Rapport with physicians brings peace to the ED

How to handle difficult MDs

Dealing with difficult physicians creates a challenge for nursing professionals. Co-workers, patients, family members, and other hospital workers often subject nurses to behaviors ranging from poor communication to abuse.

"Physicians are no different; though managing a professional physician relationship may be more awkward for the nurse than [managing] other relationships," says Colleen Bock-Laudenslager, RN, MSN, a Redlands, CA-based consultant.

Historically, physicians have played a superior role to nurses, notes Bock-Laudenslager. "While over the years, nurses have evolved as a profession and have developed a more collegial role with their physician counterparts, the frustration of maintaining a positive physician working relationship still exists," she emphasizes. "Developing rapport with the ED physicians is essential to our practice."

The physician often sets the tone for the day, either negatively or positively, Bock-Laudenslager stresses. "Often, our reaction to their tone will create a solution for an improved work environment and an ultimately successful work day," she says.

Nurses should deal with physicians directly because they are colleagues, says Liz Jazwiec, RN, a health care consultant in Crestwood, IL. "If nurses expect to be taken seriously and respected, they have to learn to interact with all of their colleagues and not expect someone else to do it for them," she stresses.

Nurses who directly deal with physicians rarely have difficulties, since colleagues respond positively to direct interaction, says Jazwiec. "Imagine working with a clerical person who never dealt with you directly, and instead she always either went to her boss or your boss. Would you have a good working relationship with her?" she asks.

Being a consummate professional can go a long way toward avoiding problems with physicians, urges Bock-Laudenslager. "We have been taught the art of communicating effectively. We need to practice it," she asserts. "Be a good listener; clarify before reacting; ensure your body language is consistent with what you are saying; and refrain from gossip and triangulating others." (See related story on awareness of challenges faced by physicians, p. 123.)

Managing difficult behaviors

Common behaviors posing a challenge to the nurse, and tips for managing each:

1. Indecisive. Physicians with "internal medicine syndrome" have difficulty making decisions, which is a common frustration of ED nurses. "While the conscientious nature of these physicians is honorable, their need to cover all the bases’ subjects the department to patient flow issues and frustration," says Bock-Laudenslager.

The physician may benefit from a discussion with the nurse. "Ask them, Where are we in the disposition of this patient?’ The physician may tell you they can’t decide what to do. At this juncture, offer to discuss the case with them," recommends Bock-Laudenslager.

Offering solutions regarding utilization of the observation unit when appropriate, or obtaining a same-day, follow-up appointment with the primary physician may assist them in their decision-making process, Bock-Laudenslager explains. "You may also offer previous patient examples in how the treatment plan proceeded without negative outcomes."

It is difficult to redirect a physician to focus on emergent needs of the patient when they have been previously sued for an unfortunate discharge that resulted in patient misadventure, Bock-Laudenslager notes. It may be difficult for them to put that previous experience aside and make a decision about the one at hand.

"The bottom line is that some physicians are just better at their gut instincts and are willing to take more risks in disposition when they don’t have all the answers," says Bock-Laudenslager.

Don’t hesitate to share your own gut instinct with a physician about a patient’s need to be admitted. "Nursing literature confirms the expert nurse’s intuitive abilities. When in doubt, sometimes erring on the side of admitting the patient is fortuitous," Bock-Laudenslager advises. "Unfortunately, managed care and its focus on the appropriate utilization of resources has made these decisions frustrating."

Quiet docs hinder staff communication

2. Non-communicative. These physicians are often quiet or introverted. "As a general rule, they may not be communicating the plan to the patient or to the nursing staff," Bock-Laudenslager explains. "Nurses benefit from knowing which [care plan] the physician is utilizing in the care of the patient."

However, keep in mind that the ratio of nurses to physicians may be seven to one, notes Bock-Laudenslager. "Informing all the nurses, patients, and their families of pertinent information is an uphill battle for the ED physician," she says.

Ideally, the physician shares the plan with the patient and nurse simultaneously. "As the team converges on the patient, communication should include information about the diagnostic and intervention plan," Bock-Laudenslager notes. "Without direct communication, the nurse must seek out the physician and ask, What is the plan for this patient?’"

While finding the right approach to enter the physician space may be tenuous, you need communication to manage the patient effectively, Bock-Laudenslager recommends. "Make it easier for the physician to respond, have the appropriate facts, and use your personality and sense of humor," she says. "In general, ensure your demeanor is so professionally positive and fun that physicians are happy to see you approach them."

When you hear positive feedback about the physician, tell him or her, Bock-Laudenslager urges. "Often, your communication bears bad news or more work for the physician. You don’t want them to shudder when you approach. When you hear compliments directed at the physician, take the time to forward the information," she says. This will help keep the lines of communication open.

Personality styles impact communication, so approach accordingly. "If a physician is more thinking than feeling, they will be more responsive to facts," says Bock-Laudenslager. "If your approach includes comments about the patient weeping and being in pain, this may incite the physician in a negative manner."

Share objective, factual information such as patient’s vital signs, and a descriptive pain assessment demonstrating signs of discomfort. "Understanding personality types and adapting your communication will foster improved communication," Bock-Laudenslager states.

Be a good listener and ask questions to clarify issues. "If you are doing your job and keeping the physician in the communication loop, they will tend to be a better communicator to you," says Bock-Laudenslager.

