"Insulted. . ."

  1. 19

    Doctors readily admit that they’ve abdicated the throne. Healthcare used to be their kingdom. Now, healthcare is controlled by business. As medicine evolves into a “paint by number” model, doctors continue to surrender their position of authority. This shift has a major impact on nursing.

    "Insulted. . ."

    “Insulted. . .”

    A doctor I’ve work with in the ER for several years listened intently as I shared my observation that we are increasingly driven by pre-set protocols for nearly every major illness. “It seems that the art of medicine is dying. You guys used to spend time with patients and do focused testing targeting a likely diagnosis. It’s looking more and more like paint by number. The workups are predictable, and every complaint has an established pathway. There seems to be virtually no decision making in the initial onslaught of testing and treatment in the ER. . . How do you feel about it?”

    “Insulted.” He answered without hesitation. He stroked his chin, and looked past me into the distance, thinking for several seconds before continuing. “Now, if you fail in one core measure, you only get $8 instead of $10. So, we are forced to cast a wide net to make sure don’t miss anything on the list. We try more to not be wrong about certain things instead of trying to make sure we get it right.” Reimbursement as a driver for decision making is not new, but more and more medical decisions are controlled by non-medical people in faraway government buildings. Money rules. Each new mandate tied to funding dictates what doctors must do if they want to be paid by the government. “It’s an insult.”

    As the new paradigm evolves, the number of decisions made by doctors is rapidly declining. Many decisions are predetermined by mandates and protocols. On the opposite side of the coin, nurses are seeing dramatic increases in autonomy, responsibility, and labor intensity. Consider each briefly:

    Autonomy. I’m writing from an ER perspective, where nurses have historically had more autonomy than nurses in other hospital units. We’ve been able to treat fever and asthma without waiting for a doctor’s order for more than two decades. In the past few years, our authority to invoke a wide array of protocols has increased exponentially. Abdominal pain, chest pain, and possible stroke all have protocols in place which allow us to start testing and treatment. In our ER, everyone over 30 who complains of CP gets an EKG immediately on arrival, even if the history strongly suggests an injury or a musculoskeletal problem. If the story even hints at a cardiac origin, we can initiate a protocol for an IV, labs (CBC, CMP, Troponin), CXR, heart monitor, and aspirin. Until this year, we had to get a doctor, PA, or NP to remove a patient from a backboard. Under a new protocol, nurses have the option to remove them ourselves. The list of nursing “order sets” is now up to fifteen different areas of illness and injury ranging from a possible hip fracture to a UTI. We can initiate labs, IVs, EKGs, pertinent x-rays, and, in some cases, order medication. Generally, ordering specific medications remains the physician’s last stronghold on authority, but under several protocols (community acquired pneumonia for example), the doctor’s antibiotic choices are spelled out in advance.

    Responsibility. We have a lot more responsibility. With the shift to protocols, more ongoing evaluation and adjustments to treatment fall to nurses. We’ve had the responsibility of titrating drips like Cardizem, Nitroglycerin, Fentanyl, Diprivan or Nipride for years, based simply on the patient’s clinical response. A sliding scale to treat blood sugar has been around for decades. Then we added an electrolyte replacement protocol, a heparin weight-based protocol, and a DKA insulin protocol where nurses are responsible for timed lab draws, evaluating changes, and adjusting the drip rates according to preset formulas. There are protocols for Baker Acts (FL, involuntary psychiatric hold), restraints, alcohol withdrawal, etc. The sepsis protocol is the most recent arrival, boasting a lengthy flow sheet covering several possible pathways of testing and treatment for potentially septic patients.

    Predetermined pathways have spawned panels of orders packaged to hit the system with a single keystroke, introducing a new layer of gate-keeping responsibility. Nurses have to be hypervigilant to ensure that the whole panel is appropriate: “Did you really mean to order a septic workup on the hip fracture in 9?” “Do you want to run the full 2,673 ml fluid bolus on the guy in 14 with CHF?” A single click for large, sometimes unedited, order sets creates a myriad of potentially dangerous possibilities.

    Labor intensity. This one is huge. We test, treat, and document more than ever. The doctor needs seconds to order a stroke alert. One little click of the mouse, and the nurse is now saddled with a half hour of labor intensive activity pushed by a timer that starts ticking from the second the order hits the screen. An EKG, cardiac monitor, two large bore IVs, labs, banding the patient for a type and screen, a CT brain, the NIH stroke scale, and a swallow evaluation are passed to the nurse in a single click. The new focus on sepsis adds labs, including two sets of blood cultures and a lactic acid level (“deliver immediately on ice”), and a fluid bolus to a lot of patients who used to be considered minor care. Two years ago, a lactic acid level was virtually unheard of. Now, I may draw ten lactic acid levels during a twelve-hour shift. Most often, the results are predictably insignificant. With the focus on not missing a core measure, even simple patients become labor intensive.

