Let's Make a Baby King!
May 8, 2011 -- Today the New York Times published a good op-ed about physician bullying by oncology nurse Theresa Brown, a regular contributor to the paper's Well blog. Under the headline "Physician, Heel Thyself," Brown describes a recent incident in which a physician invited a patient to blame Brown for anything that went wrong. Another physician reportedly dismissed a nurse's complaint by saying: "I'm important." Brown explains that most nurses experience some form of abuse from physicians. And she notes that even though most physicians are "kind, well-intentioned professionals," the abusive ones have a major impact, causing nurses and other clinicians to pass the aggression on and disrupting vital communications, which can lead to deadly errors. Brown urges hospitals to adopt "no tolerance" policies for bullying, and she asks physicians themselves to create an environment in which such conduct is unacceptable. Brown's piece is a helpful call for more respect for nurses and she makes excellent points. Sadly, the piece understates the level of abuse some nurses face and its effect on nursing burnout. It also understates nursing autonomy and power. The op-ed's statement that "if doctors are generals, nurses are a combination of infantry and aides-de-camp" is incorrect. Hospital nurses do not report to physicians. Nor are nurses low-level assistants to physician commanders. Nurses have less power as a class, but they are professionals with their own unique scope of practice and their own legal and ethical duties. Some nurses are themselves generals; one was just nominated to be the Surgeon General of the U.S. Army. Nurses have the power to create change. And nurses can and do confront physician abuse directly. The op-ed links the outsized influence of abusive physicians to their place "at the top of the food chain," but it does not question whether physicians should occupy that exalted position. In any case, we commend Theresa Brown for raising the issue of physician abuse and the threats it poses to public health.
Bully for you
The op-ed, headlined "Physician, Heel Thyself," begins with the specific incidents. First, Brown describes her own recent experience, in which a patient whose test result was late "jokingly asked his doctor whom he should yell at." The physician pointed at Brown and said, "If you want to scream at anyone, scream at her." Brown notes that this did not happen on House, or "30 years ago, when nurses were considered subservient to doctors," but to her just a few months earlier. When Brown asked the physician if she could quote him in an article, he said "Sure," and added: "It's a time-honored tradition -- blame the nurse whenever anything goes wrong." Brown says she felt "stunned and insulted," but does not record if she said anything else to the physician or the patient. Later in the piece, Brown says that "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."
Brown proceeds to explain why this is not just a matter of hurt feelings, stressing that attitudes like those of the physician
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.
Much of this is very helpful, and we especially appreciate the point that patients are admitted to hospitals because they need nursing care. And the last paragraph gives us some sense of what nurses actually do. Unfortunately, readers are likely to see that description as consistent with the aide-de-camp model. Readers are left to assume nurses are doing all of this under the close supervision of physicians. And there is no detail about what it takes to detect if a "patient takes a turn for the worse," or more generally, that nurses act under their own practice model to monitor patients, detect subtle changes, intervene with treatments, advocate for patients, teach patients and family members how to cope with their conditions and stay well, all with little or no physician involvement. The closest the op-ed comes to suggesting that maybe nurses have some autonomy is the earlier reference to the fact that nurses were "considered subservient" to physicians 30 years ago, which at least implies that something has changed. Of course, many did "consider" nurses to be subservient 30 years ago, and many still do, but it's important to make clear that they were just as wrong 30 years ago as they are now.
The op-ed describes the problem of physician bullying in more detail. Brown assures readers that "most doctors are kind, well-intentioned professionals, and I rarely have a problem talking openly with them," and says that "most doctors clearly respect their colleagues on the nursing staff." (That did not stop some physicians from responding to this moderate, nonconfrontational op-ed with online attacks.) However, Brown explains that when a physician "dresses down" a nurse in front of patients or families, it's an "incredible distraction, taking our minds away from our patients, focusing them instead on how powerless we are." The op-ed argues that
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.
