Nurse-doctor collaboration

I have finally landed a job in Denver with a 15 member critical care group that oversees care at three hospitals, covering about 120 critical care beds. That's a relief, and now I can continue on with my plans to write a couple papers, maybe to be published or maybe not. I submitted a draft of a paper on nurse-doctor collaboration in the hospital this month to a lawyer I'm working with at the University of Pennsylvania that essentially states that it's better for patient care and it's cost effective to have better collaboration between nurses and doctors ( a kid might say, "Well doy!") Since doctors and nurses come from different backgrounds it may be helpful to have some training together in medical and nursing schools. This might include having medical students and residents shadow nurses in hospitals and vice versa. Each could learn the stresses and duties of the other, allowing for better understanding of each other's roles, and perhaps breaking some of the barriers to communication that exist at varying levels of care.

The problem is that there would still have to be a decision-making hierarchy. The empowerment of nursing has stressed the traditional hierarchy of the hospital in that physicians have traditionally held decision making responsibility while also being held predominantly responsible if something goes wrong. The call for cross training in school has been from nurses since the risk for distress in interactions is usually born by nurses. Doctors can be assholes at times. Although I believe that more cross training may actually limit some of the stress felt by both parties it seems that our biggest problem in the profession is narcissism predominantly from the physicians side, less often within the nursing profession. Many in the hospital get their undies in a bundle because they aren't getting enough attention and praise. I'm guilty of this like everyone else. Maybe we would be better off if we could somehow send a message to doctors in training that we often bear eventual responsibility for the care of a patient, be it positive or negative, but that we work in a complex setting that requires the input from not only nurses but also pharmacists, respiratory therapists, medical assistants, nutritionists and effective administrators and an array of others that can make or break a system of delivery. Some humility seems in order. Physicians are successful, or not, as a consequence of the huge and complicated network of human interaction that makes up a hospital. The reputation of the Mayo Clinic was partially an outcome of two dedicated and inquisitive doctors, Charles and William Mayo, but it survived into the future because of Dr. Henry Plummer, who set up the administrative infrastructure at the Clinic that is second to none, the Sisters of St. Mary nuns who collaborated with the Mayo brothers to develop a deep system of nursing and the people of Rochester, Minnesota who helped the Mayo brothers establish there rather than somewhere else, supplying help with making hotels into hospitals and acting as host for this world renowned institution. The Mayo Brothers would not be the icons we know without the infrastructure that Dr. Plummer and the people of Rochester created.

As for nurses, these are generally the most kind and compassionate of the medical professionals that directly impact patients. They care for the comfort of a patient with such dedication and this is often out of a doctor's emotional range and ability to regulate time given the pull of many patients as structured expectations would have it. Nurses also gather personal information about patients that no doctor could gain since they are with patients and their families more during a hospital day than any other member of the hospital team. But a flaw in the nursing literature and one that I have noticed by practicing with nurses is that there is a desire for control and decision making that may not be institutionally warranted. It would take a social change to allow more control and responsibility to be given to nurses, and this would also require that nurses accept more responsibility for negative outcomes. At the University of Pennsylvania less than 10% of law suits name a nurse in addition to the doctors involved. It is even more of a rarity that nurses are solely named in law suits. If nurses want more decision making responsibility they would have to be willing to help restructure the decision making hierarchy in the hospital and accept the responsibility of negative outcomes due to that decision making. Not out of the question, but I think it would limit their ability to be the nurturing arm of care in the hospital, maybe I'm too paternalistic here. The evolution of nurse practitioners may prove me wrong. This seems to be a work in progress.

If I were king of the hospital I would suggest that doctors take a little more time to be genuinely more kind to their nursing colleague and to take advantage of the wealth of personal knowledge that the nurse may know about the patient that we are unable to obtain. Information that may be helpful in their care. To nurses, I would have to stress that in today's society doctors have eventual responsibility for the outcome of the patient so in cases of disagreement there must remain, for the time being, deferral to the treatment plan endorsed by the doctor. In the end some of this lack of understanding between the two groups, doctors and nurses, shadowing each other in training may allow for better understanding of each other's role in patient care and a chance for discussion and exchange of ideas that does not currently exist.

These suggestions are made with humility and a desire not be thought of as a know-it-all but as someone who cares a lot about how patients get treated in a hospital. Don't we all.