My readers are pretty bright, and for that I am thankful. As you have no doubt noted, I posted a nice, cranky rant this morning. Shall we examine it dispassionately in the light of day?
Any doctor who takes care of inpatients walks a fine line. As most nurses know, docs can be real assholes. While asshole-ism is never justified, it is sometimes explainable. Many hospitals are unable or unwilling to implement standing orders for basic comfort measures. It is theoretically possible to write a ton of "prn" orders to cover any contingency, but it's unlikely.
For the non-medical folks, I'd like to explain what nurses and doctors actually do. Registered nurses, who provide most of the patient care in my hospital, have at least four years of university education and are not simple technicians (we have some of those too). They are the professionals who spend the most time with the patients, and who have to make most of the calls "on the ground".
Inpatient physicians usually round once a day, sometimes twice. They often have an office practice as well. Most of us are on call all day, every day. We take every ER call, every office call, every hospital call. We must not lash out (at least not often) because, aside from the moral aspect, if we discourage a call for something important, we may hurt someone.
For nurses, there is often a fine line to tread between hospital policy, common sense, and needing to wake a doctor. Any decent nurse knows when and if they can give out a throat lozenge, but most hospitals will require a written doctor's order. Where the judgment comes in is in deciding whether something is important enough to warrant calling the doc ASAP. One commenter pointed out that since we physicians must take call as part of our lives, we should suck it up. This is half true. I don't have a lot of choice but to be on call every day. I know the nurses, and most exercise exquisite judgment. We all have had the experiences, though, of being awakened for "low BUN", "I woke up the patient to ask them if they want a sleeping pill", etc. These are thankfully rare, but not rare enough.
My hospital has been pretty good about pulling physicians aside and having a conversation when their behavior is not so wonderful. But there is, at many hospitals, no mechanism for addressing minor problems at night, other than having a nurse decide whether to wake a physician.
Those of us who take care of our own patients in the hospital rarely do it for the money---the payments are negligible compared to the time. We do it because our patients like it. If the system, including nurses with questionable judgment, makes it even more difficult, there will be no one left to care for you but hospitalists whom you've never met.
I understand that many see doctors as arrogant, unfeeling, rude, or whatever, but doctors are actually human beings, as you so often remind us. It is not unreasonable to expect to be treated with the same respect as any other professional. Few of my patients would ever think to wake me for a sore throat---it would never occur to them. Most people wouldn't call their accountant at home at midnight when they open their mail to find an IRS audit. But then judgment can only rarely be taught.
Yes, I know I'm just pissing you all off even more, but hey, if I only wrote stuff you agreed with, why would you even bother?
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You well explain the demands on the doctors and nurses. But your post takes at face value that "many hospitals are unable or unwilling to implement standing orders for basic comfort measures," to the extent that "most hospitals will require a written doctor's order" for a throat lozenge. Why isn't that an appropriate target for push back?
As many a hospital administrator has reminded me, I really don't want to run a hospital. JCAHO rules are Byzantine. Just filling out discharge paperwork has become so burdensome that this alone has driven many docs out of the hospital.
RNs have less choice. If they leave the hospital, they need a new job entirely, often one with worse benefits.
So... lifting this from the demands and pressure on individual workers, and into the political arena: Isn't there a significant patient care problem when the accreditation standards for hospitals get to the point that attending physicians and surgeons want to minimize their involvement with hospital care? And -- quite relevant to current politics -- isn't there an associated cost problem as hospitals hire hospitalists, just to bridge the gap that their own byzantine rules have created between attending physicians and nursing staff?
Hospitalists may in fact save money---often, they have reduced length of stay numbers. They are not generally paid by the hospital but by the patients' insurance company, like any other care.
Hospitalists may in fact save money---often, they have reduced length of stay numbers.
I often wonder what the effect of policies designed to reduce length of stay are on things like bounce back numbers and overall quality of care. Is early discharge really a good idea? If so, when and how should it be implemented?
Nice try, Doc, but you're not even in the same county as pissing me off.
"That which is hateful to you, do not do to others.
That is the whole of the Law; the rest is commentary.
Go learn the commentary."
Better luck next time, but you're going to have to get in training if you want to seriously bug me.