    Taking the art of medicine away from doctors has a few pitfalls. Fans of government mandates might argue that forcing medical practitioners to cast a wider net is in the patient’s best interest. “Better safe than sorry.” The truth is that it’s hard to quantify the damage caused by unnecessary invasive testing, injecting contrast, exposure to radiation, etc. A wide net misdirects the focus in many cases, like the patient with epigastric pain who is admitted for observation to rule out an MI. He goes home with his epigastric pain. We confirmed he’s not having an MI, but we didn’t find his real problem. Unfocused testing creates wasteful busywork and staggering cost increases. For example, a patient sent home on a z-pack after a simple exam last year might easily spend $5,000 wandering along the sepsis maze for two hours before going home with the same diagnosis and medication this year. A paraplegic who has a chronic sacral wound, chronic low blood pressure, and a slightly tachy heart rate might end up in the sepsis line even though he’s functioning at his baseline.

    In some cases, the mandated pathway causes a reduction in the care it is designed to increase. For example, the new “thirty-minute window” to treat pain from a long bone fracture is circumvented by giving Tylenol or Motrin on the doorstep to make sure we don’t miss the cutoff for full funding. In some cases, the patient ends up getting less pain control because the mandate has already been covered. Big brother’s oversight has been assuaged, so, at least on paper, mission accomplished. Less rushed, more thoughtful treatment might have netted some Percocet.

    An old-school doctor who could have retired years ago still works with us because he enjoys seeing patients. He still leans toward a focused assessment and sensible testing. He still discharges patients home from the ER when it’s reasonable to do so. I admire his courage. I wish the money directive would go away so younger doctors would be more like him, taking control, being the artist, and making the sensible decisions they were trained to make. I want them to fight back against the insult.

    My old-school doc agreed that physicians have abdicated the throne. “I think the reason is that we don’t organize well. It started back in the 80s with managed care. Then there were increases in defensive medicine due to litigation . . .” He reminisced briefly about how medicine used to work. Then he shrugged, shook his head, and smiled a mixture of sadness and bewilderment. “Now? I don’t know where it’s going. It seems that you still need a person there somewhere to make sure we get it right.”

    He’s right of course. We do still need a person there somewhere. We always will. With mandates and protocols usurping the medical throne, more and more, that “person there somewhere” is the nurse.
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    About RobbiRN, RN Pro

    I'm an ER RN, an author, a dancer, a traveler, and a lover of the beach. I pledge to push back against the forces that assail common sense in our workplace.

    RobbiRN has '24' year(s) of experience and specializes in 'ER'. From 'Florida'; Joined Dec '16; Posts: 106; Likes: 516.

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    13 Comments

  3. by   KatieMI
    Oh, you poor old dear doctor...

    (sarcasmometer getting red hot):

    - it is YOU who killed the art of medicine. YOU shoot yourself in the leg, and continue to do so.
    Were it YOU who embraced EBM against clinical logic? Who embraced every single "evidence", "guideline", "recommendation" and such without ever checking who and why wrote it down? Who, after being wined and dined by drug reps, declared Oxycontin "non-addictive"? Who did everything and anything to avoid any responsibility for which you were not "compensated"? Who tried to get as much done on every patient, however hopeless, torturous, useless it was just because you could shell some $$$ for doing that? Who rejected wisdom and experience of countless generations just because there were no scientists in Harvard who would spend time studying acupuncture instead of being lavishly "supported" by Big Pharma?

    I can't say we nurses were always right. We sinned too - mostly, though, because we had no other choice. But, among it all, we kept our single promice and single oath - we were there for THAT PATIENT. Not for money, not for evidence, not for power - for that Mr. Jones, Ms. Molly, Ma'am Mary, Baby Nick - we were with them through it all. We spoke, taught, hold hands, entered their homes, prayed, called you, tried to speak with you, cried out of incredible frustration. Those patients saw it all. And - you know what? Now they do not trust you any more. They trust us.

    (a few days ago, I spoke with family member. The patient was hesitating to have necessary surgery. Surgeon was there, spoke with him and family, told him that it won't be that bad of recovery. Patient was still hesitating. After I repeated that literally word to word, he happily signed consent. I asked family member why he didn't believe surgeon; the answer was "well... you're the nurse, we trust you". I literally cried then and there.)

