Good morning

Then don't insist that I call you about every damn order I need. Since this post is addressed to "RN", my comment is adddressed to "Dr.". Do you have all day for me to tell you about the dumbass comments about orders that I get all the time from certain MDs? I don't get the imopression that you are one of those, but neither am I an idiot who can't think for myself. Your Board of Medicine and my Board of Nursing put certain constraints on us and we all have to live with them. There now, we've both vented, do you feel better? I know I do.

Dear PalMD,

I am terribly sorry to have disturbed you this morning, but you are so very welcome that I *waited* until six a.m. this morning to call you as this patient of 'ours' has been on the call bell three times an hour since one a.m. asking, begging, beseeching me to get her some cough drops. When I told her that I would have to call you and wake you up to get an order for cough drops, she assured me that you are such a "nice doctor" that you "wouldn't mind" (in contrast to her "mean nurse" who doesn't care enough about her to get her a cough drop). I am so sorry that I was not consulted when the hospital policy that requires RN's to obtain a MD order for cough drops was written or certainly I would have protested. It is also not my fault that the administration of this hospital is so concerned with our Press Ganey scores that I am required to treat patients like "customers" and satisfy their every whim accordingly. Naturally, I aim to please -- I aim to please the patient, you, my manager, my coworkers -- in fact, I have made a life's work out of not only pleasing others but also catering to whims. I could never have imagined that my education (modest as it is, compared to yours) would be put to such good and important use.

I would not dare imagine that you live in a small box like a veal calf. Because that, Mr.Dr.PalMD, is how I live. And before you imagine me going off to my cozy bed while you are hard at work saving the world, imagine that I must first go home, pack lunches, get the kids to school, take my car to be repaired (for the third time this month)and try to make it to bed by noon, since I have to be up at three to pick up the kids and, alas, back to practicing caring, the very art of nursing, by six forty-five this evening. Never mind that my circadian rhythm is turned inside-out or that I have not slept more than four consecutive hours in the last ten years (I do it for the extra $2 an hour), that I can't afford to actually see a doctor myself, never mind that my phone will ring *all day* and that today is landscape day at my veal-box and the mowers and blowers will be going full speed ahead, right outside of my window, three feet (at most) from where I rest my head.

Of course, for a health warrior such as yourself, there is nothing glamorous about being called at six a.m. for a cough drop. As a soldier in your army, I can tell you that it is equally unglamorous to have a patient puke on your shoes, especially when they are new.

So please, accept my sincere apology for something that, all things considered, is NOT MY FAULT.

your irreverent handmaiden,
RN

Hmmmm...

From the explanation provided by RN it seems that he/she is in an untenable situation, help the patient and inconvenience the DR, or not help the patient. Given that the DR is paid quite well for this inconvenience the choice will, and should, always be to help the patient. Sorry PalMD, but as valuable as I find your blog(s) I cannot support you in this. The fault seems to lay squarely on hospital policy, if you want to sleep in then change the policy or get a new profession.

Greg

PalMD is the biggest egomaniac I have ever had the displeasure to encounter. If you can't fulfill the requirements of your job FIND A NEW ONE and stop thinking you are so special because you have an MD, it really doesnât mean that much....

Wow, you must be real pleasure to work with. It is always nice working with a person that feels they are better than you. I am thankful that I don't have arrogant colleagues such as yourself.

Where can I sign up for this job of being put in a veal box being force fed lucky charms and amphetamines? I can't imagine the pay is worse than that of a post-doc :p

It may be that this anecdote does not translate well to non-physicians. You all might want to think about your doctor's state of mind and the cost of your care if you really think waking your doctor in the middle of the night for a sore throat is an appropriate use of resources.

Just sayin'.

To the nonphysicians:

Perhaps an analogous situation might help.

Paperclips and staples are an important part of the workplace.

As a manager, however, you aren't normally concerned about the paperclipping and stapling habits of those people who report to you. You value these people for their acumen, their unique abilities at their actual job. When you hired them, you did not check their resumes for paperclipping and stapling experience. Imagine you know that the people who often report to you work hard, through the night, even when you're home sleeping. You trust them to take care of things, because they're very good at what they do.

Now imagine the company has put into place a policy that requires them to call you, even in the middle of the night, before using a paperclip, or stapling a small stack of papers.

Is it really your job to wake up in the middle of the night to say yes, they can staple? Don't you trust them to know the situations in which it would not be a good idea to paperclip? You didn't go to school to approve paperclipping, nor did your worker, who you respect for their ability to do their REAL job (not their ability to be a hospital puppet for press ganey scores.)

