Have physician-nurse relationships improved?

April 11th, 2012

by Jonathan H. Burroughs

My daughter Serena will graduate from Oregon Health & Science University School of Nursing in September and I wonder if things will be different for her than for the nurses I worked with more than thirty years ago when I entered the healthcare industry.

When I was a new emergency department medical director at Valley Regional Hospital in Claremont, N.H., I was running a code and asked for epinephrine and atropine (we used atropine in those days!) and the new nurse told me she didn't know what those were or where they were kept. In my most caustic and superior tone I told her so that everyone could hear, "If you don't know what epinephrine and atropine are, you should not be here; please send me a nurse who knows what s/he is doing." She left the unit in tears and we completed the code without her.

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The next day, the chief nursing officer (CNO) came to see me and asked to speak with me privately. Being a wise manager she began by saying, "Jon, I'd like to apologize to you for sending you a nurse who was not properly prepared to assist you in the code. It won't happen again."

I was feeling pretty vindicated at that point and puffed out my chest, smiled and returned, "I appreciate that."

And then she went on, "I am concerned that she was so humiliated by the experience that she and the other nurses in the hospital are worried that they will not be able to work with you due to a lack of professional respect and we all hope that you will be able to help us to rectify the situation." She then quietly turned and left the room.

I didn't get much sleep that night and realized with much sobering reflection that part of my training at some of the nation's most prestigious academic institutions was wrong. Treating people with disrespect and shame will not improve human performance nor will it help patients to have better outcomes.

The next day I went to the CNO and said, "I thought a lot about our meeting yesterday and would like to do two things: train all nurses who are interested in advanced cardiac life support (this was a radical idea at the time, as only physicians were trained in the technical aspects of resuscitation), apologize to the nurse whom I disparaged in front of her colleagues and let them all know that it will never happen again."

The CNO smiled and said, "I appreciate that Jon; it will go a long way towards helping the nursing staff to heal." As a thank you, the next week she brought me in a "bird of paradise" which I kept for a long time to remind me of human fallibility and how we all are vulnerable to misinformation as a part of our professional indoctrination.

And so I wonder, will my daughter have to go through a similar traumatic episode on the firing line? Are those days truly over or is there a residue of the perfect physician overseeing an imperfect world and having to defend himself or herself in dysfunctional ways? Can we move towards a world of physicians and nurses working together as functional teams or is that still patient safety rhetoric? Has our professional world evolved sufficiently over the past 30 years or is it still the same?

What do you think?

Jonathan H. Burroughs, MD, MBA, FACPE is a certified physician executive and a fellow of the American College of Physician Executives. He is president and CEO of The Burroughs Healthcare Consulting Network and works with some of the nation's top healthcare consulting organizations to provide "best practice" solutions and training to healthcare organizations throughout the country

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Like Dr Burroughs I can recall many instances of unprofessional behavior on the part of my clinical colleagues. But it was one of early bosses that set the tone and provided me with guidance on the relationship between doctors and nurses (and in fact everyone else in the hospital).

There was never a time when you would not see JK holding a door open for any staff member approaching a ward and I recall vividly him opening the door for the ward domestic on his way in for an early morning ward round.

Not only did he demonstrate the professional values and respect to everyone he was also at pains to highlight the importance of the nurses and all the other ancillary members of the team on every ward round. We never had a ward round without the nursing staff and if at all possible the ward sister or charge nurse if they were available. He went to great lengths to explain to me as a junior inexperienced doctor that the nursing staff were my best friend to help navigate the challenging world of medical care - as he put it

"Most times the nurses know more than you do so heed their advice or better yet ask their advice"

Sage advice to a young 22 year old House Office (PGY1 equivalent) who may have passed his medical finals but knew little about the management and care of patients on a busy ward. In fact I made such good friends with the nurses I married one (she is a nurse, midwife and health visitor).

