This MD culture

[darren_callcareer18]

I just want to vent out a little because I had to call a doctor at 7PM because my patient was complaining of alot of things. First chest pain that radiates to her back .They did trops, X-RAY and ECG they were all negative. However, at the beginning of my shift she was complaining of numbness and tingling on her face all morning and reported to the MD since potassium was low. He ordered for a replacement to that. However all vitals were normal.

Few minutes after that I was called by my supervisor and was told not to call the doctor and to call her first. I don't know, but I feel like that my call to the MD was not valid.

I just want cover myself because what if this patient complaint was really something? Then they would asked me why I did not do something after finding out the patient report.

Just kinda discouraging to start my 12 hour shift.

[Jory, MSN, APRN, CNM]

On 3/3/2019 at 8:12 AM, Davey Do said:

You never know why Docs will do some of the things they do.

One time that really stymied me was when I worked in surgery. I was scrubbed in with a podiatrist doing a bunionectomy and everything went well. Afterwards, the assistant supervisor approached me and said, "Dr. C doesn't want you to scrub in on any more of his surgeries". I asked why and she said he gave no reason.

I had friendly chats with the Doc about running shoes and this and that in the past and I thought we had a very pleasant relationship.

That was over 30 years ago and I was much more sensitive and had a need to be liked, so I was kind of hurt.

I have since learned and accepted that we all have our foibles, idiosyncrasies, and shortcomings and I don't have to like it, I only have to accept it.

To me...this is a bigger problem.

Hospitals should not be catering to the ego of these physicians and honoring stupid requests. A request should have to go through the OR manager and if it's not valid, it should be declined. I cannot stand docs with a God complex. He had someone else to tell you b/c he was too much of a coward to do it himself.

[Hoosier_RN, MSN]

On 3/3/2019 at 4:12 AM, Davey Do said:

Follow Wuzzie's advice, darren, and make sure you don't get your smiles mixed up!

Wuzzie knows about head spinning:

I love it!!!

Now, I’ve been a house supervisor in a small hospital years ago. After a while, house sups were asked, by the doctors, to have all calls between 10p and 6a go through us. Why? Because drs were getting 40-50 non emergent calls each night. While the drs didn’t mind true emergency calls, the calls that weren’t made it hard. Before anyone jumps and says that’s their job, yes on call is for urgent presenting issues. Not calls for, say, family wants to know d/c plans (at 2 am). And yes, I’ve known of a couple of nurses who would do things like this.

[JKL33]

^ A ton of those calls could have been mitigated with appropriate use of PRN orders, though, too.

And I still maintain that the issue of RNs who need guidance should be handled individually. No one seriously improves from the 'only supervisor can call route.' It's the lazy way out and does absolutely nothing to develop any individual RN.

[Hoosier_RN, MSN]

^^^I agree. And it usually ended up that the “idiot calls” still happened, because those nurses thought it wasn’t them. It just slowed down serious intervention calls. One of the reasons I don’t work in the hospital anymore. Knee jerk reactions abound!

[KatieMI, BSN, MSN, RN]

4 hours ago, Jory said:

To me...this is a bigger problem.

Hospitals should not be catering to the ego of these physicians and honoring stupid requests. A request should have to go through the OR manager and if it's not valid, it should be declined. I cannot stand docs with a God complex. He had someone else to tell you b/c he was too much of a coward to do it himself.

The problem is that it is that physician who brings $$$$$$ to hospital. OR manager, nursing supervisor, that very nurse - they bring, as far as The Powers concerned, nothing. Even more, $$$ has to be spent on them. And they are dime a dozen, while a successful surgeon is, well, a rare thing which has to be catered to.

Love it or hate it. That's the fact of life as it is right now.

[Kooky Korky, BSN, RN]

On 3/3/2019 at 7:12 AM, Davey Do said:

You never know why Docs will do some of the things they do.

