Shocked by MD attitude

  1. I'm a new grad NP on my first job, so am on a steep learning curve in a rural primary care clinic. A female patient came in with her children and hubby for an urgent appointment. She had seen her regular doctor the day before for what she thought was a cold or flu, but now reported she felt worse and was jaundiced since this morning. She looked really sick and as I began the physical exam, she began crying due to anxiety and just feeling horrible. She was slightly jaundiced and had abdominal tenderness over her entire abdomen. The patient and her husband were also upset because when they saw their regular MD the day before, just as he was leaving he said her annual labs indicated some liver issues, but that they would have to come in for another appointment to discuss those (LFTs elevated twice the high end of normal). While the patient was in the bathroom leaving a urine sample, her husband told me he was thinking of taking his wife to the ER. He also said he knew his wife was an emotional person (which I remembered from the one other time I saw her), but he strongly felt there was something really wrong. He wondered if he should take her to the ER. My honest response was he knew his wife better than me and he needed to trust his gut feeling. I also felt something was seriously wrong.

    I have a good relationship with this MD and I later reported to him what had happened. to my astonishment, he was upset because "it make him look bad" that I had said to go to the ER! He ranted on and on, said her liver issues were trivial, they were (several four letter words) and so on. He never asked how she was doing. I asserted that 1) I didn't want him blindsided if they complained about him (he doesn't have the best interpersonal skills), 2) I couldn't forbid them from going to the ER, 3) we are in a rural area and if I had ordered more tests, it would have been a 48 hour turnaround and 4) in my clinical judgment something was really wrong with her. That shut him up.

    The next morning, as I walked into the office we share, first thing the MD said was ranting about that patient and he bet there was nothing wrong with her and I should call her. A couple hours later during a break, I did call her. She was glad I called and said she was admitted to the hospital and still there; a lot of tests had been run and no diagnosis had yet been made. When I reported this to the MD, he was visibly surprised, but then began ranting again! I was shocked and dismayed. Again, he didn't ask how the patient was doing. If the hospital admitted her, this clearly was not a trivial issue.

    My school taught us to trust the patient and their family if they felt something was seriously wrong, and also to trust our own gut. This is because a toddler had died in that hospital when staff ignored the mother's conviction that something was seriously wrong with her child, prompting a vigorous quality improvement program for the hospital and associated schools.

    I feel I did the right thing, but was very upset by this MD's attitude. If the roles had been reversed, my first concern would have been for the patient. Is his attitude common?
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    About FullGlass, MSN, NP

    Joined: Dec '17; Posts: 471; Likes: 668

    33 Comments

  3. by   TuxnadoDO
    If he truly reacted the way you say, then he sounds like a jerk. But...did you ask him how he would have preferred that you handle the situation? Did he want to be consulted before sending a patient to the ED?
    I won't comment on the clinical aspect, since I don't know which labs were elevated or what her symptoms were.
  4. by   Oldmahubbard
    I am Psych, but this lady would have scared me. I would have definitely told her to go to the ER.

    LFT's 2 x normal shouldn't cause acute illness, or jaundice, so something else was certainly going on.

    My only other comment is that we tend to believe things we have personally witnessed much more than things we only hear about from someone else.

    And you are a "lowly" NP, still new in that position.

    Now if it turns out she has something life threatening, he'll be eating crow, but he probably won't say another word.

    And yes, I have seen things like this.

    Turf war. As NPs we are often doing the same thing as physicians, but for half the price, on average. When we outshine them, which sometimes ain't hard, it really looks bad.
  5. by   MikeFNPC
    It's easy to get in a rut when you've been a provider for a while. Your fresh eyes is just what that patient needed. Kudos to you, forget what the MD is saying. He needs an attitude adjustment. Good job!

    Mike
  6. by   traumaRUs
    As to the physician - I have had a few who have ranted and sworn at me. However, I am old and mean and I tell them (very quietly) that when they can control themselves, I will be glad to discuss the issue as professionals. Then, I walk away.

    When I was a new APN, there was a doctor that I worked with who would throw me under the bus, get in the drivers seat and run over me a couple of times just to make sure I understood my position in life. However, he was not well thought of as a physician or person and ended up leaving the practice.

    I spoke to another physician whom I trusted and he gave me some pointers on dealing with physicians like this:

    1. Realize they have interpersonal issues. Sometimes its best not to give too much info. So, in this case, I would say, "the husband wanted his wife seen in the ED." And end the conversation there. As you stated, you had nothing more to add as the physician already knew about the test results and he deemed them "okay."

    2. If a physician or any colleague starts to get out of control, stop them by making good eye contact, speak very softly and tell them this behavior is unacceptable. Then leave the situation. There is never a reason to tolerate an out of control person.

