White Coat Underground

A couple of days ago I posted a cranky rant that most doctors can relate to. But folks aren’t too interested in what doctors think, apparently, so let’s examine what others think.

I confessed my behavior to a number of nurses in a local hospital, and the summary response was, “I would not wake a doctor up for a throat lozenge, and don’t be such an asshole.”

Responses on the blog were roughly of two types: nurses need to do their jobs so you should take whatever they dish out you arrogant prick; you’re an arrogant prick; and hospitals should create rational policies, you arrogant pig.

I’ve been accused of arrogance before, and I don’t think I’ve denied it exactly, but I have argued that arrogance is a distractor. When doctors make mistakes based on their own sense of infallibility, this is an arrogance problem, but also a systems problem that is fairly easily fixed.

But the criticisms in the comments need some parsing out to find out what in there is most important.

First, any criticism from a nurse rises to the top. Nurses spend the most time with patients and have a big hand in training young doctors. This doesn’t mean that they are always right, but that their opinions often save lives. Several of my friends made the point succinctly, but it boils down to this: no matter how idiotic a call (and some really are), it is never good to act in a way that discourages calls from nurses. If they are too scared of your temper to do their job correctly and fail to call you, you as a physician share a good deal of the guilt.

This responsibility goes both ways, of course. In caring for a patient, the nurse and doctor must work together to do things right, and to maximize their own ability to get things right. As a physician, I can’t stomp around yelling at nurses, and nurses can’t just refuse to follow doctors’ orders without going through a certain protocol. They also shouldn’t call a doctor every time a patient sneezes. It’s not “wrong” to do so, but it’s not a bad idea to ask a colleague first, as you may need a wide-awake doctor later for a serious problem.

This balance usually works quite well, which is highlighted by the fact that we like to tell stories of the few times it breaks down.

Next, I’m sticking to my point of doctors not being locked in a booth like a veal calf being force fed lucky charms and amphetamines. We are a limited resource. We don’t work all day and all night because we love sleep deprivation but because that’s often the only way. We are not paid for this in suitcases full of million dollar bills. We have families, we have our own health to look after, and we have other patients to attend to. To accuse me of being a whiny baby who needs to find a new job is a statement of stunning ignorance.

I have written very often of the special responsibilities we as doctors have. But society must remember, just as we must not behave like gods, you must not have god-like expectations of us. If you think any primary care doc is getting rich working all day in the clinic and hospital and then taking calls all night, you live somewhere I would like to move to.

I have a choice not to care for my patients in the hospital, and some day I may avail myself of that choice. But at present, the balance favors my staying. My patients appreciate it, and I think I bring something to their hospital care that a hospitalist cannot. The trade off is disruption in my family life and my sleep, and the affect on my mood, which I chose to share with you with my lozenge anecdote.

If you’re not sitting in the doctors’ dining room or the doctors’ work room, you’re not going to hear this stuff. It may be a bit too much like sausage making for your taste, but it’s real, and I’m not going to start lying to my readers to make myself look good or to tell you what you want to hear.

Comments

#1 becky
October 18, 2009

This is something I fear, as a vet tech looking at a human nursing career. As far as patient care goes, I don’t want to make a stupid choice in either direction, whether it be calling a doctor for something trivial or neglecting to call a doctor when I should. As it is, I work overnights in an emergency veterinary clinic and have to wake doctors up in the middle of the night according to my judgement. There are a lot of differences in veterinary medicine, though. Vet techs aren’t given as much training as nurses and often don’t have as many actual medical responsibilities, and the vets I’ve worked with have been very accessible for the most part.

I don’t think it was unreasonable to vent in your blog, though it might be less reasonable if you were actually mad at the nurse, unless she has a history of calling for unnecessary things.

