Prioritize Relationships, Not Solutions

Robert Chang writes…

I think one of the biggest issues we have to reckon with is the amount of human interaction our job entails.  We’re surrounded by stressful situations between nurses, patients, administration, clerical staff and so forth, either in a moment’s interaction or an interaction over years.  When burnout is one of the crucial limitations to each of our careers, every stressful situation represents an opportunity or an obstacle.  We have the choice of responding aggressively and/or antagonistically, which may feel great for the moment and result in a solution at the cost of relationship, or we have the chance to seize shared common goals, stand on professional high-ground and prioritize mutual benefit.  While neither of these stances guarantees an outcome which results in change that we ultimately want, it is surprising how much mutual understanding melts a frozen stalemate and how good-will and personal relationships can soften stances.  While hard work, finding mutual goals changes our mind-frame from finding “the solution” to prioritizing relationships for everyone’s mutual benefit.

I still have a page saved from October regarding one of my favorite interactions I’ve had between myself and a nurse.  A patient with severe connective tissue disease was receiving cytoxan, and in our institution, only certain physicians are cleared to write for agents that are used as chemotherapy.  The attending on the rheumatology consult service entered the orders but was unfamiliar with the computer system, and forgot the IV fluid to limit/prevent hemorrhagic cystitis, routine anti-nausea medications, acetaminophen for management of fever or pain and so forth.  The nurse taking care of the patient was fantastic and had previously worked on several oncology floors and caught approximately four missing routine orders over roughly five hours.  Over that time, I think both of us were getting frustrated because of the errors – she attributed those errors to me and despite reviewing the orders with the nurse specifically, she had to call me back three more times.  She sent one last page to me just before I was about to leave, asking for acetaminophen prior to treatment, but she didn’t page me to a phone.  Since computer-order entry, our physicians have seen a dramatic increase of requests for an intervention (i.e. “can you order Tylenol?”) without a return number for speaking directly with the nursing staff.  A little irritated, I sent her back a page to a phone asking if there was ANYTHING else that she needed, because we had to go back and forth so many times over the day.  Her response was “it would be nice if I didnt have to notify you for every order that should be entered – Get the orders right and I wont bother you!!!! [sic]”

Wow I was angry.  I vented with my colleagues in the work room who were shocked and yet entertained by the return page, somewhat like a horrific scene in a movie that we know is going to be ugly but just can’t turn away from.  After a few minutes, I grabbed the phone, called the floor, asked that the nurse localize to a private room so I could speak with her and stormed up the stairs.  After the first flight of stairs, I started to laugh.  I sat down on in the musty stairwell and looked at the situation.  Here was a nurse who had performed tremendously and caught multiple orders that the patient needed, and myself who had responded within seconds of every error that the nurse brought up and fixed. We were at odds at the end of a long day over basically…nothing that either of us had really done.  I had the chance to roast the nurse on a professional level for the page that she sent but I was actually quite grateful for all the care she had given.  I saw that she probably felt slighted for doing a good job and receiving the page I had sent which criticized the good work she had done.  I walked up the remaining three flights, found the nurse and we just talked.  I shared that someone else had written the orders, that I was thankful that she was catching errors but was just on my way out the door and she had not paged me to a phone where we could discuss things.  She said she had a hot temper but was doing her best for the patient and to give great care and then be criticized for it was frustrating.  She looked at the page she sent and said “Oh.  Oh yeah, that’s…that’s quite a page.”  The final kicker came out when she realized that I was an attending, not a resident.  We talked about the chance that she had to teach physicians about what a professional relationship could look like, where two people clearly working towards the same patient care end could work together to a mutual professional end as well.

I’m unconvinced that this one conversation changed that nurse’s perception on physicians.  But that interaction served as a microcosmic example of valuing relationships over problem-solving and the potential benefits of such.  Sure, I could have “fixed” that nurse for the page that she sent by professionally lambasting her.  A negative interaction with me would probably be just another one of several she had in her career.  The reality is, however, that she will go on to interact with tens to hundreds of physicians in her career, many of whom are residents and are yet learning how to interact with nurses.  The importance of acting professionally, regardless of physician training stage, was the white elephant that we both non-verbally recognized and the rebuke didn’t need saying.   Her perception on hospitalists was on the line, once she realized I was an attending.  The motivation to remain committed to doing hard work needed to remain in line with her understanding of how physicians appreciated her work.  The downstream effects of prioritizing relationship in this situation and showing that the relationship mattered rather than being “right”, offers a solution that truly benefited everyone, the nurse, myself and the patient.  This could have easily been a conversation that I would have looked back on with regret and/or chagrin, but fortunately, it didn’t.  We ultimately have to choose whether to let the frustrations of our job consume us or act as an opportunity for teaching, conversation and a renewed sense of commitment to one another.