Wouldn't that tick you off? Is it really your fault that you're being frustrated at being woken up in the middle of the night for this? Couldn't the damn staple have waited until 7? Maybe to your colleague it's clear the reasons why the staple can't wait until the morning, but from the comfort of ones bed, very few staples deserve a middle of the night call.

In a case such as this one, as Catherine points out, the rules require a doctor's order for a throat lozenge. My frustration is not so much that. If all of my couple of thousand patients were to call about sore throats at odd hours, none of my ill patients would get care. Hospitalized patients have very serious problems, and while minor comfort issues are important, they may or may not be important enough to wake up the attending md at night, taking away this limited resource from other patients.

Six a.m. is not the middle of the night. Middle of the night calls contributing to out of control health care costs? You're right. I don't get it. But I'm not going to argue about it because I'd rather let it go (and have a beer!).

PalMD

I agree that you need your sleep to preform your job well, and I can't think of any argument that would say otherwise. I also understand that you are human and can get cranky like the rest of us and sometimes miss what to others may be obvious misplaced annoyance. If your hospital requires the on-call doctor to sign off on every thing given to a patient, even a cough drop, then it's unfair of you to lash out at the RNs that have to follow this policy. I don't think you need to be a physician to know this. In this specific case, your post, it seems that you just did what any of us would when woken early for a very minor reason, you let it become personal and it pissed you off.

Being a Dr is a stressful and demanding occupation, I know not from personal experience but from the stories of my good friend who runs an ER (I'm sure you know what a stressful job this is), and I doubt there is anyone that can be expected to be nice all the time. He admits that he can be an ass when he does his job and he hates that part of it because he wants to be nice all the time, but it's just not possible.

From your blog you seem to be similar to my friend in that you are obviously very good at what you do and often annoyed at the shortcomings of others in your field that just aren't and seem to go out of their way to make things more difficult than they need to be. I don't think that this RN intended to wake you just to annoy you, though I admit I cannot know this, but unless you do know this maybe you should consider apologizing and mending some fences. A policy review is probably in order as well.

Greg

PS. You should also be flattered that nurses are reading your blog BTW, especially those that work with you, it's something that reflects well on all concerned.

There has to be some common sense used when making decisions. I tell my patients, when in doubt, call. It is better to call and work through a problem than to let a potentially important thing go because someone didn't want to be a bother.

However, common courtesy should also play a part. Things like throat lozenges could easily wait until 7 am or a more reasonable hour. I think that most people would find this agreeable.

By the way, things like throat lozenges should be allowed without a doctors order. If there is a medical reason for nothing to be given by mouth, then this would be stated in the patients orders. But this is another issue.

WCT: You get one little detail of your analogy wrong: doctors are not "the boss" of nurses. Nurses work for patients and report to other nurses (as bosses). The scope of practice is obviously very different for doctors and nurses. If you are terribly worried about getting called for paper-clipping and stapling in the middle of the night or early in the morning, as the case may be,(and I will not mention here how insulting this analogy is to nursing), then YOU have the power to write the order for PRN paper-clipping and stapling. Perhaps you didn't pay much attention to your patient's complaint of a scratchy throat, then it's your tough luck if you get called.

The Blind Watchmaker

I'd like to agree with you, but if you are the physician on-call then you are expected to be prepared to work during those hours, so the time of the call is irrelevant. If the patient needs something and policy says you must get the permission of the physician on-call then you call, period. It sucks, but it's part of the job and to take it out on the very people who are essential to allowing you to do your job is wrong. Trying to justify it only makes it worse.

Greg

@Catharine

Attacking the details of analogy is hardly relevant. I somehow thought describing parallel reporting tracts in a brief analogy would have been over the top. On the other hand, how is describing throat lozenages as paper clipping insulting to nursing staff? Every nurse I know is competant to take care of patients. Every nurse I know generally knows the (very few) relative contraindications to giving a lozenage. They are competant to take care of much more serious complaints than "i need a lozenage for my sore throat."

So how am I being insulting by pointing out that such a question is small fry to a good nurse, and that hospital policy forcing the nurse to ask that question is silly? I'm by no means calls from the MD by nursing where nursing actually had a question "stapling." If you aren't sure, don't know, or think you should ask, ask. But when I get a call about throat lozenages, the nurse will say "Hey so and so has a sore throat, I'm giving them a lozenage, please put in the order." They know it's ok, I know it's ok, we both know that the call was just because someone somewhere decided the nurse can't put in that order themselves.

I've worked with a wide variety of nurses in my brief time in medicine and they're good at what they do. I think making them call me for things that we both know they can make a call on on their own is insulting!

