The weather in my head

"Washington Post" and "New York Times"�on physician anger management

 
The most common way people give up their power
is by thinking they don't have any.

                        Alice Walker

March 16, 2013 -- This month major press entities ran pieces addressing the ongoing problem of conflicts between nurses and physicians in clinical settings. On March 4, The Washington Post published a long article by Sandra G. Boodman about the growing use of anger management programs to deal with "out-of-control doctors" in hospital environments that are increasingly team-oriented and less tolerant of abuse and tantrums. The piece is good as far as it goes, conveying lots of helpful information about why the abuse happens, programs to address it, and how it can affect patient care. But the focus is overwhelmingly on the perspectives of the physicians themselves, with only one nurse consulted briefly, and there is no real effort to explore what the actual victims of the abuse think or experience. Instead, readers get a long section in which an abusive surgeon provides a slew of reasons/excuses for her conduct, mainly how much she herself suffered in her brutal training. And today, Theresa Brown, RN, posted a well-written blog entry on the New York Times site about the choices nurses face when they disagree with a physician's care plan. Brown briefly discusses how nurses can protect patients in a world in which the nurses have less practical power than physicians--and in Brown's view, a world in which nurses fall below physicians in a "legal, established hierarchy" that must be obeyed. But in fact, nurses do not report to physicians. The two groups practice distinct professions. In hospital settings, they have separate management structures. And nurses are legally and ethically bound not to accede to physician wishes that threaten patients. Of course, Brown is right that nurses who stand up to physicians face risks; they range from bullying to assaults to being fired by nurse managers who fear the physicians' power as revenue generators. But there is no formal "hierarchy" between the professions, just different scopes of practice and a longstanding power disparity. Brown seems to argue that physicians should have final authority over all clinical decisions, possibly because of a view that one type of health professional has to be in charge of everything, an idea that is regressive and untenable in the highly diverse, patient-focused modern health care environment. Brown recommends interprofessional education programs, and we agree that they improve relations between the professions. But simply trying to persuade physicians not to abuse their power, while meekly embracing a subservient professional status, is not enough to protect patients--or nurses. Nurses need collaboration and autonomy.

Anger management: Washington Post on programs for angry physicians

Self-determination: New York Times's Theresa Brown on nurses confronting physician power
 

Anger management

The Post article's headline is "Anger management courses are a new tool for dealing with out-of-control doctors." The piece focuses on a "long-festering problem that many hospitals have been reluctant to address: disruptive and often angry behavior by doctors." Reporter Sandra Boodman notes:

Experts estimate that 3 to 5 percent of physicians engage in such behavior, berating nurses who call them in the middle of the night about a patient, flinging scalpels at trainees who aren't moving fast enough, demeaning co-workers they consider incompetent or cutting off patients who ask a lot of questions.

As an example, the piece describes a surgeon who responded to being handed a device that a technician had loaded incorrectly by slamming it down, "accidentally breaking the technician's finger." The surgeon was suspended and "told to attend an anger management course for doctors." (We wonder if there would have been far more serious consequences, including police involvement, had the finger breaker been someone other than a physician.) The piece says that bad conduct by physicians has long been tolerated as an "inevitable product of stress" or accepted by administrators who feared alienating powerful revenue generators. Now, "experts" say that situation is changing in the wake of 2009 rules from the hospital accreditation body the Joint Commission that adopt a "zero tolerance" approach to disruptive conduct.

Yet despite this apparent shift, the piece also includes material suggesting that excessive deference to physicians isn't waning as quickly as we would like:

Recently at one Virginia hospital, according to University of Virginia School of Nursing dean Dorrie Fontaine, a veteran operating-room nurse with 30 years' experience walked into her supervisor's office and quit after a surgeon screamed at her -- his usual reaction to unwelcome news -- when she told him that a routine count revealed that an instrument was missing. Hospital administrators shrugged off the episode, saying, "Well, that's the way he is."

The article itself focuses on the perspective of physicians, rather than nurses, other colleagues, or patients. And it consults mainly physicians and those who conduct their anger management training. The piece tries hard to help us understand the feelings of physicians who abuse, but does virtually nothing to convey the perspectives or feelings of the abused, including the nurses who often bear the brunt of physician anger. Thus, although the piece commendably describes how the abuse threatens patient outcomes and nursing retention and can lead to litigation, it really does not convey that the abuse causes serious and long-lasting harm to those on the other end of it. It almost seems like nurses are part of the hospital facilities, health care assets that must be protected, rather than thinking humans whose views and experiences are worth spending much time on. The piece does point to research showing that nurses too "act out . . . mostly to other nurses," but "their behavior is less likely to affect patients." The report does not ask why that might be, leaving readers to wonder if it's because even abusive nurses are less likely to allow bad conduct to harm patients, or because nursing just doesn't affect patients much. And there is no effort to explore why nurses might commit abuse. Are they looking for an outlet for the abuse they have suffered at the hands of physicians and patients, since nurses are the profession that endures the most bullying and abuse in the clinical setting? Could they be modeling the conduct they experience from the more powerful group in their midst?

