Do you have a dangerous doctor in your ED? Long vent.

[NeoPediRN]

Does every ED have that one doctor who you always fear will order you to kill your patient? That you feel you have to triple check everything they order to keep your pt safe? Extra documentation and assessments to CYA?

I'm trying not to get too specific, but I'm really struggling right now with a doctor I find borderline dangerous. This doctor will put in med orders before the patient even gets to the room, then has a two minute conversation where they literally berate the patient for coming in, speaks ways too fast for the pt to process, will tell them ok I think you're fine you'll go home soon...which would be fine except that half the patients are not fine. This doctor will only admit as a last resort and races to get them out to boost their productivity time on the computer...this doc wants their doctor's notes and nurse's notes to match up and will ask why the nurse put in this assessment if it differs, especially if it means having to run extra tests because of it or if it makes them a questionable admission. This doc constantly asks for nursing support to write a note that matches when it comes to a CYA situation (like inappropriate discharge or behavior in the ED) and looks for affirmation that what they did was appropriate when it was not. This doc will also tell us specifically not to do certain tests or assessments because it's going fishing for problems, and we'll do them anyway to CYA.

There have been so many instances where nursing has saved this particular doctor's behind...like ordering a med the pt is allergic to because they didn't read the allergy list, ordering ridiculous doses of medication, ordering 4 different nausea medications together, ordering meds that are IM only as IV, not running labs or EKGs because they don't want to go searching for problems....sometimes that's totally warranted, but come on, a patient with a crap ton of risk factors and a borderline story should have an EKG or a set of enzymes. It's a pain in the ass, you know it, I know it, but one of these days there's going to be a patient with a borderline story that this doc doesn't order anything on and that will be the patient who ends up having a massive STEMI or a brain bleed. This doctor is smart, but really pushes the boundaries. Don't write up complete discharge instructions and prescriptions before you even see the patient and seen the meds they're on.

There have been a handful of this doctor's patients who have come in over the past month after being treated because they still have pain or a fever and ended up with a totally different diagnosis and a few of them have been admitted. I won't say this doctor isn't smart, a lot of the time the doc is right about not looking for problems and I'm all for not doing unnecessary testing, but this doctor is unreceptive to discussion and ****** the nurses off. S/he has told me to f*** off before when I questioned them on something, and last night they took a child's temp (beating me to the room because they will take the pt from triage themself to get a jump on getting things started) and was like ok that's not a fever you can go home, I'll write your D/C papers....I felt the pt who felt hot and was flushed and said something to the effect of, "he actually feels pretty warm, I'm just going to check that temp one more time." S/he said in front of the family "the nurse is going to recheck the temp because the nurse doesn't think the doctor knows how to take one" very pointedly. Well guess what? The pt had a temp of 103 and HR in the 180s. The doctor made me take the temp again because "Well it was wrong once, maybe it's wrong again." Temp was the same again. When I told the doc about the HR they snidely said "how do you know it's that high?" I told them I double checked and auscultated the HR after seeing it on the monitor to which s/he said "so you listened to the HR and you're telling me you counted 180 beats in a minute?" and kept going on about the word auscultate....I told them at this point to cut the s*** and listen for themself rather than argue with me....the patient was actually pretty sick and needed several interventions, and the family was very upset that the doctor tried to D/C the patient right after assessing....the only reason this doctor didn't is because I refused to d/c without further workup.

I can think of at least 5 potentially serious errors this doctor made just in this last shift. I keep trying to bite my tongue and let it go because it's a very small ED and I keep thinking I'll just keep challenging this doctor when I need to and won't let them harm my patients, but it's getting really irritating. Being careless is one thing, being stupid and arrogant is another. How this doctor treats staff and patients is directly proportional to what is going on in their lovelife at the moment, which is another can of worms entirely.

Tell me there's one of these docs everywhere, and it's just something I need to adjust to?

[Altra, BSN, RN]

I have to say that I have not experienced what you are describing, though I have worked with the polar opposite: a couple of MDs who would evaluate a patient with a fairly benign set of symptoms, "well, it could be XYZ Extremely Rare Disorder" ... which predictably sent the patient & family into orbit.

