The 'Time-Honored Tradition' Of Blaming The Nurse

One of Theresa Brown's patients jokingly asked who he could blame after a long wait for test results. The doctor pointed at Brown, a nurse, and said, "Scream at her." Brown and Dr. Rahul Parikh, who writes the PopRx column for Salon, talk about the tensions between nurses and doctors.

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NEAL CONAN, host:

This is TALK OF THE NATION. Im Neal Conan in Washington.

A hospital patient jokingly asked who he could blame for delayed test results. The doctor pointed at the nurse and said: If you want to scream at anyone, scream at her. Afterwards, in the hallway, the doctor shrugged the crack off as part of a time-honored tradition: Anything goes wrong, the nurse always gets the blame.

The nurse in question, Theresa Brown, attacked that tradition of bullying, condescension and insult in an op-ed piece in The New York Times titled "Physician, Heel Thyself," heel spelled H-E-E-L.

Doctors, nurses, how does this tension play out where you work? Give us a call, 800-989-8255. Email us, talk@npr.org. You can also join the conversation at our website. That's at npr.org. Click on TALK OF THE NATION.

But first - later in the program, comedian Aisha Tyler. But first, doctors and nurses, and we begin with Theresa Brown. She joins us from member station WQED in Pittsburgh, and it's nice to have you back on the program today.

Ms. THERESA BROWN (Nurse; Author, "Physician, Heel Thyself"): Thank you very much.

CONAN: And you write after being slapped-down in front of that patient, you'd think twice about speaking up around that offending doctor.

Ms. BROWN: Yes, unfortunately, that's the case, and I don't think I'm alone in feeling that way.

CONAN: Was he serious, do you think, or just joking? And I'm not saying it was an appropriate joke, but was he entirely serious?

Ms. BROWN: Well, that's - in the sort of blogosphere, people said this nurse needs to get a sense of humor. And what I would contend is that the only reason people would think that that's a joke is because they think it's okay to make fun of nurses, and it's a joke to say that nurses aren't competent, or they should be blamed for everything.

So he may have been intending to make a joke, but the joke itself is a symptom of the problem.

CONAN: And the problem, you say, is - well, it goes back to - a very long way to doctors who persist in portraying nurses as little more than candy-stripers.

Ms. BROWN: Yes, and I do want to be clear, though, and say it is a very small percentage of doctors who do have these negative attitudes towards nurses and act out negatively towards nurses.

But with this small percentage, the behavior, the demeaning comments, the sarcastic remarks persist.

CONAN: And is there a larger percentage that engages in what you call condescension or refusing to answer phone calls, that sort of thing?

Ms. BROWN: I think again it's a small percentage of doctors. In my experience, most doctors work very well with nurses, and I enjoy working with doctors, and also the flipside is true.

There are nurses who can be very difficult for doctors when they're in training, and again I would say it's a small percentage of nurses. But for these few MDs, the behavior persists, and then unfortunately for nurses, we never know - well, now could this doctor, who's usually been nice, could he suddenly be like this?

CONAN: Oh, I see.

Ms. BROWN: Or if I ask a question, is this person going to jump on me? So it makes all of us nervous, and we can't protect our patients and stick up for them the way we need to.

CONAN: And according to your piece, anyway, it sort of infects the work atmosphere at the hospital, and it perpetuates the old traditions of where the doctors tend to dominate the nurses and sometimes, as you say, older nurses, more experienced nurses, might tend to bully a younger doctor sometimes.

Ms. BROWN: Yes, and I think it's a perpetuation of any sort of negative cycle. You can see a cycle of child abuse in families. So nurses see: Wow, these important doctors get away with this behavior, and then when they have the opportunity because they're angry, they can take that out on doctors, and everyone starts to see this really negative and destructive behavior is accepted, even though it's by a small percentage of actors.

And I've been having a lot of conversations lately with people who say this level of incivility that's tolerated in health care, you just, you don't see it in a lot of other professions and that it's quite remarkable that, in a sense, we haven't cleaned up our act.

CONAN: What's been the reaction to your story?