To its credit, the piece does briefly quote Fontaine, noting that she has "written about disruptive behavior and confronted it as an operating-room nurse." Fontaine says that many years ago "medicine was more hierarchical" but now teamwork is critical, "making interdependence, not autonomy, paramount." But "autonomy" is consistent with interdependence. And minimizing autonomy does nursing no favors, since nurses are the ones who struggle to work to the full extent of their scope of practice; no one could seriously doubt that physicians enjoy "autonomy." In any case, the piece includes nothing from Fontaine about how the abuse affects nurses.

The Post does include substantial discussion of the effects of the abuse from a policy perspective, referring to the "corrosive effect" abuse has on staff morale and the threats to patients when nurses are reluctant to advocate for them, with lots of quotes from non-nurses. A psychiatry professor from George Washington University stresses that a "very small number" of physicians are involved "but the ripple effect is profound." Indeed, "experts" say the conduct "is not merely unpleasant" but "has a corrosive effect on morale and poses a significant threat to patient safety." The piece cites a 2011 survey of hospital administrators that found "widespread concern" about the effects of disruptive behavior on patient care, and a 2008 study in which significant percentages of physician and nurse respondents linked the conduct to errors and even patient deaths. Peter Angood, leader of a physician executives group and formerly chief patient safety officer at the Joint Commission, "compares the problem to road rage." And the piece notes that like road rage, physician abuse "can have deadly consequences," citing the deputy chief of enforcement at the Medical Board of California, who says the board has investigated fetal and maternal deaths resulting from the failure of nurses to alert physicians to worrisome fetal monitor readings "for fear of being chastised or ridiculed." Internist Alan Rosenstein, who worked on a 2002 study finding "bad behavior by doctors drove nurses from the profession, contributing to the nursing shortage," notes that such conduct can also have "expensive consequences in the form of lawsuits by employees alleging the existence of a hostile workplace and an exodus of experienced nurses who are expensive to recruit and difficult to replace." Goodness--where will we find more of these special nurse-widgets?!

But at least the piece does convey something of how patients suffer:

Rosenstein cites one case of a physician who ridiculed a nurse after she called him at home, worried that a patient in the intensive care unit had developed aspiration pneumonia, a potentially lethal complication that occurs when a substance such as food or vomit is inhaled into the lungs. "He told the nurse to 'get better training' and refused to address the issue," Rosenstein said. "The patient died."

And by implication, these passages do convey to the attentive reader that the nurses must have some skill and responsibility, if their failures can lead to death. On the other hand, it sounds like nurses' only life and death responsibility is alerting physicians; in fact, nurses have patients' lives in their hands in conducting many of their duties, quite apart from physicians.

In any case, the bulk of the piece is an extensive discussion of why the abuse happens and recent efforts to improve the situation. The problem seems to be most common among surgeons and other specialists "who do procedures," and most who enroll in programs to address the problem are "middle-aged men sent by hospitals or state medical boards that have ordered them to shape up." The piece includes a lot of praise for the technical awesomeness of these physicians. Many, we learn, are "technically excellent," winning teaching and "top-doctor" awards, "the smartest group of people on the planet" (according to social worker George Anderson (right), and some are even "beloved by patients." On the other hand, the Post says, the physicians are often "narcissistic, compulsive perfectionists who insist that they are the real victims when complaints are lodged and defend their behavior by saying they were doing what was best for their patients." J. Kim Penberthy, who co-directs a program at the University of Virginia, attributes much of the problem to difficulty "coping with change." And Anderson notes that despite the physicians' high IQs, "their emotional intelligence scores are really pathetic." He says that one surgeon he working with, in the words of the piece, "booted an anesthesiologist out of the OR, leaving the patient unmonitored during surgery." We might note that the patient was probably not completely unmonitored during the surgery, due to the presence of OR nurses who actually play a leading role in making sure patients stay alive. But of course, the patient did have the right to a qualified anesthesia professional for the surgery, and it was probably malpractice to eject anyone. We realize that surgeon characters on influential dramas like Grey's Anatomy often order people "out of my OR," and it looks so awesome and powerful, but real patients need a range of professionals to address their needs during surgery. Surgeons are not qualified to do that, and they are not in charge of anesthesiologists, nurses--or patients, who, after all, are supposed to be directing their own care.

