Not long ago, nurse Theresa Brown wrote a provocative Op-Ed in the New York Times about the tension between nurses and doctors. “It’s a time-honored tradition,” one doctor sniped at her, “blame the nurse whenever anything goes wrong!” Publicly airing this friction opened Brown up to sharp criticism. “Drawing and quartering your coworkers in the Sunday New York Times might be run-of-the-mill for politicians. I’d like to see something better out of doctors and nurses,” wrote one physician over at the Atlantic. But don’t count me among her detractors. Brown used her story to advocate for civility in medicine. Mutual respect, she correctly argued, would improve teamwork and the care of patients. Her essay raised a question far more important than who was right or wrong: If both nurses and doctors want to make their patients better, why is there so much conflict and controversy between them? And how do we do a better job of working together? To help me answer these questions, I asked Theresa Brown herself. Before I get to that, it’s useful to understand the cultural underpinnings of the doctor-nurse relationship. In one sense, nurses have spent the last half-century fighting to overcome the stereotype that they are defanged doctors. It’s a division rooted in education, income and gender. Doctors — men, affluent, with a professional education — reigned supreme in the hospital. Nurses — female, working-class, with a trade school-level education — were their handmaidens. This stereotype is probably something you would expect to see on a vintage TV medical drama, though critics point out that it still is the norm on contemporary shows like “Grey’s Anatomy. Despite the rigidity of that power structure, nurses smartly honed their own skills of influence. This was best described in 1967 when a psychiatrist named Leonard Stein published an essay called “The Doctor-Nurse Game.” “The nurse is to be bold, have initiative and be responsible for making significant recommendations, while at the same time be passive. This must be done in such a manner so as to make her recommendations appear to be initiated by a physician,” Stein wrote. If a nurse didn’t play well, she was “a bitch,” or “unconsciously suffering from penis envy.” What changed between then and now? In 1990, Stein published “The Doctor-Nurse Game Revisited” to answer that question. The public lost confidence in doctors and medicine (something I’ve addressed before in this column). There was a rising demand for nurses, and the profession evolved into one with specialties (pediatric nurses, ICU nurses, etc). That’s the context in which I approached Brown. Why, despite all of these changes, does so much tension fester between doctors and nurses? Brown holds a Ph.D. in English from the University of Chicago and she also wrote the book “Critical Care: A New Nurse Faces Death, Life, and Everything in Between,” recently out in paperback. As you might expect, she is articulate and smart. She is also warm and introspective and, despite what her critics say, does not have an ax to grind. She has written just as strongly about bad behavior between nurses. Brown answered the question by talking about the way nursing education has changed. In the past, nursing schools were based in hospitals, which put students directly under doctors’ influence. While that no doubt perpetuated the doctor-nurse game, at least it exposed both groups to each other. But over the past 40 or so years, nursing schools have become university-based. “Nursing school was now independent of doctors,” Brown explained. “Yes, we are taught to be patient advocates, but we are also taught to be a check on the doctor. The problem with that is we’re only taught to see docs as adversaries,” she told me. An essay by a nurse in the British Medical Journal echoes this idea. “Nurses have been indoctrinated with the belief that doctors are capable of exercising only a cold, scientific medical model,” she writes. “They treat the disease, not the patient. Nursing literature is full of anecdotal accounts of the distant approach that doctors have towards patients and their careers.” As a result, Brown admitted that nurses “never get a good understanding of the stresses and strains of what it’s like to be a physician.” I told her that medical school provides next to nothing in terms of how nurses approach patients either. “If that’s the case, how do doctors and nurses learn to behave and negotiate with each other?” she asked. I didn’t have an answer, but in reflecting on what she said, I realized that over the years, I hadn’t made much of an effort to understand nurses myself. As a resident, for example, I never read a single note in a patient chart penned by an R.N. — a “care plan” as they’re usually called. They seemed extraneous to me, and doctors have argued that they don’t impact their care of patients. But had I read them, I may have been able to bridge at least a small divide between me and the nurses who cared, side by side with me, for my pediatric patients. We compared other notes. What do nurses want from doctors? I asked. “Respect, a willingness to listen even when we’re bringing up something stupid, a sense that we’re on the same team,” Brown replied. Doctors demonstrate a great deal of variability in all of those things. Again, though, we agreed that this variability goes both ways. I’ve worked with, and continue to work with, amazing, caring and competent nurses. These are the R.N.s who would be my first-round draft picks, even over other doctors. On the other hand, I’ve been driven nuts by nurses who consistently botch a patient’s care plan, misinform parents about their child’s health, or simply refuse to do what’s needed of them. That brought up the next question: Can doctors and nurses hold one another accountable without picking the scabs off old emotional wounds? Her suggestion was that if there’s conflict or a mistake made, debrief together. “Be honest, say what happened, work together to solve a problem.” One way doctors do this is by having regular “morbidity and mortality meetings,” where individual cases are discussed and the physicians involved are asked to explain why a patient was hurt or another bad outcome occurred. Nurses are not part of that process, and the tendency among them is to “just say something bad happened, not talk about it again.” “If we really want parity and respect we also need to be held accountable,” she said. In principle, Brown has a point. In practice, the jury is out on how doctors and nurses can hold each other accountable when their skill sets are complementary but still very different. Brown and I both agreed that bad behavior between health professionals (be it between doctors and nurses or even between doctors and other doctors) is