Unity Against HMOs Eases Clashing of Nurses, Doctors.

NURSES will tell you that some doctors -- especially those from the old school -- think and act as if they have the lifesaving power of God.

Doctors, on the other hand, will counter that there are plenty of know-it-all nurses out there with their own healthy egos.

Tensions between doctors and nurses are as old as the medical profession, but in an era of cost containment, doctors and nurses say they feel a bit more united, despite increased workplace pressures.

"I see them working better together because they have a common enemy -- the people who operate the HMOs,". said Dr. Robert Weinmann, president of the 6,000-member Union of American Physicians and Dentists. "Everyone recognizes when they're not being given the resources to do their jobs."

Charmine Navarro, an emergency room nurse at Northridge Medical Center, agrees that a new spirit of camaraderie has crept into the longtime rivalry.

"It does feel like we're closer, that we're in the same battle," she said. "Are we going to be able to do this or that procedure or test for a particular patient? We're all asking the same questions."

Natural rivalry

It hasn't always been that way. Conflicting egos have long played a role in the complicated relationship between doctors and nurses.

Not all doctors are problematic, but Kay McVay, president of the California Nurses Association, recalls running into plenty that felt they were omnipotent.

In one case, a doctor tried to have her fired for questioning his decision to subject a terminally ill patient to a painful test. McVay thought the test was unnecessary at that stage of the illness.

"That evening the patient died, and it turned out the test wasn't going to help," she said. "People don't realize that by law in the state of California, every registered nurse must act as a patient advocate. You need to have the ability to challenge doctors and ask questions. If you don't, you're not fulfilling your duties."

Navarro has a close relationship with the doctors she currently works with at the Northridge emergency room. But in her years as a nurse she has come across some who treated her more like a janitor than a health-care professional with a master's degree in trauma care.

"It just really depends on the doctor," she said. "The mentality of a lot of people entering the medical profession is that they're on the top rung, and nursing is just a job."

That rubs a lot of nurses the wrong way.

"You always hear stories about doctors who yelled at a nurse, but I've seen plenty of times when nurses were yelling at the doctors," said Weinmann, a neurologist.

Problems can also arise when professional responsibilities get blurred, and those involved forget that doctors are responsible for diagnosis and treatment, while nurses are charged with overseeing care plans.

In recent years, though, the relationship between doctors and nurses has been most impacted by increased pressure from changing working conditions, with medical professionals on both sides being asked to do more with less resources.

"I've been in this business for 25 years, and more people are unhappy and frustrated and disillusioned than I've ever seen before," said Dr. Tim Cannis, a Los Angeles-area emergency room physician.

Switching sides

McVay added that many nurses are becoming overwhelmed, as hospitals and managed care companies cut costs. For instance, in the past, many critically ill patients were routinely cared for in the intensive care unit, where the staffing ratio can be as low as one nurse for every two patients.

Now patients who might have been sent to intensive care are often shipped to "step-down" wards, where one nurse might be responsible for as many as 12 people, McVay said.

"In the first year after graduating, 20 percent of the nurses are leaving the profession. In the second year, 50 percent are leaving," said McVay. "We've never experienced this kind of turnover."

Ironically, the ire of many nurses is shifting from doctors to nursing colleagues who have gone over to the other side.

"Many HMOs and insurance companies use RNs as gatekeepers to deny care," said McVay. "It's very lucrative. They don't have to work night shifts, but it sets them up for a confrontation with other nurses who are trying to get care for patients."

Such developments have served to unite many doctors and nurses.

"People come into this profession with the highest convictions and best attitude," Cannis said. "They want to provide great care for people in need. But the pressures on those people have almost become intolerable."