Thursday, February 18, 2010


I have said before that I feel like a mole in MD school but today my nurse-self was on, full force.

In class one of our clinical instructors was going on about how when the shite hits the fan, the nurses are the first to point out that it was the doctors orders or the doctors mistake. He went on to describe how a friend of his worked in the really horrible psyche ward where "the nurses looked the same as the patients" blah blah blah...then he sees me sitting in the front row, "Er, but there are a lot of brilliant nurses and nurses that will help you out but..." then he goes on to tell how a psyche patient committed suicide and the nurses blamed the doctor for not writing stricter observation orders.

Now my classmates are shooting dagger stares at me and the guy behind me starts kicking my chair.

So I promptly advise him to tell a story where a nurse saved his ass...because kids I can talk until I am blue in the face on that topic (and no--not all 'when I saved the day stories', I have seen old Nurse Ratched's with 200 years experience curtail bad situations before they happened many oh many times). Just like I have seen bad nurses try to shift the blame to doctors. But if it is story time here people, let's at least make it fair!

He mumbled something about being in the NICU the first time and not knowing how to hold, feed, or look at a baby and the nurses being very helpful.

I wasn't really that offended by the remarks because for the most part the blame game does happen in health care when things go wrong. But I pointed out to him that patient care *is* ultimately the doctors responsibility, that is why they have an additional 4-7 years of medical training, that is why they make more money, and that is why they get respect in society! Responsibility.

I have made mistakes at work and when I have, the finger was never pointed at anyone else. There are crappy nurses out there just like there are crappy doctors. I am just glad that my presence at *least* caused him to apologize and admit to the fact that for the most part nurses are a helpful and important part of the team.


OMDG said...

It's upsetting to me that he seemed to have missed the whole team concept that's so critical to patient care.

When I observed MICU rounds yesterday, I was struck by how for each patient we saw, the resident, RN, and pharmacist all weighed in. It a) seemed to take pressure off the resident, who was no longer expected to know everything themselves, b) was also educational -- for instance the pharmacist knows a lot more about drugs than we do -- and she taught us stuff as she explained what various drug interactions were for a particular patient, and c) it incorporated opinions and observations of everybody of the team.

Nurses not only save doctor's asses, they are an important part of the team whose opinions matter.

Beach Bum said...

In my limited experience, the doctors who most complain most about the nurses are generally the lazy, slightly less competent ones. This is, of course, a gross generalization...

Keet said...

Good healthcare definitely comes from good teams.
Teams where all the voices are valued, and followed up by intelligent discussion, debate, and decision making.
In order for this to happen, there needs to be strong training and preparation in Uni, and motivated, intelligent, and collaborative people in these roles.
I really think it comes down to selection and training.

I'm so glad you're doing what you're doing. Maybe someday you'll sit on selection committees, and train aspiring doctors... LOL I'll teach public health epidemiology and research methods for the nerds who like data more than people. :P

Anonymous said...

Oh my gosh, I almost just choked on my sandwich reading that post. Are you kidding me?? You are really diplomatic - kudos to you. I don't know how I would have reacted in that situation but I'm pretty sure fur would have been flying.

There were so many days at work where I came away with the feeling that nurses are the patient's last, best defense against doctors. I don't know how it was where you worked but at the hospital where I am nurses are blamed for everything. If the aide screws up it's the nurses fault for not supervising them. If the Doc screws up it's the nurses fault for not catching it (treatment, med, whatever) before it reaches the patient.

A huge reason I am in med school is because as a nurse I was constantly being forced to take responsibility for things beyond my scope of practice, like acting as quality control for MD's. I thought forget that if I'm going to do the work I'm going to get properly trained and paid for it!

I totally agree that there are crummy nurses out there, but mostly they are awesome, and they are the backbone of healthcare. Your classmates have no idea how lucky they are that you are in that class and were there to shut down Dr. TrashTalk because the first time they try to pull that superior attitude with their nursing staff they are suddenly going to find that their jobs are a *lot* harder.

Rogue Medic said...

What Keet wrote.

There are plenty of paramedics (advanced care paramedic in Canada?) who will not listen to anything a basic EMT (primary care paramedic in Canada?) has to say about patient care, because the medic is a whole rung up on the pecking order ladder. A suggestion from a family member, or the patient, is on the same level as child pornography.

I have been fortunate to have had basic EMTs and patients point things out to me that I missed. I have been smart enough to listen to them, rather than to my ego. My ego speaks in a language I do not understand, so I am relatively safe from that. ;-)

OMDG said...

medrnninja said something that really resonated with me -- the part where she talks about working in an environment where everything is the nurses fault. One thing I realized recently, is that in environments like that, oftentimes all parties feel like they're the only ones catching the blame. The nurse may feel she/he is the only one getting blamed for not catching an error, but what he/she doesn't know is at the same time the doctor is getting blamed for a) making the error,or b) not reminding the nurse to do something. Often people aren't aware of the blame that is being passed around to other staff.

The underlying problem is the blame culture in general, and bad processes of care.

Albinoblackbear said...

OMDG--Yup. Especially in acute care where the RN's are literally at the bedside ALL the time (versus large medical floors where they have 10 patients each).

You make a good point that blame is being spread among the MD's as well as the nurses when things go wrong, it is not one directional.

I don't know if I've harped about this before but many facilities are starting anonymous error reporting so that
a)people will actually admit to errors
b)we can figure out where/why/how they happen and how to prevent them
c)we can actually keep more accurate records regarding errors

In the places that implement this there is A LOT more changes made when systematic errors keep occurring. And others actually learn how to avoid the same mistakes.

And lets face it, when an error happens it NEVER happens in a vacuum, there are always dozens of contributing factors.

Yeah I was bummed about the comments but as I said, glad I was there to cause him to at least realize that his remarks were inappropriate.

