Wednesday, January 12, 2011

Snow Day


Addendum 6/14/11:
It has come to my attention that there are readers out there who are unwilling or unable to read the post below as an occasion of BLOWING OFF STEAM on a particular day about a particular set of individuals at a particular practice. Really? No one at work EVER did anything to annoy you? You never mouthed off just to VENT about a particular frustrating occurrence - even those of you who might be on, for example, a forum "designed to act as an outlet for blowing off steam?"

Please consider that in the comments section under this post I do take to heart the admonitions of readers who point out that my views might be biased or unfair or objectionable, and I do reflect and admit that I have some growing to do; that I do realize my mouthing off about two or three people was probably not fair to the dozens who don't come under the same category; that I try to describe to a reader the advanced training and clinical abilities of CRNAs; and finally, that this was actually discussed among physicians and CRNAs in our practice, and the views of both sides - the objections of CRNAs to being lumped together and criticized unfairly, and the objections of physicians to subpar work ethic from some CRNAs who, despite considering themselves MD equivalents did not demonstrate an MD-equivalent commitment to actually SHOWING UP - were laid out on the table. Each side asked the other to shape up on the particular problem being pointed out. Nevertheless, my chief and I persisted in the opinion that we did not feel we were "allowed" to call in sick, ever (though we sometimes do actually get sick enough to require it), and that we were held to a (perhaps unreasonably) higher standard than most professions have to meet.

While I can see why it would be tempting to demonize me for expressing how I felt on this particular day, I would ask that people consider that I was venting, that I was not alone in feeling this way, that some CRNAs in my practice actually agreed with me, and that some of the points raised (especially in the comments) might be worth discussing or even be of some value despite how grating they may sound.

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Boston had another blizzard today. I was really worried about this one. It was supposed to snow hard, about three inches an hour from 3 a.m. to 12 p.m. with poor visibility, impassable roads, etc. I've driven home in snow like that, and I find it terrifying. Your car won't do what you want it to, and worse, OTHER PEOPLE can't be counted on to be either careful or able to control THEIR vehicles or even able to SEE you.

I texted my chief to see if there was any chance the O.R. would close and cases would be cancelled for non-call personnel, but it was business as usual.

So I went back to the hospital to spend the night last night before the snow started. My husband and I had been planning a quiet evening together, but all he could do was wave sadly at me from the window as my car pulled away.

My chief, worried that the bridges connecting his area to the hospitals would be closed, drove to the hospital at 2 a.m. and set up an air mattress in the anesthesia office.

My other colleagues left their homes at least an hour earlier than usual to brave the blizzard and arrive at work on time.

100% of the doctors in our practice made sure they reported for duty at the appointed time, literally come hell or high water.

How many of the nurses and nurse anesthetists did the same?

To be fair, one of the nurses had the honor and dedication to trudge through the snow from her house in order to make it. I don't mean to imply that there aren't dedicated, hard-working nurses. But several of the nurses called in "sick" and only ONE of the nurse anesthetists who were scheduled to work this morning actually bothered to come. What was their excuse? Too much snow.

It has become common for nurses to seek to be recognized as equal to physicians in much of the work that they do (even publishing articles to that effect in newspapers and journals). But on days like this, it's IMPOSSIBLE for the docs to gather around the water cooler without noticing and commenting on the vast difference in work ethic between M.D.'s and non-M.D.'s. It's just not possible to get through med school and residency making excuses for not showing up and meeting your duties to patients, just because conditions are inconvenient. Nor do we get to feel entitled to extra pay or time off for the extra time and effort spent getting to work hours and hours early due to a snow storm.

Moreover, with our verbal Socratic oath I believe most of us take an attitudinal, internal oath to be there for our patients whether or not we feel like it, have had enough breaks during the day, etc. Why else be a physician, if you don't have this kind of commitment to taking care of your patients?

So it grates. I hate to admit it, but it grates when what you think of as the practice of medicine, not only a duty but also a calling to be there to heal others, gets generically lumped in with the practice of other "health care providers." There is a difference, generally speaking, not only in training but also in the overall attitude to the work. Doctors don't take snow days.

28 comments:

Anna McNonymous said...

I wonder if you can thank nursing schools for some of the difference in work ethic between doctors and nurses.

