Physician, heel thyself

Physician, heel thyself

Pittsburgh USA.
It was morning rounds in the hospital and the entire medical team stood
in the patient’s room. A test result was late, and the patient, a
friendly, middle-age man, jokingly asked his doctor whom he should yell

Turning and pointing at the patient’s nurse, the doctor replied, “If you want to scream at anyone, scream at her.”

This vignette is
not a scene from the medical drama “House,” nor did it take place 30
years ago, when nurses were considered subservient to doctors. Rather,
it happened just a few months ago, at my hospital, to me.

As we walked out
of the patient’s room I asked the doctor if I could quote him in an
article. “Sure,” he answered. “It’s a time-honored tradition — blame
the nurse whenever anything goes wrong.”

I felt stunned
and insulted. But my own feelings are one thing; more important is the
problem such attitudes pose to patient health. They reinforce the
stereotype of nurses as little more than candy stripers, creating a
hostile and even dangerous environment in a setting where close
cooperation can make the difference between life and death. And while
many hospitals have anti-bullying policies on the books, too few see it
as a serious issue.

Today nurses are
highly trained professionals, and in the best situations we form a team
with the hospital’s doctors. If doctors are generals, nurses are a
combination of infantry and aides-de-camp.

After all,
patients are admitted to hospitals because they need round-the-clock
nursing care. We administer medications, prep patients for tests,
interpret medical jargon for family members and double-check treatment
decisions with the patient’s primary team. Nurses are also the
hospital’s front line: We sound the alert if a patient takes a serious
turn for the worse.

But while most
doctors clearly respect their colleagues on the nursing staff, every
nurse knows at least one, if not many, who don’t.

Indeed, every
nurse has a story like mine, and most of us have several. A nurse I
know, attempting to clarify an order, was told, “When you have ‘M.D.’
after your name, then you can talk to me.” A doctor dismissed another’s
complaint by simply saying, “I’m important.”

When a doctor
thoughtlessly dresses down a nurse in front of patients or their
families, it’s not just a personal affront, it’s an incredible
distraction, taking our minds away from our patients, focusing them
instead on how powerless we are.

That said, the
most damaging bullying is not flagrant and does not fit the stereotype
of a surgeon having a tantrum in the operating room. It is passive,
like not answering pages or phone calls, and tends toward the subtle:
condescension rather than outright abuse, and aggressive or sarcastic
remarks rather than straightforward insults.

And because
doctors are at the top of the food chain, the bad behavior of even a
few of them can set a corrosive tone for the whole organisation. Nurses
in turn bully other nurses, attending physicians bully
doctors-in-training, and experienced nurses sometimes bully the newest

Such an
uncomfortable workplace can have a chilling effect on communication
among staff. A 2004 survey by the Institute for Safe Medication
Practices found that workplace bullying posed a critical problem for
patient safety: rather than bring their questions about medication
orders to a difficult doctor, almost half the health care personnel
surveyed said they would rather keep silent. Furthermore, 7 percent of
the respondents said that in the past year they had been involved in a
medication error in which intimidation was at least partly responsible.

The result, not surprisingly, is a rise in avoidable medical errors, the cause of perhaps 200,000 deaths a year.

Concerned about
the role of bullying in medical errors, the Joint Commission, the
primary accrediting body for American health care organisations, has
warned of a distressing decline in trust among hospital employees and,
with it, a decline in the quality of medical outcomes.

What can be done
to counter hospital bullying? For one thing, hospitals should adopt
standards of professional behavior and apply them uniformly, from the
housekeepers to nurses to the president of the hospital. And nurses and
other employees need to know they can report incidents confidentially.

parties, whether doctors or nurses, would be required to undergo
civility training, and particularly intransigent doctors might even
have their hospital privileges — that is, their right to admit patients
— revoked.

But to be truly
effective, such change can’t be simply imposed bureaucratically. It has
to start at the top. Because hospitals tend to be extremely
hierarchical, even well meaning doctors tend to respond much better to
suggestions and criticisms from people they consider their equals or
superiors. I’ve noticed that doctors otherwise prone to bullying will
tend to become models of civility when other doctors are around.

In other words,
alongside uniform, well-enforced rules, doctors themselves need to set
a new tone in the hospital corridors, policing their colleagues and
letting new doctors know what kind of behavior is expected of them.

This shouldn’t be
hard: Most doctors are kind, well-intentioned professionals, and I
rarely have a problem talking openly with them. But unless we can
change the overall tone of the workplace, doctors like the one who
insulted me in front of my patient will continue to act with impunity.

I wish I could
say otherwise, but after being publicly slapped down, I will think
twice before speaking up around him again. Whether that was his
intention, or whether he was just being thoughtlessly callous, it’s
definitely not in my patients’ best interest.

(Theresa Brown,
an oncology nurse, is a contributor to The Times’ Well blog and the
author of “Critical Care: A New Nurse Faces Death, Life and Everything
in Between.”)

© 2011 The New York Times

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