bad for business. In her case, it’s unforgivable that the doctor who chastised her didn’t have the decency to confront her privately about any concerns. His goal wasn’t to figure out what happened but, like a hot teakettle, merely to blow off steam. A recent survey suggests that this abusive behavior really is disturbingly common among physicians. That kind of behavior undermines the patient’s confidence in his or her medical team, and we absolutely need teams to be successful in an era of medicine as complex as ours. If there’s one hope for both of us, it’s our patients. As one observer points out, “for decades we understood the professions as a conventional nuclear family, with doctor-father, nurse-mother, and patient-child. But our hope for total wisdom and protection from father is forlorn, our wish for total comfort and protection from mother unachievable, and the patient has grown up. A new three-way partnership should displace this vanishing family.” Finally, I asked Brown which fictional character she might give credit to for being a more realistic portrayal of a nurse. “Nurse Jackie,” she said. A foul-mouthed, grouchy drug addict as an iconic nurse for the masses? Yes, she confirmed. Because Jackie is flawed, fallible and therefore as human as a nurse can be. I suspect that if all of us, doctors and nurses, embraced our own flaws, admitted our own fallibility and realized that we need each other every single day, we would take yet another step forward at getting better together. This Article Was Written By Rahul K. Parikh at Salon.com
Personally I am in a declared war with all the nurses , they are just rude, always looking for fight and making problems
Dr, felicia,did u went to medical skul to learn how to war wit ur coworker,dont u have character? to delare war wit ur coworker shows u will still declare war wit ur uncoperating patient, u are nt fit to be a doc,then go to the army were war are declare,learn to accormodate peple. ur country like war war war,that is nt a civilzed way of doing things.is babarian mannars
util doctors realised dat patient mgt is all about team work and not solely the handwork of one man there will always b this rift btw nurses and doctor,nursess are paient advocate and by the time you advocating for ur patient and the man (docs) do nt want to listen ur patient life is in danger out of negligent u will nt be happy that u are nt been listen to,this ego of doctors,they want to protect at all cost wether patient life is involeved they dont care, is realy worrisome,i think most doctors should learn wat i call on the job character whish they realy lack
Dear Mark I don't think it is in your hands to judge my manners or my character or my abilities to be a good doctor or not.....if you don't like my posts or what I say /my opinion/my country/my religion and you consider yourself way better than me, that I am so savage, just ignore what I post and we will both feel great. P.S. I am not going to answer back to any other of your posts in which you insult me or attack me as a person in any way.
what I see in hospitals that doctors want to deal with nurses in a good way , but some nurses hate doctors because he / she makes the orders that nurses must achieved and during my study too, nursing student hate us and always try to defeat us too ,,but keep in mind that not all of them !! The fight come from problems in understanding the responsibility of each one ..which make bad Dr.-Nurse relationship
For those doctors who are saying that they are in a "declared war with all nurses." Please can we ask you if you a doctor or a soldier in the battle? And I'm sure if you are like this with all nurses , you will also like this with your patients and also with your own family! I'm sure. One advice for all those pre_medical students : don't be a doctor if you are not a good social communicator.
I believe that doctors and nurses as said above are part of a team, wich means that both must have comprehension from eatch other, as a doctor I have always thougt that the best nurse is not the one that thinks shes the best neither the one who feel she is less but the one that can think as doctor will. What I mean is that we both need from one another, and it is best if we have understanding. The best nurse I have ever had was the nurse that helped giving an opinion expressing her knowledge about patients problem as she would also be a step ahead of what was going on, she normally knew exactly what to do even before we told her the new order, she said "It is allways the most logical thing" , and maybe she could have been mistaken sometimes she found those times as an oportunity to ask why we did it in a diferent way as I like to think a nurse in thirst for knowledge. Some nurses are definitley trying to prove greatness indeed, I know a nurse that beacause of her 20 year experience she says she is better than any doctor, if it is true or not I rather not say, but what I can surley tell that she loves to pick fights with doctors. The best relationship is to think that we are entwined brothers and sisters even though we have a diference of opinion we are still both results of centurys of evolution of medicine both in search for the best care we can provide for patients.
In undergrad I took a nursing pathology course while I was waiting to find out if I got into medical school. I honestly can say I never have been angrier at any one person as much in my entire life. The instructer always was instructing the students that as nurses they would know what is better for the patient. She even went as far as to tell them that as nurses it would be within their scope of practice to perscribe drugs if they thought the doctor had it wrong. She never mentioned the many years of additional and indepth study that is required to become a doctor. Having spent time studying with these men and women in many classes (chemistry, anatomy and pathology) I would NEVER have allowed many of these people to come within a 10 foot radius of me with a needle. They scared the daylights out of me with their lack of knowledge. Conversions were consistently done incorrectly and more than one admitted to only going into medicine so they could marry a doctor. Sadly these were the students who talked the most and the loudest. The worst part is that many of my friends are also in nursing school and will be wonderful nurses. If they would let me I'd love to be on the team with them. It is the few people out there that are making a bad name for the rest of us. In medical school we are taught that we are going into a team and everyone has to work together for the well being of the patient. Many a time have I seen this done to perfection, but only when everyone admits to their individual strengths and weaknesses.
