Now that you know when it’s okay to argue with a doctor, here are four things to keep in mind if an argument with a doctor can’t be avoided. Follow these rules to ensure you do the least amount of damage possible to your reputation and your relationship with the doctor.


1. Think before you speak


If you feel like you need to let the doctor know that he or she did something wrong, or that you disagree on the course of action, don’t just blurt out your concerns. Not all doctors do things the exact same way and no two patients are exactly alike. What looks strange or incorrect to you may actually be the correct treatment for a patient, or the doctor might be using a technique you aren’t familiar with. Thinking for a minute about the doctor’s point of view and whether it has merit before you say anything can save you from countless arguments.


2. Don’t raise your voice


Personality conflicts at work only get worse at higher volumes. Even if the doctor is yelling or belittling you, the best thing to do is always stay on an even keel. A calm, professional demeanor will earn you respect – if not from the doctor you’re arguing with, at least from other coworkers.


3. Be aware of your surroundings


The last thing you want to do is argue with a doctor in front of a patient. Just imagine how you would feel if your life is in the hands of people who are arguing about how to care for you, or just don’t get along. Nobody wants to be under the care of someone who’s emotionally unstable or downright angry. Move the argument to a neutral area, preferably an empty room with a door that closes.


4. Let your supervisor know


Anytime you have a disagreement with a doctor, it’s a good idea to go to the nursing supervisor and let him or her know what happened as soon as possible. That way, if the doctor complains about you, your supervisor will be aware of your side of the story. If the first time they hear about the disagreement is from a complaining doctor, then you’re going to be in the unenviable position of having to explain yourself to your superior.


Nobody strives for conflict with coworkers, but sometimes it can be unavoidable – especially in the high stakes and high stress environment of a hospital. You will need to stand your ground at some point in your dealings with doctors. If you follow these tips and make sure to keep your emotions out of the equation, you will be able to navigate these workplace landmines so you can concentrate on getting your work done and giving your patients the best care possible.

As demand for health care services has grown, physicians have stopped serving as the sole gatekeepers for their patients’ entry into the system. So physicians must increasingly share their patients — not only with one another but also with other professions. Teamwork is the new mantra of medicine, and nurse practitioners and physician assistants (sometimes known as midlevels or physician extenders) have become increasingly important care providers, particularly in rural areas.

But while all physician organizations support the idea of teamwork, not all physicians are willing to surrender the traditional understanding that they should be the ones to lead the team. Their training is so extensive, physicians argue, that they alone should diagnose illnesses. Nurses respond that they are perfectly capable of recognizing a vast majority of patient problems, and they have the studies to prove it. The battle over the title “doctor” is in many ways a proxy for this larger struggle.

For patients, the struggle has brought an increasing array of professionals trained to deal with their day-to-day health woes, but also at times confusion over who is responsible for their care and what sort of training they have.

Six to eight years of collegiate and graduate education generally earn pharmacists, physical therapists and nurses the right to call themselves “doctors,” compared with nearly twice that many years of training for most physicians. For decades, a bachelor’s degree was all that was required to become a pharmacist. That changed in 2004 when a doctorate replaced the bachelor’s degree as the minimum needed to practice. Physical therapists once needed only bachelor’s degrees, too, but the profession will require doctorates of all students by 2015 — the same year that nursing leaders intend to require doctorates of all those becoming nurse practitioners.

Dr. Kathleen Potempa, dean of the University of Michigan School of Nursing and the president of the American Association of Colleges of Nursing, said that the profession’s new doctoral degree, called the doctor of nursing practice, was simply about remaining current. “Knowledge is exploding, and the doctor of nursing practice degree evolved out of a grass-roots recognition that we need to continuously improve our curriculum,” she said.

Last year, 153 nursing schools gave doctor of nursing practice degrees to 7,037 nurses, compared with four schools that gave the degrees to 170 nurses in 2004, when the association of nursing schools voted to embrace the new degree. In 2008, there were 375,794 nurses with master’s degrees and 28,369 with doctorates, according to a recent government survey.

Dr. Potempa said that nurses with master’s degrees were every bit as capable of treating patients as those with doctorates.

