hated by medical director.

[gfauker1]

i am a dialysis RN with 10 years total experience, one in dialysis. I know I am smart but I have made a few bad decisions to which our medical director held me accountable. one incident was a pt had a fever. I emailed the MD, (doesn't like to be called). while waiting for his response i had 8 other patients with various problems to address on the floor. the febrile pt said "i want to come off the machine early." ok i said to him, and off he went. 30 min later i checked my inbox only to find the MD's email that had orders to give abx and draw blood cultures. I sent him an email saying the pt signed off AMA. I was written up because I should have had the pt wait until the MD responded. I didn't so technically I let an unstable pt (febrile 99.4 temp) go on his way. I get it. a mistake, yes. more of a failed communication on my part i would say.

I received a verbal warning and was told by my boss that he, in the five years of being a mgr, has never seen the doctor that ****** off.

Last week a i sent a pt to the ER before her treatment as she was c/o chest pain and left arm pain/numbness. thats a no brainer as I told the medics they couldn't get here fast enough! this incident happened at 0545 in the am. meanwhile pts start coming in at 0550 at which time its very, very busy until about 0900 because of meds, problems on the floor, etc. at 0845 the MD came in, who dislikes me since the time of the first mentioned episode. He asked where the pt was. not having time to email him as of yet, i expalined to him that I sent her to the ER. He was livid and demanded i be disciplined yet again.

my manager, who i consider a friend and a boss is taking the heat and has no choice but to act like a boss in the matter, now writing me up for a second time. he then responds to me, "you know i need you here but you are on the doctors **** list." i expressed anger in the way the MD handled the situation. my thought is, why couldn't the MD just pull me aside and say hey you know you let an unstable pt leave and expect that to never happen again and be done with it? but i think its something deeper, a genuine dislike or even hatred for me. instead, he believes that i am incompetent, not smart enough, and def not a good fit for dialysis.

However, i am very good at my job and have the ability to think critically, a key requirement of a good dialysis nurse. yes i know i screwed up, twice now, but I am human. I see my mgr make mistakes all the time. not necessarily in a sense of poor decision making, rather technical errors as in running the saline bag dry while giving meds and denying doing so. or leaving a tourniquet on a pts arm. "nope not me i know better. " is his attitude toward his own mistakes.

what should I do? should i start looking? plain and simple i think this MD is wanting me out of there and is forcing my boss to start putting me under the microscope. I am sick and tired of living in fear of royally screwing up again, only this time to be terminated. again, i have only been in dialysis for a year, the other 9 were med surg.

your opinions and suggestions would be helpful. thanks

[Emergent, RN]

My feeling is, yes, start looking at the job postings. You've gotten on the wrong side of a person with clout. Seek a job now, while you are still employed.

The mistakes you list don't sound like you are a total idiot. A patient has a right to leave. Patients aren't our prisoners. A fair share of dialysis patients are on the non-compliant side of things as it is. As long as you inform them of the risks, and chart appropriately, they have every right to leave AMA.

Regarding your chest pain lady, you did the right thing by calling EMS and having her sent to the ER.

Sounds like your doctor is egotistical, controlling, and has taken a disliking to you. Time to seek greener pastures.

[MunoRN, RN]

First off, don't be so quick to assume you actually did screw up. Unless they've been declared otherwise, patients are free to leave AMA. The doctor is free to come and talk to them if the patient feels like waiting for them, if not you legally can't make them stay. What the physician seems to be suggesting is that you were wrong for not committing a felony. How chest pain is dealt with varies by facility, but in general if you don't have the ability to evaluate and treat then they need to go somewhere that does, so again I'm not sure what they problem was.

I think the biggest problem is that your boss is failing to maintain the separation that usually supposed to exist between the medical chain of command and the nursing chain of command. Typically, the doctor is not your 'boss', nor are they the 'boss' of the nursing managers. In theory, when an MD gets out of line and goes to the nursing management, nursing management is supposed to remind them of how things work.

I think if you want to stay there, you're probably going to have to get some clarification so that you can avoid future conflicts. Although you make want to consider if you really want to work somewhere that the physicians run rough-shod and the people who are supposed to protect you are too weak to do so.

[Psychcns]

Agree with the two posters above. Start looking for a better work environment.

[lifelearningrn, BSN, RN]

I definitely agree with the other posters, this doc sounds like a real jerk. There are lots of positions out there for experienced dialysis nurses, I think it's time to start putting in applications. Good luck to you.

