Challenging Relationships with Doctors

[resilientnurse]

Greetings,

Can anyone elaborate on the circumstances of challenging relationships you may have with medical doctors in the workplace and how you deal with it?

I have become aware of complaints to the administration from the doctors that we, the NPs, are stealing their patients. The biggest complainer is my collaborating physician whom I thought I had an excellent rapport with. We are not "stealing" anyone of course, patients are open to choose the provider they want. I am salary so I get paid the same regardless of the number of patients I see. What I thought were good professional, collaborating relationships are now starting to feel like the strikers versus the scabs.

Before becoming a NP I worked in a large teaching hospital where nurses, doctors, and allied health worked closely together for the benefit of the patient. Financial incentives had nothing to do with patient care. My role is different now, but this is totally perplexing to me. Perhaps I am being naive as a new graduate, but I truly thought it was all about the patient. My workplace is not openly hostile, but knowing this has definitely shattered the facade.

[BostonFNP, APRN]

Sadly for some physicians is it not about the patient care; medicine is a business and if this MD is paid on performance than he/she may very well be upset about patient leaving his panel to yours.

What you should be able to say to him is to provide better care and patients wouldn't want to switch. However that would make things difficult for you.

I would try and approach it from a collaborative standpoint. Have a proactive discussion with him about your goals as a TEAM in providing the BEST POSSIBLE CARE for your MUTUAL patients.

My two cents. Sorry this is a crappy situation in which you are doing everything right but still need to "kid gloves" the other provider.

[futureeastcoastNP]

The brightest minds go into medicine. Do you think it's all because they want to help people? Of course not, the brightest minds choose medicine because it pretty much guarantees high income and job security for the rest of their lives. For the first time, though, it is being threatened by the ACA and NPs. Salaries are falling and physicians are scared. Hence all the scare tactics the AMA uses against NP independence.

For a select few physicians, it really is all about what's best for the patient, and you will find those tend to be highly supportive of NP practice. For the rest, the dollar comes first, and if that means limiting patient access and increasing wait times for visits by holding back NPs, then so be it.

[rnsrgr8t]

I have seen that happen in other divisions where I work. In my division, there are MORE than enough patients to go around and they welcome any patient I can see. I tend to see the patient's with diagnoses that take a lot of time and teaching. They allow me a 45 minute slot for my new patients and the patients are a lot happier. This frees up the MD schedules to see the type of patients they want. If there are not a lot of patients (AKA business) to go around and they are paid on productivity... it can get sticky. Makes me wonder why they hired an NP to begin with...they knew you were going to be seeing patients right? Sorry you are going through this!

[resilientnurse]

The situation was causing me so much anxiety that I went straight to the top to inquire about my job security. The director told me not to worry, my job was safe, my billing more than covers my salary, and that I have the highest return/follow-up appointment rates. Apparently there are computer programs that provide this data. He acknowledged the complaints but stated that the organization has been cited for long patient wait times and that the doctors can no longer hoard patients.

What had been happening is that a thousand people get scheduled in five minute appointment intervals with the doctors. They would take their time showing up until the waiting room was good and full. Now, in reality no patient can be seen in that short amount of time, so patients wind up waiting for hours and hours. The NPs are not contractual and schedule more realistic appointment intervals. So, people are definitely seen upon arrival with us.

I don't think this changing landscape is easy for them to accept. We are talking about doctors used to making $12K for 2 days work (not even 8-hour days).

[futureeastcoastNP]

Competition is good for the consumer, and physicians are trying to keep the monopoly on healthcare so they don't have to compete - just as you said in your example, they leave patients waiting for hours because the patients have no other choice. Now NPs are empowering patients to have a choice, and to choose providers that value their time and don't treat them like a burden. If physicians don't like it, they should step up their game, not complain about the NPs.

Kudos to you regarding your positive patient data, resilientnurse.

[resilientnurse]

Well, it is official. My organization is actively trying to get rid of the doctors and replace them with salaried nurse practitioners. They only intend to keep one to serve as our collaborator and they could care less which one which they retain either. Not all collaborating physicians should be charged with collaborative responsibilities.

While I am clearly on the winning team today and grateful to be gainfully employed, this business strategy does not sit well with me. It has not taken the doctors long to get hip to their game and they are quitting left and right which means more work for us as we will have to absorb their case loads which tend to be the more difficult complex patients. I learn so much from the doctors I work with and have never saw myself in competition with them.

What if sometime down the line social workers and psychologists gain prescriptive authority and turn out to be cheaper clinicians, then I will be fighting for my job too. This situation just does not feel right to me.

[Pachinko]

Wow, resilientnurse. Do you mind if I ask which field of care you are in (primary, psych, etc.)?

[traumaRUs, MSN, APRN]

Wow is right! Is this some type of government-subsidized care/clinic/practice?

[resilientnurse]

I work Psych. This sort of thing probably never happens in Primary Care, huh?

[myelin]

Honestly, if the docs were trying to see psych patients in 5 minute intervals so they can rake in as much cash as possible, then yeah, I can see why your organization is trying to get rid of them. I honestly wouldn't feel bad for doctors who lose their jobs with that kind of patient care.

[automotiveRN67]

This is an interesting discussion. It brings up the question of how nurse practitioners should move forward in the next round of growth. Physicians have been short-sighted for a long time, and see their finances whittled away. I guess it is difficult to imagine having your salary cut 30% or more. But then, when your salary is $400K per year or more like many of the physicians I am familiar with, I don't feel bad for them.

States will expand the nurse practitioner role to fill the needs of the patients. I am not trying to get into the political debate of the recent healthcare expansion, but our practice is now expanding to fill the needs of patients who have not had insurance for a long time. Their only option had been to go to the ER with a real illness, or wait until they became ill. Now they are walking in with a laundry list of needs.

I do wish the nurse practitioner organization would tone down the "we are independent" "and a bargain at that" thing, and understand that a soft approach may still get us where we want to go.

The model I see works well in our practice. Physician and NP work together to efficiently see the most patients. We usually alternate with our patients. I usually see all of the hospital follow up and add-on patients. I do most of the non-invasive testing and interpretation of that.

I really feel for physicians who became employed by larger corporate groups for the short-term, and are being pushed out for less expensive, and in their mind, lesser quality NP's. Now is the time to soften the tone a little, and hopefully keep our quality high. I really hope these online programs don't come back to bite us. From what I read on this site, many new NP's just aren't prepared to step up. Physicians read these discussion forums also, and so do tech-savvy patients.

Just some thoughts to add to the discussion.