Friday, January 8, 2010

Somedays I Feel Like A Mole or Why I Went to Medical School

I always wondered what doctors really thought of nurses, or how nurses were portrayed to medical students.  I could never really get an answer I truly believed because none of my doctor friends would ever make disparaging comments about nurses around me (or if they did they'd preface it with some disclaimer so that I wouldn't be offended).

I saw how some doctors listened to nurses, I noticed how some would always do the opposite of anything a nurse suggested or would ignore any information a nurse brought to the table.

The dynamics were always very different too, depending on the department and location.

The first ED I worked in the docs and nurses got on fairly well as a general rule. There was banter between the two, you could clarify an order without attitude, you could ask 'why?' if you didn't understand the rationale for something being given to a patient. It was expected with urgent patients that the blood work, x-rays, and I.V's would be initiated by the nurse before the doc saw the patient and you had better run for cover if they weren't. It was a pleasant place to work, although I must admit I was nauseated and insomniac with fear the first 6 months (I was a new grad).

In my second/third ED the nurses and doctors barely even spoke to each other, except out of necessity. The doctors wrote orders, put them in a slot, the nurses picked them up and carried them out. R.N's wouldn't initiate any sort of treatment (other than I.V's) without an order. And with certain M.D's you wouldn't even do that because then they'd make some passive aggressive remark to the patient like, "I wasn't going to order an I.V and make you get a needle for no reason but the nurse decided you needed one".

The two camps never socialized together. 

On the wall in the hallway to the department were a bunch of historical photos and documents from the hospital when it was established over 100 years ago. One of the documents was a framed timetable of nursing duties which started off with "0630h--clean and mop doctors lounge and locker room".

I am sure that some of those docs wondered why the nurses weren't still doing that before report.

Then I started working up North where the nearest doctor was hundreds of kilometers away (by plane ride only) and my sole interaction with them was by phone or teleconference. I generally had a great working relationship with all these colleagues who I strangely never met but spoke on the phone with many times. When I needed a medevac they'd arrange it and find me a bed in the south--no questions asked. There was a great deal of trust and respect (for the most part) because many of the physicians who worked in the receiving hospitals had been to these remote communities and knew what we were up against; we could do chest and limb x-rays, HgB, WBC (using a microscope, counter, and half an hour of spare time), HCG, fetal fibronectin, and RBS. With only 1 exception of the 11 stations I worked in there was no defibrillator, no monitors, no I.V pumps, no rapid troponin machine, and no blood.  The new residents were told in no uncertain terms--if an outpost nurse calls you for a medevac--you arrange it.

My only major head-bang-into-concrete-because-it-feels-better-than-this-conversation moment was once when I called to arrange a non emergent transfer of a patient who clearly needed a cardiology consult in the south. I told the ED consultant that the patient had been having unstable angina for over a week and due to his past history of heart attack and hypertension I felt that keeping him in the high arctic (i.e 8 hours by plane to a major hospital and cath lab) was unsafe. He told me not to "use the word 'angina' because that was a diagnosis. And nurses don't make diagnoses."

After that I worked in a very busy ED which happened to be at the bottom of two very large mountains that skiers, snowboarders, monoborders, and telemarkers enjoyed--sometimes to the tune of over 20 000 people on a busy day. This was like a fairy tale ED. 80% of the patients were pretty healthy but had some acute injury which we were really good at dealing with. People came in, we fixed them or stabilized them, and they went away satisfied (for the most part). This is not usually the case in most emergency departments. The morale between the nurses, docs, and paramedics was very good. They had Christmas dinner together, stood up for each other at their weddings, skied together, biked together, raced together. I loved it there and knew it was a place of trust when one day I saw the orders for a fx humerus that read: analgesic.

The paramedics, nurses, and docs were all very good at orthopedic trauma (to the extent of which I didn't appreciate until I had to witness ortho trauma handled in my subsequent ED's). With no doubt in my mind if any of those doctors were asked their opinion of nurses their deep respect and trust would shine through in any answer they gave. And the patients knew it too. Time and time again I had patients tell me--everyone here is just so nice and all of you seem to get along so well!

