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?
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.
I don't see that happening where I work at all. More often than I really care for when I call an MD they ask me what orders I would like. There's been a few times I've been like well...you're the doctor, what would you like to do?
But then I work in a SNF. We have rounding providers but we don't have access to an on site physician and frequently when we need to call one for orders it's an on-call that has zero knowledge of the patient so they do really rely on our assessment and frequently ask for our recommendation before giving orders since we know the patient and they don't at all.
In my experience as long as you have your ducks in a row and give a good, quick summary of what's going on with the patient and are able to answer any questions the doctor has without sounding like a blubbering fool the provider has nothing but respect for the nursing staff.
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
Hey, you aren't the only one. Have I got stories! Yes, we arose from the chairs so the doctors could sit, as I was told, "their time is more precious than ours", then again, they came to the hospital in the morning, went to the office, came back to the hospital and did surgeries and delivered babies. Patients called the doctors at home if the office was not open. The days of the old doctors who did it all. They were doctors 24/7 and we were nurses 8 hours a day. Yes, I also remember when our aides were grandfathered in as CNA's if they had one year experience, if they didn't they had to take classes.
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? ?
Your one female intensivists needs a smart crusty old nurse to tell her, "You need to stop that, it's not helpful." Stop what? YOU KNOW. ?
Yes, this still exists. With some doctors, you have to be careful to not seem to be making a suggestion or to be voicing an opinion, because if you do you will be slapped down hard. And I say this as a master's prepared RN with two specialty certifications and thirty years experience. And it saddens me to say that this occurs most often with female physicians of a certain age.
Yes, this still exists. With some doctors, you have to be careful to not seem to be making a suggestion or to be voicing an opinion, because if you do you will be slapped down hard. And I say this as a master's prepared RN with two specialty certifications and thirty years experience. And it saddens me to say that this occurs most often with female physicians of a certain age.
Wow. I am so sorry you have this experience. I have never felt that way about voicing my opinion or advocating for my patient. My recommendations that I give are just that. My recommendations are not always taken, and that is okay, if the rationale for proceeding in a different way sounds good, it is always in the best interest of the patient.
When have you felts shut down? What type of environment do you work in that does not allow nurses to voice their opinion? The way I view it, I am the last line of defense for the patient, I don't want to do anything unless I am sure.
I can see that it exists with certain doctors to an extent. The doctors I’ve noticed that have that attitude usually have insecurities. We are all part of a team, we can’t do our jobs without each other. I’ve had doctors straight out tell me they don’t want to order XYZ (when you are adamant that something is wrong with the patient) and those same patients end up crashing when the next set of doctors get on and they end up in the ICU. Unfortunately, situations like that make it difficult to feel part of a team. There are negative outcomes for the patient (delay in care, etc) when the provider doesn’t want to work with the nurse and vice versa.
Specializes in Med Surg, Geriatrics,Hospice/Home Care, Wound Care.
Great article. I've been away from the floor for some time now, but I definitely recall suggesting via subtle assessment points. I also recall using the tactic in home health and home hospice. Some docs would rely on us as partners in their patients' care and others clearly had the hierarchy in mind. You had to know your docs when contacting them for guidance.
Something came to mind as I read, however, since I left the floor before the number of men in our profession skyrocketed. I'd be curious to know whether they experience less of this (any sort of pushback/discipline from docs) than we female nurses do. Might be an interesting topic for a future article!
As long as there are egos there will be the "Doctor Nurse game"
The article made me have whiplash with all the agreement I was doing. Some Doctors you still have to make a suggestion rather than asking directly for an order of if you see something questionable. At my place some don't like you speaking unless spoken to. Or they feel they have a "special" seat at the NURSES STATION where they will stand uncomfortably close and ask you numerous times how long you will be.
On the other side of the coin there are Doctors who values the nursing staffs expertise and input.
kbrn2002, ADN, RN
3,969 Posts
I don't see that happening where I work at all. More often than I really care for when I call an MD they ask me what orders I would like. There's been a few times I've been like well...you're the doctor, what would you like to do?
But then I work in a SNF. We have rounding providers but we don't have access to an on site physician and frequently when we need to call one for orders it's an on-call that has zero knowledge of the patient so they do really rely on our assessment and frequently ask for our recommendation before giving orders since we know the patient and they don't at all.
In my experience as long as you have your ducks in a row and give a good, quick summary of what's going on with the patient and are able to answer any questions the doctor has without sounding like a blubbering fool the provider has nothing but respect for the nursing staff.