Just my two cents.
#2 MikeMa
October 18, 2009

It is my impression that docs and nurses both gain from the interaction. Neither doc nor nurse comes fully formed from school and needs time and experience to gain competence. Each has knowledge the other can use. That said, the nurse to doc ratio is almost always greater than 3 to 1 and often much higher so if every nurse’s issue needs a doc’s opinion, I see a problem. Asking a more experienced nurse first might lesson the extra interrupts without compromising patient care.
#3 Greg Laden
October 18, 2009

Hmmmm…

Of all of the arrogant people I know, many are physicians. But it is also true that many (most) of the arroganti, as far as I can tell, are academics. Of those, mostly social scientists in my experience. Arrogance is nurtured in higher education.

But then again I have the ability to chose to avoid the arrogant but less educated (like my friend Josh at Quiche Moraine), and I spent many years living among the arroganti of the Ivy League, so there is the distinct possibility of confirmation bias on my part.

I’ve met PalMD and he didn’t seem particularly arrogant, at least relatively. Then again, it was in the context of a blogger’s conference, and bloggers can be pretty arrogant, so maybe he just blended in to the background.

The hospital setting can be a stressful place. Stress is the hobgoblin of both inappropriate behaviour and misconception. My own most recent visit to a hospital (to an ICU visiting a relative) involved a very nice nurse two very nice medical technicians, and a very nice doctor. Of course, this was Minnesota where we have Minnesota nice, so everyone in the room was seething with passive-aggressive pheromones.

Which is different from arrogant.
#4 Dianne
October 18, 2009

Responses on the blog were roughly of two types: nurses need to do their jobs so you should take whatever they dish out you arrogant prick; you’re an arrogant prick; and hospitals should create rational policies, you arrogant pig.

Isn’t that three types? I hope my response (if I even wrote one) comes down in the last category. Hospitals should try to create rational policies whenever possible, whether you’re an arrogant prick or not. Which I don’t personally see you as being.
#5 skepville
October 18, 2009

I’m curious about something – are you always on call for your inpatients? My dad was an orthopedic surgeon and he shared call with the other surgeons. I assume that they also covered each others’ admitted patients, but I could be wrong. My recollection is that the 3 am calls mostly came when he was on call.
#6 Cat Faber
October 18, 2009

Gosh, now I feel like I should have said something before instead of just nodding and moving on.

Sleep is very important. It makes the difference between a rational, compassionate person and an irrational, uncompassionate one, and therefore is particularly important when lives might depend on your rationality and compassion. Not to mention that I seem to recall that lack of sleep is thought to contribute significantly to the likelihood of serious medical mistakes. When someone interrupted your sleep unnecessarily, of course you were upset–so would I be.

I didn’t think there was anything wrong with not liking it, or venting in your blog. Actually taking it up with the nurse who did it requires a more delicate touch, because you have to maintain good relations with your coworkers and people have to feel free to come to you when necessary, even if you’re sleeping, but I figured you had used that more delicate touch.

I’m sorry lots of people jumped on you; it doesn’t seem justified to me.
#7 daedalus2u
October 18, 2009

Many of the hobgoblins of stress are mediated through low nitric oxide, including insomnia, hypertension and shifts in the HPA axis. I think it mediates some of the cognitive effects of stress too. It would be surprising if it didn’t. NO is a neurotransmitter that is actively used in the brain (the vasodilation observed in BOLD fMRI is mediated through NO). Stress hormones, i.e. cortisol, epinephrine, and norepinephrine lower NO levels and/or counter the effects of NO (e.g. by constricting smooth muscle instead of relaxing it) (but really it is a lot more complicated than this).

Becoming more “conservative”, that is being less open to new ideas and new ways of doing things is one of the mindsets that low NO tends to bring on. It occurs because the functional connectivity in the brain (what is measured by BOLD fMRI) is reduced under conditions of low NO, so there fewer neurological resources available to evaluate the new idea. One defaults to familiar ideas rather than try to evaluate or figure out new ones.