“If it ain’t broke, why fix it?” asked Dr. Afaf I. Meleis, dean of the University of Pennsylvania School of Nursing.

Some health care economists say the push for clinical doctorates across health professions could be misguided. They argue that anything requiring students to spend more time and money getting trained will invariably result in longer waits and increased costs for patients, because fewer students will meet the increased requirements and those who do will eventually demand higher compensation.

“Everyone’s talking about improving patients’ access to care, bending the cost curve and creating team-based care,” said Erin Fraher, an assistant professor of surgery and family medicine at the University of North Carolina School of Medicine. “Where’s the evidence that moving to doctorates in pharmacy, physical therapy and nursing achieves any of these?”

Depending on their area of specialty, nurse practitioners earn a median salary of $86,000 to $90,000 annually, according to the Medical Group Management Association — a bit less than half of what primary care physicians earn. Nurses with doctorates generally earn the same salaries as those with master’s degrees since insurers pay the same rates to both. Physician groups fear that the real reason behind the creation of the doctor of nursing practice degree is to persuade more state legislatures to grant nurses the right to treat patients without supervision from doctors.

Twenty-three states allow nurses to practice without a physician’s supervision or collaboration, and most are in the mountain West and northern New England, areas that have trouble attracting enough physicians. Nursing groups have lobbied for years to increase that number. “This degree is just another step toward independent practice,” said Louis J. Goodman, chief executive of the Texas Medical Association.

Not true, Dr. Potempa said — the new degree simply ensures that nurses stay competent. “It’s not like a group of us woke up one day to create a degree as a way to compete with another profession,” she said. “Nurses are very proud of the fact that they’re nurses, and if nurses had wanted to be doctors, they would have gone to medical school.”

Should medical students be introduced as Doctor?

“Is it illegal for a medical student to introduce themselves as ‘Doctor’ before they have received their MD?”

One of the answers that was rated highly was “I think it is more unethical than illegal.” Clearly, if a student is deliberately misrepresenting themselves as a ‘doctor’, it is grounds for disciplinary action. More often than not, this misrepresentation is not deliberate on the part of the student. For example, some of our prior work demonstrates that medical students often report that they were introduced by other physicians as a doctor to a patient and that to a lesser extent, students may not correct someone who mistakes them to be a doctor.

Complicating matters is the propagation of the term “student doctor” at some institutions which is especially problematic. After all, how many patients will be quickly discern that ‘student doctor’ actually refers to ‘medical student’ and not a ‘doctor’? Unfortunately, patients who hear the term ‘student doctor’ may not hear the term ‘student’ and just zero in on the ‘doctor’ part, as they often wait patiently for their doctors to see them in the hospital. This brings us to the problems of how doctors are named in teaching hospitals. The system could not be more confusing.

■Interns. This is probably one of the most confusing terms in a teaching hospital. Interns are doctors who have graduated medical school and are in their first year of a residency training program. Of course, ‘intern’ is also the universal term for all those college students trying to get a short term experience on their resume by ‘interning’ there first. So, why would a patient think an intern is a doctor? After all, you would never put your faith in the legal ‘intern’ at the law firm to defend you in a lawsuit. To make matters worse, there is the opposite problem. Intern is often mistaken for ‘internist’, who is actually a doctor who has completed their internal medicine residency and otherwise a ‘doctor for adults.’ (Patients are more familiar with their “PCP” or ‘primary care physician,’ which could refer to either an internist or a family physician).

■Residents. Residents can refer to any doctor who has graduated from medical school and is in a residency training program (including interns). The term “residents” originates from William Osler’s era when residents did live in the hospital. Of course, they don’t live there anymore which would violate worker’s rights not to mention their regulated duty hours… but we still call them residents. The other name residents are often referred to is as “PGY1” (post graduate year) which is certainly not an improvement.

 

■Housestaff. One of our premed college students just asked me what this term was this week. I explained that while this does sound like the butler, maid, or cook a fancy estate, this term actually refers to the hospital as the “house” that the residents live in as the staff. So all residents (including interns) are part of the ‘housestaff’.