Ms. BROWN: A lot - there were a lot of angry doctors who said it's not doctors who are bullies, it's nurses who are bullies. And it's true there are nurses who are bullies. The piece I took out of those comments that made me sad was that medical students seem to feel like they are treated like the absolute worst thing on Earth by a lot of doctors and even some of the people in medicine who are training them. And so then of course you feel like, well, that's why this problem just keeps perpetuating itself.

So there was this initial negative response but also supportive comments. And in the end, the head of New York Presbyterian wrote to me and said: I really support what you said. And he had a letter in The New York Times saying he supported what I said. The head of Kaiser Permanente wrote to me and said: I really support what you said.

So I felt like there was a flurry of negative reaction but also an acknowledgement, sometimes reluctantly, sometimes not, that yeah, this is a problem, and we need to do something about it.

CONAN: Well, also with us today is Dr. Rahul Parikh, a pediatrician who joins us from the studios at the University of California Berkeley. He wrote a piece called "Do Doctors And Nurses Hate Each Other?" for salon.com, where he writes the PopRx column. And Dr. Parikh, thanks very much for being with us today.

Dr. RAHUL PARIKH (Author, "Do Doctors And Nurses Hate Each Other?"): Yeah, thanks for having me back, Neal.

CONAN: And Dr. Parikh, your piece was very specifically a response to Theresa Brown's story.

Dr. PARIKH: Yes, it was, and I was not one of her detractors or critics. I thought she did a fine job of taking a personal experience and magnifying that to address an issue about how to better take care of patients. And ultimately, that's what we're there for every day is to take care of patients.

So in taking her story and how it made her feel and then talking about how it could potentially negatively impact patient care and the workplace, she did the right thing.

CONAN: On the other hand, you wrote, I've been driven nuts by nurses who consistently botch a patient's care plan, misinform patients about their child's health or simply refuse to do what's needed of them.

Dr. PARIKH: Yes, that's true. And I think that I've probably been driven nuts by doctors who have done the same. I think the point is that how we communicate with each other as professionals, be it nurse to nurse, doctor to doctor, student to teacher in hospitals and teaching settings and training settings, really has an important impact on how we take care of patients.

And we do need to expect the highest professionalism from each other, which is why the kind of behavior that Theresa Brown experienced just wasn't appropriate.

CONAN: We got this email, and it goes to a point that you raised, Dr. Parikh, in your piece, and I wanted to get Theresa Brown's response to it as well: Doctors learn it in medical school, writes a listener who prefers to remain anonymous.

Dr. PARIKH: Well, I think what we learn in medical school - there's two - one thing we don't learn in medical school is what nursing students are going through.

And Theresa and I, when we were talking about the article, as I was writing it, told me that that's true from the nursing side as well. Historically, for many years, nurses were trained by hospitals or in hospital settings. So they were under the - there was influence and sort of cross-pollination between doctors and nurses.

But over the last, say, 20 or 30 years, there have been a move to make nursing a profession, and that's made it - in a university-based program. So we don't see much of each other anymore in the training of each other's professions.

That being said, as a medical student, I, you know, was insecure and nervous and often felt that things rolled downhill, so to speak, whether it's a doctor to you or a resident to the student or a nurse to the student.

So it's not something - we learn - our training could be more - our training could be better in terms of that kind of civility, as well.

CONAN: Theresa Brown?

Ms. BROWN: Yeah, I want to reflect also on what Rahul said about the importance of communication. Health care is so complex now, and it's just going to increase in complexity.

And so, as he said, you'll have a nurse who drops the ball. You'll have a doctor who drops the ball. And these things, they happen. And so we need an environment where you can say to someone this ball got dropped, and they're going to pick it up and fix the problem rather than trying to find someone to yell at about it or just blow up at you because you're the one who told them, whoever it was.

So - and unfortunately, from what he's saying, right, it sounds like in medical school, the model instead is everything rolls downhill. And as Rahul and I spoke about, we as nurses don't get good training in how to work with doctors. We're basically taught to see them almost in an adversarial way.

We're taught we're the check on the doctor. We're the patient advocate, suggesting that the doctor is not the patient advocate. And then we don't learn how to have just normal interactions. How do you discuss with the doctor is this really the right blood pressure medication? Should we be giving this high dose of narcotics for pain? And so nurses just have to suss all that out, and it's not so comfortable for us, either.