    In the meantime, we grew smart and strong. In 20 states, we legally can do 90+% of what you do in primary care, and we do it just right. There is not a shred of your beloved "evidence" that Nurse Practitioners provide care any worse than physicians - despite not going into residency and not knowing the exact name of that epigenomic modifying sequence which can (or cannot, we do not know yet, we need more research) modify responce on ACEIs. We just follow the algorythm AND we speak with patients, so that they finally start to throw less salt in their food and go out for a walk once in a while. And apparently it works just fine.

    Your time is passing. You still can abort the change, but for that you'll have to come back to where you came from. Stop being the God's incarnations. Come back to these suffering, hoping people. Speak with them, teach them, come to their houses, share their sufferings and their despair. Be honest with them. Stop bill for every second and every breath. Stop piling one drug on another and one surgery upon another one. And then, after the current generation will pass, the next one might remember the old doctor who was always there for their kids, who brought, if not immediate relief, then hope and peace.

    Now, I must get back to my Harrison. Yes, YOUR Holy Big Harrison Book. No, it was not recommended by my school. But I am reading it anyway - and, trust me, I'll use it well.
  4. by   RobbiRN
    KatieMI, BSN, RN, excellent response and points well made. I would question one thing though, the failure of nursing to push back more effectively because "mostly we had no choice." On a case by case basis, individual nurses would be putting our jobs on the line, but collectively, our failure to have a stronger voice against the developments which have ruined the art of medicine has been an abysmal failure. Even though we have been less motivated by money and generally more intimately involved in caring for patients, like doctors, we have not organized well and taken a stand as lunacy marched into control. We have also had a choice. We have also failed. The mantle has passed to us to some degree in the current shift, with so much control and responsibility given to us recently, we are newly positioned to succeed where the doctors failed. A day without nurses? Unthinkable things would happen . . .
  5. by   WestCoastSunRN
    RobbiRN, this is a great piece! I really love how you paint the picture of what this looks like in the ED setting. I agree with Katie AND you ... nurses didn't have a lot of choice for many years -- an oppression of sorts has always been an implied characteristic of the nursing profession -- ie., the doctor's hand-maiden. It hasn't been until the last 50 years or so where there has been the real possibility of sweeping change within the profession and in its ability to affect Health Care. That of course relies heavily on our ability to have a collegial role with physicians -- which everyone is still working on (turf wars and all). Both Nursing and Medicine are making missteps along the way --- nursing is poised to rule the world, really .... but could blow it by pandering to the "markets" (nursing school is BIG business these days). And I can't agree more with the idea that if we knew how to effectively organize (ourselves and WITH medicine, too! --- wouldn't that be swell?) the entire profession --- not just elite groups like the NIH -- could have enormous impact on figuring out the craziness that heath care has become in this country. Just my .02.
  6. by   Orca
    Quote from KatieMI
    There is not a shred of your beloved "evidence" that Nurse Practitioners provide care any worse than physicians - despite not going into residency and not knowing the exact name of that epigenomic modifying sequence which can (or cannot, we do not know yet, we need more research) modify responce on ACEIs.
    On Wednesday, I went to an urgent care facility for an upper respiratory problem that has been stubborn to treat. I saw an MD. He came up with a very quick diagnosis that I am pretty certain is incorrect, and he acted as though he couldn't get out of the room fast enough. Two weeks ago, at the same facility I saw one of the NPs. He spent a lot more time with me, listened to what I had to say, came up with a diagnosis that made sense, and he explained the treatment regimen. The doctor, on the other hand, seemed to be giving me canned answers based on nothing more than a hunch.
  7. by   RobbiRN
    [QUOTE=WestCoastSunRN;9470624]RobbiRN, this is a great piece! I really love how you paint the picture of what this looks like in the ED setting. I agree with Katie AND you ... nurses didn't have a lot of choice for many years -- an oppression of sorts has always been an implied characteristic of the nursing profession -- ie., the doctor's hand-maiden. It hasn't been until the last 50 years or so where there has been the real possibility of sweeping change within the profession and in its ability to affect Health Care. That of course relies heavily on our ability to have a collegial role with physicians -- which everyone is still working on (turf wars and all). Both Nursing and Medicine are making missteps along the way --- nursing is poised to rule the world, really .... but could blow it by pandering to the "markets" (nursing school is BIG business these days). And I can't agree more with the idea that if we knew how to effectively organize (ourselves and WITH medicine, too! --- wouldn't that be swell?) the entire profession --- not just elite groups like the NIH -- could have enormous impact on figuring out the craziness that heath care has become in this country. Just my .02.[/QUOTE