The general consensus of comments is that things have been improving albeit slowly but the road is long and still littered with fall out from some who perpetuate old school notions of inequality. This review on Fierce health focused no the comments and as they rightly pointed out:

...as recent research found that hospital training programs aimed at increasing physician-nurse communication and teamwork helped reduce surgery-related complications, including blood clots and infections. Moreover, hospitals that used teamwork training saw a 15 percent decrease in patient deaths, compared to a 10 percent drop at hospitals that didn't use the program, according to a December 2011 study in the Archives of Surgery.

Quite!

I'm looking forward to my discussion with Karen Kirby, RN, MSN, NEA-BC, and Kathy Douglas, RN, MHA on #VoiceoftheDoctor on HealthcareRadioNow this Friday at 2:30 ET

Hope you can join us then

Previous post: Greening the operating room

Next post: My philanthropic advice to America’s healthcare supporters

Facebook a template for electronic medical records - not as radical as it might sound at first. I blogged the same point back in 2008
A Facebook Medical Record

It sounds like Facebook would make a great starting template for a vast interconnected medical records system. But the reality is that the electronic medical record (EMR) industry is still stuck in the era of the BBS.

Open easy access that includes mandated sharing and open standards rather than the proprietary old fashion mechanism currently entrenched in the EMR systems. I'm willing to be that patients might drive this in the near future as we move to a more personalized system that is managed with individuals managing and controlling their personal health record.

The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.

“Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative. “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.”

Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters. But their change of heart also reflects recent changes in the health care marketplace.

Insurers and other payers are seeking to shift more of their financial pain to providers like hospitals and physician practices, and efforts are being made to reduce financial incentives for doctors to run more tests.

The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine Foundation and in partnership with Consumer Reports.

The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.

The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.

Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.

Other efforts to limit testing for patients have provoked backlashes. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.

“Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make,” said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. “With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients’ ability to make decisions themselves.”

Dr. Christine K. Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, disagreed, saying the United States can pay for all Americans’ health care needs as long as care is appropriate: “In fact, rationing is not necessary if you just don’t do the things that don’t help.”

Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.

Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation.

Still, many specialists and patient advocates expressed caution, warning that the directives could be misinterpreted and applied too broadly at the expense of patients.

“These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder. “This kind of one-size-fits-all approach can be a real detriment to good care.”

Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease.

“I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a ‘super responder,’ and now I have no evidence of disease,” said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. “Doctors can’t practice good medicine if we tie their hands.”

Many commended the specialty groups for their bold action, saying the initiative could alienate their own members, since doing fewer diagnostic tests and procedures can cut into a physician’s income under fee-for-service payment schemes that pay for each patient encounter separately.

“It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”

This article has been revised to reflect the following correction:

Correction: April 4, 2012

An earlier version of this article misidentified, at one point, the organization whose member groups recommend that doctors curb the use of 45 common medical tests that may be unnecessary. It is the American Board of Internal Medicine Foundation, an organization that promotes physician professionalism — not the American Board of Internal Medicine, the specialty board with which it is affiliated.

In a great new step nine of the medical speciality boards have joined together to help guide doctors and patients to help decrease the waste in healthcare.

The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.

THe list includes:
EKG's done as part of routine physicals
MRI's for back pain
Antibiotics for sinusitis
Stress cardiac imaging in asymptomatic patients
Lower dosage medications for acid reflux
Decreasing scans for early stage breast and prostate cancers that are unlikely to spread
Rigorous review before commencing on chronic dialysis

Look for the back lash as patients and patient advocate groups leap in as we saw when the guidance on frequency of mammography screening was reduced from annual to every 3 years. Its inevitable as you take away things that people believe are necessary and see as their right but if we don't want to see rationing of care

In fact, rationing is not necessary if you just don’t do the things that don’t help

But tied to this as Sam Bierstock rightly pointed out in our discussion last Friday - much of this is driven by defensive medicine and fear of litigation and until this aspect fo the equation is dealt with the impact of these initiatives are likely to be muted.

Will plan on talking about the imaging aspects of this with Dr Bill Boonn (@wboonn) this Friday in my weekly discussion on #voiceofthedoctor