■Fellow. This is perhaps one of the most disconcerting names for a physician as it may sound like it refers only to male doctors (and conjure up images of young man from England with excellent manners i.e. he’s a fine ‘fellow’). In fact, a fellow is a doctor who has completed residency and is getting advanced training in a certain subspecialty.

■Attending. Attending to what you may wonder? The attending physician is actually the doctor who has completed training and is legally responsible for the care provided by residents. In other words, this is the ‘boss’ doctor as my residents sometimes introduce me to the patients on our team.

A few years ago, we tried to improve the situation for our patients by having doctors introduce themselves with baseball cards with their pictures on the front and the roles of the doctors were displayed on the back. While we were able to increase the percentage of patients who knew who their doctor was, we were surprised to discover that fewer patients stated they understood the roles of the doctors. How did we make it worse? Perhaps ignorance is bliss. By trying to unlock the secrets of these names, patients realized the names we use in teaching hospitals are confusing.

However, this confusion is more than just a name, it is also a patient safety issue. After 18 year old Lewis Blackman died in a South Carolina teaching hospital without an attending evaluation when his family kept asking to see the doctor, a new law in his honor aims to address the issue. It requires that patients receive written materials describing the roles of the trainees on their team and also how to contact the attending if they have a concern. More recently, the ACGME, which accredits US residency programs, has included a mandate in its now infamous policy restricting resident work hours that states “residents and faculty members should inform patients of their respective roles in each patient’s care.” While it is not certain how this will be implemented at every teaching hospital across the land, it’s certainly time to make our naming system easier and more transparent for patients to understand.

types of residents that medical students will encounter

Every medical student is a bit apprehensive when he/she knows they will be assigned a new resident. The same questions always come up. Will the resident be nice? Will they understand my busy schedule? Will they make me do a ton of scutwork? Will they make me write all of his/her progress notes? And maybe most importantly, will they let me leave early to study for boards or enjoy the occasional night out?

After a year and a half of clinical rotations in various hospitals throughout NYC, I have learned that every resident can fit in to one of three general categories.

The amazing resident

The first type of resident is my favorite. He/she is the one that still remembers what it’s like to have freedom and no responsibility as a 3rd and 4th year medical student. They understand that the medical student is strictly there to learn some cool things and see some interesting procedures, then get out of the hospital to study. This resident is almost always cognizant of the fact that the medical student does not want to work through lunch to finish a progress note that should be done by the resident to begin with.

I have also noticed that this type of resident is usually more efficient and smarter than his/her colleagues. He/she is able to get their work done without a medical student, therefore does not have to rely on him for help. Since this resident is usually smarter than the average bear, they often times impart unique clinical knowledge to the student. The funny thing about this resident is that I am MUCH more willing to do the lowest of scutwork to help him/her out because of their teaching and understanding of the medical student’s role.

The horrible resident

On the other extreme of the spectrum is the resident that makes the student think that unless you work longer and harder than the resident, then you will ultimately be a horrible doctor and unworthy of the MD degree. The darkest of these types of residents will even taunt the medical student’s worst fears by threatening the notion of giving you a bad evaluation if you’re not breaking your back to make their life easier. This means that if you eat lunch before finishing scutwork for him/her despite the fact that you’re about to pass out from hypoglycemia, you are unworthy. This type of resident will berate you if anything goes wrong during their shift. This can include yelling at you for misplacing the central line in the carotid rather than the external jugular, despite the fact that you were only an observer during the procedure. And for your information, it will always be your fault, thus it is easier not to argue and merely accept the blame and state that you will never do it again.

This type of resident can either be smart or not so bright, but one thing is always true, their idea of “teaching” is very misconstrued. They think that making the medical student call another hospital to get medical records, or calling the primary care doctor regarding a patient that they know nothing about, falls under the category of teaching, Therefore, this fulfills their role as a “teacher,” resolving them of having to waste their time explaining the reasoning for ordering potassium levels q4h on the DKA patient.

