Patronizing Nurses

NursePatronizing, def:

    3. To treat in a condescending manner.

I’m not talking about talking down to a nurse.  You do that at your peril, and you cannot win.  I’ve never intentionally done it myself, but I’ve seen it a couple of times, and the best outcome was a bloody draw for the doc.  No, I’m talking about how things are done in medical communication.

It has never made sense to me that a nurse with experience, a been-there and done-that nurse has to accept being addressed by their first name by anyone, especially new docs.  I felt about 2 inches tall early in my career, when addressing senior nurses as "Marge" when my West Texas upbringing told me I should be saying "Mrs. Saint", or similar.  As I get older it’s getting a little easier to use first names, but I still feel uncomfortable.

This custom has to be a throwback to the early days of medicine when Docs were Minor Deities and Nurses were the happy handmaidens of the doctor.  Those times are gone (insert your comment below), but some of the behaviors have persisted despite the evolution of the overall relationship.  I think it’s time to bring some formal respect to our interactions, but wonder about addressing my nursing compatriots as "Nurse Nightingale", so I’ve not yet started the newest fad.

I still don’t get medical patronism.  Yeah, there’s a lot of things I don’t get, but this one has always bugged me.

Update: title spelling changed from ‘Patronizating’ to Patronizing.  So much for the new spellchecker!


Comments

  1. I agree with you, Doc..but it’ll be a tough time to bring about such a change.

  2. Mrs. Fred says:

    That suth’un upbringing is worth cherishing!
    Especially when dealing with us ol’ gals!

  3. When addressing RN’s in this manner, two words come to mind:

    Nurse Rachet!

  4. Sweetwater Doc says:

    I agree with the thrust of your comment – simple courtesy would indicate that address on a first name basis is a gift, not a right – but the security issues that mandate first name only name tags in the ER and on the floor complicates what should be a simple issue.

  5. I guess being mostly a northeastener I have a bit of a different view.

    I call nurses by their first name, but also insist they call me by my first name as well. If they call me “Dr. MacGinnitie” by mistake, I jokingly call them “Nurse last name.”

    In most of the settings I’ve worked in (mostly academia) that has been the norm, except for a few particularly old and/or senior people.

    I think that works well for everyone, except sometimes the nurses get confused about which doctors like to be called by their first name and which don’t.

    There is nothing I find more annoying that young MDs who insist on being called “Dr. so and so.” Get over yourself.

  6. In my school’s ED, one of the attendings quotes literature about how formality leads to improved patient compliance — he’s referring to shirts and ties and white coats but also lays it on thick with the titles. I know there’s evidence for the clothing (also evidence for germ-spreading) but I wonder whether patients pay attention to formality between staff…

    Certainly the nurses here insist on first names, and know which doctors are the same…

  7. Bad Shift says:

    Agree with Dr. Andy, but most patients in my experience would prefer to see their doctors addressed as Dr.-. (Not all, of course). Are you not concerned that if the nurse calls you Joe that the patient will a) assume you are more intimate with the nurse than is appropriate? or b) suspect you are somehow not in charge or are lacking in experience?

    I wish there was some way the nurses could call me by my first name in the doctor’s room, but by Dr.- in patient care areas. Too complicated, probably.

  8. i realize that progress has been made… but do i hear the thin, sickly strains of gender bias, even so?

  9. Derrick Lowery says:

    Hmm… reading this post makes me wonder if this is some type of regional or socioeconomic difference. In the ED I work in, everybody is on a first name basis (even the chair of the dept). It seems to me that this fosters a strong sense of camaraderie.

    Maybe if we could get a few people willing we could get a multicenter servey started to find some answers out about how patients would prefer their nurses and doctors refer to each other – heck, in the survey we could ask how patients themselves want to be referred to. I did a medline search and didn’t come up with much. Anybody game? Summer is coming, and this would be a great project for some summer volunteers to take on!

  10. GruntDoc says:

    Derrick, good idea!

    Send me the abstract when you’re done!

  11. I think nurses usually refer to me as “Dr. MacGinnitie” in front of patients (as in “Dr. MacGinnitie will be in shortly”, but I also refer to, say, fellow or residents by their last name when I am in front of patients. I have to admit I don’t use the nurses last names, but then they don’t introduce themselves to the patients by their last name, whereas I do.