CONAN: Well, let's get some callers in on the conversation. We want to hear from doctors and nurses and other health care workers today about the tension in the workplace, 800-989-8255. Amira(ph) is on the line calling from Columbus.

AMIRA (Caller): Hi.

CONAN: Hi, Amira, go ahead, please.

AMIRA: Hi, yeah, you know what? I am so happy to say that I worked at a facility that we do not experience that. You know, I've been - I don't know if I can say the facility, but we have great interaction between the nurses and physicians.

It is a teaching facility, and the residents defer to us at times, and I think we appreciate it. You know, I would say Theresa, come and work in Ohio State.

(Soundbite of laughter)

CONAN: Is this a job offer?

AMIRA: You know, it's a wonderful place to work, and I really feel so lucky that we have - I've never seen that. And I've seen situations where there have been problems and conflicts, and I've never felt demeaned or spoken to in a way that I didn't appreciate, you know.

CONAN: Well, Theresa Brown, you did say nurses these days are trained much more in a university setting rather than a teaching hospital. And might it be different there?

Ms. BROWN: Potentially, potentially. I mean, I love hearing this story. I like to know there's at least one place where, you know...

(Soundbite of laughter)

Ms. BROWN: And of course I'm writing down the name of the hospital and the HR department, right, but...

AMIRA: Please do. I'll give you the number.

(Soundbite of laughter)

Ms. BROWN: It's - potentially it can make a difference, but we have to start this practice of treating with - treating, responding to errors or mistakes or confusion with sarcasm, condescension, belittling, yelling because it becomes a habit. I think it becomes a habit, and for people who maybe aren't sure how to handle situations like that, it becomes an easy way for them to react, and it's not helpful.

CONAN: Amira, thanks very much for the call, and when the fever goes up, I'll be checking in there.

AMIRA: Okay, great.

CONAN: Appreciate it. Stay with us, please. We're talking about tensions between doctors and nurses. Give us a call, 800-989-8255. Email talk@npr.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION from NPR News. Im Neal Conan in Washington.

When Theresa Brown, a nurse, wrote an opinion piece in the New York Times last month that called out doctors for bullying nurses, it set of an often intense debate. Do nurses and doctors really not get along? If not, who or what's to blame? What effect does that tension have on patient care? What can be done to fix it?

We're talking today with Theresa Brown, an oncology nurse and a contributor to the New York Times Well blog. We've posted a link to her piece, "Physician, Heel Thyself," at our website. We've also posted a link there to the response to that piece from Dr. Rahul Parikh, a pediatrician in the San Francisco Bay Area who writes the PopRx column for salon.com. He's also with us to talk about the issue.

Doctors, nurses, how does this tension play out? 800-989-8255. Email us, talk@npr.org. You can also join the conversation at that aforementioned website. Go to npr.org. Click on TALK OF THE NATION.

And let's see if we can go next to - this is Joe(ph), Joe with us from Knoxville.

JOE (Caller): Hi, good afternoon, Neal. Thank you for an excellent family program. And Theresa, thank you very much for posting this article.

I find, in my nursing experience, that a lot of problems arise when there's ineffective communication between both parties. An order is put in, and somehow it gets lost. And it's not just the nurse and the doctor, it's the medical receptionist. It's a multilateral position.

And in addition, you know, we have rising acuity levels and a very litigious world that we live in, and I think that just builds a great deal of stress.

And what I've found is helpful, just as sort of a protective measure, is just very effective, clear documentation of everything you do such that even if the doctor doesn't put in the correct orders and doesn't do what they need to do, you've documented that you've brought the issues to their attention, you've documented timely, efficiently and accurately that everything that you've done so that there's no question if something has to, God forbid, be brought up in a court of law that everything has been addressed.

CONAN: So more paperwork is the answer, Joe?

(Soundbite of laughter)

JOE: Unfortunately, I think that's the world we live in.

CONAN: Okay, Dr. Parikh, do you think so?

Dr. PARIKH: Well, I think what he - the caller is getting at is an important point, which is how we communicate. I've actually written several essays about this, and we - we really could do a better job, I think, of handing patients off to one another, whether it's between doctors and doctors and doctors and nurses.

Whether that's paperwork or in a conversation, you know, is up to you or through an electronic medical record.

