Many years ago, I responded to an older woman's sudden strange behavior (on a medical unit) and told the Physicians, who were 'rounding.' 'Doreen', the chief res said, ' you are too psychologically oriented - it's all in your head.' Within five minutes the (very dignified) woman ran down the hall naked, knocked that doctor to the ground, laid on him and began gyrating suggestively. As I walked by, he yelled for me to help. I leaned over her body and looked him in the face: 'Don't worry - it's all in your head.'
I helped contain the woman; the physician admitted he deserved my quip...none of that team dismissed my observations after that. For those who wonder: her medications had triggered a salt-wasting brain tumor; saline IVs offered temporary return to herself; surgery removing the tumor was successful.
Today, nurses are most often dismissed by (young) MDs, who say 'the numbers' don't support the nurses' concerns, unaware subtle change precede 'numbers.' Early intervention is the best intervention.
19
Believe the nurse's observations and gut feelings.
They spend more time with the patients than the docs.
24
Your nurse is at your bedside. Doctor glanced by hours ago. Trust your nurse.
19
What I would like to know is how many times your "gut feelings" were wrong? Because they can't have been right all the time. In my 35 years of practicing Internal Medicine, the majority of times a nurse called me with a bad feeling, they were wrong. The patient had been at no risk of impending doom. The fact that the nurse can't articulate what their intuition tells them is what made this kind of call so infuriating. Had the nurse actually collected some data, even vital signs, I would have had some clue as to what she was concerned about. In the example of the woman with cardiac tamponade, there would have been some signs of it developing, some kind of clues.
I have found that nurses rely on anecdotal evidence very often to make judgements about what is happening to a patient. I usually heard, "I had a patient once who had the same symptoms as this patient and she had....", when in fact the current patient had nothing similar to her former patient.
I think the problem isn't that the medical staff didn't listen to the nurse's gut feeling, it's that the hospitalists don't bother examining their patients. I'm not even sure they know how to how to perform physical exams. Had these doctors done a thorough exam they may have been able to detect a pericardial effusion before it became tamponade. Doctors don't talk to their patients anymore and they don't take the time to observe them.
It's just part of the continuing decline of medical care, which is only going to get worse.
26
Shame on the doctors for not understanding that the nurses know the patients far better the they and are capable of seeing the subtle differences in the health of the patient.
Hospitals ARE getting better are giving the observations of the nurses, particularly in intensive care units.
The ethic of listening to the nurses and giving credibility to their thinking is slowly working its way through the other areas of the hospital.
If this system works as advertised, it will speed the day when the eyes of the nurse will become the day-and-night care that all patients are entitled to receive.
It can't come too soon.
13
C. F., BSN, CPNP, MPH.
As a nurse, and wife of an excellent physician, I have always maintained that Medicine (and Nursing) is an art and a science. Great physician don't just interview patients. they observe them during the interview with a practiced eye. Nurses similarly read their patients. Gut feeling comes from experience and skill. It is 'taught' by observing mentors in both the fields.
16
Such things are somewhat common in many areas, it is why real AI is nowhere in sight.
4
I've done high-risk pregnancy homecare for years. We see pregnant moms at home to check on blood pressures, do fetal monitoring, etc. We've joked for a long time about the "pajamas sign." Patients who have greeted us cheerfully, fully dressed and sitting on the couch for weeks or months are suddenly in their pajamas, unshowered, and in bed. There's nothing objectively different with symptoms or vital signs - but that momma-to-be is about to go into real labor/get hypertensive/show signs of fetal distress. I've seen it over and over, and when I send her in to the hospital to be assessed by someone who doesn't know her, occasionally she gets sent home sometimes when she shouldn't, and hours or a day later is back, and delivers early. Fortunately we work with good docs who usually do listen to our "gut feelings".
12
Ms Brown is entirely correct about the value of "gut feelings". I'm impressed there has been a move to quantify them to any degree; well done; a difficult job.
I suggest one addition to the use of the Rothman Index; a designated senior nurse who can add weight to a nurse who feels ignored and urgent. If people are listening to the duty nurse's gut; fine- if they aren't, and they should- there should be a senior person on staff whose job it is to a) know the nursing staff, and the value of their respective guts; and b) have the clout to say to the oblivious team "Wake Up!"
An added voice, when needed, would save lives.
11
It's amazing to be able to relate to this article. As a mother over the years I've very often had a "gut" feeling in regards to my daughter. And the very few times I was either talked out of acting on it, or ignored it on my own , a situation would soon follow. Now all grown up my daughter, a nurse has had situations where she instinctively knew something " was not right" , and after speaking out was not given credence and sure enough an episode took place. That intuition, whatever you want to label it should be weighed in and most of all encouraged. Experience, maturity as in the business world carries, at least in my estimation as the other results, symptoms in a diagnosis. As a patient I would welcome any help even if proven wrong at least it would be ruled out.
