Doctors Don't Always Listen: Bridging the Communication Gap

“Justina”, an ICU nurse, received a 10 year old girl from the ED who had no significant medical history. However, in the past 4 days, this patient had frequent emesis and complaints of stomach pain, with no fever. You might think you know where this is going, but what was truly going on was catastrophic. After approaching the doctor more than 4 times in 30 minutes with grave concerns, the doctor yelled at Justina and stormed away. Justina then went over his head….to her charge nurse.

Doctors Don't Always Listen: Bridging the Communication Gap

"Emily" was in the nurse's office at her school when her mother was called. She had thrown up again. The nurse and the mother were both perplexed - the mom had taken her to the doctor three days in a row with no answers, no fever, and on again/off again stomach pains. At wits end, mom picked her up from school and brought her to the ED. In triage, the nurse heard "strange" heart sounds while doing her assessment, and notified the ED physician immediately. An EKG was done and she was having trigeminy rhythms. Emily was immediately transferred to the PICU for a cardiology consult.

Justina received report and brought the crash cart to her room while waiting for Emily to arrive from the ED. Everything was in place. When Emily arrived to the unit, she was sitting up and smiling. This did not look like a sick girl when she rolled in. The team immediately hooked Emily up to monitors, took vitals, did an assessment, and went through the admission process. Her rhythm on the monitor was erratic. Emily would act fine, then pause and look ill, then smile and start talking again. She was not scared to be in a new place, and was loving the attention...and then she would look sick - turn a little cyanotic - and then talk again. This was going on again and again - her actions matching her rhythms.

Justina printed out strip after strip from the monitor, approached the intensivist over and over. He had done his assessment but had other patients' notes to write and then a meeting to be at. He only briefly acknowledged Justina's concerns. "The cardiologist has been paged - what else do you want me to do?!" he finally yelled at Justina. Then he stormed out of the unit.

Justina called her charge nurse over and explained the situation. With the crash cart in the room, Justina and the charge nurse were getting information from mom, talking "casually" while another RN entered the admission info in the computer, all the while drawing up and labeling meds. Epi. Atropine. Calcium. Potassium. This was going to happen - if not on this shift, on the next.

The charge nurse had the clerk page another cardiologist to the unit ASAP. The first one was still not in the hospital. Justina remained very calm and the mother did not feel any sense of anxiousness from the staff. Emily, sitting up and answering questions said, "I feel like I am going to throw up - " then her eyes rolled back in her head, she fell backward on her bed, and began seizing for about 15 seconds. It was at that time, the second cardiologist walked in.

Emily was coded for 45 minutes. She was placed on ECMO. She received a heart transplant. She lived. All because of the watchful eyes of a nurse.

I have nothing against physicians. The one in this story may have just had a really bad day, or wasn't thinking - I am not sure which. Caring for our patients is a team approach, and nurses are a key player. It is the nurses who know what their patients ask when the doctor is not around, who can see minute changes, who have assessed how the medications are affecting the patient, and who LISTEN and are CUED in. If a nurse has a concern about their patient, a physician would be wise to be concerned as well.

A recent article in Nursing2015 cites patient safety is highly dependent on team collaboration in order to prevent errors and improve patient outcomes. The article continues to explain reasons this age old problem of physician/nurse dilemma continues: Physicians may have inappropriate, abusive, or disruptive behavior; dismissive attitudes about nurses; gender/power issues; and collaboration/communication issues.

Look at this example of a student nurse who caught a huge problem during her patient assessment:

Jessica was a student nurse in her Med Surg II clinicals. Her patient was a 7 year old boy who was in for respiratory distress. He was to be discharged that day. As Jessica was doing her assessment on him at the beginning of her shift, just as she had learned in school, she noticed the boy's fingers were slightly clubbed. She asked the mother about his medical history, and he didn't have any, except frequent respiratory illness. Jessica nodded and said she would be in to check on them in a little while. She went to look through his medical chart and did not find any history or documentation relating to clubbed fingers. She asked her preceptor about it, and the nurse said she had not noticed, but if Jessica wanted to, could tell his physician when he came by. So, Jessica did. The provider smiled and said, "Ok, show me."

Jessica entered the room with the physician and as the doctor examined his fingers looked at her and winked. "We need to order an echo" he told her. And guess what? Jessica was right. The boy had mitral valve prolapse. How refreshing to have a provider acknowledge a concern!

Getting doctors to listen to nurses may be a difficult task. Sometimes, physicians are outright rude, they are rushed, they do not have respect for the nurse, or they just have other things on their mind. How do we, as nurses, help to bridge the communication gap when doctors don't listen?

Here are four steps to begin this construction process:

  1. Be prepared - know the facts for every possible question. Your patient is in pain? What is the pain level? What have you done? What has worked/not worked? Urine output is low after kidney transplant or bladder surgery? What have you done to fix the problem - what has worked, etc. What are the latest lab levels? What is the EKG reading? Know your stuff - or have it right at your fingertips.
  2. Use the SBAR to quickly tell the physician what is going on. Situation, Background, Assessment, Recommendation. Get to the point and don't "chase rabbits".
  3. When you are prepared with your information and know what you are going to say, be assertive, not rude or demanding. Get your point across in a respectful and concerned manner.
  4. Take responsibility for YOUR actions, no matter how the physician responds, and avoid EMOTIONAL reactions!

Oscar London, MD wrote in his book:

Quote
"Kill as few patients as possible", "Working with a good nurse is one of the great joys of being a doctor. I cannot understand physicians who adopt an adversarial relationship with nurses. They are depriving themselves of an education in hospital wisdom."

Smart man!

If you have any more tips that can help nurses bridge the gap, please share!