These are great examples of what nurses endure, though we're not sure why more subtle bullying would be more damaging, unless that is because it is more common. In fact, nurses have recently suffered everything from repeated sexual assaults to having bloody organs thrown at them in the OR by physicians; conduct like that is hardly more benign than a sarcastic remark. And we're not sure there is a general social stereotype about surgeons having tantrums in the OR; that may be more something nurses are particularly aware of. Society's stereotypes about surgeons focus more on the brilliant, single-handed life-saving seen on shows like Grey's Anatomy. The piece goes on to assert that
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 organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.
Brown is exactly right about how bullying by some can create a hostile environment for all, and of course, the effects of bullying do not stop with clinicians. Patients and family members of clinicians can suffer from transferred abuse. And bullying is not just distracting and hurtful for nurses. It is a significant factor in nursing burnout and turnover, as research has shown, which increases health care costs and exacerbates the global nursing shortage.
Don't be meek today
Unfortunately, the vision of clinical care in this op-ed understates nurses' authority and overstates physician authority. Physicians are not "generals" and nurses are not "infantry" or "aides-de-camp," a term that is not far from the handmaiden stereotype that has plagued nursing for decades. Nor are nurses "powerless." Of course physicians have more practical power, but nursing is an autonomous science profession led by nursing scholars with doctorates in nursing (many of these leaders live in Pennsylvania (1, 2, 3, 4, 5), as the op-ed's author does). Nurses and physicians inhabit different management structures in clinical settings. And so hospital nurses do not report to physicians, but to senior nurses, in chains of command that extend through nurse managers up to the chief nursing officer, who reports to the CEO. Some nurses are themselves hospital CEOs.
And sticking with the military analogy, U.S. military nurses are commissioned officers, just as physicians are. Earlier this month, a nurse was nominated to be the Surgeon General of the U.S. Army. This nurse, Major General Patricia Oroho, is not really an aide-de-camp. Nor is General Clara Adams-Ender (Ret.), who served as head of the Army Nurse Corps from 1987-1991. Sure, the role of some direct care nurses might be compared to that of the infantry. But the infantry is led by infantry officers, not by people with some other specialty or training.
Of course, this is not the only recent example of nursing advocacy to suggest that physicians are and should be in command of the clinical environment. In a January 17, 2011, interview on Boston radio station WBUR, journalist and nursing advocate Suzanne Gordon made good points about the value of nursing and the need for physicians to respect nurses in order to protect patients. But she also essentially endorsed the idea of a clinical "hierarchy," with physicians on top, and said that it's fine for physicians to be the "captains" of the health care ship and "make the decisions" as long as there are rules in place to ensure that physicians pay attention to nurses' concerns in making those decisions. But physicians are not the "captains" of the health care ship. (See our FAQ on this topic.) Physicians have no authority or expertise to make decisions about nursing or other professions, and physician decisions about medicine should be closely examined, just like the decisions of anyone else with a responsible job. In fact, an argument can be made that if anyone in health care apart from the patient has a role similar to that of a ship's captain, it is the nurses and primary care providers who take a holistic, long-term approach to patients' wellbeing and try to guide them safely on the voyage of life!
Some nurses actually respond directly to physician abuse by explaining why it is wrong, both in terms of process and on the merits, rather than just looking hurt and slinking away. Nursing leader Kathleen Bartholomew (right) has many good ideas about how nurses can respond to aggression in a constructive way. In our view, a nurse could respond to the blame-the-nurse physician in the op-ed story by explaining what actually did cause the delay in getting the patient's test results. Or she might have extended a polite invitation for the physician to track down his own test results. Tests are part of the physician diagnostic process, and if physicians can't get the results themselves, they should hire clerks to do it. Too many physicians wrongly believe that nurses are there to serve them. But nurses are there to serve the patient, and they are busy every shift returning the patient to health, educating her, and advocating for her, to make sure the health system itself does not kill her. A nurse might also tell a physician who said something like this that she would be glad to accept blame for things that are her fault, but she would also assign responsibility for other problems--like creating a hostile work environment--where it belongs.
