Standing up to MDs - consequences?

itsnowornever, BSN, RN · Jan 17, 2013

It's all about communication and if you are able to get what you are thinking across. Just the tone of your post makes me think you may have to learn this lesson first.

LouisVRN, RN · Jan 17, 2013

i don't think so. Although this has several answers. First of all imo you have to develop a good relationship with the doctors, and also deliver good quality care to their patients. Second you have to be willing to explain your thinking to the doctors, especially when working night shift. Third you have to know when to not take no for an answer. Fourth, it is always ALWAYS important to document your conversations with physicians, but especially so when you disagree with the physician's course of action.

Under no circumstances do you tell a patient that their physician is wrong and to seek a second opinion. You i'm sure would be fired. You can however say, I can see you're concerned about xx, it is within your right to request a second opinion if that will help make your decision easier/put your mind at ease, etc. But it has to be the patient's choice, you can only ensure they know that they have that right.

MedChica · Jan 17, 2013

Hi all, my very first post, so hope I'm in the right place.
I am a 30 year old mom to 7 (!!!), former Philosophy major (what does anyone do with that anyway? :)) who has spent the last 3 semesters doing core req so I could hopefully get into an eve/weekend AS program. I did, and I'm supposed to start in 10 days.
So it's a good time for my personal life to cause me serious doubts about my career choice. I've had multiple awful experiences with OBs, and am currently going through another. I won't bore you with details but basically the OB I'm currently seeing is completely wrong about something. I mean wrong. No questions, just wrong. In talking to one of her nurses today, she basically just kept feeding me the OB's line - "the doctor says these results are normal" while I rattled off studies, sources and general common sense saying it was NOT normal. She got very quiet, said she'd talk to the doc, called me back saying doc is insisting she's right and she'll "deal" with me at my next appt.
Did the nurse know enough to agree with me? I don't know. But the whole thing has made me wonder if I will be able to KEEP a nursing job in the current healthcare system. If I'd been that nurse I would've chewed that OB up over such a negligent error, I would not have given a patient wrong information, I would've said "You're right, and if I were you I'd get a second opinion."
Can I do this job with such a mindset? Does standing up to a doctor when they are clearly wrong get you fired? Or reprimanded? What do you do when you KNOW a doctor is wrong and even after giving your opinion they proceed on their merry way?
I appreciate any insight as right now I'm wondering if I should withdraw.

Whenever I was snippy with a provider (physician, NP, PA), it was always in defense of myself. That's a seldom thing, though.

I don't know of too many nurses who could be called 'pushovers', though. Perhaps others differ but I can't. Not the nurses that I call family or work with. Hell, no.

I mean, even when I worked in another section of the hospital, the nurses were always 'no nonsense' looking. They all had that 'look'.

Not a 'mean' look. Not exactly. It was... more like a, 'We're really not going to entertain whatever it is that you're trying to dish out.' type of demeanor. LOL

'Specially the ward/ICU nurses.

I had an idealistic perception of Pedi/Nicu nurses -- until I did maternity/child clinicals...LOL 'Baby nurses' are pretty hardcore.

But, no. You don't just run about chewing people out. That's tacky and unprofessional. More to the point, you don't really have to.

Our providers are busy people. They're human. We're all busy and errors in judgement do occur.

It's not like they sit on high and just hand out orders, though. The provider will listen to your input. Most times, they will ask for it. "Here's what occurred ______and here's what I did in response _______ but I noticed that the pt/resident was ______ and I believe it's because they're on ________. So I was thinking that the pt might need/could use/d ______"

Then, the provider will say, 'Yes, we could _______" or "No - let's not _________. Let's __________."

Sounds like a plan.

At least that's how it is where I've worked, so far. They trust our judgement and our word. Our providers are always open to suggestion. They have to be. Who the heck spends the most time with the pt/resident? Who the heck would know the pt/resident best but their nurse? LOL

What happened in your situation? I have no idea. No specifics but it seems different from what I've described above.

...especially if she had to repeatedly tell you 'what the doc said'...?

...and the doc told her that she'd 'deal with you' on a later date? (has this scenario happened before?).

...and you have a track record of getting into ******* contests with your OBs.

I can only imagine. LOL

The situation doesn't read like the nurse had a problem 'standing up to' anyone.

fyrestar · Jan 17, 2013

Thanks for your responses.

Obviously I'm emotionally involved in this situation so naturally having a stronger reaction. Perhaps I just need to avoid OB/Maternity at all costs since I don't believe most OBs practice evidence-based medicine and would rather work with MWs.

Basically, I am having a likely miscarriage, absolutely certain of my ovulation date and had an ultrasound at 7w1d. Baby measured 5w4d (a whopping 11 days behind) with a low-normal heart rate of 126 bpm. My request was for a follow-up u/s to recheck growth and viability. The OB said "Everything looks normal." That's the line the nurse repeated over and over. I at first figured the OB merely assumed I, the silly uninformed patient, miscalculated my LMP/ovulation date, so I explained to the nurse that short of an immaculate conception, it was physiologically impossible that I was anything less than 7w0d at the u/s. It would also mean I conceived 3 days AFTER my positive test. I explained that measuring 11 days behind was not "normal," that an u/s at this gestation was +/- 5 days, maybe 7 at a stretch, but 11 days put up red flags to me for a chromosomal issue and likely miscarriage and certainly warranted follow-up.