On the other hand, I must admit that this type of resident is not entirely bad. I once had a resident that often left the building before me leaving some of his work for me to complete. He would ask me to get an ABG on his patient with respiratory distress, and then go home while I was in the patient’s room. Although this was incredibly annoying, I did become extraordinarily competent on many procedures. I can now do an ABG blindfolded and I don’t need any assistance other than a nurse to place an NG tube. Thus, I must thank that resident for being a bad teacher and leaving me to learn things on my own.

The okay resident

The last type of resident is markedly different than the others, but sometimes has traits of both extremes. I believe the primary problem that undermines this resident is that they aren’t aware of the fact that the student has needs such as going to the bathroom and eating. They tend to forget that the student actually exists and is more than just a fly following them around. This resident is not directly vicious (like the “horrible resident”), it’s that they are usually too overwhelmed during the day and just don’t know how to utilize the student effectively. This leads to a medical student that is bored and zones out because he/she is not engaged and is left to stare at the paint drying on the wall.

I don’t want to generalize this category of residents as being not smart, but they don’t get it like many of their colleagues. The fact that they are overwhelmed by work is because they don’t know how to manage their time appropriately and when needed, ask for help from the medical student. I have met quite a few of these residents that are very smart, it’s just that they tend to be thorough with their patients, which doesn’t allow any time for them to think about how to have the student interact. From my experience, it seems that their strict attention to details stems from their paranoia of making a mistake and somehow killing a patient. This leads me to believe they need to read Samuel Shem’s books and grasp the idea that less is usually better in the healthcare world and their meticulousness is hindering rather than helping.

Turf Wars

The doctors are angry.


Let me rephrase that.


The medical doctors are angry. Not all of them, a couple of groups have been very vocal about nurses earning their doctorates, and using the title of “Doctor” in their practice.


Why, the public might be confused!


I tend to give the public a little more credit than that, and I absolutely give nurses credit for never passing themselves off as physicians.


Did you catch the article in The New York Times, “When the Nurse Wants to Be Called ‘Doctor’”? It opens with a nurse practitioner introducing herself , saying, “Hi, I’m Dr. Patti McCarver, and I’m your nurse.” (Emphasis mine.)


Dr./Nurse McCarver has her DNP, and she identified herself as a nurse immediately. She is fully within her rights to use the title of “Doctor”, just as anybody with a doctorate in any field has the right to use the title.


Nurses are obtaining advanced degrees, including the Doctor of Nursing Practice, because the level of care that registered nurses are capable of providing as advanced practice nurses requires this level of knowledge. They are capable of being primary care practitioners, and they are capable of doing this without a physician standing over their shoulders.


They are neither replacing, nor supplementing physicians.


Some in the medical community are fighting. The arguments against nurses (and other health professionals) practicing independently with advanced degrees are many and run deep. It’s more than loss of control over the title “Doctor”. Per the NYT article, it’s a loss of control over prescribing authority and loss of income, as other professions with higher degrees demand more money.


Demand more money? These days? You can demand all the money you want, no one is going to get paid any more than the system doles out. It poses an interesting idea, though. Nurses who practice independently have tended to gravitate to areas that are underserved (aka: lower income) where physicians don’t/won’t go. Will that change as more DNPs incur student loans/need higher incomes?


Loss of prescriptive authority? What does the medical profession lose if a nurse practitioner is able to independently order blood pressure, cholesterol, reflux or NSAID medications, for example? Other than a need to see a physician to get the medication, leading to loss of income.


Just answered my own question.


Medical and nursing education are different, but they have their similarities, too. Nursing is also a science-based profession and advanced practice nurses study pathophysiology and disease. Most DNPs have worked for years with patient populations before going back for their doctorate. But nurses also study health and wellness and the human response to it all…


And when you walk into their office they see you as a whole human being and they take time to actually talk to you.


Then again, so does my own physician.


Both the nurse practitioner and the family physician can provide primary care, manage your illnesses, help you stay healthy and both of them will refer you to specialists when something needs attention.


There is a place for both medical doctors and doctorally prepared nurses in primary care and lord knows there aren’t enough of either to care for the millions in this country who need primary care.


Stop the turf war long enough and you’ll see that the presence of the DNP in primary care does not diminish the prestige, or the “power”, of the MD in the least.