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The "disruptive physician" label.

Dr. Tamzin Rosenwasser writes that the "disruptive physician" label is frequently applied by hospital nurses and defended vigorously by nursing management. (1) The nursing profession advocates adamantly for the right of nurses to question doctors' judgment. However, when doctors complain about the interference of the nurse in appropriate patient care, the disruptive label appears.

As a hospitalist, I have no problem with being questioned by nurses. I take their questions or concerns seriously and explain my rationale for deviating from the CMS quality measure or giving an order outside the nurse's depth of knowledge or field of expertise. The problem I do have is with the nurse who refuses to carry out my orders for care or directly countermands my orders despite my explanation. Here's an example.

A restless man was found unconscious on the street and brought to the emergency department by police. I ordered a dose of lorazepam so that a CT scan of his head of acceptable quality could be obtained. The nurse refused to give lorazepam, citing hospital policy against the use of restraints, physical or chemical. I gave the lorazepam over the nurse's continuing and vigorous objection.

As I explained previously, (2) complaint within the institution was futile. I was labeled "not affable." I did complain about the nurse who refused my order to give lorazepam, but not to management within the hospital. I filed a formal written complaint with the state licensing board for nurses. I was told that complaints about nurses interfering with and refusing to carry out doctors' orders were sharply increasing.

If you want to file a complaint with a nursing licensure board, I suggest the following format. After you have summarized the details of your complaint, list the nurse's failings: (1) Refusing or countermanding my order [specify order] is the practice of medicine. The nurse is not licensed to practice medicine. She acted outside the scope of her license and should be disciplined accordingly. (2) Refusing or countermanding my order placed the welfare of the patient in jeopardy [explain how]. The nurse should be disciplined accordingly. (3) Refusing or countermanding my order for care amounts to patient abandonment. The nurse should be disciplined accordingly.

As a locum tenens physician, my "punishment" for filing the complaint with the nursing board of licensure is that I will not be hired by that hospital in the future. If you are a full-time attending staff member at the hospital who files a complaint with the nursing licensure board you can be sure there will be reprisal. Consider seeking formal peer review of your care of the patient. When your care is deemed appropriate, have the peer-review body notify nursing management. Document every reprisal or appearance of reprisal, and specify date, time, and circumstances-who, what, where, and when. Most reprisals will not be through formal peer review but apparent from attitude of nursing personnel, the scuttlebutt, or an increase in complaints about you. (Be on your best behavior!) Therefore, the reprisal is not protected from disclosure by state or federal statute, and you may be able to take legal action--libel, harassment, or other injury. As a last resort go to the media. The media love a good story about medical malfeasance. In any event, the message that you are giving to the hospital and nursing management is that you take the care you provide to patients very seriously and will protect your patients from harm.

(1) Rosenwasser TA. Physicians must learn from history, or become its victims. J Am Phys Surg 2011; 16:112-115.

(2) Peraino RA. Affability: desirable physician attribute, or synonym for mediocrity?--a case study. J Am Phys Surg 2011;16:14-16.

Robert A. Peraino, M.D.

Franconia, N.H.
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Title Annotation:Correspondence
Author:Peraino, Robert A.
Publication:Journal of American Physicians and Surgeons
Geographic Code:1USA
Date:Mar 22, 2012
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