To the extent many nurses simply absorb abuse because they reasonably fear physician power--and physicians have tried to get assertive nurses disciplined or fired--that does not mean it has to be that way forever. Star Trek character James Kirk memorably noted in an original series episode that humans can admit that they are killers, but vow that they are not going to kill today. Similarly, some nurses might admit that they are meek, but they're not going to be meek today. Of course, a critical part of direct care nurses standing up for themselves is the knowledge that nurse managers will stand behind them, and we know that is not always the case. But every major change has to start somewhere. Every nurse can do something.
The op-ed cites some data to support the idea that bullying affects patient outcomes. The piece notes that 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.
The piece notes that the Joint Commission, which accredits hospitals, has also grown concerned about "a distressing decline in trust among hospital employees" leading to "a decline in the quality of medical outcomes."
The op-ed closes with some good ideas to address the abuse problem. Although nurses standing up for themselves directly is not among them, the piece does urge hospitals to adopt and enforce "standards of professional behavior," and it notes that "nurses and other employees need to know they can report incidents confidentially."Those who break the rules should be required to undertake "civility training," and "particularly intransigent doctors might even have their hospital privileges -- that is,their right to admit patients -- revoked." But the piece correctly notes that rules are not enough to create change.
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. 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.
The ideas for reform in the piece are sound and we commend Brown for raising them. We also like the references to "my" patients, which underscore that patients do not belong solely to the physicians--a misconception that is common in real life and the media.
But we remain troubled by the apparent assumption that physicians are and should remain in command of the whole hospital--as if the best nurses can hope for is to persuade the most powerful physicians, or a critical mass of physicians, that it is enlightened self-interest to protect vulnerable nurses from physicians who get out of line. However, it may be that the most important change is not for abusive physicians to learn that their physician colleagues expect better conduct, helpful as that would be, but for the physicians to learn that both good health care and basic human decency require that they treat everyone with respect and be open to input from everyone, that they are not gods but people, no more "important" than anyone else.That might also save those physicians from the embarrassment of making comments like those reported in this op-ed, which are difficult to reconcile with adulthood. Many people--even some nurses--wrongly believe that there is a hierarchy in hospitals with physicians reigning at the top. But when Kathleen Bartholomew presented her keynote speech at our recent conference Empowering Nurses and Improving Care Through Better Understanding of Nursing, she described the real legal and ethical structure that surrounds the patient. It is basically a tribe structure, like the one diagramed here, with different types of care givers surrounding the patient.We all have a duty to work collaboratively, but our obligation is to the patient, not other health care workers.
The op-ed does not explore the extent to which physician abuse springs from the very fact that physicians enjoy such high social and economic status, yet seem to suffer from a rigidly hierarchical and insular professional culture--a combination likely to lead to just this kind of abuse and impunity. One small way to address this situation is to stop referring to physicians as "doctors," as if they were the only ones who could earn doctorates or the only ones who really deserved the honorific. We suggest "physicians" as an alternative. It's true that "doctors" is more common, but "physicians" is hardly obscure; physicians themselves use it. And it is possible for language to evolve.
Brown closes by candidly admitting that "after being publicly slapped down" by the blame-focused physician, she will "think twice before speaking up around him again," and that is "definitely not in my patients' best interest." She's exactly right. In addition, a future in which nurses think and act as if physicians are in charge, and in which nurses can only hope that physicians will not abuse them, is not in patients' interest. What is in their interest is a marked increase in the power nurses and others have relative to physicians. And that starts with nurses standing up for themselves, taking steps to empower the profession, and rejecting the idea that physicians are awesome "generals" who rightly call the shots from "the top."
High-profile advocacy like this op-ed is an excellent way to raise awareness of physician abuse of nurses. We commend Theresa Brown for writing it and the Times for publishing it.
See Theresa Brown's op-ed "Physician, Heel Thyself" published May 7, 2011 on the New York Times site and May 8 in the print edition of the New York Times.
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