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Does the Doctor-Nurse Game Still Exist?

Nurses Article   (2,249 Views 22 Replies 902 Words)
by Nurse Beth Nurse Beth, MSN (Advice Column) Writer Innovator Expert

Nurse Beth has 30 years experience as a MSN and specializes in Med Surg, Tele, ICU, Ortho.

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The Doctor-Nurse Game- Does it Still Exist?

The doctor-nurse game is a unique method of communication between nurses and doctors. Some say the doctor-nurse game no longer exists...what do you think?

Does the Doctor-Nurse Game Still Exist?

The Doctor-Nurse Game

Those of us nurses who have been around for a time remember some truly archaic nurse-doctor dynamics. The expectations seem laughable in today’s world. Some nurses remember having to stand up and give their seat to the doctor whenever he appeared. Honestly, back in the day, a doctor could hold out a cigarette and a nurse would rush to light it, or so I've been told. Which is disturbing on many levels!

In the mid-80s, I remember trailing an orthopedic surgeon (aka "God") down the hall while he rounded on his patients, most of them housewives with back pain admitted for 5 days of bedrest and traction. He would call out orders over his shoulder for me to write down “Give her some Maalox.” “Valium 5mg tid.” I’m still not sure he ever “saw” me.

The “doctor-nurse game” was coined by Leonard Stein, MD, in his seminal paper of the same title, and to some degree, it still exists today. His observations were in the 60’s, which was a decades ago, but even so, it did not reflect the social norms of the time. The 60’s was a time of feminism and a decade of change for women. At least outside of the hospital. Inside the hospital nurses wore white dress uniforms, caps and white stockings. 

The doctor-nurse game relies on the assumptions that nurses are handmaidens and that doctors’ egos must be protected. The nurse learned to use her femininity as an asset when interacting with physicians. 

Leonard Stein re-visited the topic in the 90’s and declared that the game had ended because nurses had decided not to play. I beg to differ. Many handmaiden aspects of the role have fallen by the wayside, true, but the game is still going strong. It’s definitely not obsolete.

Rules of the Doctor-Nurse Game

  • Be indirect. If you want something for your patient from a doctor, you must be indirect and never straightforward
  • It must appear that the doctor initiated the idea. Nurses can subtly suggest a treatment but it cannot be their idea. “The lungs sound very wet” ...and wait expectantly
  • Never directly disagree. Doctors cannot be wrong and they cannot be questioned
  • Deference at all times. Wait for the right time to speak, being mindful that the doctor may be very busy and stressed with life and death matters
  • Be grateful. Convey respect and gratitude for the wise response

How it’s Played

Nurses play the doctor-nurse game for the sake of their patients and to get what they need for their patients.

Here's an example:

Nurse: “Mr. Smith’s potassium level is 5.6

Resident: (in alarm) “That’s really high

Nurse: (realizing resident does not know what to do) “He responded well to Kayexalate before”

Resident: “Good” ...pause. “What dose was that?

Nurse: "15 gms

Resident: “Good, then! Let’s give Kayexalate 15 grams”

Nurse: “Kayexalate 15 grams. Thank you, Doctor! Ok if I recheck the potassium level after that?”

Resident: “Why, yes. Yes, of course. Re-check the potassium this evening

Fast Forward

So much has changed since Leonard Stein’s time. Nurses are not all female and doctors are not all male. Nurses have gained power, partly due to the development of Nurse Practitioners, and doctors have lost power, partly due to patients having easy access to medical information and partnering in their own health. So the power has equalized to some degree and in some areas. 

Thankfully there is now much greater mutual respect between nurses and doctors. Nurses now speak up and even give advice. 

We are in such a better place but let’s not kid ourselves, the doctor-nurse game still exists. Newly licensed nurses today learn how to play the game while they are still in school. Even today, the game must be played in most settings. SBAR includes the R as recommendations, as in, “Would you like to get a chest X Ray?” but most of the time nurses are passive and wait for the doctor to initiate the treatment.