As far as having written a PRN order ahead of time, I don'tknow PALMDs situation so I can only speak for my own. Generally, when I'm on call, there is at best a 1 in 3 chance that I wrote the admission orders on the patient. I'm generally on call for 3-5 services, each with their own 2-4 residents and any number of attending physicians. Each service could have anywhere from 5 to 25 patients, and on a given night I'll be on call for 70 patients or so, 10-20 of whom I might know from my daily work, 5-7 which I might have done an overnight admission for. I do my best to catch those PRNs like lozenages, but that's hardly going to be the case for every doctor, everywhere, every time.

My readers do make a very good point. It may be that it is no longer possible (as most of my colleagues have concluded) to care for both inpatients and outpatients. The system does not favor this model any longer. I have been giving serious thought to giving my inpatients over to a hospitalist service.

PalMD - is it hospital policy for the nurse to call you on a matter like cough drops? If not, then I agree the nurse shouldn't have bothered. But if it's hospital policy, what exactly do you expect them to do? They're between a rock and a hard place at that point.

Of course youre right, but the tough part is deciding whether a problem warrants waking the doc. How bad is the sore throat? Can it wait until 8 am?

Pain and discomfort is pretty subjective, so how do you tell a patient that they can't get relief so that they can sleep because their discomfort isn't worth wakening the physician on-call? Seriously, do you think that a person who would normally just go to their own medicine cabinet and get their own cough lozenge understands why, or even cares that the hospital policy requires the call, they just want relief so they can sleep as well. If its inconvenient for physician on-call then change the policy, don't force the patient to suffer or blame the nurse for choosing to do their job.

~Greg

It is the nurse, not the doctor, who is between a rock and a hard place. Nobody that I have ever worked with has ever *wanted* to call the doctor in the middle of the night, except when there is a situation that needs immediate attention. Other calls are made either because the patient insists or because the nurse lacks the knowledge and/or experience to make a good judgment - and chooses to err on the side of patient safety, even if it turns out to be nothing (and makes the nurse feel stupid for calling). In the case of needless calls, it is only human for the doctor to feel annoyed (and don't forget, the nurse is now feeling stupid), but a little patience and perhaps even an explanation of why there is no need for concern, would go a long, long way. DOCTORS: YOU CAN BE SECRETLY ANNOYED AND ROLL YOUR EYES, BUT IT IS NEVER, EVER A GOOD IDEA TO MAKE A NURSE FEEL STUPID FOR CALLING OR AFRAID TO CALL. That is a simple matter of patient safety. Most of the problems that I see between doctors and nurses arise from poor communication. Other problems arise as doctors must adjust to the recent reality that nurses are autonomous professionals and not "extensions" of the doctors' selves that do the dirty work (gotta love it when they say "I gave him lasix"), and also from nurses who don't know and don't know that they don't know (a condition known as double ignorance which is bad enough in nurses but extremely dangerous in doctors). And, believe me, as a veteran critical care nurse working in a teaching hospital, it can be just as annoying to sit by and wait (as my patient suffers) while inexperienced interns and residents go through the "learning process" while dealing with a condition/disease/situation that is new to them when I have been there, seen that, done that a thousand times already while these doctors were still sucking on their mothers' teats (usually not that long ago). Doctors who have busy private practices and continue to care for hospitalized patients are bound to come across inexperienced nurses who seem to lack "common sense" but those nurses are really are just trying to do the best for their patients, just like everybody else. My guess is the nurse *waited* until six in the morning to call Pal, most likely after s/he was driven batty all night by constant and unrelenting complaining and requests by the patient. The one thing that everyone seems to be forgetting in this discussion is that ultimately it is not about the nurse calling or the doctor getting mad or whatever. We (hospitals, nurses, doctors) exist in order to care for the PATIENT. And it is the patient's needs, whether real or perceived, that drive all that we do -- or at least *should* be motivating force.

Fortunately, I work in critical care where calling a doctor for cough drops just isn't an issue. Fortunately, in my unit, nurses and doctors work together, tightly, usually in harmony, and there is a great deal of mutual respect and trust. Fortunately, I work in a unit in which an experienced nurse is considered higher on the totem pole than a medical student. (And I notice and take pleasure in this fact only when an arrogant medical student comes along who, for some reason, is hostile and behaves in ways that are demeaning to nursing - when he would do well to keep his mouth shut and have some respect for his own ignorance; this same medical student (for some reason)thinks he is a doctor already, does what he can to separate himself from nurses - you will know this student by the way he says "we" and means doctors while others use a "we" that includes nurses - and he should realize that a nurse is his BEST FRIEND. Sooner or later, he will be taken down and it will be painful but, for the nurse, fun to watch.) We don't talk cough drops in critical care, we talk life and death. Luckily, just as nurses are always present, doctors are always present. If a resident should be lucky enough to get a few minutes in the call room, and if an issue comes up that I think needs attention, one that is beyond my scope of practice (EVEN IF IT IS A MATTER OF PATIENT COMFORT), you can bet your fucking ass the intern/resident is going to pay attention to what I have to say. I will allow a doctor to blow me off exactly one time. After that, s/he may dislike me but it's not my job to make sure the doctor is happy, I do what I have to do FOR THE PATIENT. Isn't that the point??