The nurse went back to the OB with this info.

She came back saying the doctor said she "absolutely would not" order any follow-up u/s, that the u/s was normal and she'd deal with my concerns at my next appointment.

I told her to cancel the appointment.

Ironically, I started bleeding a couple hours after I got off the phone, and will probably make a trip to the ER today since I'm currently without CARE provider.

I don't know what the nurse's thoughts were - did she really believe 11 day growth restriction in the first trimester could be called "normal"?

But I know I would not have been willing to call my patient back with that info. I would have at least said, "The doctor thinks right now everything looks good, but I understand why you're concerned. Maybe the doctor will be open to ordering an u/s at your appointment, and if anything changes - bleeding, pain - either give us a call back or go to the ER."

I just want to make sure if the time comes when I'm being asked to do something, say something, inject something that's incorrect or potentially harmful I will be able to stand up for my patient without getting kicked to the curb.

Thanks again.

HouTx, BSN, MSN, EdD · Jan 17, 2013

First of all - SEVEN KIDS????? Wow! You should be telling that OB what's what. Hats off to you hon. I don't think that there is anything you can't do at this point. World domination could even be a possibility - LOL

Second of all: if I do not feel as though my relationship with my personal physician is truly a 'partnership' I fire her. Have done so on more than one occasion.

But the situation you are describing is in an office, right? In this case, the physician is actually that nurse's employer.... dicey situation. Contradicting or arguing with your employer can get you fired. Don't expect any of them to be your ally. Is the nurse an RN or LV/PN? There are big differences in scope of practice and knowledge base.

From a legal perspective, there are also state-to-state differences in how the nurse's 'duty' is defined. In Texas (yep) we have a legally defined "nurse patient duty" that has been in effect since the early 80's. It means that we (RNs) have a legal duty to the patient that cannot be trumped by the physician-patient duty. That prevalent "captain of the ship" doctrine that is used elsewhere as a model for ensuring that the physician is always in charge. . . does not work here. So, if I am approached by a patient who wants to know different treatment alternatives & I know those alternatives - I am legally bound to inform her, no matter what the physician thinks about it. This does not mean I can trash the physician or undermine her reputation or relation with the patient. As a Tx RN, I am also legally bound to initiate further actions (chain of command) if a physician is failing to act even though (based on my professional judgement) they need to do so.

It's a delicate balance. Nurses with greater expertise (specialty certifications, more education, more years, etc.) are accountable at a higher level than newbies. But if you need that job, you're not going to do anything to jeopardize it.

fyrestar · Jan 17, 2013

You make some great points. I have a lot to think about, unfortunate this personal crisis had to come up this close to starting...hard not to let it cloud my judgement, but I'm trying.

I would definitely be looking to work in a facility (probably night shift, while said seven kids are asleep LOL!) so maybe my fears don't apply so much. I'm sure I can act courteously even when I feel I'm being treated as inferior, as long as I can still protect my patients in some way. I've been in the patient role so much, especially with a kiddo with special needs, it's hard to see how little credit nurses are given for their knowledge and care.

Thanks again :)

monkeybug · Jan 18, 2013

Thanks for your responses.
Obviously I'm emotionally involved in this situation so naturally having a stronger reaction. Perhaps I just need to avoid OB/Maternity at all costs since I don't believe most OBs practice evidence-based medicine and would rather work with MWs.
.

First of all, sorry for your loss, if that's how it turned out. The loss of a pregnancy is sad. I was a labor nurse for many, many years. I worked with OBs and midwives. The majority of OBs I worked with DID practice evidence-based care and really did care for their patients. And I never had to listen to an OB chant for EIGHT.SOLID.HOURS. "You are a birth goddess. You must have delivered many babies in your past lives." I had to listen to that sloppy crap from a MW for a whole shift. Yes, you probably should avoid L&D at all costs, unless you can find a free standing birthing center to work in, because no doctor is going to appreciate being told that they are making up crap as they go. There are good MWs and bad MWs, there are good OBs and there are bad OBs. You sound like you got one that didn't suit you, and the best thing for both of you was probably cancelling that appointment. Also, 126 bpm is absolutely normal. Not "low normal" just normal. I have seen some babies that run in the 150-160s all the time (or at least all the time that we monitor them), and likewise I've seen babies that run in the 110s. I was always taught that anyting 110-160 is normal.

As for learning to advocate and still keep a job, it's a fine line you learn to walk. I've always found that if nothing else works, I treat it as a learning situation. I ask the doctor to explain the rationale to me so that I may understand it. It's not threatening, you get their thought processes behind the situation, and you sometimes learn something valuable in the process.