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March 19, 2013

Another look at the 'hospital hierarchy'

Daily Briefing

Dan DiamondDan Diamond, Managing Editor

The state of nurse-doctor relations isn't strong—or so Daily Briefing readers believe.

That takeaway is drawn from a poll that ran in in Monday's issue, within a story detailing how clashes between physicians and nurses can lead to deeper patient safety challenges. And overwhelmingly, readers felt that relations between the two professions were "poor" or, at best, just OK.


In some ways, that result's not a surprise. About one-quarter of physicians have admitted to disruptive behavior. Many hospital workers say that they've been intimidated by coworkers, either physically or psychologically.

But it's still a downbeat state of affairs, given that many hospitals and staffers have worked hard to strengthen interdisciplinary collaboration in recent years. And for good reason: Not only do conflicts in the workplace lead to staff burnout, but achieving successful relationships can actually boost patient safety. Note the following chart, taken from a recent Nursing Executive Center study on communication and collaboration.


Are relations truly that strained?

"It’s difficult to say whether the state of nurse-physician relationships is actually improving," according to Rachel Keller, who's helped lead the Advisory Board's research on managing problems in the workplace. "So much disruptive behavior flies under the radar and does not get reported." 

It's possible that hospitals are investing in building better relationships, but workers are being stymied by a handful of new barriers. The Nursing Executive Center study notes that emerging challenges, like larger teams and patients with more acute conditions, are causing problems for care coordination.

It's also possible that Daily Briefing readers voting in the poll were influenced by Monday's issue, which summarized a column from the New York Times. In her original piece, nurse Theresa Brown described her decision to question an oncologist's order. The doctor had quickly dismissed an EKG, which Brown believed showed evidence that the patient was having a heart attack.

    This particular doctor was known for his explosive impatience. On a good day his temper simmered just below the surface. On a bad day, he openly seethed. If I asked him to delay the transplant it would be ugly for me; if I said nothing, it could be very dangerous for my patient. So I asked for a delay.

    In the hallway, the doctor, in front of the rounding team, his large body twisted down to put his face close to mine, yelled, “Why?”

    This was intimidation, plain and simple. But it was also an example of a doctor’s abusing the legal, established hierarchy between doctors and nurses.

Extrapolating from that argument, Brown argued that physicians are quick to blame nurses when they're inconvenienced by routine requests and late-night pages.

But weighing in on his popular blog, the anonymous surgeon known as Skeptical Scalpel suggests that Brown helped provoke the confrontation by challenging the physician in front of his colleagues. "Maybe it would have been better," Skeptical Scalpel writes, "if she had said to the [doctor], 'Can I have a word with you in private?'" 

(And as it turned out, Skeptical Scalpel notes, the oncologist's impression of the EKG turned out to be right in the end.)

"One of the reasons so many doctors are depressed and burnt out," the blogger adds, "is the seemingly endless supply of articles like Nurse Brown's blaming us for everything that is wrong with medical care in the United States."

Finding a better path

Perhaps Brown's request could've been handled less obtrusively, as Skeptical Scalpel suggests.

"Nurse Brown laments that there are no protocols to resolve disagreements between doctors and nurses," the blogger writes. "I disagree. Since the overwhelming majority of orders are not of a life-or-death nature, one can simply go up the chain of command.

Meanwhile, Keller notes that creating a healthy workplace requires taking "a systemic view of the problem," with a balanced look at the stakeholders and who in the hospital is allowing bad behavior to persist. But the instinct to take collaborative ownership for patient care should be applauded, she notes.

"It’s good to be surrounded with a high-performing team that is checking and double-checking that the outcome is a good one," Keller says. "Humans are fallible."

More from today's Daily Briefing
  1. Current ArticleAnother look at the 'hospital hierarchy'

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