  • During multidisciplinary rounds, doctors still act as the experts and quiz nurses on the spot
  • Doctors are almost always accorded expertise, even when the experienced ICU RN can clearly manage a patient on pressors better than the doctor
  • Doctors can be late to meetings without criticism
  • Doctors are automatically considered to be the expert in meetings
  • Doctors’ misbehavior is tolerated much more readily than nurses’ misbehavior
  • Nurses aim for approval from doctors but doctors do not aim for approval from nurses

Nursing and Medicine: Interdependency

Nurses and doctors have been locked in an interdependent dance since the beginning, but not necessarily a collaborative one. While nurses do not make independent treatment decisions, patients benefit when doctors and nurses collaborate. A good model is found in ICU where there is more collaboration and doctors are more receptive to the nurse’s recommendations.

What's your experience with the doctor-nurse game?

Nurse Beth

Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!

Hi! Nice to meet you! I love helping new nurses in all my various roles. I work in a hospital in Staff Development, and am a blogger (nursecode.com), author (Your Last Nursing Class: How to Land Your First Nursing Job), and I hope a helper to my fellow nurses :)

15 Followers; 91 Articles; 229,551 Profile Views; 1,888 Posts

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JBMmom has 6 years experience as a MSN and specializes in Long term care; med-surg; critical care.

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I think some of what is presented here as a doctor-nurse game is how we approach many situations in real life, nursing or not. Everyone knows the best way to engage others in any situation is to make them feel that they have been part of the decision process. The conversation listed above implies to me that the nurse thinks the doctor is incapable of making the decision to give kayexalate without their input. If a nurse has been thinking about a clinical situation, they have probably taken the time to think things through and come to a determination of a potential treatment. To expect that every doctor would come to the same conclusion in an instant just because they are a doctor is not fair to doctors. And if a nurse is able to give the input and with collaboration, get the treatment that their patient needs, do the details of how the conversation goes really matter that much. I'm not a doctor, I don't have the medical training of the doctor and there are many things they could do that I can't. On a day to day basis, I provide more direct patient care and can focus on more of these details. I am treated with respect by the doctors I work with, but of course a hierarchy of sorts will always exist. Their license is on the line in a different way than mine.

As for some of the bullet points, none of the doctors I work with quiz any of us during rounds. They sometimes have genuine questions but I have never felt challenged.

Yes, I can probably manage my patient on levophed, phenylephrine and vasopressin more readily than the doctor, but that's my role. Any doctor I work with could physically manage it, but it's not the nature of their role in the ICU.

I think everyone should make an effort to get to a meeting on time out of courtesy, however, nurses and doctors alike are sometimes delayed for reasons beyond their control.

I don't feel like my coworkers, doctor or nurse, display behaviors that I would call misbehaving. However, there are jerks in all walks of life, not all behaviors have to be attributed to title.

Maybe I'm fortunate to work with doctors that are respectful for the most part, and treat the nurses as members of a team. I think that sometimes people are looking for us vs them situations where sometimes there are none. (I admit that working with surgeons has been more of a challenge at times because of the personality types that are attracted to the specialty of surgery)

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PeakRN specializes in Adult and pediatric emergency and critical care.

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I'm happy to say that I've never had a relationship like this with any physician. There are definitely some old school PCPs, surgeons, and hospitalists who have tried, but I've shut it down every time (as well as the other nurses I work with); I suspect that my nursing experience being exclusive to the ED and critical care units has certainly helped me out. The fact that myself and most of our critical care charge group have multiple specialty certifications definitely helps too.

My docs have to trust the nurses if they want the patient to get the best care. It is very rare that the docs don't trust us when we ask for an xray or a new med. We aren't asking because it is more convenient for us or that I think it might be beneficial, I'm asking because I think the patient needs it. If I played word games instead of just asking for the order I want our docs would be beyond annoyed. This isn't to say that sometimes myself or our other nurses ask for an order and the docs want to wait or try a different therapy, but we have a clear and honest conversation about what is the best thing for the patient's care.