My late mother was a nurse for over 40 years. She was trained in the 3-year program at St. Anne's Hospital in Chicago during the early 50's, a time when nurses spent a lot more time with a lot fewer patients. Her work ethic was identical to yours -- you go to work, no matter what. People don't stop being sick just because the weather is inclement, and they still need to be taken care of. I remember times when I was growing up when Mom didn't come home from the hospital or left for work hours early because of heavy snowfall.

For various reasons, I spent a semester in nursing school about 10 years ago. This would have been about 50 years after my mother was in nursing college, and things had become very, very different. We were not to call the people we were taking care of patients; they were "clients." And there lies all the difference. A patient is one who is under medical care or treatment. A client is a customer, a person who seeks professional advice or services.

It's a different focus. This difference leads me to wonder if that can make all the difference in how dedicated you are and in how you view your responsibility to your job. Are you taking care of them? Or are you providing them with services? That might be the nub of it.

T. said...

Anna - Thank you so much for your insightful and thought-provoking comment. You've touched on something else I find intensely irritating - the (WRONG) move to call patients "clients.". UGH. Terrible. And you may be quite right about the training process in general, for nurses AND doctors. From what I hear, today's residents are getting increasingly spoiled, entitled, whiny, clock-watching, and selfish. There has to be some way to humanize work hours without fostering these lapses in dedication to patients!

Resident Anesthesiologist Guy (RAG) said...

Whenever we have snow or other weather/ events that can threaten the hospital staff I'm confident that there will be a stark contrast between physician and nurse. And I've not been proven wrong. Once when we received pages that a mass casualty was being expected and that no one could leave, guess who was the first to ask to help out and who was the first to ask to leave because it was past 5pm?

Now, some of the residents have poor attitudes towards staying late or getting to work earlier and some of the nurses are very committed - but by and large it's definitely different.

Anonymous said...

Great post -- I don't know a single resident that didn't show up to work on Wednesday. On the other, there was not a single nurse manager in sight. Frustrating.

Doctor said...

I'm an anesthesiologist and chair of the ethics committee at my institution. We addressed a similar concept when H1N1 was at its peak. The question that arose was duty to treat. There does seem to be an unspoken social agreement between physicians and the general public regarding the expectation that we place ourselves at risk for the good of society. This unspoken contract (with its many flaws) does not seem to be discussed much in the literature of non-physician medical staff. Having said that, we didn't have any nurse's call in sick during its peak (except those that had H1N1!). More interestingly, all the ancillary staff were there too. Our ORs were always cleaned. (See my blog at www.mortalityandfriends.blogspot.com.)

Anonymous said...

I'm not a doctor or a nurse, but when I made a six figure income I made a much bigger effort to be at work in bad weather than when I made well under $100k. Another related factor may be the risk - a nurse has less money to pay the deductible for his or her car's repairs after a weather related accident than a doctor.

T. said...

There MAY be something to what you're saying, Anon, but there are plenty of primary care docs who make five figures who would still do their duty out of a sense of higher calling, not because of any practical considerations. There are also plenty of nurses who make well above 100K. The difference in attitudes that I've alluded to in this post is, I sincerely believe, CULTURAL and as such comes less under the influence of car repair payments and more under what people are "mentally trained" to act on.

Anonymous said...

Frankly, Im not a doctor or a nurse, but I would not want a nurse practicing 'medicine' on me. Medicine is supposed to be practiced by a physician. I find it pretty appalling that people just out of an undergrad level education can try to claim to be equivalent to someone who has gone through MUCH MORE education, and TRAINING. I dont want any nurse anesthetist working the gas if I have to go under.

T. said...

I agree that our training is not equivalent, but I want to point out that nurse anesthetists have much more advanced training than nurses who are not anesthetists. They must have at least two years of critical care experience BEFORE attending CRNA school and they have rigorous didactic sessions while in graduate school to become nurse anesthetists. As with all the professions, there are superb CRNAs and weaker ones, just as there are superb physicians and weaker ones. Some CRNAs are more trustworthy than some MDs. In general, though, it's been my observation that the extensive medical training undergone by MDs does provide a certain level of comfort with difficult judgments and complications that I haven't always seen in CRNAs, except in a few very excellent ones.

Anonymous said...

Yes, there IS a difference. I absolutly feel the way you do, so far away (I am an internist working in a private Hospital in Lisbon, Portugal). Our medical ethics are a part of our souls, and I don´t see it in non-MD. I do think that only a doctor understands other doctor in theese feelings. There is a difference that other people can´t see.