Putting people under stress is a reliable way to make them less effective. The “traditional” way to train MDs was to put them under tremendous stress. That can only be effective if the stress is finite and is eventually relieved. Otherwise people burnout.

Stress also makes people more willing followers as in Stockholm Syndrome. This is part of the method behind the madness of hazing in the military (and in medical school). That is what the bullying style of management is trying to do too. It is a poor management style if you want people to think instead of follow like automatons (no good health care providers wants any automatons in their workplace).

Positive interpersonal interactions increase NO levels (a little bit). That increased NO mediates a lot of the positive effects of those positive interpersonal interactions. The NO levels are lower than there are techniques to measure, but they are important. Raising the systemic NO level lets the good things happen with a lower threshold.
#8 antipodean
October 18, 2009

Ahh yes.

Nitric Oxide: the cause of and solution to all of life’s problems.
#9 Uncle Glenny
October 19, 2009

Nitric Oxide: the cause of and solution to all of life’s problems.

Well, in some cases, nitrous is better.
#10 DLC
October 19, 2009

Re: the original rant-post :
What? a doctor’s order for a frakkin throat lozenge ?
A throat lozenge ? !!?
come on! what kinda bloody insane rationale is that?
The patient could just as well walk down the hall and buy a package of cough drops out of the vending machine.

And yes, I can understand you would be put out over being woken up over something that damn trivial — I would too.
But.. a throat lozenge ? I’m sorry. if that’s a hospital rule, they need to change the damn rule.
On the other hand, if it was your order that you be called for any change in meds and you said it or wrote it in a manner which does not leave room for interpretation, I gotta tell you.. you’re hoist on your own petard and deserve what you got.
#11 micheleinmichigan
October 19, 2009

DLC – admit it – you just wanted to write “hoist on your own petard”
#12 BB
October 19, 2009

Hey DLC, at the frakkun’ hospital where I had my ankle repaired, the bloody nurse would not order me a kosher meal (I’m Jewish and adhere to dietary laws) because it was.not.in.my.doctor’s.orders. I went for over a day without food.
#13 Dianne
October 19, 2009

The original problem strikes me as a Rashamon situation:

From PAL’s point of view, a nurse woke him at 6 am for a sore throat. A sore throat? Couldn’t that have waited another couple of hours when he’d be there anyway? Who dies of a sore throat (at least acutely)?

From the nurse’s point of view, she took the heat from the patient for 5 hours in order to not wake the doctor in the middle of the night to request a throat lozenge and the ungrateful twit yelled at her for it.

Unfortunately, I don’t see any way to avoid the problem.

All medications need to be written by a doctor or nurse practitioner. This may seem like a silly rule but any medication can be dangerous to a patient who is acutely ill enough to be in the hospital. Consider a throat lozenge. Sounds harmless enough and generally is. But most contain sugar and if the patient is admitted with diabetic ketoacidosis, the additional sugar (especially if he/she takes lots of lozenges) could make a previously adequate insulin drip no longer enough. Or something like Maalox for indigestion. Harmless, right? Everyone takes it…except if you have kidney problems and can’t get rid of the magnesium in the maalox. And so on. So someone has to approve all medications.

In BB’s case, the order simply should have been changed to Kosher as soon as the problem was noticed. The problem is that what if BB had had diabetes or kidney problems or some other condition that diet could affect as well? A regular kosher diet could be dangerous in that case. So it has to be written too.

In short, I’m not sure what the solution is. One can write a bunch of as needed orders, but covering every possible situation is…not possible. One could argue that the doctor should take the hit and just prescribe the lozenge at 1 am but how long is s/he going to be able to keep that lifestyle up? What happens if no one is willing to go into medicine because the lifestyle is too ridiculous? Nor do I like the idea of making the already overworked nurses work harder. So I don’t see a clear social engineering solution. More night float?
#14 daedalus2u
October 19, 2009

antipodean, not all problems, just many problems that are exacerbated by stress.