We have had a handful of docs who don't behave appropriately with nursing staff, whether it is around orders or just their general behavior. Our CMO and the various specialty medical directors shut that down real quick, and those physicians find themselves working in a different system. Ironically the docs who do this aren't necessarily old docs and quite a few residents and docs new in their practice have shown these behaviors. Most of our physician leadership (and thus the docs that support a good nursing and medical relationship) in our medical center are the old school docs who have been in practice longer than I've been alive.

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Davey Do has 35 years experience and specializes in Psych, CD, HH, Admin, LTC, OR, ER, Med Surge.

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What's your experience with the doctor-nurse game?

I first noticed a difference in the late '80's when the new docs introduced themselves using their first name.

The medical director of the chemical dependency unit, Dr. H, was an internist who had a practise with a couple of other relatively young doctors. I met one of his colleagues one weekend who was covering for him. He introduced himself with, "Hi Dave, I'm Brad C!" Of course I referred to him by "Dr. C", but it was rather refreshing to feel on common ground with a doc. Something I never felt with the seasoned ones.

I had a good relationship with a relatively young Korean surgeon, Dr S, when I worked in OR. One time I asked him, mostly in jest, "Hey, Dr. S- If I see you out in public, say Walmart, can I call you by your first name? You know: 'Hi, Ho!'?"

Another nurse was present and she nurse immediately said, "DAVE!", probably indicating that she thought  my question was inappropriate.

Dr. S just shook his head.

I took that as a "No".

 

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Jory has 10 years experience as a MSN, APRN, CNM.

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This article FREAKING NAILED IT.  

I worked under a physician once that was working way past retirement age...he was starting to have periodic memory lapses (the fact he still did surgery...was scary).

We were once in the middle of a sterile procedure in this office and he forgot the steps.  I had to prompt him, every time.  

Nurses get really good at making physicians look great.

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Hoosier_RN has 20 years experience as a MSN and specializes in LTC, home health, hospice, ICU, ER, dialysis.

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Yes it still exists, on a different level.  Some Drs/providers are confident and secure enough in their skills that they don't put anyone on the team down, and value input, and other who have issues and make everyone around them miserable.  I've seen nurses that think that they run the show, provider stop them dead in their tracks, and nurses who show our added value to the team.  Basically it's all in the approach.

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futurepsychrn has 3 years experience as a ADN and specializes in Pschiatry.

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I have literally been in trouble for "not showing the Dr enough respect." My reply?  "Respect is earned." This for a Dr that placed an 89 year old pt on a Behavioral Health unit because (his exact words), "You actually qualify for a skilled unit, but you'll get much more attention paid to you on this unit." At the time we had an extremely loud, violent pt and the poor man was terrified, and offering people money to " keep me safe." What I learned in nursing school was to be an advocate for my pt!

Edited by futurepsychrn
Grammar

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Not to this extent, I don't think. But out of my 3 intensivists (one male, 2 female), one of them loves the opportunity to question the presenting nurses during rounds and humiliates them every chance she gets. You can see her savor those moments, it's very disturbing. Don't get me wrong, she is extremely smart and is quick on her feet. She has been reprimanded several times for her behavior. 

Male intensivist definitely loves the indirect doctor-nurse game, and everyone thinks it stems from his 'lack of street smarts', as he is the newest of them. In my opinion, I do notice that certain older nurses, and even very few newer ones, act very submissively and exacerbate this situation. 

My take away? Doctors and nurses are all very smart and capable obviously. But they are only human, and are not perfect. Ego exists, nurses exist, doctors exist, and safety of patients exist. Can we all exist on the same plane? 🙄

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Hoosier_RN has 20 years experience as a MSN and specializes in LTC, home health, hospice, ICU, ER, dialysis.