Inês Leal, Portugal.

premaseeker said...

I honestly don't feel that this generalization is fair beyond the anecdotal confines of your institution. I'm from the Midwest and don't see a distinction like you've mention.

Leslie said...

My sister is a nurse and she loves it. I told her about your blog and she's been following you ever sense!

Keep staying strong and keep the posts coming, we all appreciate it!

Leslie Turk

T. said...

premaseeker - you may be right; the anecdotes that I and other physicians have posted here may not fairly represent the difference in MD v. non-MD mentality, but clearly it's been noticed in more than just our institution. To be fair, our around-the-water-cooler frustrations were triggered by one particular CRNA who PREDICTABLY called in and whose work ethic has always been, to our minds, source of frustration. A neighboring hospital had 100% CRNA attendance and some docs that called in "sick" that day, so you certainly make a valid point. Still, it's been years we've observed this, and many of us from various areas around the country/world continue to notice these attitudinal/work ethic differences in our workplaces through the years.

Leslie - so glad to know of you and your sister! Blog's been a little quieter lately but I'm still around... :)

laura anne said...

I believe it's the CNRA's, maybe it's because they know the doctors are there to do the work. If you know that there is no one else that can replace you you are going to get to work. On our unit all the nurses except for one , came in. I would never not show up to work because of weather. I also think ethics and commitment have a lot to do with personality I don't know how much education makes a difference.

Camilla said...

I work in an environment (administering academic computer systems) which has a fair number of men who work the second-string job in their family. Couples where the man has chosen flexible hours and lower pay to support his wife's career.

Snow days also aren't really a matter of contention for us - it's quite acceptable to work from home. But, it does seem very much the case that everybody who comes in on a snow day is either single, or has a spouse who works fewer hours for less pay than they do.

This doesn't excuse anything, or explain how doctor-doctor households manage, but it does suggest a slightly more charitable theory.

Anonymous said...

I think it may also be a generation issue as well. I'm an RT in my early 30's, and I've noticed that people in their 20's just don't seem to have a strong work ethic or drive. It doesn't appear to matter if they are residents, nurses, respiratory therapists or whoever. Their apathy upsets me. I don't believe they are old enough to have had family die in the ICU and understand what it is like to be on the patient's side of things. I have noticed that the ones who do work hard are those that grew up with nothing and have been through hell and back. Honestly it kind of ticks me off that a lot these people were not held to the same standard that I was while I was in school ten years ago. I went to school in Michigan and unless the college was closed you were still required to attend clinicals. A blizzard up there is like an every other week ordeal due to lake effect snow.

Bleeding Heart said...

Its got nothing to do with professionalism. A doctor who misses a day's work loses a hell of a lot more money than does a nurse. I came into work sick and in bad weather when I was a resident. I can't believe I was so stupid!

T. said...

I don't follow. A doctor who misses a day of work still gets the same annual salary - it's not about money at ALL. I think it's all about professionalism, holding oneself up to a higher standard, and staying committed to one's calling and duty.

Lisa said...

Very interesting. I was watching the news the other night and they interviewed a woman on the road in the storm. She was a nurse and had to head into work. I remember thinking that I guess she has no choice. She's an essential worker who deals with life and death and weather can never be an issue. I guess that's not always the case.

T. said...

Again, to be fair, I have to mention that each unit within a hospital has its own culture, and I have to say that most of the nurses on our maternity ward wouldn't THINK of missing work for any excuse other than EXTREME illness, hardship, or personal tragedy. I don't know why the O.R. and recovery room teams have different standards, but it's a noticeable difference.

Anonymous said...

This post grates. I think it was greedy and insane of your institution to not cancel any non-essential surgeries in a blizzard, and I think if you asked most patients who cares more about them, and who is more essential to their healing, they would say their nurses, not their doctors. Doctors have a little bit of a god-complex, and a gross competitiveness that never sleeps. Hence the macho, militaristic and completely inappropriate training that they so prize throughout their lives (ie residency). Personally, I don't see what the ability to work on little sleep has to do with one's proficiency as a healer, but show me a doctor who doesn't reference the hell they went through in residency at least once a day as some kind of badge of honor, and I will be quiet. The system is so, so, profoundly broken. I think you need to examine your own biases a little more. This post was repulsive.

Anna McNonymous said...