Fast forward to my last 4 months of nursing before moving to Ireland to become a medical student. I was working as a travel nurse in 2 different emergency departments--one was very rural and one was about 1 hour away from a tertiary center. Something changed, in a very palpable way, when my physician colleagues discovered I was going to medical school. Even though my knowledge base, education and experience hadn't changed--the way I was treated by the docs changed. One day a doc I barely knew and had hardly worked with turned around at the desk and said, "hey! aren't you the nurse that is going to medical school?" Um yes, and apparently word travels fast. He didn't know my name but he knew that fact about me.

Suddenly I was given more opportunities to suture (most of them knew that I sutured up North), I was invited to look at x-rays and shown what they were looking at, I was handed lab work and asked what the differentials were, I was doing small procedures under their direct observation. When I asked questions they really took the time to explain it to me, and then would often grill me about the answer at a later date. I was loving it. But it also left me feeling a little uncomfortable. I hadn't done anything special to deserve this treatment. There were many of my nurse colleagues that would have appreciated (and certainly deserved more than me) the interactions and opportunities I was getting.

If I had consistently had that degree of respect, that chance to discuss cases, and my opinion listened to I might not have gone into medical school. But every time I saw some medical student working through a list of differentials with a doctor or looking at an x-ray I thought "Hang on. I have a brain. I am curious. I want to know the rationale for these choices--not because I am being a bitchy-know-it-all-emerge-nurse-who-questions-your-every-move, but because I want to learn too".  But I was a nurse. And even though as a triage nurse I had to come up with differentials and acuity for every patient I saw I never had the reason or forum to bounce ideas off my physician colleagues. I did learn a great deal from the many fantastic, brilliant, hilarious nurses I've worked with along the way who've taken me under their scrub sleeve and shown me the way when I was walking around in circles (you know who you are...)

But it was that change in responsibility when I was seen as the 'nurse who is going to medical school' -and those extra opportunities started occurring--which solidified my decision. I was making the right choice to become a doctor. I couldn't live in the arctic permanently just so that I could have that autonomy and respect. At some point I'd have to live in the south where I was required to get an order to give a tylenol to a patient. It was too schizophrenic and too bizarre.

So now I am in medical school. And I feel a little schizophrenic again. Because I am still a nurse yet I am also a medical student.  Someday I will be a nurse and a doctor and I don't know what that is going to feel like or what that it going to look like in my practice. 

My first interface with the medical world as a medical student was very brief but gave me a glimpse of what is to come. We have this aspect of our education called the Early Patient Contact program which pairs us up with another medical student and we are given a chronically ill patient and a prenatal patient to follow for 2 years.

Our first meeting with the prenatal was at the doctors clinic, but we arrived before the doctor and the patient. The nurse greeted us and got us all set up in her office, let us use her computer to look at the charts, and went back to the main reception. During our entire interaction I wanted to tell her "hey! I am a nurse too!" but there was no need to and it would have seemed strange and artificial for me to just blurt it out. I guess a part of me wanted her to know that I knew where she was coming from, I wasn't some completely clueless 1st year medical student.

I have to chuckle at the irony of always wanting to come across to the medical students as a 'with-it' nurse yet now I wanted to come across to the nursing staff as a 'with-it' medical student.

I am pleased to see in my lectures from visiting consultants or during PBL sessions, nurses are mostly referenced with respect or used in anecdotes as the person who 'really knew what was going on'. Lecturers have made points to our class like "listen to the nurses", "respect the nurses and their knowledge", "nurses will save your ass" and "nurses will make your life hell if you come off as an arrogant medical student/doctor". All of which I, of course, agree with.

I almost never feel like a medical student, but some days I feel like a mole--sent by my nursing sisters and brothers to see what happens on the *inside* of medical school. What doctors really think about nurses, how nurses are portrayed in medical education. And of course I know, it comes down to the individual doctor and the individual nurse.

I am interested at the layers this metamorphosis will have for me. I like that the lines between nurse and doctor for me will forever be blurred because I know that I will always be a bit of both.   

In the meantime I'll be reporting back and keeping my fellow med students in line.


OMDG said...

Ok, please don't take this the wrong way, but those doctors gave you extra attention because you were *going to go* to medical school, not because they suddenly saw you as one of them. Happened to me too before I went to med school. Most doctors I have worked with treat the nurses FAR better than they do the residents or medical students. Or even each other.

