Conflict between physician and nurse

When it comes to doctor- nurse interactions, when is enough, enough?

Recently, I dealt with an upsetting situation involving a physician and nurse. A little background: The nurse has been working on our unit for years (since it first opened). She is very smart and savvy when it comes to nursing. She constantly gets feedback from the patients as being one of the kindest, most thorough nurses. I look up to her in many ways.

The physician, also notable, one of the few physicians in this specific program. I always say if I ever need a doctor in this specialty, I would go to him. He is unbelievably thorough and great with patients.

She was approached by a physician wondering why the blood pressure medications of a certain patient were being held over the past few days and he was not notified. This nurse, being very diplomatic, offered a response to the physcian, “I’m not sure, I didn’t even know that happened, let me look into it for you and get back to you.”

Unrelenting, the physician pressed farther: “There’s no need for you to look into it further, I’ve been sitting her for 20 minutes looking at the blood pressures and medications given–and it makes no sense.” Getting louder with each word.

Knowing she could offer nothing useful in this conversation with it escalating, she simply walked away saying, “I don’t know, I’ve literally taken care of this patient for 4 hours.”

The nurse pulled me aside to talk it out–she was worried she had done something wrong. At this point, we are both thinking, honestly, we do not get paid enough to deal with this type of interaction.

Physicians come with a full picture of the patient that they’ve known over months to years. Nurses come in and get a snap shot of the patient that the previous nurse discloses. Over the first four hours of our shift, while we are running around attempting to maintain sanity, we may not get a chance to look back over specific details for individual patients.

I think bigger questions come to light in the midst of these types of interactions:

  • Where is the mutual respect among colleagues here?
  • Where is the team work? If we continue to treat each other (and this goes both ways–not just physician to nurse) in this way, it undoubtedly will be to the detriment of patient care.

I understand this occurs both ways, and my intention here is not to bash physicians. I simply want to shed light on a problem that needs addressing.

Sarah Beth Cowherd is a nurse who blogs at SaraBethRN.com.

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  • http://makethislookawesome.blogspot.com/ PamC

    There’s a brilliant field of study called “wrongology.” One of the things noted in this field, by Kathryn Shultz, is that when things go wrong, we first assume the person is misinformed. If they have all the same information, we then move on to the assumption that the person is an idiot. If the person is not an idiot, we then move on to the assumption that they’re acting maliciously: “They know the truth and are deliberately distorting it for their own malevolent purposes.” 

    She goes on to say, quite wisely, “This is a catastrophe. This attachment to our own rightness keeps us from preventing mistakes when we absolutely need to, and causes us to treat each other terribly.”
    I think that’s what happened here. For the talk by Kathryn Shultz, click here: http://www.ted.com/talks/kathryn_schulz_on_being_wrong.html

  • Anonymous

    Docs get frustrated and have bad days like everyone else, so I try not take things personally, especially if the outburst is not normal for that particular doc. In this case, it sounds like a nurse who has been there forever and a long time physician and they probably know each other, so I’m not sure why one sentence of a raised voice was such a huge issue.

    MY response might have been “No, it DOESN’T make sense, but you asked me about it so give me a chance to answer your question without biting my head off!”

    A classier way might have been, “You’re right, it makes no sense at all, I’ve been with Mr. Smith for just a few hours. Let me work on it.”

    The doctor wasn’t upset with your colleague. He was upset with the situation.

    You can take on nurse/physician communication in general, but for the most part I see it as an individual thing – one nurse/physician at a time because that is what we are, individuals. 

    Was it right? No. Do nurses take the brunt? Yes. But if we stop walking away and either keep communicating or stand up for ourselves (depending on the circumstances), we’ll be respected and trust me, do it once, and the doctor will treat you differently the next time.

  • Kevin Windisch

    Let’s see, you’ve taken care of this patient for 1/3 of your shift but failed to verify that medications to modulate one of his vital signs has been administered as ordered but it it the doctor’s problem for speaking up.  If the patient coded it would be the doctor’s liability.  This sounds like making excuses for nursing negligance.  It was the current nurses responsibility to insure that she understood what needed to happen to properly care for this patient but out of laziness she neglected to do so.  Don’t turn this back on the doctor.  Luckily it was caught before the patient suffered.

  • Anonymous

    docs do not realize how threatening they can be when they come down on ancilaary or nursing staff. when a med error or order is not followed it can be serious but the answer is to gain insight as to why it has occurred. to interupt a team member from the terrible patient loads and asking them to drop everything to investigate is wrong. to ask them to restart the med or therapy is the thing to do and present the problem to an administrative member. staff members are burdened with heavy workloads these days and the interuption is likely to cause further mistakes. docs often show their temper and try to blame whoever is in front of them.  many have reputations for this. this behavior is representative of “parenting” instead of professional interactions. why something occurs is not going to help the situation at hand, just restart the order and let administration deal with the proceedure issues.

  • Anonymous

    There are a few odd things about this conversation.  #1, The doctor really took twenty minutes to figure out why the meds were not given? That is quite a patient doctor that is very generous with his time. #2 If a med is not given the reason is usually documented, i.e., patient refused, in a procedure, etc. No one documented this  “for a few” days?  #3 How about parameters on BP meds…that’s pretty basic and didn’t occur to anyone? 

    It is totally fine to explain you have only been caring for the patient for a few hours and can’t recite their meds. I think most doctors get that, but to not be able to do a little on-the-spot problem solving doesn’t lend itself to gaining “mutual respect.”

