Tuesday, July 8, 2008

Respect and Arrogance

Guitar Girl talks about an incident where she corrected an intern, and leaves the implication that the intern didn't take it too well. Madness has a different take on the story, and feels that it is silly for us to try to be careful of the doc's ego while they crush ours all the time. Go read those two posts before reading my take.

You back? Okay, here is what I think: two wrongs certainly don't make a right, and just because we sometimes get mistreated doesn't mean we have carte blanche to return the favor.

In the case of Guitar Girl's story, I don't see any reason why she needed to say anything in front of the patient. The danger to the patient wasn't imminent and because the facts were on her side, she would have had support from others outside the room. This is a situation where the only danger to the patient would have been if the nurse had gone and picked up the medication and administered it, so there was plenty of time to talk to the intern in the interim.

It would be a different story if she were in the room and the doctor had pulled up 60 of Toradol and was getting ready to push it, or in the middle of a code situation when you notice that something is being done incorrectly. In situations where the danger is immediate, then I think whoever notices the mistake has the responsibility to at the very least stop the action and pull the person away from the patient to explain, or if necessary, to say it right there and then; because you are right: safety trumps ego.

But here it is about more than ego for the doctor. Here we have a patient who is now doubting their treatment. If Ego gets undermined, who cares, but now we have credibility undermined, and a patient who doesn't think she is going to get the treatment she needs. Not only does this lead to lower satisfaction scores (who cares), but it leads to worse outcomes for patients. I'm a strong believer in the power of the mind over healing, and I have seen time and again that a patient who does not believe that they will get good care somehow doesn't get good care, regardless of what the caregivers actually do. Anything we can do to help a patient feel like they are getting the best possible care will improve outcomes, lead to better results, and improve patient satisfaction and Press Ganey scores.

So yes, there is absolutely no reason that doctors should arrogantly boss us around and make us look like fools, but there is also no reason that we should return the favor, unless we are saving our patients from immediate threat.

From the comments at Guitar Girl's post come two very good points: "Never go to a teaching hospital in July" and "Why is an intern giving a verbal order for a non-emergency med anyway?"


Mz.Elle said...

Keeping in mind that I have zero experience in this field(or any other for that matter) I agree with you.
It's a matter of respect,not so much for the intern but for yourself and the patient.
Very good post! Thank you also for leading me to two other important
points of view.

GuitarGirlRN said...

Just to defend myself: I agree that I probably should have stepped outside to correct him. Please know that I didn't correct him to make him feel bad, or to make myself feel superior; I just heard him mention a dose I had never heard of before, and since I'M always up to learn something new, I wanted to clarify the dose, so I looked it up. The doc himself thanked me for my help after our interaction, and as far as I know, he didn't feel bad about it. When I apologized later, he stated that he didn't even remember the conversation.

Braden said...

Actually, Guitargirl, in reading your post and your comment later, I understood that you were not trying to make the intern feel bad, and everyone has moments where you wish you could take something back. I was using your example to go a step further and talk about whether or not it is acceptable to correct the doctor and when and how to do it.

I think we all agree as Monday Quarterbacks that you made a mistake doing it in front of the doctor in this situation, and I think it is big of you to own up to it and go apologize.

I had something like that happen to me a while ago where I said something about not wanting an ambulance patient to a nurse just as the ambulance patient rolled by. It completely came out wrong and I had to try to come from behind in the patient's eyes (at least I assume so... he never said anything about it).

Thanks for commenting. I didn't even know you stopped by my neck of the woods. For that matter, I didn't even know woods had necks.

Vitum Medicinus said...

"Why is an intern giving a verbal order for a non-emergency med anyway?"

I haven't been on the wards enough to know the rules, but wouldn't this be in the best interests of the patient ie. so they can get their pain meds faster??

Just asking, I admit ignorance...

Braden said...


I started to respond as a comment and it turned into a post. Go check it out.


CountyRat said...

Good question, Vitum. It is a matter of clarity and precission. The doctor's order must be noted in the record. If the doctor does this him or herself, there is one fewer link in the chain between decission and execution, eliminating one potential error. This does not mean that the doctor cannot verbally ask the nurse to administer the does as he or she is writing. However, a good nurse will repeat the doctor's order out load, wait for him or her to confirm that the nurse heard correctly, and then, look at the chart and confirm that what was said (twice) and what was written are the same.

I know this sounds like a time-wasting ritual, but it isn't. In a well-functioning team setting, the whole business takes about twenty seconds or less, and the risk of error is reduced. Any reduction of harm to the patient is worth the investment of twenty seconds.

As you spend more time in clinicals, you might be surprised at how much time and resources are devoted to just keeping mistakes from happening. I was. This is very true in nursing (I am not a doc, so I can't comment on that). One of our most important roles is that of sentinal. We are often the only licensed professional who is in the unit with the patient continually, so it is natural that our role as guardian of patient safety should be such a big part of what we do. Good nurses do this so skillfully that the patient will not even know how many precautions are being exercised, doctors will not be detained in their work, and treatment will not be delayed to a degree that causes the patient harm or avoidable discomfort. Pulling that off is harder than it would seem, especially when things get hectic, but nursing is not supposed to be an easy job, it is supossed to be a properly done job.

Love your stuff, Vitum. Keep blogging as much as your med student lifestyle allows!