One time that really stymied me was when I worked in surgery. I was scrubbed in with a podiatrist doing a bunionectomy and everything went well. Afterwards, the assistant supervisor approached me and said, "Dr. C doesn't want you to scrub in on any more of his surgeries". I asked why and she said he gave no reason.

I had friendly chats with the Doc about running shoes and this and that in the past and I thought we had a very pleasant relationship.

That was over 30 years ago and I was much more sensitive and had a need to be liked, so I was kind of hurt.

I have since learned and accepted that we all have our foibles, idiosyncrasies, and shortcomings and I don't have to like it, I only have to accept it.

The first time I circulated on my own, the Sup told me afterwards that

Dr. Butthead said I wasn't ready to fly on my own yet. I asked why, looking for some honest and helpful feedback, believing that I was perhaps not ready, since I was new, and figured I could learn something. No feedback was given except to switch me to Cysto, which I hated. I thought it was pretty messed up. And I was hurt and angry and frustrated. Life did go on.

[KatieMI, BSN, MSN, RN]

Doctors rarely say "do not call me about...." also because they just cannot imagine anyone calling for THAT reason. For them, if a guy on HD had K+ 6.9 before the run, it is only logical that the next morning his K+ will be 5.7. Yet, some nurse very well might call just because "it is critical" and he/she just ought to "do something and let someone know".

I'll never forget how a traveler RN in ICU called a first year ICU resident (the event took place in August) about "critical value" of INR 5.3 in patient who was "coumadined" to the point with target of 4.9 - 5.2. It was "critical value", it was "above the target" (by 0.1), it was by policy (well, it was, but it was also against common sense), she must protect her license and she just felt antcy all over unless she "let someone know" about it. So she called, received and dutifully followed order of double vit K and a load of FFP, meanwhile giving me a lecture about how lazy, irresponsible, and overall terrible, nurse I was. I honestly tried, in vain, to tell her that what she was doing was darn stupid, but she was so much in her Goddess Nurse role that she just spread her wings and saw nothing till the patient started to ooze blood from every point of his body, including sweat and tears. The momentary INR reversal on FFP predictably caused quick-developing DIC, with all the trimmings. The only good omen was that he died rather quickly.

The resident was canned out of the program, the nurse, AFAIK, lost her license. Two careers, two lives broken, and one lost. Just because one following some stupid thing named "policy" over common sense.

[LilPeanut, MSN, RN, NP]

As a provider, I've definitely had those 3am calls where I'm like....really? You're calling me at 3 because a newborn has milia? Or a mild diaper rash? And not only that, you are calling every time you go into the patient's room because you are basically just telling me everything you see when you are there?

If every nurse was doing that, I would not be able to function. It would essentially be alarm fatigue. The system is structured so the more patients you have, the more you are going to rely on those in the chain who have fewer patients to accurately and reasonably keep you in the loop, but you can't have the same level of knowledge and awareness as a bedside nurse when you are the provider. You just can't. A NICU nurse has 2 patients. I have 8 if I'm on days, 25 if I'm on nights. Asking me at 2 am if we wanted to do a non-urgent intervention that would typically be done by the primary team is not appropriate. I round at night, checking in with the nurses and either tell me then or gather all those ideas together and at the end of the night, share them with me. That's what I do with the fellows. They have at least double my number of patients and if I am calling them with every time a nurse calls me, they definitely won't be able to get stuff done.

I also have known nurses to "punish" providers they don't like by calling them constantly all night, which is just petty. A provider shouldn't be brushing someone off, rather explaining what is and isn't important for a call, but also, critical thinking and respect on the part of the nurse too. It's sort of like the person who shows up in the ER at 4am because they have had a rash for a month. Ok, but what made you decide *tonight* at *this time* to go to an ER, instead of earlier, or seeing a PCP? Same thing with calling providers, it's helpful to keep in mind the SBAR framework. Situation, background, assessment, recommendation.