Doctors aren't unique in this; if anything you at least get the satisfaction that when you're paged at night it has some actual consequence to a human being vs. oh, I don't know, some minor impact to the course of internet capitalism. But I do agree that being paged at night for inconsequential bullshit due to poor judgment is a larger burn-out risk than almost any other lifestyle impact.
My wife is a doctor who used to take call, I know exactly where you're coming from.
I hate the staff that call her home number instead of paging her because they "don't want to bother her". They bother me instead!
Can't we just make a law that prescriptive authority should be granted to RNs with X years of experience?
No, because that's not their training (as opposed to nurse practitioners). There are actually some quick fixes to some of these things, but really, there is no good way around this. Part of it is me and people like me overworking to accomplish something we think is important, and occasionally losing it at the 1 per cent of bad calls that come through.
We all have our stories about being awakened for a critically low BUN and being tempted to say, "hang some BUN, stat!" but in reality, most calls are necessary. For those of us in small groups, there is not good way around this except to give up our hospital practice if we are approaching a burn out point.
"Few of my patients would ever think to wake me for a sore throat---it would never occur to them."
I think you underestimate the influence of hospitalization on stress-related lack of judgment. It's a good thing that patients don't have pager numbers for their docs, because when it's 4 AM and the sound of clanging linen carts has woken up the aching, exhausted sick person from that light doze he's finally managed, suddenly that sore throat seems like it's the end of the world. The only thing that stops inpatients from going on crazy postal-style gun rampages is the absence of semi-automatic weapons (and trench coats) in the gift shops. Well, that, and the inability to get out of bed without assistance. Okay, and the difficulty in handling heavy weapons while rolling an IV pump with a catheter bag discreetly hanging from the lower hook. But you see my point.
my experience has been that more problem episodes happen because of doctor's behaviors than any other reason. Nonetheless there are extremes in every category. In one hospital I covered, long ago and far away, there was a night nurse feared and hated by all the staff. This person was nicknamed the "antinurse." At 12:01 AM the antinurse made rounds and pulled out all the IV catheters that were, technically, overdue. Once at 3 AM I got this phone call (I swear... only the names are changed...) "Are you Dr Smith?" yes, I am. "There are 2 Dr Smiths here... are you David Smith or Bob Smith?" I'm David. "Are you the Doctor Smith that's taking care of patient Jones on the 8th floor?" yes, he's my patient. is there an emergency? "No emergency. I just wanted to be sure which Dr Smith to call in case something happens later."
The antinurse was a rare exception, an outlier on the bell curve. Most of the nurses I've worked with are candidates for sainthood, overworked, overstressed, underpaid, and under-appreciated.
Can't we just make a law that prescriptive authority should be granted to RNs with X years of experience?
Nurse practitioners have some prescribing privileges but APNs rarely work on inpatient wards. At least not as general nurses on the night shift.
I knew about NPs, that's why I thought it would be a not-totally-logistically-crazy thing to do.
And PalMD- you are just being a grump-a-bump who doesn't want solutions. How much training does it take to be able to prescribe a cough drop???
Just because doctors tend to be subjected to obscene levels of formal education and training doesn't mean that that's the only way to learn. There are plenty of job categories which require "a Masters degree or higher" OR "X number of years of experience". Most every medical professional I know has a story or two about a nurse with decades of experience saving the tush of some new hot-shot doctor.
Or if you don't like "experience = expertise", couldn't there be some kind of board-certification for prescribing, maybe set up in modules?
Regarding becca's comments: My mother's an RN who recently retired and we've had quite a few conversations about health care practices in the US. I've long been of the opinion that doctors have been jealous of delegating responsibilities, especially with regard to nurses, and I've often mentioned such solutions when talking about various problems with my mother. However, interestingly, she's usually just lukewarm to such suggestionsâand it's not that she's in awe of physicians, she's not that type. She's just well aware that a lot of things which appear to laypeople to be appropriate for nurses really do require the expertise of a physician...at least a non-trivial portion of the time.