Having been the patient who ended up taking ibuprofen out of my purse in the hospital the night after surgery because apparently calling my surgeon for the forgotten pain control after hours was out of the question...well, I'm torn between sympathy for the patient and a strong desire to tell them to suck it up. Either way, whether the medication in question is a cough drop or a fucking vicodin for someone who just had chunks cut out of her abdomen, it would sure be nice if there was a mutually agreeable option for getting the job done (perhaps one of those nice nocturnists we all hear about these days).

*sees 10-foot pole on the ground*

wimp. i did it (motivated by sleep deprivation, but still...)

Dear PalMD,
As a new mom, I know what sleep deprivation can do. It is crazymaking. I sympathize with you not wanting to get up at 6am- a time my personal circadian rhythm is convinced is a WRONG time to be anywhere but cozy in bed.
At the same time, as a new mom, I feel nothing is worse than being up at 4am, completely exhausted, and not being able to do anything to comfort a very miserable (little) person.

Nurse: I want to help this patient
PalMD: my sleep is more important than the patient's comfort, or you being able to help them.

Sometimes your sleep is more important. It's ungracious as hell to say it, but it could also be true.
In this case, I think it's a pretty shitty hospital policy that does not serve doctors or nurses well, let alone patients.

"I do not live in a small box like a veal calf, sitting next to a phone, being force fed Lucky Charms and amphetamines."

You weren't night cover, then? That sounds like an on-call room to me. (Where are the bitter interns and crusty surgeons? I am amazed no one has pointed out that being asleep at 6 AM is an obscene luxury, and sleep deprivation in the service of medicine is a rare honor, damn it.)

Yet another nursing perspective:

By 06:00, if the patient has been up all night with a sore throat, the RN has done you a favor by waiting until that late to call. If the patient just woke with a sore throat, yeah, she (only a 10% chance it's a he, so "she") would have heard about it while doing her last med and assessment rounds for the night before report. She's trying to get the order in so it arrives with the big AM meds delivery, usually sent up around 8.

If she leaves a note in the chart for you, you'll write the order PRN, days will eventually see it and maybe ask the patient about his throat at her rounds (after report) and then will either request that pharmacy send up the meds as an interim/new med (in which case fat CHANCE the pharmacy will send it before noon meds, because they don't consider a sore throat a priority either) or will just wait hoping it will turn up with the noon meds. Either way, that poor patient is going to wait hours for that cough drop if the night nurse doesn't get it in with the morning meds.

A more cynical point is that according to the Pain Service, pain is pain, it's subjective, and it's whatever the patient says it is, so if your patient says, "Well, my incision's great, a 2, but my throat is killing me, a 10," the nurse has to call for the cough drop, just as she would if the throat was fine but the incision was a 10/10. Ignoring 10/10 pain of any type gets concerned frowns from Charge and earnest lectures from the Nurse Manager, and eventually inservices that the whole night shift has to come back for in the early afternoon because that's when day shift and evenings can reasonably attend and when the QA staff is available.

Note to self; take your own damn lozenges, analgesics, eye drops, chap stick to the hospital with you.

Anything else I should know about that's too trivial to wake the doc up for at 6 am? Inquiring potential patients want to know...

Don't ever start a sentence like this:

It may be that this anecdote does not translate well to non-physicians. You all might want to think about ...

It sounds kind of arrogant.

Obviously, the solution to this problem is to issue cough drops and other simple amenities that are not even really medical in nature to the hospital rooms so anybody can have one when they want.

I have no idea how the system works or the typical working relationship between nurse and doc, so I'll focus on the letter itself.

Fabulous! Sometimes I find your writing awkward, but this one, probably written in the full flow of crazy is full of charm! It's your blog, rant all you damn well please!

It isn't the page for a cough drop that sets you off, it's the 40th page of the night about something that can wait for the primary team in the morning. Is it right to get angry, no. Is it understandable? Yes. Normally the page is "re pt M on 642-1, sorry to bother you but she would like a lozenge." o.k. enter order for cepacol, flop back down on call room bed. Or page about lozenge; then repage about the same thing in 2 minutes, then when you call the RN back nobody is at the phone; not o.k.