    How to organize? - that IS the question. I'm thinking low maintenance, easy to sign up and add your voice and passion, open to all healthcare providers from CNA's to administrators. Come up with a clear agenda by distilling the feedback, make a list of changes to regain some control and sensibility, then turn it into an online petition to use as a bargaining chip. Allnurses is a good place to start, with 1 million plus members, then multiply that by our coworkers, friends, and online extensions... there is plenty of passion in this arena.
  8. by   Daisy4RN
    Good reading! I think that both MD's and RN's have lost "the art of practice" because of all the busy work that comes from mandates. Either in the ER or floor, nurses are expected to check for varies issues (that have nothing to do with why they are in the hospital), fill out forms and forms, give vaccines etc., all of which takes away time from the patient so we are left with telling patients "here is your hat, what's your hurry" without fully addressing relevant info that brought them in. We have jumped through many many hoops but have failed to have the time to "practice the art". Jack of all trades, master of none.
  9. by   MunoRN
    Measures that reduce sloppy practice and errors aren't a bad thing, Atul Gwande in The Checklist Manifesto put it more eloquently, but basically the reason why some Physicians feel "insulted" by these initiatives is that it violates their "freedom" to practice crappy medicine, not because it impairs their ability to provide quality treatment, since it doesn't.

    These measures are actually extremely flexible, you can give just about any reason you want as to why you aren't following the recommendations and still be compliant. Just because your GI bleeder has a Hgb of 4 which then makes them tachycardic, tachypneic, hypotensive, elevates their lactic acid level, etc in no way means that you should give them 3 liters of NS, and any physician who is evaluating the patient correctly won't order that fluid.

    The OP is correct that there once was a time when we under-assessed septic patients and just sent them home with a z-pack, which resulted in too many preventable deaths, which is why there's been a push to do a better job of treating these patients. There is certainly an argument that it's possible to over-screen and over treat based on unreliable or non-specific assessment, but I think the best route is to fix those instances when we're doing too much, rather than to just settle for doing too little.
  10. by   RobbiRN
    Quote from MunoRN
    Measures that reduce sloppy practice and errors aren't a bad thing, Atul Gwande in The Checklist Manifesto put it more eloquently, but basically the reason why some Physicians feel "insulted" by these initiatives is that it violates their "freedom" to practice crappy medicine, not because it impairs their ability to provide quality treatment, since it doesn't.

    These measures are actually extremely flexible, you can give just about any reason you want as to why you aren't following the recommendations and still be compliant. Just because your GI bleeder has a Hgb of 4 which then makes them tachycardic, tachypneic, hypotensive, elevates their lactic acid level, etc in no way means that you should give them 3 liters of NS, and any physician who is evaluating the patient correctly won't order that fluid.

    The OP is correct that there once was a time when we under-assessed septic patients and just sent them home with a z-pack, which resulted in too many preventable deaths, which is why there's been a push to do a better job of treating these patients. There is certainly an argument that it's possible to over-screen and over treat based on unreliable or non-specific assessment, but I think the best route is to fix those instances when we're doing too much, rather than to just settle for doing too little.
    If mandates only kept docs from practicing crappy medicine, they would be a wonderful thing. In my environment, they create far more overkill than efficiency and accuracy from what I've observed. I picked on mandates and protocols because both remove decision making from doctors. It seems protocols, like a sliding scale for example, increase efficiency, whereas mandates, powered by a penalty for missing something, create wasteful and potentially dangerous overkill. Like defensive medicine for other reasons, it is hard to remove the areas where we do too much when there is a penalty for missing something and little incentive for efficiency. How would you do it?

    In the nursing area, as KatieMI mentioned above, there is a lot of clutter introduced by mandatory screening questions and "fixes" which have nothing to do with why the patient has come to see us. Screening for domestic violence sounds good, but those who want to talk about it tell us on the doorstep. "I'm here because my boyfriend beat me up." Asking a 46-year-old guy who lives alone and came in to get a fishhook out of his shoulder if he is a domestic violence victim usually gets an amusing response but wastes fifteen seconds on 99.99 percent of our patients. Does it sound reasonable to click through 8 boxes to get a fall risk score for a toddler who falls all day?