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Providers usually have ego issues because they know that they are the income generators for the facility.  Caregivers (nurses, aides, techs, etc) are expenses, so the hospital will generally (not always) have the income generators back, but then complain when short staffed due to poor treatment of caregivers

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RNNPICU has 13 years experience as a BSN, RN and specializes in PICU.

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I haven't ever felt this imbalance of power.  I have always felt comfortable giving what my recommendations might be (aka, advocating for the patient), and then the MD can decide from there.  Sometimes I am right, other times the MD has better ideas.  But at least making a recommendation is a good starting point for discussing the best options for care of the patient.

 

I have some MDs that I call by their first name, others I call by Dr.  It was the same in school, some professiors I called Dr, others by their first name.  Some of it depends on how well I know the person or have developed a relationship with that person, others it is different.  

 

During multidisciplinary rounds, doctors still act as the experts and quiz nurses on the spot I have never experienced this in 13 years.  I have seen it being used in the multidisciplinary rounds directed more at the fellows and residents.  RNs are the ones now to summarize the plan of care

Doctors are almost always accorded expertise, even when the experienced ICU RN can clearly manage a patient on pressors better than the doctor  Many orders now allow for the RN to titrate dips according to MAPs or other parameters. 

Doctors can be late to meetings without criticism -  I haven't seen this ever in the past 15 years in health care.

Doctors are automatically considered to be the expert in meetings -  I think this depends on who is running the meeting, if this is a family meeting, usually the Attending MD is the one who initiates the overview

Doctors’ misbehavior is tolerated much more readily than nurses’ misbehavior - I don't agree with this as there is much more emphasis on healthy work environments as well as lateral and other work pplace violence awareness, 

Nurses aim for approval from doctors but doctors do not aim for approval from nurses - I have had MDs come up to me specifically and ask if they think that situation X is apropriate.  I don't think that RNs are aiming everyday to please the MD or look for their approval.  I don't even know how RNs seek this approval.  

 

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What is my experience with the nurse/doctor game?  I never knew it had a name for one thing.  However, I have pretty much seen it all, from collaboration, to nurses and doctors becoming real friends, to practical enemies. I could write a 1000 page book.

I believe the relationship has a lot of basis in the abilities of each prospective nurse or doctor.  For instance, if you have an inexperienced nurse and a very experienced doctor, the physician may be impatient or have less respect for the nurse.  This also goes the other way around.  I believe the wiser you become and the more experienced you are the better you are able to manage the nurse/doctor relationship.  Sure, there is uneven power at a certain level.  But, I am not afraid to professionally tell a doctor what I think or ask them what they think.  

In addition, We should consider culture in the relationship.  Foreign physicians are not uncommon and their culture may categorize women or nurses into subservient roles.  I knew a physician whose wife ran his bath for him as part of her role.

I have so many interesting and amusing stories. Such as, a local physician and a local nurse who worked together for 20 years and the doctor was being an A-_ _ _.  She gave him the finger and said, F---- Y---.( They made up ).  I have heard a nurse telling a physician that he was being a "brat".  I have seen doctors throw things, "get me somebody who knows what the H---- they are doing!". 

This is a huge topic and much can be said about it.

Overall, I feel that physicians value nurses, just as nurses value aides.  I can't do my job without my aides and physicians can't do their jobs without us. We are important.

 

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traumaRUs has 27 years experience as a MSN, APRN and specializes in Nephrology, Cardiology, ER, ICU.

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Awesome article NurseBeth!

I'm gonna date myself but I was a NA (before there were CNAs) in the 1970's when I was in high school.

We had to all stand up when the doctors came to the nurses station.

We had to carry charts with the doctors/nurses on rounds

Everyone (including pts) smoked at the nurses station.

 

No games now in 2019 - I am a respected member of the team and my advice is sought out. Nursing is so much better now

 

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