What kind of experiences are other nursing staff having working with this MD? I ask because it's important to try to figure out whether the behavior you describe is occurring all the time, or if the two of you unfortunately have some kind of massive communication problem.

The incident you describe with the patient's heart rate and temp does sound concerning -- this is objective data. I did work with a resident who was particularly confident in his assessment skills being superior to those of long-time experienced nurses. His attitude adjusted after nurses repeatedly called him on it front of patients -- handing him a BP cuff if he was dismissive of a reported BP, for example. But other than PEA and artifact ... the monitor doesn't lie.

I would make every effort to keep all conversations about objective data. "What are we doing about this heart rate? If you feel it's due to fever, how about some Tylenol and IVF and then we can recheck it in about 90 minutes?" or "Medication policy here states the max dose of X med is Ymg. Do you want to start with that and see how the patient responds?"

However, the "**** off" comment needs to be addressed immediately, IMO. I would have had a private conversation with this MD immediately letting him/her know in no uncertain terms that that language is unprofessional and unnecessary. If it was repeated, particularly in the presence of other staff or patients/families ... I would take that up the medical chain of command within the department.

[Larry77, RN]

I would document some specific issues...then talk to the medical director of his/her group. If they do not act you can report the doc to his/her licensing board. They have to answer for their practices just like we as RN's do.

Good luck!

[NeoPediRN]

Altra, this doctor treats all the nurses the same, and even talks down to the hospitalist and pointedly asks other doctors why they want this doc to do particular tests during sign out. This doctor is a new-ish attending and has already had a lawsuit/settlement I could truly go on and on about the things they've missed that nursing has advocated for the pt on (true stroke symptoms and a stable head bleed are two examples). This doctor's attitude is what is going to really be the problem. Patients and families are always very upset after their first interaction with this doctor because of the dismissive and condescending attitude. The nurses are always left to pick up the pieces and vouch that yes, the doctor is very fast but knows what they're doing and is smart.

[Altra, BSN, RN]

If the behavior and lack of clinical judgement are consistently as over the top as what you describe, I don't think it will take long for the situation to correct itself.

And if I lacked confidence in the provider's judgement, I would not have a reason to be picking up the pieces and smoothing things over with patients & families. If s/he treats patients & families badly ... let the chips fall where they may.

One caveat: it is possible that this physician was hired by the medical director to improve throughput. *IF* that is the case, but increased speed is occurring at patients' expense ... obviously someone has misinterpreted something, somewhere.

I still say I would start with addressing the "**** off" comment -- it has no place in any working environment.

[VICEDRN, BSN, RN]

To the OP:

Don't know why you feel the need to endorse the MD to the patients. Patients inherently trust us to be honest with them. I wouldn't throw the MD under the bus but I might make subtle suggestions like, "If your gut says so, it might be time to ask someone somewhere else." Its vague and covers me either way. Or I remind them to advocate for themselves.

If they point blank ask me if I trust the MD, I say, "There are people I would want to see as a patient and MDs I don't want to see."

I wouldn't EVER pick up the pieces behind this loser. Contact your charge, your house supervisor or the chief of staff if the issue is just absurd.

[Medic2RN, BSN, RN, EMT-P]

I understand what you are experiencing.

Let's just say my ER did what Larry suggested and we never saw that doctor again.

[thelema13]

Had a similiar experience with a new MD. Ordering IV 40 mEq K+ on resulted labs WNL, ordering ridicuolous amounts of fluids on low BP's over insanely short amount of time (2 litres over 30 minutes for BP of 100/60 on pt with hx of CHF), 4mg IVP dilaudid, I could go on and on. When orders are questioned, the most typical response was "who is the doctor and who is the nurse, and who is supposed to be giving orders and who is supposed to follow orders?" I didn't experience the downright, disrespectful swearing, but the unsafe orders were pretty much placed on all pts. And the 'holier than thou' attitude got old after the first 15 minutes.

I went to my charge, to my supervisor, and they said they would talk to the ED medical director. Nothing happened, so I printed some of her orders, including lab results and whatnot to back up my position, and personally handed them to our medical director, Dr C., and had a 15 minute cordial conversation explaining my concern for pt safety.

She was not scheduled again. And the shifts she was scheduled for were covered by another doc.

Good luck and stand up for what you know to be right.