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The Overly UN-zealous Hospitalist

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Nurses are by NO means physicians. The roles are very different, and yet they tend to overlap consistently in modern healthcare. Relationships are becoming strained and tired as demands grow. Small seeds of mistrust have been planted and are festering. Health care needs to SLOW DOWN and see the bigger picture. Without a pause, danger sets in.

Specializes in Med/Surg, Onc., Palliative/Hospice, CPU. Has 3 years experience.

The Overly UN-zealous Hospitalist

It's 0730 and bedside rounds with the night staff and day nurses have completed. Morning labs have been reviewed and the rush has begun. A new physician has strolled onto the scene with his coffee and nonchalant smile. "Good morning" he pleasantly addresses to the passers-by. We smile awkwardly as we rush to meet morning needs (of which are always so great). Orders start popping up as I read through each one. My brows furrow together as I see some oddities that make me uncomfortable. I head to the Doc box (where our physicians reside) and inquire on some of the new tasks I've been encouraged to complete via CPOE (online orders). "Are you sure that the patient with the COPD should truly be on beta blockers? It's typically contraindicated," or "I understand that you just ordered that fluid bolus on the patient with the low blood pressure, but they do have heart failure with renal failure, I think it may be in their best interest to decrease their Lisinopril." He looked at me with bugged out eyes and waved his hand dismissively. 'I'll look at it later."

Later came a lot faster than usual. I paged the hospitalist again to request orders for physical therapy, case management for skilled nursing placement, medication corrections, medication reconciliations from the night before and writing scripts for discharges. Text page after phone page and back again, I am back at ground zero with empty hands. So, I page again and again. None of these are returned. At this time I am allowed to STAT page. So I do. A monotone voice answers, "Doctor?" 'Yes?' Then I progress to mention what I've been paging about for the last five hours. 'I was already there this morning, I am leaving at three, so the night physician can take care of that.' I press and press. He hangs up.

My blood is starting to boil. Families have questions, patients want answers and yet I cannot bridge the gap. My charge is notified and she does what's in her jurisdiction. Still no response, no meds corrected, patients are growing more frustrated and families are now angry. I page and page, the end of shift comes. I explain my dilemma to the night nurse who gives me a talking to, seeing as I "sat on these issues" all day long and "didn't do anything about it". Needless to say, I'm speechless and defeated from the hard work I attempted, and was yet spat on for trying.

Unfortunately, the next day was the same. I was told to fix things myself by this doctor, or to page someone else to take care of the orders because he was 'just too busy'. Despite his busyness, despite his idea of workload and time management, I was trying to explain that a lack of treatment for these patients would increase their hospital stay as well as (in the end) screw us with reimbursement services if we did not provide. Another blank stare, 'I have to go' was all I got.

I watched those white coat tails billow behind his short frame as I felt my trust wither and flilt away with him. I did the only thing I knew, I contacted the chief of medicine. Seeing as my charge nurse was aware, at the time was without management, the next best thing was the Chief of Medicine. He showed up in person not even thirty minutes later. He corrected what was missing, adjusted the meds that fell short, or overtreated in dangerous ways and then thanked me for my diligence.

I was pleased for the action that had been encouraged from my so-called 'tattle-taling' but I still felt as though I had accomplished nothing. It shouldn't be the nurse to correct your dangerous orders. Yes, we are a checks and balances group. It is often a good thing to have more hands in the pot in order that things can get done. But when issues arise and your choice is to act to sit quietly, sit quietly should not be the option you choose.

For nurses, this is a frequent occurrence. I know that we are all imperfect and things often need fixing, titrating, or medications are given because of a 'greater good' outcome. But it's a lack of action that will continue to endanger our licenses, our ability to assist patients in their ultimate care and to act as an advocate.

If we speak up and suggest and are incorrect, teach us. Otherwise, we look to you as doctors to act and please address concerns and issues as they arise.

It's why we are all here, isn't it?