BB--haha, yes...well I realized this guy was a lot more arrogant than I thought.

Keet--You know I agree with this but *how* can that be taught in a non-cheeseball manner? Ok so maybe we should open ABB And Keets Discount MD School in Northern Ireland and see the future we can create for healthcare! ;)

Ninja-I think the main reason my fur stayed on was because up until that point I really liked him as an instructor--he always gave very relevant (and hilarious) clinical sessions.

Also, Ireland is *much* more old school than North America in terms of nurses and doctors. And the lines that exist between them. They are very much like the UK system where the nurses are called "Sister" and they wear these crazy uniforms that look like something off Star Trek. So I kind of took the comment with a grain of salt.

In some ways I appreciated his comment--that you are responsible and the buck stops at you. I think many people in my group have no concept of the weight of responsibility that will befall them.

I didn't mean to make it sound like there are tons of crummy nurses in my world--there are many nurses to whom I would trust my LIFE to over lots and lots of doctors. It's like anything--there are good and bad in all professions. I just hope that because my classmates see what my knowledge base is on a day to day basis they will think twice next time they view a nurse as "just an asswiper".

It sucks that you've had to deal with such nasty work environments. I hate those scenarios (partly why I love travel nursing--you just come and go and never get involved with the politics of a place).

Rogue--Yep it is the same in all the levels of care, everywhere. The paramedics don't listen to the fire fighters, the doctors don't listen to the paramedics, the ACLS paramedics don't listen to the nurses, etc. etc.

EGO is behind most of it and I think most people in health care have either an overly inflated one or a very fragile one (or maybe both?) which is what motivates so many of the pissing contests.

RH said...

Great post and absolutely true. It is unfortunate, but it is rare to work in a facility where all levels of staff work as a cohesive team (from medics to physician). When it does happen, patient care improves and the staff is happier and safer.

Hopefully, those students in your class listen to your experience and learn from it. Respect and communication is everything in health care.

EMT GFP said...

I completely agree and its a lack of trust and team work from the bottom up. Firefighters/EMTs don't trust those with little training, nurses don't trust them, doctors don't trust nurses etc. Kudos to you for correcting the doctor!

I have two very different quiet stories on this topic. One was the other day when I was handing off a patient to the doctor at the local hospital. it wasn't emergent and I didn't know if they were having a bad night or something (they weren't on emergency bypass), but the doctor seemed frustrated that I was giving him a report. Yeah, I may not be the best, but I was a little upset when he at one point asked to just "see my report" (we have ePCRs and they can show a digital report quickly). I would think that observing the patient would be a wee bit more important than the ePCR.

The other was a call that a medic was dispatched along with the BLS crew. We (the BLS crew) got there well ahead of the medic and had gotten a good look at the patient and gleaned a lot of facts from the family. It was a patient who had fallen over an hour ago and the family was worried about altered mental status since they had not been there when he fell. I gave my report to the medic and he had started to do his assessment. We had started to board and collar when he came so we had stopped to let him assess. He almost didn't finish till I repeated that his family could assure us his mental status was greatly altered and that the swelling on both sides of his neck was highly unusual. We ended up boarding and calling the patient along with fully handing her off to the medic unit for transport.

Some listen, some don't. I appreciate the ones that do. Sorry that was so long winded.

Bostonian in NY said...

I dunno if I'm weird in how I practice, but I generally value what the other team members have to say about the patients that I cover.

When I'm in the ED and there's a medic standing next to the patient, I like to get a quick rundown of how the call went. If one of my floor nurses has their spidey-senses going off, I'll generally listen and address it. I'm generally stuck in front of some computer charting, or rounding or in hours of lecture and I only get to spend a few minutes with the patients...I need eyes on my peeps!

I had my butt saved by a speech therapy grad student because she couldn't get one of my patients to wake up enough to do the swallow study...I had already dropped my note for the morning and wasn't planning on swinging by until the afternoon, but we were able to get things rolling a lot quicker because she paged me.

Then there's the ones that decide to make my life a living hell because I'm wearing a short white coat and I couldn't possibly have learned something outside of their 30 years of med/surg floor experience that may accomplish the same effect but cause a whole lot less drama later on (like the use of an IV antiemetic over IM because the patient is a big complainer with a low pain threshold). I'll have a post about that later I'm sure

Albinoblackbear said...

RH--Thank you.

I think most of the people in my class just roll their eyes whenever I open my mouth...I'm just the old lady who sits near the front who knows random heathcare facts that they don't. Heh.

EMT-No apologies necessary for long winded-ness. That is what this entire blog is fueled by! hahah

It's frustrating and demoralizing to say the least when co-workers don't respect your opinion/assessment.

Remembering how that felt will be one of the things that makes up better doctors, right? :)

BINY--"I need eyes on my peeps" exactly. And different eyes!

Jerome Groopman talks a lot about how we like to go down a garden path in medicine and enforce our conformational bias by missing clues that point in other directions. That is another reason why the team approach/communication is so important. Others will bring things to the table that we might not have thought about (or like you said--had time to observe ourselves).

We've gone back and forth a lot in the past about nurses and medical students and I know that you are a medical student that *doesn't* think nurses are idiots. Which will make you a good doctor and will make your life easier.

And yes, I know about the evil RN's who hate medical students--and I am sorry that they work hard to make your life hell. It's going to be one of the tough aspects of clinical that I am not looking forward to.

(As an aside, I know a LOT of nurses--myself included--that get just a wee bit irritated when medical students/doctors reference them as "one of my nurses".) :)

Bostonian in NY said...

I say my nurses because there part of my team, like I say my intern or my attending. No ownership implied!

Albinoblackbear said...

BINY--Ok, you're forgiven. ;)