The piece points to the "brutal" way physicians are trained as a key factor in the abuse.

Traditionally, "medical students were told, 'You don't know anything, so shut up until you do,'" Rosenstein said. Many, he said, emerge from training as "autocratic, independent and dominant," and they imitate the ways they were taught. "It's a setup for disaster."

Right. So would it make sense to re-examine the entire structure of physician education, rather than just send the most extreme products of that training off for anger management training?

The piece doesn't ask, but it does explore the "cottage industry of therapists who provide anger management counseling, which is sometimes billed as 'executive coaching.'" That term presumably helps the participants save face, though it doesn't do any favors for the people who the participants may wrongly believe they supervise, including even other physicians, like the ejected anesthesiologist. And Vanderbilt's program is called the "Program for Distressed Physicians," which makes it sound more like the physicians are really just very worried about something, rather than screaming and throwing scalpels at people, which might be considered assault, battery or worse, if it weren't being done by a physician. But the program does require participating physicians to "role play the incident that brought them to Nashville," and it focuses on improving coping and communication skills. Co-director William Swiggart describes his approach to the physicians by noting that he is "happy to assume your heart's good. But your behavior sucks." A preliminary study of the program showed "statistically significant reductions in disruptive behavior as rated by co-workers, administrators and the doctors themselves."

The piece concludes with a long section in which the surgeon who broke the technician's finger is given ample opportunity to explain how she feels and to offer a number of reasons/excuses, with no effort to challenge her apparent self-absorption or ask her to imagine how the tech or other colleagues might feel. The section's heading: "One surgeon's story." The surgeon describes the accident as being "fueled by sleep deprivation and a crushing workload"; plus, the tech's hand was "'where it shouldn't have been' -- on the patient's metal leg strap"; plus, she was trained by male surgeons who barked and threw instruments, and she never had a female mentor; plus, men get away with more bad behavior than women do; plus, the surgeon was "completely distraught" that she had it in her to "do that." Of course, it's not that any of this is wrong or irrelevant, but it places all the responsibility elsewhere, when the fact is that none of those other people were the ones who broke the technician's finger. The surgeon concedes that her career has been marked by "'difficult interactions," especially with nurses, and that she "felt hated," but "thought that some were jealous of her." Of course, jealousy is not impossible and female physicians do face special challenges. But contrary to what some physicians and members of the media think, very few nurses would like to be physicians, and it's far more likely that the nurses were projecting ill will because this surgeon was earning it in spades. The piece does note that the surgeon has now learned that co-workers avoided her because of what they saw as a "harsh style and chronic bad mood." She admits she was "not functioning well," but says the Vanderbilt program helped her to "better regulate her emotions and soften her brusque demeanor." She says that the "most powerful part was listening to other people's stories and telling my story."

By "other people," she presumably means the other abusive physicians in the program. We see little evidence that she or the Post are interested in the victims' stories. There is no comment from the technician with the broken finger and no account taking us deep inside the mind of anyone on the other end of the abuse, no extended analysis of why the abuse happens from someone actually experiencing it. The reporter might be slyly offering this physician the chance to prove that the abusers are indeed narcissists obsessed with their own victimhood, as suggested in passing earlier in the lengthy piece, but that's really not going to be what most readers take away; the tragedy here seems to be all about what the surgeon has experienced. In any case, despite this imbalance, itself a clear indication of the excessive regard physicians continue to enjoy, Boodman and the Post do deserve credit for highlighting the abuse problem and for including some discussion of the negative effects on patients and health care generally.

Self-determination

Theresa Brown's New York Times blog post is "Healing the Hospital Hierarchy." The piece discusses what nurses can do when they disagree with a physician care plan but the physician is unreceptive or even abusive. The post conveys the potential threats to patient wellbeing and, to some extent, to nurses themselves. As usual, Brown writes well and shows readers that nurses are sentient beings, not widgets. But the piece also reflects the incorrect view that physicians are and should be in charge of all patient care, while any nurses who disagree are impractical ivory tower types. Of course physicians have more power, but that does not mean that nurses do or should report to them, or that nurses can only beg physicians to treat them better. As in other fields were different professionals work together, disputes can be resolved by negotiation, by the enforcement of uniform rules of conduct across the hospital workplace, and if necessary by the intervention of higher workplace decision-makers, including ethics boards. Nurses are legally and ethically bound not to implement physician care plans that are not in a patient's best interests--and indeed, to actively work to change those plans. We're not saying it's easy or safe for a nurse to stand up to a physician who wrongly has more power. Just that it's part of the job.