Molded and formed by a drive to live up to her own expectations, Jacquie ultimately thrives on creativity. Dreams, testing her limits, and traveling all fuel the fire, thus leading to adventures of the past and yet to be: http://misadventuresofanurse.blogspot.com/

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51 Comment(s)

xoemmylouox, ASN, RN

Has 13 years experience.

Sadly this is nothing new with some physicians. The question is what will the hospital do about it? Will they punish the MD (prob. not), will they even speak to that MD about his behavior (maybe).

calivianya, BSN, RN

Specializes in ICU.

I saw a lot more of this in my first job. I see almost none of it now. The difference (at least for critical care) is having an intensivist. I will never work anywhere where I have to call the hospitalist service about my patients again because there are no intensivists if I can help it.

I actually kind of feel sorry for the hospitalists; I'm sure their patient loads are unmanageable. Then again, it is what they signed up for.

Was it a cardioselective beta blocker? Beta blockers aren't an automatic no-no for COPD.

What type of renal failure? Decompensated CHF? Sometimes CHF patients can tolerate 250-500 boluses. ACE inhib used for renal protection in CKD III/IV?

I get your point, I am just thinking of what would be running through his head

Are you sure that the patient with the COPD should truly be on beta blockers? It's typically contraindicated,” or I understand that you just ordered that fluid bolus on the patient with the low blood pressure, but they do have heart failure with renal failure, I think it may be in their best interest to decrease their Lisinopril.”

If you said either of these to me the way you have written it, I would try to politely dismiss you as well.

In your article you come across as a know-it-all who knows too little. It's too bad you think you did the right thing.

Jacqueline.Damm

Specializes in Med/Surg, Onc., Palliative/Hospice, CPU. Has 3 years experience.

Are you sure that the patient with the COPD should truly be on beta blockers? It's typically contraindicated,” or I understand that you just ordered that fluid bolus on the patient with the low blood pressure, but they do have heart failure with renal failure, I think it may be in their best interest to decrease their Lisinopril.”

If you said either of these to me the way you have written it, I would try to politely dismiss you as well.

In your article you come across as a know-it-all who knows too little. It's too bad you think you did the right thing.

I wrote the article in the manner you quoted above in order that the entire situation could be encapsulated in a matter of sentences. The additional information about the beta blockers and the fluid boluses was to inform those reading this article (if they aren't used to these types of medications or situations). I am not here to toot my own horn or try to look like I know more than physicians. With that said...

I do no boast that I know more than the next person, any CNA, RT, MD, NP, PA (and the list goes on). I actually find my job extremely humbling because you can never know everything. In nursing there is always a learning curve. Which brings me to my next point...

For the issue related in this article, hospitalists in the in-patient setting are being given more and more patients (a ratio that is entirely unacceptable). So do I look at things a couple of times, you better believe it. Do I double check my orders? Of course I do! Do I question things? Yes! I absolutely do- in a respectful manner. The more communication between professionals, the better. I've approached situations in the past where I asked if something would be appropriate for a patient. When I was told no, the physicianed utilized that instance for a teaching moment. This is SUPER important for all clinical people involved in patient care. This is how we can grow as nurses. I will never be able to remember everything I read while in school, or every med, or every disease process. But as long as I'm given the chance to learn from a situation, I (like most people) will eat it up! When you think about it, when people's lives are at risk and you feel like you have a part of the puzzle that may assist in healing or helping, you want to bring it to the table. Am I wrong?

Regardless, the point I was trying to make, of which I feel that you may have missed (maybe not, I'm not sure) was that there are times when care providers get frustrated, lazy or downright worn out. These are the times where things happen, things get missed, and no one is above or below that happening (including nurses). But it is up to those providing care to mention it in a therapeutic way so that issues can be addressed. When patients are getting (in what nurses may feel as) neglected, they have every right to speak up and go up the chain of command. Being at the bedside makes us the patient's advocates to a level that many outside of this field have a tough time grasping.

With that said, without checks and balances in healthcare, and with the growing responsibilities for inpatient caregivers, I fear that issues will continue to grow if we don't lend each other a helping hand.