But I want to also address I think what he said about complexity. A couple of weeks ago, Atul Gawande gave the commencement speech at Harvard Medical School, and...

CONAN: The doctor and writer, yes.

Dr. PARIKH: Yeah, doctor and writer in the New Yorker. And the speech was titled "Cowboys and Pit Crews," and he urged the graduating class at Harvard Medical School to stop - to look at their career as doctors, or upcoming career, not as individual physicians, kind of who have to know everything and do everything, but as part of a team, a pit crew. You know, to use a racing analogy, with the patient as a driver and being part of that team with nurses and other people to really take good care of the patient.

And I think that's the most important shift we're talking about here, and that's the generational shift that I think Theresa hit upon in her essay.

CONAN: Slander against cowboys who work closely together as a team.

Dr. PARIKH: Sorry.

(Soundbite of laughter)

CONAN: In any case, Joe, thanks very much for the phone call.

JOE: Thank you.

CONAN: Let's see if we can get - this is Paul(ph), excuse me, Patty(ph). If I could read, this would help. Patty's on the line from Bend, Oregon.

PATTY (Caller): Good morning here, and thank you for this. I am a retired RN and nurse practitioner, and I happen to have taught medical students and residents and sometimes teaching fellows at UC San Diego.

And one of the things I - well, I taught how to communicate with patients, how to examine patients, and in doing that, because I at the time was just an RN, I came under fire, of course, by everyone.

But the greatest problem was with nurses because I had stepped out of my role as a subservient handmaiden and the physicians. And so they were my biggest problem.

I also got to teach nurse practitioners and midwives, and that is when I escaped from underneath that communication glitch and became a nurse practitioner.

Now, I'd love to have some comments by your guest about how they see, you know, how are nurses stepping out of the traditional role? But I want to bring into the discussion the business of compassion, compassion for the very, very difficult field that all of these people are in that there's no time to, you know, listen to the aches and pains and the woes of staff because you're so focused on your patients, and everyone's overworked.

Everyone's tired. Everyone, everyone can get grumpy. How do you find the compassion? I also got to be a therapist, psychotherapist for medical students, and...

CONAN: Well, you've raised a lot. So let's see if we can get some responses, Theresa Brown.

Ms. BROWN: Well, this team concept is very, very central to this issue, and Rahul brought it up, and I'll emphasize it, that that is the way floor nurses are stepping out of their roles because there really is a concept of a medical team now that's operating on hospital floors where you have an attending physician, at least in teaching hospitals, even not that you'll have an attending physician, you'll have a nurse, you might have a physical therapist, someone from dietary.

And all these people have to work together. And so the nurse needs to be recognized, and here he needs to also recognize themselves this way as the person who's with the patient for an extended period of time during the day and can have a sense, minute by minute or hour by hour, what's going on with that patient and then talk to the appropriate member of the team about what she or he thinks needs to happen.

And it is a different model from doctor knows best, or the doctor is the father and just directs everything. The nurse needs to be there...

CONAN: And the nurse is in charge of compassion as the mom.

Ms. BROWN: Exactly, right, right. The nurse needs to be there putting in opinions about here's what I think is happening, here's what we need to address, when it's appropriate, of course.

CONAN: Okay, Patty, thanks very much for the call, appreciate it. Let's see if we can go next to - this is Kim(ph) and Kim's on the line from Kansas City.

KIM (Caller): Thanks for taking my call.

CONAN: Sure, go ahead, please.

KIM: Yeah, I'm a physician. I work at a children's hospital in the ER. But I remember during medical school being petrified of starting clinical rotations because the nurse, who lived in the apartment below me, who knew I was a med student, would talk about how they would torment the residents or, you know, the doctors in training by calling them at one or maybe two in the morning, just when they knew they'd gotten to sleep, to ask questions like: Does this patient need an enema in the morning?

So I think sometimes the poor communication and the not treating each other well goes both ways. And maybe it does a disservice to write an op-ed that focuses only on one party so much. But I would totally agree that the team approach is the best thing.

I mean, in the ER, we have to be listening to the nurses and the respiratory therapists and everybody who comes together to do what's best for the patient if we really want to do what they need. And I think that team approach and valuing everybody's contribution to the patient's care is really where it's at.