Brown frames her post with a story in which she herself evidently found the courage to advocate for her patient, at least briefly, by telling an abusive physician something he didn't want to hear. She explains that a few years ago, one of her oncology patients who was scheduled for a stem-cell transplant was experiencing symptoms of a heart attack, which would make the transplant risky because one chemical involved could have serious cardiac side effects.

An EKG was done, and we were waiting for a cardiologist when the oncology team came by on morning rounds. The attending physician heard about the patient's chest pain, then glanced at the EKG while checking his smartphone. "This does not concern me," he said, tapping at his screen as he pushed the EKG paper aside. 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.

Brown does not reveal any more of this specific encounter, except to note near the end of the piece that her patient was "lucky" because the cardiologist "arrived on the heels of the oncologist's temper tantrum" and, based on the EKG, determined that the patient was not having a heart attack and the transplant could proceed. The rest of the piece is a mix of basically accurate statements about the problem of abusive physicians and an insistence that nurses are and must be beneath physicians in some "clinical hierarchy." Brown points to the "latent consequences" of the abuse, noting that given "the power differential in hospitals," "if a doctor chews out a nurse it tends to make her less likely to speak up the next time." She explains that "the silencing of nurses inevitably creates more opportunities for error" in the complex health care system where lives are at stake. And she notes that "preventable medical errors kill 100,000 patients a year, or a million people a decade," according to "Wall of Silence" by Rosemary Gibson and Janardan Prasad Singh. That's all correct, although we note the troubling use of the phrase "chews out," which means to reprimand, as one would a subordinate of some sort.

But Brown is much more direct than that about nursing subordination. She says the oncologist was "abusing the legal, established hierarchy between doctors and nurses." Brown does not explain where that "legal, established hierarchy" might be spelled out--we are not aware that it actually exists. She may believe that a "hierarchy" flows from the authority of physicians to write prescriptions, which Brown consistently calls "orders," an admittedly common term that reinforces the notion that physicians are indeed in charge. Brown mentions as another example "the doctor who reacts rudely to middle-of-the-night pages, even though, legally, the nurse must get an order even for something as ordinary as Tums." Brown also says that "nurses cannot give orders, but they are considered the 'final check' on all care decisions that doctors make, and we catch mistakes all the time." She cites a time when "chemotherapy intended to be given intravenously was ordered with the formula for delivery to the brain," which "could have been a thousandfold dosing error."

These are good examples of how nurses save lives by using their skills to catch errors. But the fact that physicians have authority over what medications patients get does not mean that nurses report to them as a general matter or that nurses have no autonomous scope of practice, points that Brown never makes. Brown leaves readers with the impression that physicians direct nursing care across the board, or that nursing care involves little more than giving drugs and checking for drug errors, none of which is true. Nurses are obligated not to implement care plans they believe are not in a patient's best interests, which can constitute nursing malpractice (something Brown's readers might be surprised to hear even exists).

Brown contends that there are no systems to resolve conflicts between physicians and nurses about care plans. She says that there are "no protocols" and "no established way" for nurses to resolve such conflicts, noting that "most docs will recognize the mistake and correct it." (We note the affectionate diminutive "docs.") However, Brown says, if the physician won't correct the error, "the nurse's only fail-safe option is to refuse to perform the order." But "the harsh truth is that such intrepid nurses can easily be fired." And "the lack of an established, neutral way of resolving such clashes works to everyone's detriment." We agree with some of this, but there is a great deal missing.

First, nurses do have a number of other options. Nurses can speak with another physician, perhaps a more senior one; of course, that will not endear the nurse to the first physician, but neither will refusing to carry out the care plan. The nurse can also speak to his own manager, who is, in fact, another nurse. It is this person who might actually have the authority to fire the nurse, something Brown fails to mention, leaving readers to think physicians hire, fire and supervise nurses. We agree that some nurse managers are weak enough to fire a nurse because a physician is unhappy, but that is hardly an inevitable situation that should be accepted, much less embraced, and we hope it is becoming less common. Nurses have successfully fought back, particularly with the benefit of numbers or unions. And many hospitals have ethics boards composed of different professionals, including physicians and nurses, to resolve such conflicts. Brown mentions none of this, nor does she propose any structural reform in the clinical setting that might address the outrageous situation she describes.