Even so, it seems to me that over the course of my lifetime (as a middle-aged man with a lifelong medical condition) that the rise of nurse practitioners and physician's assistants has been particularly underwhelming. They are not as ubiquitous as they ought to be, and where they are, they are underutilized. And it's not clear to me that these should be the only two intermediary steps in expertise in the wide terrain lying between nurse and physician.
Yeah, I appreciate the sentiment, becca, but honestly I didn't want to be a doc when I worked as a floor nurse, and I don't think any amount of nursing experience can actually make a nurse a doc. Their focus is so different from ours, and their expertise so much their own that even if a nurse worked with the same population in the same setting for twice the time a doc did, I don't necessarily think she'd have the same expertise. (Note again, I use the feminine pronoun to refer to nurses, because for whatever reason the 10% male proportion of nursing hasn't budged upwards in 20 years, so it's reasonable to assume a nurse is a chick.)
Ultimately, although a nurse prac who'd been through specialist training could reasonably prescribe, I don't think RNs should. We don't have the training, our time is spent differently, and we have enough responsibility as it stands without having the expectation that we'll manage "lower level" prescribing as well.
"Hospitalists may in fact save money---often, they have reduced length of stay numbers. They are not generally paid by the hospital but by the patients' insurance company, like any other care."
OTOH, hospitalists do cost more money, if it means a $400 hospitalist visit (as happened to me last December) because my surgeon didn't pick up the phone to call my internist for free (or 4 cents, however much the local call would have been). Hospitalists in other words encourage a visit where a phone call would do, thereby driving up costs. And if I needed to be seen in hospital, my internist would see me.
Odd, but I don't view doctors as "arrogant" in general.My mother had diabetes(and complications), my father was, well, ancient: they each had great doctors (2 each),who I often see around my neighborhood.And I'm glad to see them.I could write about many incidents when any one of the four went totally out of his way to help one of my parents.Also, their presence in the hospital made a difference, especially to my father, towards the end.
A vaguely analagous situation:
I'm a computer technician. I show people how to use software, fix operating systems when users have "experimented", and sometimes take apart the hardware with a screwdriver.
Here's a selection of telephone calls that I've had recently - at home, after midnight:
* How do I switch between Insert and Overwrite mode on MS Word?
* I need you to come round to show me how to set up an email distribution list.
* The thing with the flashing light isn't working.
* I need a new printer - how much should I pay?
* That email address you set up for me - what was it again?
* Tell me again how to post to my blog.
* I've read up on operating systems and I want you to put Windows 98 on my laptop.
* The internet's gone down. Fix it now please.
Maybe I should just set my phone to play the message to any callers, "Read the fucking manual. If that's too difficult for you, you're too ignorant to use a computer".
@19
Nick Burns, is that you?
@ Kapitano
Are you familiar with the show The IT Crowd? I think you would enjoy it.
http://www.youtube.com/watch?v=gt9j80Jkc_A
And one for you PalMD...
Darkplace ~ a funny british comedy taking the piss out of programs like murder she wrote and Quincy set in a hospital. The main characters are heroic doctors in a hospital with a door to hell in the basement.
http://video.google.ca/videoplay?docid=-3311296398556365633&ei=kODVSqvf…
Enjoy, if you have the time...
Well, you folks continue to visit your doctors and pharmacists. When I'm not sure what drug I should choose amongst several roughly equivalent ones, I will be asking my Aunt the nurse (with... 30 some? odd years of experience and a penchant for collecting enough certifications to wallpaper her bathroom with, she's better than any Dr. I've had. And, since I'm at an academic med center, I get some awfully good doctors. Of course, I also see their training from talking to med students. Doctors, sausage and laws... don't watch how we make them).
"How do I switch between Insert and Overwrite mode on MS Word?"
In fairness, Overwrite is the most frustrating abomination to ever exist and is a glitch not a feature.
Still, after midnight?
OTOH, hospitalists do cost more money, if it means a $400 hospitalist visit (as happened to me last December) because my surgeon didn't pick up the phone to call my internist for free (or 4 cents, however much the local call would have been). Hospitalists in other words encourage a visit where a phone call would do, thereby driving up costs.