3. Jokesters. A physician with a positive sense of humor is a great team member; on the other hand, one with a wayward sense of humor can be deprecating to the team, says Bock-Laudenslager.

Teasing is easily misunderstood. Before you react and walk away with hurt feelings, clarify the intent of the teasing. "It may not be malicious in nature," says Bock-Laudenslager. "If the teasing occurs in front of patients or their families or is a pattern, ask the physician to stop. Take into consideration your own teasing patterns and always choose an appropriate time and place for communicating your concerns to the physician."

4. Lack of common sense. Every profession has individuals who, for whatever reason, use poor judgment, are unable to see the whole picture, and fail to make consistent, safe decisions, Bock-Laudenslager notes.

"This scenario is delicate for the nurse confronted with evaluating medical practice," she says. "As an advocate to the patient, stakeholder of the institution, and a responsible professional, we are required to say something when inappropriate medical management exists."

A nurse must always clarify orders if, in his or her best judgment, an inappropriate order is being given. "Simple mistakes are understood in a chaotic work environment. If a pattern of concerns regarding physician care and potential negligence occurs, the appropriate chain of command must be utilized," Bock-Laudenslager says.

In most institutions, the chief of service and ED nurse manager are consulted regarding process of follow-up. "Nurses may be asked to document quality concerns regarding physician practice," Bock-Laudenslager explains. "This is always an awkward position for the nurse and demands immediate support from management and physician leadership. Nurses, while not encouraged to be adversarial, should be rewarded for doing the right thing.

5. Inconsistent/Passive-aggressive. Some physicians have control issues and respond in a passive-aggressive way. "[For example], if you suggest Ativan, they order Valium. If you suggest Morphine, they order Demerol." This situation may call for approaching the physician about the issue in a professional, caring manner.

"They may be controlling during slow parts of the shift, and then passive when the department is saturated," says Bock-Laudenslager. The nurse’s autonomy in the mind of the physician is based on the needs of the physician at that time. "This [inconsistent] behavior is one of the most frustrating of all the behaviors," says Bock-Laudenslager.

Realize your comments may not affect years of behavior on the part of the physician. "Departments which have established protocols or pathways for common ED diagnosis often thwart issues related to this kind of behavior," notes Bock-Laudenslager.

Typically, nurses respond by not moving in on the patient until the ED physician has seen the patient. "This may not always be in the best interest of the patient in terms of expediting the plan of care and dispositions," argues Bock-Laudenslager. "Many times, the physician-leader may have to be a participant in addressing this kind of behavior."

Sexual harassment doesn’t work here, either

6. Sexually harassing. "Some physicians are unable to keep their hands to themselves. Despite sophisticated harassment training, issues of harassment continue to annually cost hospitals a tremendous amount of money," reports Bock-Laudenslager.

Most nurses have their own individual acceptance level of what is appropriate touch in the workplace. "The nurse must follow the harassment guidelines of the facility for which they work," Bock-Laudenslager explains.

First, ask the physician to stop, advises Bock-Laudenslager. "Do so in a private location and keep your nursing leadership informed, as the employee has a right to a harassment-free institution," she says.

7. Abusive. In rare instances, a physician’s behavior may cross the line and become truly abusive. "It ranges on a continuum of rudeness, arrogance, demeaning behavior, and harassment," says Bock-Laudenslager. "We always assume everyone we work with is emotionally healthy, but that is not always true. A physician may be going through emotional upheaval in his or her personal life."

Serious behaviors such as drug and alcohol intoxication or improper conduct need to be reported immediately, Bock-Laudenslager stresses.

Handle problems in a professional manner

Always be a consummate professional. "If they are harassing you, never stoop to their level of behavior. Always have good emotional boundaries for yourself in terms of your own behavior," urges Bock-Laudenslager.

Use the appropriate chain of command, says Jazwiec. "After we have tried to talk to the person and let them know how their actions are affecting patient care several times, explain to the colleague that if the behavior doesn’t change, we will have to take the issue to the next level. That means taking the issue to both the physician’s superior and the nurses’ superior."

When dealing with abusive behavior, use the same standard for physicians as you would for other colleagues, says Jazwiec. "Ask yourself, If this were another nurse, would I be feeling as upset? Would I go to her boss about it?’ Often times, we let our nursing colleagues get to us. We sometimes have a different standard for physicians," she explains.

Maintaining paper trail is VERY helpful

If you see a pattern of abusive behavior, maintain a paper trail of dates, times, and specifics. "Use factual statements, not value judgments. It is an irritant to administration when nurses complain without documenting facts. Your facility may have a QI (quality improvement) concern or staff incident form established for these kind of concerns," says Bock-Laudenslager. "Also, keep your nurse manager informed regarding issues at this level. They can offer guidance and support you as you navigate the process."

Every effort should be made to foster a positive relationship with the ED physician.

"Unlike any other nurse in the hospital, the ED nurse has the distinct privilege of working alongside the same group of physicians 24 hours a day," Bock-Laudenslager notes. "The ED nurse is enriched by the mentoring of the ED physician. Whatever role the nurse can play in developing collegiality and rapport with the physicians will serve to improve the work environment, preserve the integrity of patient care, and develop nursing professionalism."