    3. Always keep your focus on your patients' well-being. YOU were the one seeing the patient the next day, not the physician. In instances where I have contacted a physican and felt the patient was more ill then what the physician thought, I always state, "in seeing the pt today, they appear acutely ill and have changed from when you last saw them due to (and then name the new symptoms), "shie is now jaundiced with sceral icterus and diffuse belly pain." Very few physicians that are not seeing the patient with you will disagree with this strategy.

    4. As to making him "look bad" oh well. Its not about US, its about the patient.
  7. by   LibraSunCNM
    It sounds like you handled everything clinically well. I recall from your past posts that you are a direct-entry new grad, so I'm guessing you don't have a ton of experience with physician relationships---seriously, don't let this upset you. Yes, the doctor should care more about the patient's well being, but the reality is that many doctors care more about their egos than their patients (this is not unique to doctors by any means, but if you're an NP it might be helpful to cop to this quickly). Keep focusing on your practice, and know that some of your colleagues will not practice the same way you do. Don't let it get to you.
  8. by   JudyB88
    I find it amazing that other NP's and the DO tactfully criticize you. You gave enough symptoms and gave him more leeway than I would have with 34plus years as an RN (not an NP). As a DON I often encourage my nurses to advocate for the patient FIRST! Don't worry about stepping on toes. If your impression was wrong and she is fine (which anyone with the most basic nursing education knows she is NOT) then better to say sorry than join in on someone's downplaying a serious medical issue. If this were his wife/mother/ child, he would not have waited a minute and demanded the appropriate follow up of additional tests. Your patients deserve the same. PLEASE do not fold to such arrogance, it is what kills people. Honestly, you are exactly the type of practitioner that we want and need. How dare someone say you just want to "rant" about your "boss" (that word alone tells me the mindset). He is not your boss but rather your colleague and you need to be in an environment that you support each other and make each other stronger and better, not worried about a hierarchy. GOOD FOR YOU!
  9. by   mmutk
    I agree with TraumaRus, don't give too much info because that opens you up for criticism. Hey I saw that patient again today, she was jaundiced and complained of worsening belly pain. Her husband wanted to take her to the ER, so he did.

    End of story. Not much you can complain about there. It's not like you did a direct admit.
  10. by   JudyB88
    Great feedback TraunRUs
  11. by   TuxnadoDO
    Quote from JudyB88
    I find it amazing that other NP's and the DO tactfully criticize you
    Excuse me? I did not criticize. I did ask an additional question, which I find missing from many of the personal work stories posted on here. Over and over I see people posting stories of negative interactions with other nurses and physicians, and in those interactions they never ask "well what would you have me do?" "Why did you need this right away," "why was it wrong to do this?" Etc.
    Communication is extremely important our industry and it's often lacking. Anyone can dig their heels in, react, get pissed off, be proud. A skilled communicator questions the root of the disagreement and reaches across the aisle to understand the other person.
  12. by   FullGlass
    Quote from TuxnadoDO
    If he truly reacted the way you say, then he sounds like a jerk. But...did you ask him how he would have preferred that you handle the situation? Did he want to be consulted before sending a patient to the ED?
    I won't comment on the clinical aspect, since I don't know which labs were elevated or what her symptoms were.
    Thank you for your feedback. I want to clarify he was ranting about the patient more than me and this MD does respect me. I did ask him what I should have done and his response was to order more tests or just have them wait to see him again, which I calmly told him that in my clinical judgment was not appropriate given what I observed. AST and ALT twice the high end of normal, tenderness/pain over entire abdomen on palpation, slight jaundice of abdominal skin, patient and her husband reported jaundiced sclera, but patient was crying so all I saw was red sclera. This MD is new to the clinic and came from an upscale big city hospital. We are in a rural area and getting more tests, depending on the tests, would have been a 48 hour to days long turnaround. Honestly, if this had been my spouse, I would have taken them to the ER.
  13. by   FullGlass
    Thank you to everyone for the feedback. Yes, I am a new grad NP w/o RN work experience. However, I am also middle-aged and was previously a business executive, so I am not easily intimidated.
  14. by   GoodNP
    I'm just being candid, and I mean this constructively. Referring patients to the ED is at times absolutely necessary, but as I'm sure you already know, it is undesirable when it is not necessary. You have described yourself as a new NP, so I gather you are building your experience base. First the first year or so, I recommend discussing cases with your MD or a peer before sending them to the ED. It is a great way to learn.

    You ask if his attitude is common. Yes and no. Cursing and yelling are not common, but insecurity and defensiveness are. He might be a tad bit insecure. Although I see no evidence that you did anything untoward, just keep it in mind that he has a low threshold for what he perceives makes him "look bad". For example, you could say something along the lines of "I explained that her liver enzymes were only mildly elevated and could be due to something like FLD, etc..."

    One last thing, if he continues to give you static, explain that your goal is to provide safe patient care while protecting the interests of the clinic as well. You are looking out for him too. So in an effort to collaborate, request feedback on how you could have handled the visit differently and give his feedback serious consideration. If he feels you are looking out for him, then he will also look out for you. (Please don't read into this "at the expense of the patient".)

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