    I intermittently encourage younger kids to call me “Dr. Andy” because my last name is so hard to pronounce.

    I wouldn’t read too much sexism into this as in pediatrics the majority of doctors are now female as well. If anything they struggle more with this because people are likely to mistake them for nurses.

  12. Ah hell, Al – if you and I worked together, what would they call us? Big Al and Bigger Al? Doc Al and Nurse Al? Tex and Ass?

    The mind boggles at the possibilities. :-)

  13. I tend to call physicians by their first name — except in the presence of patients and/or families. Then I call them Dr. Last Name. Our NNPs (I’m a neonatal nurse) introduce themselves by first name, so I call them by first name.

    The younger and more inexperienced a physician, the less likely I am to slip and call them by first name in front of parents, in particular. I’ve been a nurse longer than some of them have been on the planet, and I believe that it would call too much attention to that fact if I call them by first names in front of families who are already looking to me as the voice of experience.

    There was one doc last week I really wanted to do that to, but I think she’s salvageable, so held it in right up to the point where she asked me why the baby’s IV only lasted 48 hours. Ask a stupid question and the answer has to be, “He’s a baby, it happens.”

  14. Bad Shift-

    In my experience, it’s not too complicated- just make it known. Many of the nurses with whom I work call me by my first name (once they know it) when not in front of patients. I’ve found it helps to introduce yourself and make the request, and introducing yourself becomes easy once you realize you don’t know the name of the nurse who’s talking to you! After a while, word gets around.

  15. Nurse Mairead says:

    Posted by Bad Shift:
    “or b) suspect you are somehow not in charge or are lacking in experience?”

    If you think the doctors are really “in charge”, you are sorely mistaken. At least that’s not the case at my facility.

  16. Nurse Mairead is having fun with me (she works in my joint). Oh, and we’re glad to have her back, so she can say whatever she wants. For a while.

  17. Nurses put up with it because we need to keep a job. Making the nurses mad may get you 2am phone calls for discharge orders, but making the wrong doctor mad can get us fired. I’ve been on a first name basis with a few docs at their preference, but have also been known to slip in a first name in front of junior residents if a more senior one tried to pull rank. A little juvenile but fairly effective.
    I am also of the opinion that patient care would not suffer if we as a population took doctors down from the pedestal and treated you like normal people. I’m in the rural south, and my experiences here color my perceptions.
    Jamie

  18. I’m not a nurse nor a physician. But, I do immediately notice if a physician addresses me by Ms. so and so. If I’ve never met the physician before I always appreciate them referring to me this way–it shows that they are being respectful.

  19. Nurses may or may not respect an individual physician, but they should show professional respect for the medical profession. A big part of their responsibility is carrying out the orders of the physicians. These are orders, not recommendations or suggestions (I commonly get suggestions and recommendations from nurses, and I am grateful for them, but some are appropriate, some are not). Calling a person by first name implies parity or equivalent rank. An attorney would never call a judge by first name in court, even if they once were law partners; maintenance of hierarchy is part of the process. That is not to say that doctors (or judges) are never wrong, only that the default position is that the doctor (and judge) knows best by virtue of training or position. A smart lieutenant will always pay heed to the recommendations of his sergeant (who may have 2 decades more experience), but the responsibility of leadership goes to the person who has the position and the credentials. Nothing should be done to damage this relationship.

  20. The above post is an example of the biggest cause of conflict between doctors and nurses. I respect good doctors. I also deserve respect. A hierarchical relationship is not in the patient’s interest. Nursing is a profession with a distinct body of knowledge. IOW, you went to school longer to become a doc, but you still don’t know how to be a nurse. The best physicians realize this and take advantage of it in patient care. Besides following orders (which a good nurse never does blindly), nurses assess the patient on a continuing basis, inform physicians of changes in status, educate patients about their condition and treatment-including the low-tech stuff that often makes all the difference, act as patient advocates, plan and coordinate care. Following appropriate orders is important, but is far from the majority of a nurse’s job. The comparison of the relationship to that of lawyer and judge is faulty. The judge is also a lawyer and knows the law. The physician has greater knowledge in medicine but the nurse knows nursing. The attitude that the doctor carries all the responsibility damages the relationship.
    It has been my experience that physicians who take nurses seriously have patients who get better care-both medical and nursing.
    Jamie