I'm tired and grumpy today so maybe being unreasonable, but I'm going to say it anyway: So what you want is for your internist to give you $400 worth of care for free. Yes, I know a phone call is less than a visit, but after the 10th or so in a given day, the amount of free care given through phone calls gets wearing. Especially when patients try to demand that you manage them over the phone because they can't afford what it would cost them to come to the office (high copay, no insurance, or even can't afford the transporation/time off work.) I don't blame patients for this, of course, they're clearly the victims, but it's a problem nonetheless.
@JohnV: Nick Burns, is that you?
No, but he sounds cool.
@Greg: Are you familiar with the show The IT Crowd?
I am indeed. But it's not a sitcom - it's a hard hitting fly on the wall documentary.
Still, after midnight?
Frequently. Sometimes I have to explain multiple times that I don't know how to solve a particular problem - or that their description of it isn't enough for a diagnosis. I've come to the conclusion that IT people are regarded as omniscient and essential but contemptible.
We're disposable gods. Probably much like doctors.
I get the impression you would like Nick Burns, your company's computer guy. http://www.hulu.com/watch/19050/saturday-night-live-nick-burns
Although in your defense, being called any time after 6 or so, let alone midnight, really has no justification :P
FWIW, my vote is to give pharmacists
prescriptive ability within reason.
Granted this might not work too well in a
hospital setting...
@becca and others with MS Word Insert/Overwrite
issues - the mode (INS or OVR) is
displayed in the lower right side of the
status bar at the bottom of the page. If
the Ins key was mistakenly hit, throwing
you into Overwrite mode, press the Ins
key again to get back into Insert mode.
HTH, HAND.
@Kapitano, I agree that the IT person's
"differential dx" can be extremely
difficult/trying at times. Disposable =
outsourceable...
So, same question, different thread, what else should I take with me to the hospital so I'm not inadvertently getting in the middle of the clash of the titans? I will bring anything else in addition to my own throat lozenges if the alternative is pissing off the nurse AND the doctor when I'm sick and in pain and fearful and 6:00 am is too early to wake everybody but the patient.
(Another reason to dread ever having to go back to hospital...)
Personally I think the old trope of the arrogant doctor archetype is getting a little old and baseless. Probably some of the reason it's pushed PAL's buttons.
I'd rather have an arrogant doctor than an ignorant one.
But I'd rather have a physician like PAL who's neither.
I am a bit more offended at people who actually make a living complaining about paging at night.
The "simple techs" referenced get plenty of on call that they have to deal with and a fair amount don't even get benefits. That was the boat I was in for about 3 years. I did two separate healthcare jobs during that time that were considered 'essential staff', meaning I have to show up to work whenever I was assigned on call or whenever someone quits. But I didn't have a chance at getting health insurance or pay for school.
Working 6 days a weak and barely making 30 hours when you get called in at three in the morning was really really hard. It didn't pay the rent, thats for sure. And that was just how it worked for all but a handfull of full time workers. Other places my shifts were half days and half graves, so I never really slept for about 8 months. I was just greatful to get enough hours to pay for my basic expenses. A relative's work in a hospital mirrors this experience, and obviously meeting other people in hospitals. I finally got a good job before the reccession hit, but I went through a lot to get my foot in the door and could not have done so without help.
Im not trying to start an oppression olympics here, but jeez. Have you guys actually looked at the people in a hospital lately? Does it not bother you that things get more female and less white the more the pay scale goes down? EVERYONE works really hard in a hospital, and I don't know any department/position that doesn't deal with some form of severe annoyance and sleep deprivation to keep things running. Just please realize that a lot of people are working really hard for almost nothing, and there isn't even much admiration from anyone like doctors or nurses generally get.
If I'm going to complain about the care I get in hospital, it's going to be about something with a bit more substance. As in, being left on NPO for an extra three days because the abdominal surgeon who pulled my appendix couldn't get around to me the next day (flatus and bowel sounds back to normal, thank you) and wouldn't delegate the postop exam.
One way or the other, fine.
And even so, this is the first time I've mentioned it in more than ten years.
And did it occur to you that any particular nurse has 6-10 doctors to go with her patient load? If she gets the shift from hell and has to have orders from all of them before the shift is over at 0700, she has to begin making calls at 0600 (or sooner) to get them all in. Somebody has to be first.