CONAN: Did you read the op-ed, Kim?

KIM: I did. I was actually driving home from the hospital and heard online and made a note myself that I needed to go on and read the op-ed and the responses.

CONAN: Okay, well...

KIM: I could be a little bit wrong about my take on it, just from what I've heard about your show, or from the show today, absolutely.

CONAN: Okay. Well, Theresa Brown, you get a chance to respond.

Ms. BROWN: Yes, well, I have written before about nurses bullying nurses both on the Well blog and in my book, called "Critical Care," which is about my first year of being a nurse.

I have a chapter called "Switch," where I explain why I left my first job, and it was because of bullying by nurses. And in fact, my first few years of nursing I had experienced much worse bullying at the hands of nurses than at doctors, than from doctors.

So I sort of woke up late to the reality of the problems that can come between physicians and nurses only because I had had such intense problems with nurses. So of course we all need to admit that the problem goes both ways. Then the question is: Where does it start?

And my feeling is it starts that we - because we allow these very important MDs to act with impunity, in ways that are just unacceptable.

And it's not just my opinion. The Joint Commission has even made that, made addressing these behaviors, part of an accreditation requirement for health care organizations. And the bad news and the bad behavior, it does trickle down.

CONAN: Kim...

KIM: I would agree that it is a trickle-down, and it's addressing it, you know, from the top that there has to be good behavior on both sides and all around, and that's so incredibly important to how our patients end up being treated. How we treat each other plays a huge role in how we're able to take care of our patients and their families.

Dr. PARIKH: Can I just add something? I completely agree with the caller and Theresa's response. I think the ability to disagree is very important as part of this communication. And whether it's a disagreement between a doctor and a nurse or a physician and a physician is really important in how we address it.

And that's something that is a subtext here. Having a disagreement in front of the patient only ruins the quality of care, the service and confidence that the patient has in the medical team. And that's not something we want to do.

CONAN: Thanks very much, Kim, and appreciate the phone call. I wanted to follow up with Dr. Parikh, and there was something you said: Can doctors and nurses hold each other accountable without picking the scabs off old emotional wounds? And that's important in the context you raised of morbidity conferences where doctors go back and say, what happened here? How come this patient died? Could we have done better? What might have been a difference? Nurses don't participate there.

Dr. PARIKH: Yeah. I mean, my impression in this in most of the places I've trained with a student that was that this was an exclusively physician health conference and it was for physicians, by physicians, where, if there was a case where it was a bad outcome, the group of specialists would meet and discuss the case. And then, without pointing fingers, would try and sort out what happened.

I think it's a tremendous opportunity to learn as a team, if you begin to include other people in the process and really is worth considering as we go forward and try to make these relationships more sound.

CONAN: Theresa Brown, would you advocate that?

Ms. BROWN: I definitely would and I would love it if there was a tradition in nursing like morbidity and mortality conferences. When I first heard about them, I thought, we should do that too. I mean, I would like to hear what the doctors have to say about their own cases, because I'm sure I would learn a tremendous amount that would help me help my patients. But I would love it if a nursing - we did that also, because the systems we use now are so complex: electronic health records, phone calls, this piece of paper, that piece of paper, sending this to the lab to know how someone else made what seemed like a simple mistake that may be was serious, may be it was not, could just be tremendously helpful in improving the quality of care.

CONAN: Let's go next to Georgia, Georgia with us from Minneapolis.

GEORGIA (Caller): Hi. I'm a physician and a physician leader of a hospital group in Minneapolis, Minnesota, 25 physicians. And I have both a comment and a question. My comment is that, if we approach this is as a sort of personality-driven issue where - this hurt my feelings, the workplace isn't as a friendly as I would like to be, I don't enjoy going to work because of the atmosphere - I think we're really missing the larger issue. That if a nurse or any member of the health care team is reluctant to contact a physician because they'll yell at me or they'll belittle me, right away, we know that that's a big risk to patient safety. You know, doctors and nurses have to be willing to talk to each other. So I think the patient's safety is really at the heart of this issue.

My question for your guests is, with the change from ambulatory physicians to hospital physicians, where a doctor is in the hospital all day long, I see the same nurses every day, they know me well, they work with me, do either of your participants think that has changed this dynamic for better or for worse?