  21. Jamie-
    I agree with almost everything that you wrote, but I disagree with your conclusion. I cannot imagine anyone thinking that nurses do not deserve respect, and certainly I agree that nursing is a profession with a distinct body of knowledge. I do not know how to be in nurse, nor have I ever claimed to. I have never asked a nurse to blindly follow my orders, and I have been grateful to nurses who have pointed out errors that I have made in writing orders. The nursing activities that you enumerate are critically important, and can literally determine whether a patient lives or dies. I also agree with you that physicians who take nurses seriously, and consider them as colleagues in patient care, will have patients who do better.
    Where I disagree with you is in your statement that ?a hierarchical relationship is not in the patient’s interest.? As you stated, you know how to be a nurse, and I know how to be a physician, and I hope that you will agree that there is a fair amount of overlap in our clinical activities. For example, I prescribe medications, and you administer them, and both of us have to do this correctly in order for the patient to benefit. Like it or not, somebody has to be in charge, and the way that our medical care system is set up, the M.D. is the ?boss? of the R.N. in the areas where our professions overlap. You can refuse to administer penicillin to a patient with an allergy, but your license will be in peril if you proceed to administer a different antibiotic without an appropriate MD order, even if the substituted antibiotic is medically appropriate, and given in correct dose and form. Similarly, you may believe that an imaging study or lab test should be done, and you may be medically correct, but a physician’s order is required before these things can be done. This is not a situation where everybody gets an equal vote. In our society, one of the markers of the hierarchy is how we address each other. Societies where everybody is theoretically equivalent in rank and all address each other as ?Comrade? tend not to do well. I would have no problem with physicians addressing nurses as Ms. or Mr. Lastname, and I not infrequently do this, especially with nurses who are older than me. In clinical settings, patients do better when they have confidence in their caregivers. When they feel sick, they go to the Doctor, and they want to be cared for by the Doctor, not by Jimmy, Janie, or Mary Lou. As I said, if nurses as a group or individually prefer to be called by their last names, that is entirely appropriate, and it is something that the nursing profession should pursue.

  22. I am perfectly okay with either first name or title and last name. I don’t like when it is mismatched. I’ve never considered procedures (including meds) which require a physician order as a hierarchical function. To me, it is more a division of labor. Each of us is doing what we are educated to do. Some decisions fall within your education and responsibility, and others within mine. Part of a nurse’s responsibility is to carry out decisions made by the physician, barring ethical, safety, or legal conflicts. A collegial relationship in which both parties understand both their own and the other’s roles allows for better communication. A relationship in which the physician is “boss” often leads to nurses who are afraid to or actively discouraged from offering suggestions or even information about the condition of the patient. Probably the most dangerous thing about the hierarchy, though, is that the more inexperienced the physician, the less likely he/she is to actually listen to nurses, regardless of the nurse’s experience. Thus the resident who ignores the nurse’s insistence that a patient’s rising pulse is a problem-until the bp drops and the surgeon has to cut a pt already in shock to fix that small bleeder. I’ve got more, but I’m sure you’ve seen just as many.
    Jamie

  23. I don’t see prescribing of medication or ordering tests as a hierarchical function, but more of a “trade union” function. This particular trade union has lobbied to gain the legal right to control access to certain products and services, for the purpose of protecting members’ income.

    I can recall reading a blog entry where a doctor rhapsodized about the “power of diagnosis” or some similar nonsense, claiming that a woman couldn’t truly pregnant until a doctor said she was. No, this wasn’t satire. I’ve also seen discussions about how unreasonable it is for a patient to expect to be told the results of lab tests without paying for a second office visit.

    As a nurse in a gyn office, I answered at least 2 phone calls every day from women needing requisitions for their annual mammogram. They elected to have the mammogram, chose the facility, made the appointment–and virtually always it was the same place they went last year–but they still needed my permission on a piece of paper. Well, the doctor’s, but of course the doctors didn’t wish to be bothered by such trivia and expected the nursing staff to sign for them.