Brown not only believes that physicians do have the final say on care decisions, but that they must: "Most people in health care understand and accept the need for clinical hierarchies." And she goes further, directly challenging nurses who disagree:

Some nurses reject the whole idea of doctor's orders; they think the term makes nursing sound subservient. As a working clinical nurse, I don't find that a practicable approach: someone has to be ultimately responsible for clinical decisions, and M.D.'s have that authority. The challenge is making the system we have work smoothly all the time.

Yes, the use of terms like "orders" sure does make nursing "sound subservient," but it doesn't make nursing actually subservient--which is what "some nurses" really care about--except to those who embrace the incorrect, regressive assumptions behind the term. These assumptions may include the idea that physicians know far more about all of health care than nurses do and so should naturally direct all their work, and perhaps that nurses as a class lack the courage to make important decisions on their own, so someone else has to be in charge of them. Countless nurses have proven these ideas wrong, including the hundreds of thousands of advanced practice nurses, and all nurses have vast knowledge of patient care that physicians lack, such as in wound care. So it is absurd to believe that physicians would be qualified to direct nursing care, any more than nurses would be qualified to direct physician care. Brown's pointed reference to her status as a "working clinical nurse" is meant to suggest that those who disagree are innocent theorists who are unfamiliar with real clinical settings. But many nurses who disagree have decades of clinical experience, and they have practiced without timidly treating physicians as their superiors.

Brown's claim that we "need" clinical hierarchies because "someone has to be ultimately responsible for clinical decisions" is wrong. The diversity of health care knowledge is now so great--even within medicine, to say nothing of nursing, physical therapy, respiratory therapy, pharmacy, dental care, and so on--that the only person who should be "ultimately responsible for clinical decisions" is the patient. Many different professions collaborate on complex projects without one needing to be "ultimately responsible" for every decision. Engineers and architects manage to work together without either being in charge, as do lawyers and accountants. Maybe nurses should have to check in with physicians before giving a Tums; and maybe physicians should have to check in with nurses before undertaking surgeries and other interventions that could be contrary to a patient's best interests. Indeed, ensuring that nurses have the power to stop dangerous physician surgical plans is a key part of the reforms proposed by prominent patient safety advocate Peter Pronovost, MD.

Brown does describe one promising measure that can be taken to "improve how nurses and doctors work together," namely interprofessional education in which nursing and medical students are trained together. And this measure is one we fully endorse. Brown's example is none other than the University of Virginia, whose nursing dean is Dorrie Fontaine, the same person briefly quoted in the Washington Post piece above. As Brown describes the UVA program:

Courses, training modules and even faculty members are shared across both disciplines. Medical and nursing students are taught to respect each other's areas of expertise and contributions to their shared mission. One of the program's core areas of focus is what collaboration means to doctors and nurses. Doctors believe they know what teamwork is, but for many it may mean what Tina Brashers, the lead physician for the interprofessional education program, calls the "poof factor": "Doctors type into the computer and POOF, the order happens," with no input from nursing needed and little knowledge of nurses' importance to patient care. Nurses, in contrast, are more likely to define good teamwork as a relationship in which everyone's input counts. Let's hope the interprofessional education model catches on; otherwise, patients will feel the lack.

This is helpful information, and we have long championed this kind of program, which can also include shadowing programs like the one pioneered many years ago by Ellen Ceppetelli at Dartmouth University and currently in place at institutions like the University of Wisconsin by Megan LeClair. Of course, not every educational institution where one of the two professions is trained includes the other profession, and in any case patients' lives cannot depend on one university program undertaken at some point in a clinician's past. So this could never replace the overarching need to recognize and reinforce nursing autonomy in clinical settings.

The Center for Health Ethics at the University of Missouri helps hospitals to create healthier organizational structures and manage conflicts between physicians and nurses. The Center's policy on "Relations between Physicians and Nurses" is a good starting point for any institution or individual looking for better relations between the two professions.

We thank Theresa Brown for making valuable points about the situation that nurses confront when they disagree with physician care plans. We wish she would convey that nursing is not a weak subset of medicine that can only "hope" abusive physicians will be nicer someday soon, but an autonomous profession whose members are legally and ethically obligated to protect patients from any threat, including misguided care plans from other health workers.
 

See the article "Anger management courses are a new tool for dealing with out-of-control doctors," posted March 4, 2013 on the Washington Post website. See Theresa Brown's "Opinionator" piece on the New York Times site: "Healing the Hospital Hierarchy." Write to author Sandra Boodman at boodmans@washpost.com and Theresa Brown at theresabrownrn@gmail.com and please copy us on your letters so we can know your thoughts at letters@truthaboutnursing.org. Thank you!