CONAN: Dr. Parikh?

Dr. PARIKH: So I'm sure it has. I can speak to - and I don't do any hospital work. I'm a purely outpatient physician. But the colleagues I work with in the inpatient side have a tremendously strong bond with the nurses they work with. And I can tell you that has been a huge asset to the patients who've - the pediatric patients who've gone through the pediatric ward where I work.

CONAN: And a quick response from Theresa Brown.

Ms. BROWN: It absolutely makes a difference. Our oncology fellows are there with us for hours and hours a day and we are so friendly with them. We're on a first name basis. We can informally have care conversations with them. It's fabulous the ways that we can work with them. In the ICUs in my hospital, I see that also the nurses in the intensive is - work very closely. They call each other by first names. They look at each other as colleagues.

CONAN: Hmm. Georgia, thanks much. Appreciate it. We're talking about doctors and nurses today. We have one of each. Theresa Brown, who is a contributor to The New York Times Well blog, and she joins us from WQED, our member station in Pittsburgh. And Doctor Rahul Parikh, who is a pediatrician, who practices in the San Francisco Bay Area, and with us today from a studio at the campus of the University of California at Berkeley.

You're listening to TALK OF THE NATION from NPR News.

And we have this email from Joanne(ph). I'm a retired nurse who work weekends and nights for years, so I had a lot of autonomy using standing orders to make decisions. One evening, I called a doctor in to give a patient an epidural for pain. He was unhappy that I woke him and gave me a tongue-lashing in the hall, putting his finger in my face. I generally take these things in stride but was quite angry as there was no reason for his actions. I wrote a letter to my supervisor, to the hospital administrator and to the doctor supervisor and never heard a response from anyone.

And, Theresa Brown, that suggests that when there is unacceptable behavior, it's not just the doctor or the nurse who have to figure this out. It's the hospital administration too.

Ms. BROWN: Yes, that's completely true. And that's a hard piece of that. I talked with Mark Chassin, the president of the Joint Commission, about this very issue, how to implement policies that will actually make a difference. And he said, every health care environment is different. You need your own solution for each different kind of health care setting. So, yes, how to do that is complicated, but first that you have to accept that it's a serious problem.

CONAN: And there's another email that we have. This is from Mark in Berkeley. How much of the problem could be attributed to the old issue of sexism, what with nursing still being predominantly a female occupation? Is there a less of a problem between female doctors and nurses?

I wonder, Theresa Brown, is that true?

Ms. BROWN: I would like to say, yes, but then there's also a data that shows that women doctors-in-training actually have a harder time working with female nurses. So I - when people experienced bullying by attending physicians, it tends to be men. But then, the flip side of nurses bullying doctors, it may actually be harder on women physicians-in-training.

CONAN: And, Doctor Parikh, you're, as you say, now an outpatient doctor. But you said, when you were in hospital work, you never read anything on a chart that was signed by an RN.

Dr. PARIKH: Very rarely. I mean, we would have walking rounds with the other residents and the medical students who would all talk as a team, the nurse would be present. But, you know, and this is just part of growing up, I think, as a physician.

When I was a resident and - all I cared about was, you know, getting my work done and getting - talking to the attending physician and the residents to make sure everything got done so I could go home. And that's certainly changed, I think, as I've grown older. But, yeah. Yeah. I think, you know, we have a long way to go in our educational - health educational system to kind of teach this kind of teamwork.

CONAN: Well, Dr. Parikh, thanks very much for being with us again. We appreciate your time today.

Dr. PARIKH: Thank you very much.

CONAN: Dr. Parikh's book is "Do Doctors" - he wrote a piece called "Do Doctors and Nurses Hate Each Other?" in salon.com and writes for the PopRx column for salon.com. Theresa Brown joined us from member station WQED in Pittsburgh. And she - her piece is called "Physician, Heel Thyself." There's a link to it at our website, at npr.org. And she's the author of "Critical Care: A New Nurse Faces Death, Life and Everything in Between." And thanks for being back with us.

Ms. BROWN: Thank you.

CONAN: Coming up, Aisha Tyler has done a great deal: TV, talk show host, movies. Her first love, though, she says, standup comedy. She joins us next to talk about her career and the art of stand-up. Stay with us.

I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

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