Reference

Sirota, T. (2012). Nurse/Physician relationships: Improving or not? Nursing2015. Retrieved from: Nurse/physician relationships: Improving or not? | Article | NursingCenter

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Julie Reyes

About Julie Reyes, DNP, RN

Julie Reyes, DNP, RN

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Specializes in ICU.

There is no bridging the gap with some of them.

At a previous job, a man with bad BPH started bleeding pretty profusely from his member after a catheter was inserted. He only had a particular nightmare of a surgeon on call, unfortunately. We'd soaked through four or five towels with blood before his nurse felt like she couldn't not tell someone. I was sitting right next to her when she finally called the surgeon, close enough to here her getting called a stupid C-word and informed to never call him again with this crap. He then called the house supervisor, the unit manager, and the critical care director - the latter two home asleep in their beds - to attempt to get this nurse written up for calling him.

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Specializes in hospice.

The more doctors I meet, the more I hate them. Honestly. The few decent ones stick out like sore thumbs.

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There is no bridging the gap with some of them.

At a previous job, a man with bad BPH started bleeding pretty profusely from his member after a catheter was inserted. He only had a particular nightmare of a surgeon on call, unfortunately. We'd soaked through four or five towels with blood before his nurse felt like she couldn't not tell someone. I was sitting right next to her when she finally called the surgeon, close enough to here her getting called a stupid C-word and informed to never call him again with this crap. He then called the house supervisor, the unit manager, and the critical care director - the latter two home asleep in their beds - to attempt to get this nurse written up for calling him.

What was the end of that story???

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Specializes in ICU.
What was the end of that story???

The manager "talked" to the nurse to appease the guy - basically told her that she knew the surgeon was unreasonable but there was nothing they could do about it, and just to try not to make him mad in the future if possible. He treated everyone like that indiscriminately. That hospital had a lot of problems keeping physicians - undesirable place to live, lack of amenities, etc - so the ones they had were very much catered to. Especially this guy, who was one of the hospital's first physicians and a founding father of sorts.

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I remember the days of being chastised for just trying to do the right thing but in my more recent HH experience the gap has decreased significantly. It's almost a non issue these days and what is more noticeable is the good responses from either the providers' representatives or the provider themselves returning calls and listening. Even calling the ER to explain why I'm sending a patient has generated ER physicians requesting to speak with me to either hear the report directly or to call me back for clarification and/or orders. I've instructed families to give ER staff my cell number if they have any questions and dang if I don't get some calls.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
There is no bridging the gap with some of them.

At a previous job, a man with bad BPH started bleeding pretty profusely from his member after a catheter was inserted. He only had a particular nightmare of a surgeon on call, unfortunately. We'd soaked through four or five towels with blood before his nurse felt like she couldn't not tell someone. I was sitting right next to her when she finally called the surgeon, close enough to here her getting called a stupid C-word and informed to never call him again with this crap. He then called the house supervisor, the unit manager, and the critical care director - the latter two home asleep in their beds - to attempt to get this nurse written up for calling him.

Now I want to hear that the patient did okay and the surgeon's crap backfired on him big time.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
The manager "talked" to the nurse to appease the guy - basically told her that she knew the surgeon was unreasonable but there was nothing they could do about it, and just to try not to make him mad in the future if possible. He treated everyone like that indiscriminately. That hospital had a lot of problems keeping physicians - undesirable place to live, lack of amenities, etc - so the ones they had were very much catered to. Especially this guy, who was one of the hospital's first physicians and a founding father of sorts.

Bummer.

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There is no bridging the gap with some of them.

At a previous job, a man with bad BPH started bleeding pretty profusely from his member after a catheter was inserted. He only had a particular nightmare of a surgeon on call, unfortunately. We'd soaked through four or five towels with blood before his nurse felt like she couldn't not tell someone. I was sitting right next to her when she finally called the surgeon, close enough to here her getting called a stupid C-word and informed to never call him again with this crap. He then called the house supervisor, the unit manager, and the critical care director - the latter two home asleep in their beds - to attempt to get this nurse written up for calling him.

There was a hospital I worked at in a city slum that let the docs get away with everything just so they would keep coming in to the hospital. This type of scenario would happen at least once a week to me.

I only lasted about eight months at that place.

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Specializes in pediatrics, occupational health.

I just read this and thought the doctor who said this might just make a real fine physician!

"Nurses take a lot of crap, sometimes more than doctors do, and I've worked with enough nurses to know that they can make or break a doctor, especially in his junior years. They also have a far greater impact than doctors do on the quality of a patients' stay in hospital, and the work they do cannot be undervalued. However, the hospital is sometimes a jungle, and as I saw on a National Geographic documentary so long ago, the "key to survival is respect". If we all just respect each other, let each other do their jobs, and stay the hell out of each others' way, the hospital will be a much better place."

Truer words may never have been spoken!

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I just read this and thought the doctor who said this might just make a real fine physician!

"Nurses take a lot of crap, sometimes more than doctors do, and I've worked with enough nurses to know that they can make or break a doctor, especially in his junior years. They also have a far greater impact than doctors do on the quality of a patients' stay in hospital, and the work they do cannot be undervalued. However, the hospital is sometimes a jungle, and as I saw on a National Geographic documentary so long ago, the "key to survival is respect". If we all just respect each other, let each other do their jobs, and stay the hell out of each others' way, the hospital will be a much better place."

Truer words may never have been spoken!

I recently had a patient tell me that their surgeon said patients do 100% better with home health. The actual accuracy in that statement aside, it's always cool to know who has a team attitude.

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Specializes in Critical Care.

I can think of plenty of examples of where A Physician didn't initiate the actions that were warranted because they didn't take something seriously, but to be honest I have to agree with the Physician in the first example, what else did you want them to do?

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