    This is on the level of the union guy who stalked JPL, making sure that none of the undergraduates doing summer research carried a screwdriver from one room to another, thus threatening the job of the union “porter.”

  24. I don’t see why it should take a nurse to requisition a mammogram. In most cases, women can schedule their own (unless this is a health plan policy). Of course, if one of the mammograms that you “order” has a positive finding, but the report doesn’t get to your physician, and treatment is delayed and the patient suffers harm, you are not the one who will be targeted by the malpractice lawyer. It will be your doctor.

    Any doctor who claims that a woman isn’t pregnant until she is “diagnosed” is a fatuous dickhead.
    Any doctor who believes that his time is not worth paying for to discuss the outcome of diagnostic testing is probably correct. On the other hand, my time is worth paying for.
    There are institutions in many large cities across our great land that train nurses (and engineers and executives and all sorts of other folks) to evaluate, diagnose, and treat disease. These institutions are called medical schools. Applications are available on the internet or by mail.

  25. Johnathan Waters says:

    Nurses might take some comfort in knowing that any disrespect they encounter from doctors can always be taken out on any handy xray technologist. Despite having same number of years of education, equivalent levels of CME requirements, professional and advanced specialty licensure, xray techs are still considered “the bottom of the totem pole” by many nurses and physicians alike. Seldom do nurses step foot into the xray or CT suite to see what the job involves, the few that do usually have a wake up call experience there. As the sole xray tech on a 12 hour shift, handling 20 beds of ER and the house, I get the brunt of copious disrespect when all pateints of all nurses in all locations are not taken care of at the strike of lightning. I’m fast, I’m one of the fastest xray/CT techs there is, yet the brunt of upturned noses I get from 5 nurses sitting behind a desk exchanging cookie recipes when I’m busting my butt to get it all done has made me completely numb to nursing complaints.
    Doctors are a whole other entity. I feel most are respectable, with the exception of a few that I wouldn’t bring my dog to for care. In particular, the one who, in junior college asked if I would take his anatomy/physiology class for him (for a sizeable fee) then, after returning to my home area from xray school discovered in horror that this man is practicing orthopedics! Had I have come from the families of money and privelidge I would be amongst their ranks, I hope that privelidge wouldn’t spoil me so to stoop to that kind of dishonesty. Only just a few like this have seriously shaken the implicit trust that should accompany the title M.D.
    Albeit the days of xray tech as a “button pusher” are long past, I know a number of techs in the field who still portray the underdog status, most of whom are nearing retirement. Those techs also don’t tend to look at advanced specialties or degrees to advance their own positions. However, many more of us these days wear many hats, are multi-modality and highly educated. (nurses, othopods and ER docs alike can learn a lot in my CT suite, if they are receptive) Yes, nurses, there will always be docs that will patronize you. But I suggest many of them may just be intimidated by your level of knowledge and astuteness.

  26. JanisRN says:

    Are you kidding me? I have never heard such whining from physicians and nurses alike…I have been a nurse for 27 years and still don’t take any crap from anyone..not a doctor, medical student, or a fellow nurse. Those of you who are intimidated by the other should take a long look at yourselves….remember who you are and what you are supposed to be doing…remember?? TAKING CARE OF PATIENTS!!!

  27. My husband is a physician and I’m an NP. We work in the same office. I refer to him as Dr. Name when speaking to patients. I tried referring to him by his first name and patients looked confused. He likes to be referred to as Dr. Name by nurses at the hospital and by patients. However, several nurses and patients call him by his first name. It would be OK if he asked to be referred to by his first name. It makes our office staff uncomfortable when patients call him by by his first name. How do other Doctors feel about this?

    Doctors have worked very hard for their title and I feel they deserve to be called Dr. so & so. Besides, its respectful.

Trackbacks

  1. crzegrl.net says:

    Patronizing Nurses–Perpetuation of the Problem

    I thought this post by GruntDoc on Patronizing Nurses was interesting when I first read it. Looking back now on the dialog it has produced makes it an even better read. I attended a day long regional trauma conference today…