I honestly can't think of a single time where I received special one-on-one attention from an attending during my 200 level rotations. The rationale for clinical decisions is rarely explained to us -- we are expected to look that up on our own. And I have never "bounced my ideas" off of a doctor on rounds. Maybe this is something that attendings do with each other, but as a medical student or resident, you are seen and not heard.

It will be interesting to see how things work out when you're doing your rotations. I'm sure you're going to have a BIG leg up on how to do things. I'm just curious what you will do when the first nurse is rude to you for no reason other than that she/he can be because you're a medical student. It happens.

Albinoblackbear said...

OMDG--Hahah, no worries. Oh I know it wasn't because they saw me as 'one of them', maybe I didn't make that very clear. Yes, it was because I was going to medical school but I still felt strange about it (albeit grateful).

Maybe that is the curse of large hospital rotations, but in some of my workplaces the medical students/residents were considered part of the 'team' and certainly had a voice in care decisions. And yes I have also seen the opposite where the nurses are given more respect than the med students/residents.

And yes, I am already working on my zen breathing for those days I get grief from nurses just for being a 'useless med student that only slows everything down'*. :)

*Most often cited complaint about medical students by nursing staff.

Liana said...

Just to play devil's advocate here, but I'd be curious to know what they taught you in nursing school about dealing with doctors/medical students?

OMDG said...

ABB -- I'm actually curious about that too. Our curriculum consisted of a lot of teamwork exercises, as well as many many MANY admonitions to treat the nurses well, they are your allies, they will save your ass, etc. We also had a class on the different types of nursing degrees and what they meant. What does nursing school teach you guys about doctors/med students.

Keet said...

My nurse - doc friend, as always you are insightful and brave in your writing on this metamorphosis. I question your use of the word schizophrenic to describe your experience, but you know me, mental health advocate and psychiatric label-despiser to the end. It is a good question about what we learned in nursing school about Doctors, and as you may recall, we did Inter-D 410 or whatever it was, and were constantly taught to question and learn and build relationships with our medical allies, but it often came down to who was the instructor, how long they'd been out of hospitals, and their own personal view of the role of the nurse. It's horrible to say, but I fear that academic learning is always at the mercy of the individual academics professing. We study and write about interprofessional learning and how to improve it, but until we embrace it across disciplines, both in places of education and in places where care is provided, there will always be that nurse ratchett that says doctors will treat you badly, and give as good as you get, and that Physician who will tells the nurse that they should describe the symptoms, and leave the diagnosis to him/her.
Yay for grey areas in life. This is where the exploration and self awareness comes from. I am excited to hear more on your journey.

Maha said...

Were it not for the fact that you're in Ireland, I could have sworn that this post was written by one of our ER fellows. She was a nurse before she became a doctor. I was talking to her about her transition from nurse to doctor and she pretty much said the same thing - that she would be a bit of both. One comment of hers that made me a little on the angry side was that when she was doing her ICU rotation, some jerk attending said that she should go back to fluffing pillows for missing something in her consultation notes.

Point of this comment - that was a VERY insightful post. I was wondering how the med school experience would be for a nurse.

Albinoblackbear said...

Oh Keet--I am sorry, it is good that you are around as my ethical/professional/mental health advocate editor on the blog. You are right. It was an inappropriate use of the word 'schizophrenic' but I meant it in the vernacular not in the medical sense...and not in a demeaning way to those suffering the disease.

In common language people (wrongly) associate the word with 'multiple personalities' and that is what I was trying to illustrate. And I realise by doing that I am perpetuating the (inaccurate) stereotype. But I do feel like I am developing a medical way of thinking that isn't always parallel with my nurse way of thinking. And I haven't figured out a better way to articulate it. I'll think about that.

Maha--I am really pleased that you found the post interesting. Thank you.

I would have been seriously grinding my teeth if I'd received that comment from an attending...but really, anyone who works in a hospital and thinks that about nurses clearly is living in the Bozosphere and thus all comments like that are immediately filed into my "consider the source" box.

Oh and yay! for more female emergency physicians. :)

Cartoon Characters said...