Situation: I have a patient who is having continued pain in chest that has now lasted for 5 hours, but has acutely intensified in the last 20 minutes.
Background: they were due to be discharged today, but it was postponed because of this chest pain, but EKG, troponins and whatever other big people tests you do were normal.
Assessment: While the patient was complaining of pain before, their BP was relatively stable, HR normal and no other concerning symptoms. Now with this acute change, they are diaphoretic, pale, tachypneic to 45, with an EKG that still reads normal and other big people tests pending.
Recommendation: I am looking for something to treat the pain of this patient and further guidance into the reason for the pain. I am concerned that the patient might decompensate, even though EKG is normal.

Or even if it is a mandatory notification (which can drive you nuts, because depending on your unit, some of the abnormals aren't really abnormal) to say "I am required by the hospital to call you to notify you of this value, and I do not (or do, depending on the patient) think it needs intervention at this time, open to discussion of course." That way you can communicate that it is a forced call, and that you are not asking them for an order in response, just that you have to notify them and they can say "ok, noted".

[Persephone Paige, ADN]

Our hospital is unique in that very few MDs generate $$$ because none of our patients have any. There are the exceptions though and we do get a few admits with insurance. Our charting generates a great deal of the government reimbursement that we get.

Our patients are the most needy and the least grateful for the services we provide. And it's typically the less needy and insured patients who take up the least amount of our time.

The uninsured patients think we are ignoring them, even though we can't ever do an in-and-out of their rooms, unless they are asleep. Many, many times the patient will insist that we call the MD because they feel they are experiencing a change that warrants MD notification. If we have looked at all available objective findings that don't support a change in status, but we don't call anyway, we get reported. So, I do try an communicate that on an MD call when I'm being strongarmed by a patient.

I will ad that I treat everyone the same, if given the opportunity. Insured or uninsured get the same attention to detail... with a little more time going to the truly helpless patient who can't talk, or requires interpretation of objective data to learn anything about how they are doing. I still get accused of ignoring a patient regularly because I simply don't have time to spend 30 minutes at the bedside, every other hour.

It's hard all the way around.

[KatieMI, BSN, MSN, RN]

9 hours ago, Persephone Paige said:

Our hospital is unique in that very few MDs generate $$$ because none of our patients have any. There are the exceptions though and we do get a few admits with insurance. Our charting generates a great deal of the government reimbursement that we get.

Do you really think that yours (as well as most of so-called "non-profit" hospitals in this country, to which group belongs the wast majority of teaching behemoths as well as rural/critical access facilities) work for free because most of their clientelle goes under umbrella of "underinsured and underserved population"? If so, I very much advice you to get familiar with the ways US health care system works.

In any case, nursing charting brings pennies as compared to just one procedural suite with some sort of anesthesia provider in it, leave alone pharm contracts. And please do not let me even start about ERs.

[Dodongo, APRN, NP]

That's part of call. I've gotten my fair share of silly calls, but at the end of the day, it's part of my job, I'm getting paid (as little as it is), and I'd never discourage a nurse from calling, but, I might provide a little education on why this certain issue doesn't warrant a call.

[Persephone Paige, ADN]

2 hours ago, KatieMI said:

Do you really think that yours (as well as most of so-called "non-profit" hospitals in this country, to which group belongs the wast majority of teaching behemoths as well as rural/critical access facilities) work for free because most of their clientelle goes under umbrella of "underinsured and underserved population"? If so, I very much advice you to get familiar with the ways US health care system works.

In any case, nursing charting brings pennies as compared to just one procedural suite with some sort of anesthesia provider in it, leave alone pharm contracts. And please do not let me even start about ERs.

Could well be... Our ER certainly does at little as possible. They never hang their blood, they send up patients who get up to pee and promptly have a heart attack. All they talk about are codes.

Our patients get sent home, or sign themselves out AMA. If they come back within 30 days of release, we don't get paid. And of course they come back because they live on the streets or don't have the money to comply with discharge instructions. I'm surprised we have a job at all, according to highers up, we never get paid for anything.