    I have been Registered Nurse for 8 years and giving a “Pass” to the doctor on this one.

  • Anonymous

    how many patients do you have primary nursing responsibility for? maybe twelve?  and if a set of BP meds are on hold for a patient, isn’t it appropriate that you know that, and know why, from the beginning of your shift? maybe from sign-out from the previous shift?

    if a doctor pointing this out, and questioning it, is threatening to your ego, you should be in another field. patients’ health and well-being is at stake.

    i often find that the ratio of (complaining + scheduling breaks & vacations ) / (useful work) conducted by the nursing staff is rising at an alarming rate. And it’s becoming all too easy to scapegoat the mean-and-condescending-and-unfeeling (but ultimately 100% liable) doctor.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    That’s it?

    You call that a conflict?

    I should be careful for expressing an opinion here, you might report me as a disruptive poster.

  • Wendy Felsenthal

    ….and meanwhile, the patient is lying there thinking , ‘Great, nobody here knows what the heck they are doing…’

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      “You can almost hear the three stooges music playing”

  • http://pulse.yahoo.com/_EZXKT5WPRABUZU7LVO7AWMEHGQ Josh

    I have to agree with a previous poster, you call this a conflict? I have seen fist fights break out between nurses and doctors in parking lots.

    What it appears to me is that the physician is rightully upset his orders were not being followed which would ultimately affect patient care and his liability. When someone says “They’ll look into it” and it is something as serious as BP medications, it appears as if they are blowing it off. He probably wanted someone to review the event with him right then and work with him to make a plan. Of course he is upset, and there are physicians that go over the line, but this does not seem to be one of those times.

    My question is, where is the nurses outrage that this would happen for so long?

  • Anonymous

    I guess I don’t get what the issue was.”This kind of interaction?”  What kind of interaction is that?  It does not sound abusive, but sounds like someone dropped the ball, and the dr has every right to want to get to the bottom of  it. 

    As a 35+ year nurse, I would want to know first that the med is on hold and WHY.  That should be part of report at the beginning of the shift…it should have been passed on to you.

  • http://www.facebook.com/profile.php?id=1277355225 Mark Taylor

    Interesting comments.  Everyone makes the assumption that the med was held on nurses judgement, but we don’t know that for sure from what is given.  Was a consultant doctor involved? Did they make changes to the medications?  Why did he not “catch” it 2 or 3 days prior? If he was off duty, did he read the covering doctors notes and orders or those of any consultants?  Was the med dropped off the MAR by mistake or something else?  Can the nurse find out what happened? Absolutely, but at what cost of time and patient care time does that come at?

    To me, the point is the doctor continued to press his point by becoming louder.  To me, that is the disrespectful part.   This type of behavior is what leads to more abusive behavior.  Would you accept this type of behavior from your spouse, your children, or employees? If not, why would it be acceptable from a physician?  If the physician wants an immediate answer, he can research it as well as the nurse or he can ask a supervisor to.  The belief that the physician’s time is more valuable than a nurse’s time is incorrect.  Both have pressing patient care duties that require attention.

    To the poster that stated it is the only doctor’s liability, I would like to say that it is also the nurses liability. When things go wrong, everyone must be held accountable for their own actions and all parties are sued.  Every nurse I know would LOVE to have the time to be able to review the complete chart so that answers to this type of question is known before hand, but with high patient loads and everything that must be done for them it is not possible.  Some reports are better than others, and what is not known to the one reporting off can not be passed along to the person coming on.

  • Anonymous

    All the comments seem to fall short of acknowledging the basic encounter here.  Much speculation.  Maybe both are very reasonable people caught in a system that fails both them and the patient.  Do you think this encounter would take place if there were state of the art electronic medical records to explain just what had happened?  No.  think about it.  This is a dumb situation caused by an overall inefficient hodgepodge of medical care.  1) it is preventable first from human lifestyle standpoint  that a person should even need so many meds – its our diet s___d , 2) profit motivation on the part of hospitals and physicians make having standardized medical records and overall efficient system a fantasy while as a nation we pour billions into and are captive to electronics in every other aspect of life and 3) both are probably overworked and incapable of knowing what is going on because,  irrespective of pay or potential of, number 1 and 2.  

    Only in the USA

  • Anonymous

    I was taught in nursing school, almost 40 years ago, that the nurse is the bottom line. If medicines need to be with held, the nurse is supposed to notify the physician, get an order, document completely, and pass the info on in report to the next shift.

      For medicines to be held for several days without a doctor’s notification & order, and no nurse’s report to the next shift, is completely unacceptible. However, so is raising one’s voice at another professional.

  • Anonymous

    Oh my, what a conundrum!  Is the doctor in the right? Is the nurse in the right? Who’s more concerned about the patient’s welfare.  Only someone much wiser than I could answer these questions.

    However, for the sake of discussion, let’s look beyond this specific instance and ask some questions from a broader perspective.

    1. Have you ever heard a nurse raise their voice to a staff physician?

    2. Have you ever heard a nurse question a staff physician regarding culpability when something goes wrong?

    3. Have you ever heard a nurse insist on an immediate response from a staff physician when an answer is required?

    4. Have you ever heard a nurse demand a staff physician’s dedicated attention regardless of what that doctor may be doing at the time?

    5. And finally, if you can honestly say you have witnessed any of the above, is that nurse still employed at the same hospital?