In my Nurses' training we weren't taught anything about how to react to or treat MDs. We were too busy learning everything we were supposed to know that was useful to care for our patients. Once on the unit, what we learned about MDs was from the nurses already there....and watching how we were treated by MDs themselves.
OMG: sounds bitter? I really haven't observed the "treating medical students rudely because they can" by nurses that I know...unless you mean the "rudeness" when one disregards something medically critical...and in that case, it isn't rudeness as much as abruptness out of necessity for the well being of the patien. Choose to look at it as a learning moment rather than a snub. ;)
I worked L&D and there were many good medical students/residents....and the best were those that actually cared about the patient and listened to what we told them....rather than sitting apart with a chip on the shoulder.

Albinoblackbear said...

Nurse--I think it's interesting that the subject of working with MD's never came up! It seems like a bit of an oversight by the program--I mean most modalities are really trying to push the 'team' approach and give at least some exposure/insight into what each person in the health care team contributes to care.

I have to say though, there was a difference between the curriculum at the college vs the university. At the college the instructors talked a lot more about MD's, physios, pharmacists, etc. At the university they basically told us to get our MN's and PhD's in nursing and work on developing the academic side of nursing as a profession--and allied health workers were basically ignored (other than the Inter-D class).

Which seemed really weird to me, especially looking back now.

I agree with you that nurses might come across the wrong way when trying to show a medical student something or intervene on behalf of the patient. And yes the best students/residents are the ones who respect the nurses opinions and experience.

Of course there are people with chips on their shoulders in all camps, in my experience. And I do know nurses that seem to take special glee in making either nursing students or medical students lives' hell! :)

Cartoon Characters said...

Yes, about that nursing student eat-your-young thing...I could never understand that...I have always enjoyed students ...anyone who really shows initiative and a passion to learn....why discourage?
Sorry about the typos...i am nursing a tendonitis and finger picking is not my style... :(

Cartoon Characters said...

I have been reading through Head Nurse's blog, and came across this little gem:
(just continuing with the comment by OMG re: mistreatment of medical students or residents. This is really funny, but so true)

since you are a follower of her, I am assuming you have probably read this :)

Cindy said...

I am [nearly] a chiropractor who is applying to medical school for next fall. I completely understand what you mean when you say you feel like "the mole." It seems like I'm going to find out exactly what they're teaching doctors!

Albinoblackbear said...

Cindy--Enjoy the crazy edge you're going to have during anatomy and physiology!

Good luck in the wonderfully horrible application process. :-)

heath said...

I stumbled upon your blog and I thought perhaps there might be an Ah Ha! moment when I got to the 'why I went to med school' post. I am eternally curious as to why the media portrays nurses as gophers for physicians, or non-existent (I know there is a shortage, but really! Are there no nursing staff in House's hospital?)or if there are nurses shown they are trying to get into medical school, or going to medical school while they work full time saving lives in teh busy inner city ER.
So I thought in reading your post I would find out why a nurse with a satisfying, rewarding career, who enjoyed the work and made a difference would want to go to medical school. Did you go to nursing school because you could not get into a medical school?
The closes I could find of 'why you went to medical scholl' was that when the docs you work with found out they treated you different - but WHY did you want to go to medical school? What was it about nursing that could not or did not meet your inner needs? What is it you think medical school is going to give you?

As for nurses eating their young or being rude to medical student - I call bullshit. This is not a profession selected behaviour - watch how some attendings treat people, watch how some sales clerks treat people, have a look at the news about bullying and harassment in the workplace. The sad fact is that some PEOPLE treat others like shite and nurses, as well as doctors, are people first and health care providers second.

Yeah, we should be better than that, but there are people the world over who like their little area of domination and will fight tooth and nail to maintain it. You need to know what hill you are willing to die on.

Good luck on your adventure.

Albinoblackbear said...

Health--It's funny because I've been meaning to take down that link for a while and your comment cemented the need to do so.

You're right, the post doesn't really explain the real reasons why I chose medical school. When I wrote it, it was just meant as another installment, then when more and more people started reading my blog I thought it'd be good to have a 'synopsis' of my career somewhere...and I figured that was the closest thing.

I am (mentally) working on a proper response to your questions and a clearer post regarding my career change. It will be up soon. =)

Cheers and thanks for your thoughts.