A doctor-bully epidemic is jeopardizing both nurses and patients. In news reports and hospital break rooms, stories abound of physicians berating nurses, hurling profanities, or even physically threatening or assaulting them. Doctors are shoving nurses in the operating room; throwing stethoscopes, scissors, pens, or surgical instruments. In Maryland, a surgeon yelled, “Are you stupid or something?” at a nurse and hurled a bloody surgical sponge at him. A surgeon threw a scalpel at a Virginia nurse, who told me, “He was angry because I didn’t have a rare piece of equipment he needed, so he endangered me and several others by throwing a tantrum.”
Many things surprised me during the reporting for my new book, The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital, which follows the stories of four nurses and is based on interviews with hundreds of other nurses across the country. But this disturbing problem was one of the more shocking discoveries when nurses pulled back the curtain. Most nurses have witnessed or been the victims of doctor bullying. A 2013 Institute for Safe Medication Practices survey found that in the year prior, 87 percent of nurses had encountered physicians who had a “reluctance or refusal to answer your questions, or return calls,” 74 percent experienced physicians’ “condescending or demeaning comments or insults,” and 26 percent of nurses had objects thrown at them by doctors. Physicians shamed, humiliated, or spread malicious rumors about 42 percent of the surveyed nurses. A New York critical care nurse told me, “Every single nurse I know has been verbally berated by a doctor. Every single one.”
Why is doctor bullying veiled in organizational silence? Nurses may be afraid to report doctors because they believe administrators will refuse to penalize physicians who generate revenue or garner media accolades. Nurses worry they might lose their own jobs in retaliation, or they fear the stigma of being perceived by colleagues as a whistleblower.
These fears may be justified. A slew of double standards protects physicians’ jobs but makes nurses vulnerable. Some hospitals have fired nurses for reporting doctors’ inappropriate or incorrect treatment of patients while allowing the doctors in question to continue to practice. But when nurses don’t speak up, there’s a risk that people will suffer or die.
In hospitals, “intimidating and disruptive behaviors” can lead to medical errors, increase health care costs, and harm patients, according to the Joint Commission, an independent organization that evaluates and accredits health care organizations. These consequences can occur because certain doctors refuse to listen to nurses or because some nurses are too intimidated to ask questions promptly, if at all. “Molly,” a nurse whose story I followed for a year, saw firsthand how a doctor determined to upstage a nurse repeatedly put patients’ health at risk. The Joint Commission has found that in health care organizations nationwide, 63 percent of cases resulting in patients’ unanticipated death or permanent disability can be traced back to a communications failure.
A nurse relayed this scenario to the Journal of the American College of Surgeons, for example: “Cardiologist upset by phone calls and refused to come in. RN told it was not her job to think, just to follow orders. Rx [prescription] delayed. MI [heart attack] extended.”
At an annual meeting of the Pacific Coast Obstetrical and Gynecological Society, researchers described similar issues among labor and delivery staff:
- “When a nurse reported to the physician that her patient was highly anxious and had shortness of breath, the physician told the nurse to give the patient some Ativan [anti-anxiety medication] and take some herself. Later that evening the patient was admitted to the ICU [intensive care unit] with congestive heart failure.”
- “A nurse reported that the ﬁnal sponge count was incorrect after a difﬁcult tubal ligation. The physician was sarcastic and said that an expensive x-ray would be ordered because the nurse obviously suffered from obsessive compulsive disorder. A sponge was found in the patient.”
- “Doctor’s behavior has been hostile, aggressive, threatening, and escalating in the past months … including raging at charge nurses and unit director … nurses are working in a hostile environment and fear for their safety and well-being.”
Certainly, only some doctors exhibit such behaviors, and incidents should be viewed in context. Tensions run high in life-or-death situations; doctors may not have time to monitor their tone or language when their priority is saving a life. The doctors considered the worst offenders are the specialists whose work is consistently urgent and carries the highest stakes. The hospital departments most likely to host doctor bullying are operating rooms, medical surgery units, ICUs, and emergency rooms. In the OR, surgeons are more than twice as likely as anesthesiologists and nurses to exhibit disruptive behavior.
A 2011 American College of Physician Executives survey found that three-quarters of doctors are concerned about this kind of behavior; virtually all respondents said it affects patient care. Yet “despite the best efforts of many, our profession is still plagued by doctors acting in a way that is disrespectful, unprofessional, and toxic to the workplace,” ACPE CEO Barry Silbaugh observed in the report’s foreword.
Some health care providers have devised clever strategies to handle intimidation. In one surgical department, when staff members feel tensions rising, they can call out, “Tempo!” as a reminder for everyone to calm down. In a New Brunswick, Canada, hospital, when a particular doctor bully lambasts a nurse, nurses spread a “code pink” alarm and other nurses come to her area and stand beside her in support. At another hospital, a mistreated nurse can page a “code white” to the same effect.
Still, these codes go more toward treating a symptom rather than preventing problems in the first place—perhaps fitting in an American health care model. Ultimately, these issues can be attributed to a fundamental lack of respect for nurses, who deserve much more appreciation than they get.
The physician and nurse professions, which should be considered complementary and equal, are instead too often treated as master and servant. The term nurses often use to describe the role some doctors seem to assign them is “handmaiden.”
The hierarchy is often enforced from above. When an ER doctor didn’t even try to save a man whose heart stopped in the ambulance on the way to a hospital, the nurses in the emergency room complained to the hospital’s medical director. The way the director dismissed the nurses’ complaints was both insulting and astonishing. He said, “You’re just saying that because she’s young and pretty.”
Similarly, an anesthesiologist told an Arkansas Certified Registered Nurse Anesthetist (a category of highly trained providers who may provide anesthesia autonomously), “I could teach a monkey to do your job.”
The doctor-nurse hierarchy is rooted in the past, in remembrances of outdated traditional roles. Up until the mid-20th century, nurses, almost always women, were expected to stand when a doctor, almost always a man, entered the room. Nurses were to offer him their chair and open the door so that he could walk through first, in chivalric reverse. Nurses were expected to await instructions passively without questioning the physician. By the 1960s, nursing schools were still teaching that, as one nurse described it, “He’s God almighty and your job is to wait on him.”
In 1967, psychiatrist Leonard Stein described the nurse’s role in an essay titled “The Doctor-Nurse Game.” The object of the game, he said, was for a nurse to “make her recommendations appear to be initiated by the physician. … The nurse who does see herself as a consultant but refuses to follow the rules of the game in making her recommendations, has hell to pay. The outspoken nurse is labeled a ‘bitch’ by the surgeon. The psychiatrist describes her as unconsciously suffering from penis envy.”
Today, some hospitals perpetuate what the ISMP calls a “culture of disrespect among healthcare providers” rather than treating nurses like the heroes they truly are. At Vanderbilt Medical Center in 2013, in an attempt to cut costs, administrators risked cross-contamination by forcing nurses to perform housekeeping duties, including emptying garbage cans, changing linens, sweeping, and mopping patient rooms and bathrooms, according to WSMV-TV Nashville. At other hospitals, nurses told me that they are charged for parking while physicians and techs park for free.
Nurses, skilled and educated, deserve respect, appreciation, and a voice in healthcare decisions. Is it possible to have a chain of command without implied levels of superiority? To view the various scopes of practice as complementary rather than hierarchical? By reframing doctor-nurse relationships so that providers view each other as part of a team, managers would convey that every team member deserves to be empowered as they work together toward the ultimate goal: better patient care. And then, finally, the majority of bully doctors—and projectile surgical instruments—can remain in the past where they belong.