What do you do if you get physician push-back?

Hi, everyone! This week we are going to discuss a little bit of conflict you might run into on the floor:

Physician Push-back

By this, we mean that something has changed with your patient and despite having paged the doctor, you are given no response. You may have even contacted them multiple times with your concerns to no avail. The physician refuses to give you what seems clinically indicated or may even refuse to see the patient to make their own call.

Situations you might be calling about could include:

• You need to restart a home med.
• This is not just any home med, but their pain meds, anxiolytics or other anti-psychotics
• The family has a question that you can't answer
• This also needs to be addressed as soon as possible rather than waiting until they round the next day.
• They were NPO and they don't have orders to eat
• If you are a primary care provider please just give me orders for food, so we don't have to call you for this. We hate doing that as much as you had getting the call.
• Your patient is crashing or you're trying to keep your patient from crashing.

Luckily, at the facility we work, our doctors have build trust with the nursing staff and we rarely have an issue with an MD not hearing the nurses. This takes time though to develop. If you don't have that luxury of familiarity with your care providers, you need to present the information as objectively as possible. If you start saying things like, "I think..." or "The patient thinks..." or any variation thereof the doctor might stop listening.

Use phrases like:

• Patient states...
• Vitals are...
• Lab work says...

Very concrete, very objective.
However, don't be afraid to tell the doctor how you feel. Many a patient has been helped by the nurse saying they have a bad feeling. Work in the medical field long enough and you will develop nurse's intuition.

If that doesn't seem to be working, get your management involved. Sara and I are both charge nurses and sometimes we are not told what is going on. We are there to help and can sometimes intervene long before the patient's condition begins to deteriorate. Let your charge nurse know what is happening on the floor. We can't tell you how many times we have walked out of a room and found out someone was moved to the unit. We didn't even know they were crashing to begin with!

Many facilities have teams of critical care staff, management, and possibly MD who will come look at your patient. They just have to be called overhead and they will be at your bedside to help you look at the patient! It's really that easy. There is no penalty, maybe some paperwork, and your patient gets some extra attention. When in doubt, call your Critical Assessment Team or Rapid Response Team.

If you have exhausted your communications with the MD, you can go up the chain of command. Your charge nurse can help you get this started if the patient is struggling and you are not getting the help required from the care provider. Don't be afraid or intimidated to do this. You are not there for the primary care provider to like you. You are there to take excellent care of the patient, be their advocate, and make sure they are safe.

No matter what you having going on with your patient, we can't act without orders. That is unless they have a standing hospital protocol you can act on, but this is facility specific and you should consult your policies and procedures.

So to recap:

• Present the information as objectively as possible.
• Get your leadership involved, including your charge nurse.
• Call your CAT, if you feel it necessary. 
• Go up your chain of command.

Side note to nursing students and new nurses, we have all been there and you WILL get through this! If you find yourself in a position where you’re getting push-back from a physician be sure to follow the chain of command…We’ll be sure to cover that topic later on! In the meantime, have no fear, we are nurses! We’re going to therapeutically and safely provide excellent care to our patients!

Mama Flo (Florence Nightingale. Google her; do it!) would be proud of how far we’ve come! Okay…now back to your patient and continue to monitor...