Monday, October 05, 2015

"Protocols are for nurses."

Every now and then you hear something so dramatically stupid that you have to wonder.

One such example was a couple years back, when someone said: "I only text on the highway."

The latest example comes from a resident who was being "trained" by an attending doctor.  The resident was about to administer a drug using the protocol developed by that hospital's clinical department--one based on evidence produced as a result of systematic clinical evaluations.

The attending doctor interrupted the trainee and said, "Don't do it that way. I've been a doing this for over 20 years, and that way is stupid."

The resident replied, "But I've been told that this is the protocol."

The rejoinder, "Protocols are for nurses. Do it the way I say."

Which is worse, the pedagogy that has been employed or the practice of medicine that is being carried out?

After several years of participating in resident quality and safety workshops, I can report that we hear stories about this kind of thing quite often. Each time, the resident is put in an untenable position. Each time, a patient is put in jeopardy.


nonlocal MD said...

I too have heard these comments. Playing devil's advocate for a moment however, medicine has a long history of 'mavericks' basically experimenting on patients and, sometimes, innovating as a result. (Before you recoil, in fact are medical trainees not 'experimenting' on patients? One must learn somehow.) In fact a number of discoveries particularly in surgery have come about this way. I just wonder how protocol-driven medicine, particularly if there is also a culture of groupthink and political correctness driven by administrative fiat, will affect progress. (Consider also that research funding has been cut cut cut and fraudulent research due to publish or perish has increased. Not a pretty picture overall.)

Paul Levy said...

I totally understand your point, but this was not one of those creative situations. The protocol here was not driven by administrative fiat: It was the product of doctor-initiated clinical research. Indeed, that research precisely displayed the creativity and thoughtfulness that you would hope for.

No, this doctor was a stubborn outlier, disregarding excellent work done by colleagues.

And then, of course, there is the disrespect inherent in the comment about the nurses. Hardly a good object lesson for the trainee.

Anonymous said...

Hmm - I'm also in the devil's advocate picture here, and while I applaud your general idea that protocols are favorable practice, I think it depends on the actual situation and need for standardization. The use of protocols is best when critical steps may be overlooked on a routine series of events, which is, alas, very typical of nursing duties (setting up a machine, starting a case, etc.) In surgery I often have a completely unexpected outcome, so while I use checklists and protocols at the start with a "time out", once the body is open checklists would become moot (other than instrument counts, etc.) which is primarily a nursing duty.

The attending may not have meant the comment with disrespect, and the duties of doctors and nurses are still quite different in the hospital. Again I agree with your general idea, but let's not take this too far. I think he was trying to say "make sure you THINK about what you are doing, don't just follow procedure/protocol," which is a valuable trait in a doctor.

Anonymous said...

As a nurse, I can tell you most emphatically that protocols are for nurses because we keep physicians out of trouble and patients safe. Within a hospital, protocols, for the most part, are not developed randomly nor implemented without thought. They have been vetted by committees, practitioners, and subject matter experts throughout all levels of leadership.

When I encounter a physician who does not follow protocols (and, for the most part these are family practice and internal medicine physicians, NOT surgeons!), I think to myself, "I need to pay special attention to this patient."

Paul Levy said...

Dear Anon 8:09,

Thanks for your thoughts. I could not give all the information about this case to protect my source; but rest assured that the matter in question was not one in which the doctor should have been basing the decision on something other than the protocol. Yes, we all understand that a surgeon in the midst of a case might have to vary his or her approach based on the condition of the patient. In that setting, a protocol or clinical pathway is a guideline that should be amended when the circumstances require.

Here, though, was a rather straight-forward procedure, of the type noted by Anon 9:23, which was thoroughly developed and vetted by this doctor's fellow clinicians. It was NOT a time to employ creativity.

Dave deBronkart said...

From Facebook:


A while ago I personally had a doc tell me, after a speech, "I want the autonomy to practice medicine as I like to. I don't want to practice out of some damned cookbook." In my view these doctors should have their licenses taken away; they are unprofessional and a public hazard - and as Paul says here, they are NOT rare.

richard lewis said...

I am an ob-gyn practicing in an extremely rural environment. The nearest other Ob-gyn is no less than 75 miles away and in one direction nearly 300 miles. The only thing keeping my patients and me safe is well established and tested protocol and procedure. Our professional organization, The American Congress of Ob and Gyn, publishes excellent guidance for nearly everything that I could run up against in my specialty. Even though I am alone here I have that to fall back on and believe me it works. On the other hand there are cowboys (real and medical) out here and the horror stories are legion. My advice? Leave your ego at home. Follow the protocols. You have nothing to prove save for how well your patients do with what those protocols suggest for care. It’s not about you, doc.

Carole said...

" I'm the patient "
So if I have a procedure done and protocol was not followed and I'm harmed as a result of it, this would be a case where owning it and saying sorry would not be enough! That being said the Doctor absolutely would go into survival mode and attempt to cover it up, and probably would succeed. The worry of a malpractice suit being filed is a joke as far as I'm concerned, as long as there's an opportunity and a way to hide the truth respecting protocols will be ignored. Our medical records are not PROTECTED!! No one can convince me otherwise.
We patients need to be nurses advocates, they do advocate for us, sometimes at a huge risk to their careers.
Laws, rules, guidelines, procedures, protocols were made to be followed, not by some but by all.

Barry Carol said...

On aspect of protocols that troubles me is the potential for them to be taken to a rigid extreme by, say, a chief of population management. It could well be that a given protocol is appropriate 95% of the time but there are a modest number of cases where doctors need the flexibility to deviate from them for valid reasons. If it’s appropriate 95% of the time, it should be followed 95% of the time, not 100% of the time.

I can envision a primary care doctor choosing to treat his younger diabetic patients more aggressively than his older diabetics when it comes to glucose and HbA1c goals because the adverse effects of diabetes are cumulative over time.

What we want to avoid, I think, is a rigid one size fits all mentality that demands following a protocol no matter what. That’s asking for trouble, in my opinion. For plain vanilla cases where the protocol is perfectly appropriate, I don’t see any reason why it shouldn’t be followed.

Mark Graban said...

I don't think "playing devil's advocate" is very interesting when it seems more like "making excuses for people."

Aren't these protocols developed by physicians? Where is the science and mutual respect toward everyone, including the nurses and the patients.

As a patient, I'll take my chances with somebody who follows protocols, as long as those protocols allow room for clinical judgment, over mavericks. Or, let's find the middle ground... not "cookbook medicine" but not the "Wild West," either.

Danny Sands said...

From Facebook:

So scary. Art vs science, and for no good reason.

nonlocal MD said...

Mark, I think your suggestion to find the middle ground is the important one. I was deliberately playing the devil's advocate here because I know there are a large number of physicians who feel that way, and this rebellion must be addressed, not just harangued. Please see my comment on Paul's following post about the neurologist's essay (when he wakes up and approves the comment, haha).

ALM said...

This case does not seem like varying for a patient with special circumstances, nor does it seem like creative experimentation. Instead the attending seems to have an implicit protocol ("I've been a doing this for over 20 years") and insists on that usual way rather than the new protocol.
Nor can the resident learn well when the attending simply dismisses the protocol as "stupid." If the protocol were ill-suited to the patient, the attending could explain, for example "normally that would be a good treatment, but this patient has kidney failure and the medication is nephrotoxic" or "that protocol is based on studies of 18-54 year-olds, but this is a pediatric patient."