If I'm wrong in something while at work I LOVE the teaching moment. I WANT to be a better nurse and I WANT to learn more. We have that gift in this profession. We can always progress.

From your statement above I feel that you will believe as you wish in accordance with this article I've written, and you will take whatever tone you want to away from this piece and my response. I only hope that I may have clarified what I've interpreted as your misunderstanding of my point as well as your assumption of my "know it all" approach to the situation. Your experience in care may or may not be different from my own. What I can say is that in the high acuity unit where I was working at the time of this story, the issue of a hospitalist that was seemingly uninterested in expediting patient care would make any nurse want to move at hyper speed to fix a problem before it became a code-- all for the sake of saving the patient harm. I truly don't feel like there's anything wrong with that.

I don't know about you, but code blue is definitely not my goal on a day to day basis when my feet hit the floor to start a 12-hour shift.

Prevention is key to ultimate patient safety.

Thanks for the read.

Edited by Jacqueline.Damm
More info

I (as an NP) make it a point to LISTEN to the floor staff, as they are with the patient ALL DAY and I am not. If I disagree with their opinion, I tell them why I am making the decision I am making, and then I tell them to call me if any deterioration in condition. I respect RNs, LPNs, and STNAs (I often have STNAs come to me with their concerns about patients, and I LISTEN to them too - they are all my "eyes and ears.")

Well written scenario that takes me back to my days in the CCU....ugh! I remember just putting out fires with the hospitalist but never getting all the orders I needed. More concerning though was the issue that many of the orders were not appropriate, especially in intensive care. It's important to talk to your manager and the hospitalist liaison if there is a physician that is not competent to manage your patients. Hospitalist come and go and there will always be a few that lack the knowledge and skill for the job. Speak up!

I bet people love working with you.

It's exactly this kind of attitude that does not belong in nursing. She gave a polite well reasoned answer to your response, she wasn't rude yet you take it to a personal insulting level. I would be greatful to work with a nurse that does her due diligence in making sure her patients are taken care of.

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 10 years experience.

I bet people love working with you.

I bet RNs love working with you.

FranEMTnurse, CNA, LPN, EMT-I

Specializes in LTC, CPR instructor, First aid instructor.. Has 24 years experience.

So many physicians make so many mistakes, even lethal ones, and yet the nurse gets the blame. The physicians are the ones who gets the big bucks. True, some RNs do earn a good wage, but not enough to take all that you mention. It's a shame that the nurses have to be subjected to such nonsense. You nurses are all heroes who care as you do. IMHO, you deserve a medal.

Another thing is Physicians should not be allowed to lay so much responsibility on the nurses' shoulders. Your licenses are treasures to protect. I believe Physicians should be held accountable also. :up: Kudos to you dear, for being so eloquent and thorough. You probably save numerous people from either dying or getting extremely ill.

dudette10, MSN, RN

Specializes in Med/Surg, Academics. Has 10 years experience.

So many physicians make so many mistakes, even lethal ones, and yet the nurse gets the blame. The physicians are the ones who gets the big bucks. True, some RNs do earn a good wage, but not enough to take all that you mention. It's a shame that the nurses have to be subjected to such nonsense. You nurses are all heroes who care as you do. IMHO, you deserve a medal.

Another thing is Physicians should not be allowed to lay so much responsibility on the nurses' shoulders. Your licenses are treasures to protect. I believe Physicians should be held accountable also. :up: Kudos to you dear, for being so eloquent and thorough. You probably save numerous people from either dying or getting extremely ill.

Now, let's not swing all the other way. There is a happy medium between providers thinking nurses should keep their mouths shut and the stereotype of "hero nurses with capes, swooping in to save pts from providers' mistakes.

I'd be happy if providers and nurses were recognized for being on the same team with a common goal and actually speak to each other as such.

It's exactly this kind of attitude that does not belong in nursing. She gave a polite well reasoned answer to your response, she wasn't rude yet you take it to a personal insulting level. I would be greatful to work with a nurse that does her due diligence in making sure her patients are taken care of.