How do you know the hospital didn't cancel non-essential surgeries? And what about essential surgeries? Are you going to tell the family of someone with a traumatic brain injury to wait until the weather is better?

People don't stop being ill just because there's a storm. People don't stop developing sudden complications just because it's hard for medical personnel to get there. Yeah, sometimes doctors can be obnoxious -- I grew up with them, I'm clearly aware of it. But most of them are not driven by greed. They're driven by responsibility to care for their patients. It's not like just anybody has the expertise to take their place.

T. said...

I can't deny that I do have biases, and that they come out when I vent about something, and that I therefore try not to vent TOO much in a public forum. I also can't deny that many of my biases come from that "macho, militaristic" training that you mention. Finally, I can't disagree that my biases bear reexamination - having them doesn't make them or me right, or validate what generated them in the first place. You are right about all that.

I think the intense training process is in some ways quite necessary in order to give trainees the broad and in-depth experience they need to be competent. But do we really need to make trainees feel less than worthy if they can't sacrifice EVERYTHING ELSE for medicine? Is it really right to expect them to just show up and do the work, regardless of what's happening in their personal lives? Is it fair that they be made to feel weak even if they have good reasons, even life-and-death or close-to-it reasons, for needing to do less work? I hear questions like these in the undercurrent of your comment and I agree they should be asked and talked about.

I think residency breeds a lot of different reactions in those who undergo it. Resentment at how grueling and sometimes dehumanizing it can be. Pride, perhaps, at having survived it successfully and a certain impatience with those who need to complain or fold or take a break or quit for less work. Compassion for those who have back-breaking jobs involving hours and hours of labor on one's feet, and a determination not to take teammates and other workers for granted and to show appreciation for their efforts. All of the above; none of the above. It is, I think, an experience that has a strong imprint on the mind, for better or worse.

The more negative attitudes that it engenders may not be justified, but in light of many residents' experiences, I think they are understandable. I think we who have let our resentments get the better of us have some growing to do, for sure, and I'll be the first to admit that I have been trying to heal over the scars of residency since I first got out. That said, there is SOME value in the expectation that people should just show up and do their work; in medicine I really think they should, unless they really, really CAN'T. (Kind of like that Nike ad - "Just Do It.") But you're right to point out how profoundly broken the system is.

Anonymous said...

At our hospital every nurse manager, senior director of nursing was at our hospital in every snow storm as were all nursing staff. They all came in the evening before, slept on cots, showered in empty rooms, ate cafeteria food, and were prepared to take care of patients. Perhaps you either didn't notice or overlook the people that take care of your patients. Enough of all the bashing. I appreciate our nursing staff, perhaps you should too.

T. said...

Complaining about certain colleagues with a particular pattern of behavior is not the same thing as bashing, so please don't overstate the matter. Our hospital has a number of dedicated and excellent nurses and I absolutely love working with them. I mentioned this in the post. Anonymous critics like you LOVE to hang onto every critical word as if it's some kind of personal affront without acknowledging that this post wasn't about EVERYBODY, just a lazy few, specifically a few nurse anesthetists in our particular practice.

Lindsay said...

I think it grates for CRNAs to be lumped in with staff nurses - we are not staff nurses. You cannpt compare the two. You also state "how many CRNAs did the same?" which means you do not know. I think your statement was biast. I don't feel it's fair to make a blanket statement based on what you perceive to be true.

T. said...

On the contrary, I asked the question as a rhetorical device, because I know EXACTLY how many. It's a small department.

If CRNAs don't want to be lumped in with staff nurses - and I make this comment in reference ONLY to the ones we work with in our particular practice - then they need to avoid the clock-watching, break-demanding, it's-your-patient-not-mine mentality, false-sick-calling, and not-my-jobbing that seem to be an accepted part of the nursing culture in the O.R.s with which our practice is familiar. Some of our CRNAs don't seem to be able to let go of those habits. Makes the stellar ones look REALLY great and a true pleasure to work with as colleagues and friends.

Tom Smart said...

In my 17 years working as a CRNA in Minnesota I have not missed a day due to illness or weather. When I got stranded in Chicago on a flight back home I rented a car and drove home in time to work. I don't consider myself a "doctor equivalent" but I do consider myself capable and committed to providing competent anesthesia to my community; sometimes independently and sometimes as part of an anesthesia care team. I live close enough to work that I can walk if I need to. I believe I was trained to have a superior work ethic and I find that common among my CRNA colleagues.