    On that happy note, I'm off on a cruise in the Baltics with very sporadic internet access for the next two weeks, so if I vanish from the conversation here and there it will be for a really good reason. Cheers.
  11. by   KatieMI
    Quote from MunoRN
    Measures that reduce sloppy practice and errors aren't a bad thing, Atul Gwande in The Checklist Manifesto put it more eloquently, but basically the reason why some Physicians feel "insulted" by these initiatives is that it violates their "freedom" to practice crappy medicine, not because it impairs their ability to provide quality treatment, since it doesn't.

    These measures are actually extremely flexible, you can give just about any reason you want as to why you aren't following the recommendations and still be compliant. Just because your GI bleeder has a Hgb of 4 which then makes them tachycardic, tachypneic, hypotensive, elevates their lactic acid level, etc in no way means that you should give them 3 liters of NS, and any physician who is evaluating the patient correctly won't order that fluid.

    The OP is correct that there once was a time when we under-assessed septic patients and just sent them home with a z-pack, which resulted in too many preventable deaths, which is why there's been a push to do a better job of treating these patients. There is certainly an argument that it's possible to over-screen and over treat based on unreliable or non-specific assessment, but I think the best route is to fix those instances when we're doing too much, rather than to just settle for doing too little.
    So, do you think that asking every teenage kid a few vague questions like "do you OFTEN feel sad?" or "do you feel like you won't enjoy doing your homework more than 3 days every week" within so-called "depression screen" tools is correct? As you probably know, no teenager ever feels like life is really good 100% of the time; it is more often than not sucks full way for them. For the last 100.000 years it was seen as a nature of growing up, now we "screen" these kids and start to load at least thrid of them with meds which potential actions for developing brain is completely unknown and won't be known for the next 30 to 50 years.

    Do you REALLY think it is good?
  12. by   KatieMI
    And regarding to the so-called "SIRS criteria" and their wise use:

    Patient #1 is known alcoholic, found hunting pink bunnies with fever 101.4 and HR 160, BP 90/60. DT + Afib/RVR
    Patient #2, young and healthy, was driving across the country for 48 hours with almost no food, water and sleep. Headache, myalgias, cough, BT 101.4, HR 126, RR 25, BP 100/60. Flu smear positive in ER.
    Patient #3 was a teenage kid who lowered his allergic protection and ate something that had peanut oil in it. BT 98.9, HR 148 (after Epipen X2), RR 28 SaO2 97 on 2 L, airway stable, BP 90/60.

    All these people came into the same ICU within couple of hours one busy weekend. All came with correct diagnoses and treatment ordered, and all of them had vancomycin already going on, cultures of everything and more antibiotic orders on the way because they "fulfilled the criteria" for SIRS.

    Do you think that was a good medical practice as well? Or it was a massive overblown having nothing to do with critical thinking and everything with marking dots here and there, plus waste of time and money, plus potential for making superbugs?

    I had to go to ER with allergic reactions about six or seven times since those "SIRS criteria" were widely intoduced. Every single one, I am "offered" (read: almost forced to accept) uselless but expensive studies like CT of everything, cultures, straight cath, admission till cultures are out, etc., etc. ONLY because my BP is low (it is always below 100 systolic) and HR and RR are high (shouldn't they be after epinephrine, steroid load and that much of IV fluids?) Always for the name of "wehaveanevidence", "thisisnecessaryforyoursafety" and "wearejustdoingourjobs". Half of those times, I had to leave AMA just to get those idiots out of my neck and my credit card, even when I was not sure that the reaction was over and dealt with.
  13. by   angeloublue22
    You are so right. I work with a doctor who said, "You nurses are having to do more and more. Soon, we won't need doctors anymore."
  14. by   Cherokeegirl08
    Quote from KatieMI
    So, do you think that asking every teenage kid a few vague questions like "do you OFTEN feel sad?" or "do you feel like you won't enjoy doing your homework more than 3 days every week" within so-called "depression screen" tools is correct? As you probably know, no teenager ever feels like life is really good 100% of the time; it is more often than not sucks full way for them. For the last 100.000 years it was seen as a nature of growing up, now we "screen" these kids and start to load at least thrid of them with meds which potential actions for developing brain is completely unknown and won't be known for the next 30 to 50 years.

    Do you REALLY think it is good?
    My pediatrician asked me those questions as a teen, and let me tell you, he literally saved my a#$. I doubt I'd be here if he'd have hesitated to ask. If it saves one teen's life in the future, it's worth it.

    I came from what people call a "good family" yet no one saw what I was going through. It's like that for millions of teens. Someone has to ask those questions.
    Last edit by Cherokeegirl08 on Jun 5 : Reason: ETA

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