behavior including how significantly more likely someone is to be sued if they are perceived as being disruptive.

        Key point: this is a systemic issue AND an individual issue…. not one or the other.

        I occasionally write about this stuff on my blog at PikesvillePsychologist.com/blog

  • Pete

    Wow, this is giving me flashbacks to my parents divorce. Neither could deal with their own issues and when confronted responded by pointing out the others problems.

  • Paju

    Seven months ago, our hospital introduced zero tolerance for bad behaviors. A brief list of expectations for workplace behaviors was distributed during week 1 of rollout. Week 2, we got a list of 6 behaviors that would not be tolerated, ever. The overall project theme was dubbed “Pay It Forward”.

    The program has been a resounding success. Within two months, 96% of emoloyee feedback was positive.

    No hoopla, just common sense.

    • http://www.thenerdynurse.com The Nerdy Nurse

      What state are you in… I may need to move there and come work with you!

      I am glad to see some organizations being proactive about the problem.

      I would love to see a copy of this policy, though, so that I could slip it under a few administrators doors. Perhpas if they see what others are doing, they won’t pretend the problem doesnt exist.

  • brimcmike, MD

    Kevin MD: I don’t understand your point. NB asked the physician in question if she could quote him in her blog. He consented.

    The complaints of doctors getting a public outing for inappropriate behavior is a case of poor little rich kids.

    I’ll own my bias. I am a working-class doctor. That is I am the first person in my family to finish a four-year college degree. My family IS the help, and were it not for education, I would be the help. I am keenly aware of this and it shapes my perceptions and interactions with professionals and employees. My issue is not hierarchy per se, I also spent 10 years in the Marine Corps and have no problem with supervising others.

    The problem here is failure of leadership in the setting of socio-economic and organizational hierarchicy. Well-lead subordinates, team members and employees don’t have a problem with being supervised per se. It’s really a question of leadership, not management, not supervision. Judgment, justice, moral courage and accountability are some of the dimensions of leadership. Ridiculing or making fun of a subordinate team member in front of the team and in front of others is a leadership failure.

    Doing something because you feel like doing it, and can get away with it despite it being ill-advised and problematic is a leadership failure. And just because you have the “metal on your collar” (just because you occupy a job title) does not mean you can lead. Physicians have little if any formal leadership training. Which is not to be confused with progressive responsibility in residency in the midst of the covert curriculum (Lord of the Flies meets the House of God).

    So, we get people with substantial power, responsibility and privilege without leadership training. Sounds like a recipe for organizational disaster to me. As with gender and race, etc., the dynamics of and potential for abuse in the power differential of socio-economic class are deeply embedded and heavily loaded. This milieu is the water we swim in. It is difficult, but not impossible, to become aware of it, to take responsibility for our part, and to act consciously within it.

  • http://www.lisafieldsassociates.com/ Lisa Fields

    The Doctors feel disrespected.
    The Nurses feel disrespected.

    Communication is complex. None of us were present when Theresa Brown described the situation in her NY Times Op-Ed Piece. Tone of voice, body language, and psychological preference found in the Myers-Briggs Type Indicator (MBTI) could help to give a more complete view of this situation.

    The story we are given could be an example of two people who might have a difference in the way they make decisions or in this case process feedback. The Thinking vs. Feeling preference in MBTI asks the question: Do you like to put more weight on objective principles and impersonal facts (Thinking) or do you put more weight on personal concerns and the people involved (Feeling)?

    It’s important to note people with a preference for Thinking are also Feeling people and those with a preference for Feeling are also Thinking people. Regardless of our preference we all use both functions Thinking –Feeling when making decisions.

    Thinking preference should not be confused with intelligence. People with a preference for Feeling can be just as intelligent as those with a preference for Thinking.

    Thinking Logic: I try to be impersonal, so I won’t let my personal wishes-or other people’s wishes-influence me.

    Feeling Logic: I am concerned with values and what is the best for the people involved.

    http://bit.ly/iX3Zqz
    Source: From the Guardian

    But it’s only when you the whole picture can you fully understand what’s going on.

    • http://www.myachalasia.com Hugh Stephens

      Well put Lisa.

      This whole scenario smells distinctly of being blown out of the water.

      Bullying is a huge issue in medicine. Almost anyone will acknowledge it. And it’s not just confined to medicine. I challenge you to find a field where there isn’t bullying involved at one level or another.

      But it’s far from confined to doctors –> nurses. Nurses bully doctors too (especially the young ones!), and are hardly blameless as (I think) is rather implied in her article. As a medical student, we often get bullied by anyone from administrative staff to nurses, to PSAs, to doctors and consultants. It’s sadly part of the system and won’t change any time soon.

      Medical education for a long time was all ‘thinkers’, then it has become all ‘feelers’ and is now trying to get a mix of people studying ‘the art’. Many of these issues is because we so often have two people from each extreme coming into conflict.

      While I don’t have the solution, I am certainly of the opinion that an op-ed in the NYT is not an appropriate place to discuss such matters.

      Good work fostering this discussion. It’s been fascinating to see many responses from doctors and nurses alike on both sides of the fence!

      • http://www.wjhb.de William

        Fascinating? Yes, well, I t think doctors, nurses and other medical staff would benefit more from resolutions of their difficulties where they work than from fascinating blog discussions. Some comments point towards hands-on approaches to bullying. These at least can be tried. Otherwise this thread is coming to a frayed end which sort of reflects the frayed nerves at the end of another week of too much overtime. Still, I wish us all good luck.

        • http://www.thenerdynurse.com The Nerdy Nurse

          Honestly Willliam, having approached hospital administration with a much more severe situation and being told to “let it roll off” and that basically I was the one being petty and childish by bringing it to management and to stop being so “sensitive”, I believe that if Mrs.Brown had approached her management with the complaint of a physicians talking down to her in front of a patient, they would laugh her right out of the office.
          Their argument would be that there are bigger issues and that she should get over it . They would tell her to not read too far into it. They would tell her that that’s “just how they are”. They would, in short, not think her issue was an issue.
          I’ve been there.
          And honestly, the event she speaks of is mild in comparison what type of bullying does and could continue to occur. But it gets the point across that as a group, all of us in healthcare owe it to each other to be professionals and treat each other with respect. There is no one culprit in this crime. We are all responsible and we have to take it upon ourselves, as individuals to come together to combat it.
          Should she have gone to management? Would it have been handled?
          It depends on the organizations bullying policies. Since they don’t appear to have a no-tolerance policy, it’s likely that Mrs. Brown would have ended up with the short end of the stick if she was too vocal about something that they viewed as minor. You have to pick your battles, and this wouldn’t be a battle to have with HR.

  • Duane Pool

    I was registered nurse for 14 years and unfortunately, I am also a patient as a result of a car accident. I have seen both sides of the fence. I was continuously bullied as a nurse, if I spoke up to defend myself, i was targeted and placed under a microscope. I chose to leave the profession as a result. Similarly, I have also been bullied as a patient. I am astonished, mortified and ashamed of my own chosen profession. I feel betrayed, and abandoned as a patient. The problem of bullying is very real, it does not stop in grammar school, but continues right into the workplace, and it negatively impacts the patient.