Am I the only one who thought the original comment was sincere???

Honestly, every time I see someone on a chat board castigate a nurse for how they spoke to a physician, I cringe. I worked in the corporate world for about 15 years before becoming a nurse. I saw a lot of dysfunctional workplaces. I saw people--even (especially) upper level management make ego-based decisions that were bad for their companies. I saw a lot of gender discrimination, as I was in a location that was largely still stuck in the 1950's when it came to gender roles. But I NEVER saw anyone chastised for not sufficiently stroking someone's ego when addressing an issue that they thought really needed to be addressed. Most physicians can or should be able to recognize a patient-related concern brought to their attention as simply that, and not an assault on their authority or knowledge. We do physicians, and even more so the overall nursing culture, a grave disservice when we perpetuate the notion that their egos are too fragile to handle valid concerns because we have not been deferential enough. It is that culture that contributes, in my opinion, to lateral violence in nursing as well.

It's not about earnings. It's not about education. It's not about gender. It's about simple respect for human beings.

Ok so there are some positive and a few negative remarks here.

I didn't read any tone into what you wrote, but it seems like persistence paid off. I have had too many occassions to call our medical director for orders when various doctors refuse to return calls.

What I learned to be very prepared with all the questions that I may have prior to speaking with the docs. And, I let all the other nurses on the floor know that I am calling doctor so-and-so if they have orders they may need from him/her. I find that this expedites the process and the docs call back faster because they KNOW that our facility or floor of nurses are ready with all the questions he/she may have (ie labs, vitals, etc.) prior to his return call and without his/her prompting (what are their vitals? Potassium levels etc).

And I persist. I do not allow half answers and I repeat back orders or question ones that do not seem correct. What I get from that is doctors that do not rush me off the phone and respect when I call them or question them. They understand that it is the patient that is the priority and know that I will have their backs.

Best of luck to you.

It's exactly this kind of attitude that does not belong in nursing. She gave a polite well reasoned answer to your response, she wasn't rude yet you take it to a personal insulting level. I would be greatful to work with a nurse that does her due diligence in making sure her patients are taken care of.

She didn't give a polite, well reasoned anything. I have been working in healthcare almost 30 years, and I have seen nurses like this come and go. They are generally one of two types. 1) They quietly sit and stew about everything they perceive is wrong, or 2) They go after everybody, all the time, for anything they perceive is wrong. They are never good team players.

Now if she had said to the hospitalist, "Did you mean to restart Mr. Bill Board's metformin today, or hold it for a full 48 hours after his cardiac cath?". Or "Mr. John Jumpingjack's Lantus is still on hold from surgery, but he ate all of his meals yesterday, do you want to restart that for tonight?"

Neither of the examples she gave would or should be concerns. And I imagine she feels that physicians don't listen to her because she warns of things that aren't concerns. So it would be pretty hard to take her suggestions seriously.

Are you sure that the patient with the COPD should truly be on beta blockers? It's typically contraindicated,” or I understand that you just ordered that fluid bolus on the patient with the low blood pressure, but they do have heart failure with renal failure, I think it may be in their best interest to decrease their Lisinopril.”

If you said either of these to me the way you have written it, I would try to politely dismiss you as well.

In your article you come across as a know-it-all who knows too little. It's too bad you think you did the right thing.

I find this disturbing that you would put your own ego over the health and welfare of the patient. If you or any doctor is in this field for accolades or to feel higher than thou, it would be more appreciated if you would find another line of work. That way, those who do have their patients best interest at heart and are truly advocates can get the care that they need without the ego tripping.

I bet people love working with you.

Ugh, you are that type...I bet people absolutely love working with you as well. I'll bet no one can tell you anything...speaking of knowing it all. I read the original post and immediately got what the author was saying and did in no way feel like she was being a know it all. You missed something in her post and when she goes to further clarify her position you come back with "I bet people love working with you." Really? That was a very mature response.