[jadelpn, LPN, EMT-B]

Sounds like your manager is a little short on the thinking skills..... "we can not and do not hold patients against their will" (and as an aside, I have seen patients get so worked up that they start pulling their own stuff out....THEN what would the MD have said...."you should have let the patient leave?!?!?!?!") back to the manager...."any patient experiencing chest pain needs to be evaluated by the emergency department, NOT by the dialysis department". (again, what if the patient coded....then the MD would say "you should have KNOWN to send the patient to the ED if they were c/o chest pain!) In other words, it is a poor choice that the manger did not remind the MD of POLICIES that are in place. You do not make this stuff up. However, should you not follow policy, then it is all on you....and what would the manager say then?

You may believe that the manager is your "friend" when in reality, these are process issues, and not due to your negligence. Perhaps if the MD would be available to CALL as opposed to email, then maybe the communication would improve.

Stop beating yourself up over this foolishness. Start looking elsewhere. The manager and the MD deserve each other.

[BuckyBadgerRN, ASN, RN]

I'm in the camp believing that you made no errors. MAYBE, this holier than thou MD needs to start accepting calls about critical patients instead of email. Personally, I've never heard of having to contact an MD by email only---ridiculous.

I'm also thinking be looking for your next position, like your supervisor said, you're on the MD's sheet list and he's looking for any excuse to pile it on you =(

[Ruby Vee, BSN]

It sounds as though the major issue is that you've gotten on the wrong side of this physician and the manager isn't willing (or able) to stand up for you. Have you tried communicating directly with this physician to work out your issues? If you like your job and are willing to try, it might work. If you try and fail, then start looking for another job.

While I'm not recommending this as an approach, I got ticked off at a nephrologist once who was being totally unreasonable -- patient making 5 cc of urine per hour. He called me at 0705 wanting 20cc of urine saved for him to spin down personally. At 0710 he showed up, wanting his specimen. I told him I couldn't extract 4 hours worth of urine in 5 minutes. He told me my attitude sucked, and without thinking, I snapped back, "Yeah, I'm sure the cardiologist ordered this nephrology consult just to **** us both off and ruin our days." He looked taken aback for about 5 seconds, and then he started to laugh. We got along great forever afterward. Sometimes humor works -- even unintentional, saracastic humor.

Another approach that worked was finding out that the pulmonologist with the nastiest attitude I've ever encountered was an avid sailor. I started approaching him every morning when he first wandered on the unit to say good morning. After he got over the shock about that, I started asking him questions about his boat. Eventually he started seeking me out when he came on the unit. We'd chitchat for a few minutes about our shared hobby, and then he'd ask me about any patient concerns. Months later, I overheard him reaming out an anesthesiolgist for "disrespecting the nursing staff when any (bad word representing the anal sphincter) knows the nursing staff works harder than anyone else in the hospital." Sometimes it takes approaching them as PEOPLE, nevermind that they were totally unreasonable about that situation in the past.

If you approaching the doctor and it works out for you, great. You've improved your job situation and don't have to find a new job. If you try it an it doesn't work, you can follow everyone else's advice and look for a job. Good luck with whichever.

[toomuchbaloney]

I agree with Ruby that we are each responsible for developing functional professional relationships with the medical professionals in our places of work. If you want to work there you will have to find a way to get along with the doc. They are just people...none of us is perfect.

Good luck.

[icuRNmaggie, BSN, RN]

You have not screwed up, it's a problem with their processes, and you don't deserve to be written up either. These people are not trustworthy colleagues and this manager is certainly not your friend. Be strong and do not let this renal guy make you his scapegoat. Start applying elsewhere.

[jrt4]

I agree that based on your description, you do not have the support behind you from nursing that I would expect in this day and age. It also seems that whatever organization you work for does not see nursing as an equal partner in care.

HOWEVER, I think its important to take a little personal accountability as well. Based on your description, some of your decisions have been a little dicey. Emailing a provider is not an appropriate means of communication even if the provider prefers that method. We have had to tell physicians that we cannot text them out of convenience, we are required to speak with the physician or page them. Also, sending a patient to the ED with chest pain from an outpatient center without dialing 9-1-1 is a major no-no. It sounds like the culture you are working in is not up to the minimal standards of care. I am not saying you are at fault but you need to be aware that you are working under your license and you need to protect yourself. The board of nursing is not going to care what the provider prefers when they take away your license. I would recommend looking for another job...not because you are on a s*** list but because you are working in an unsafe environment.

You may want to reference your state's nurse practice act and take your concerns to a higher level of nursing administration.

[SmilingBluEyes]

I am curious as to why your manager is your friend. A real boundary problem there. I also would say it's up to you to stick it out or not. I po'd our medical director a couple of times when I started out, learning the ropes. I never let it get me down; asked him what his parameters were and when and how I should contact him most efficiently. He seems to like me now, 3 years later. We do get along. But email is not efficient nor a good way to let an MD know about pt problems. That is where your manager should come in, clarifying this and communicating it clearly to all staff.

Seriously, your manager should NOT be your friend. If you feel that is the case, you need to move on.

Good luck.