7
Bravo, well said! After working ten years in L&D, I taught high risk and complications of pregnancy, labor and delivery at an affiliated college of nursing with a Top Ten teaching hospital. I found some physicians were excellent, good listeners to nursing concerns re. patients. In fact, they totally depended on seasoned nurses to keep them informed of their patients progress. This often enabled them to get another period in at the hockey game...or another inning in at the ball park before they had to show up for the delivery...and believe me, we nurses had highly honed skills, a highly developed sixth sense or “gut feeling” regarding the possibility of impending disasters and provided accurate, reliable information. However, some physicians certainly were not good listeners or respectful of nurses at all.
50% of all complications during pregnancy happen during L&D, and when they happen, they happen fast, with two patients to consider, not just one. Fast thinking and critical nursing skills, are of paramount importance.
When I once questioned a L&D physician, he told me, “I’m paid to do the thinking, you just do what I tell you”. He obviously forgot or didn’t care that my license was on the line as well. Not to mention what should always be our number one concern, the patient!
When consistently short staffed, and I clearly explained how we needed another RN on the evening shift, I was always told, “just make do”....when I quit, they hired 2 RNs in my place!
12
Good doctors must be good listeners.
There is no substitute for a relationship of trust between nurse and physician. When a seasoned nurse calls me to say that there is something wrong with the way my patient looks, even if she can't put it in concrete or numerical terms, I have to get off my behind and take a very careful look at that patient. And it I can't figure it out, maybe I need a consultant to bring in another pair of eyes.
Insurance companies and state and federal agencies judge "quality of care" by having their computers review the hospital computers. The flaw is that things that are missed may not make it into any of the computers.
12
Relevant and interesting information on failure to rescue research--
“Resilient teams consistently update their understanding of a situation using interpersonal trust and respectful interaction to inquire about the characteristics of the situation and consider new data to inform their situation awareness, processes known as sensemaking. Thus, resilient teams manage what they consider to be inherently uncertain conditions by continually scanning for potential problems and working quickly to mitigate those problems as they arise, often beginning this mitigation work before they fully understand the complete nature of the problem.”
https://psnet.ahrq.gov/primers/primer/38/failure-to-rescue
My sister is alive after the birth of her twins twenty+ years ago because a nurse trusted her gut feeling in the recovery room; somehow the patient just didn't look right. The nurse took her blood pressure and found that preeclampsia had hit *after* the birth and it was a life-threatening emergency.
Thank you thank you thank you to that nurse, whoever you are out there.
11
A Rothman index is clinical data not a nurse's feeling or impression so I don't see how it addresses the issue. Also, respected nurses or paramedics or the patient or family member's ominous feelings very much alarm clinicians. As a paramedic, I paid very close attention to such things. You did have to evaluate whether your informant was alarmist and inexperienced or seemed to have poor judgement, but if not, alarm bells would certainly go off. Mds I met were equally attuned to nurses' impressions, especially if the nurse was one they knew and respected. They were aware that the nurse had much closer and closer contact than they did.
8
I've worked the last 27 1/2 years as a hospital based physician in NYC, with usually 5- 8 nights a months during that time. When a nurse tells me, "you need to see this patient", or "I think you should come", I always do.
I once sent a psychotic patient, who I had never seen before, to a psych ward because the head nurse told me he had never been like that before.
My boss, the next day, admonished me for listening to the nurse, which always surprised me that he said that.
Sometimes their concerns don't pan out, but I always listen to others who may know more about a specific patient than I do.
15
Ms. Brown's conclusion, "well-honed clinical instincts matter" is a mission-critical principle in most, if not all, human endeavors. But it is too often suppressed by an institutional priority for maintaining the authority and prestige of its big-shots.
Successful organizations tend to find ways to accommodate that powerful dynamic with subtle workarounds.
That is demonstrated by the high performance factors of the U.S. Navy which long ago established a culture where it is commonly understood that "Chiefs run the Navy." They are the top three ranks of enlisted personnel who have established their technical expertise and leadership qualifications to perfect the execution of complex operations.
Aboard a nuclear submarine, the Chief of the Boat reports directly to and advises the Commanding Officer. Like senior nurses, a Chief's performance is often a matter of life and death. The big difference is the Chief has the respect and support of his officers. Unlike many MD's, Junior Naval officers soon learn that the brass they wear and prestige they enjoy contribute nothing to the speed and buoyancy of the ship.
6
As a nurse practitioner, educator, and long time critical care nurse I understand a scientists need to quantify everything. Unfortunately there are some things that just are. In a text "From Novice to Expert" the author, Patricia Benner, describes the gut feeling as a process that new nurses obtain during their first years in their career. Some do not develop the feeling, but many others do. Most of the critical care and emergency department nurses I have worked with get, if paying attention, a hunch or feeling if something is about to happen. I have seen nurses refuse to discharge a patient from the Emergency Department when ordered to do so by a physician. Noting that 'something is just not right' they stall or outright refuse. Many times the patient suddenly has a crisis or cardiac arrest. So how to we quantify these? I don't see a way, but I am so glad we allow our most dedicated nurses to act on those feelings. We should encourage this depth of thinking and not demand the need to explain it.
10
It is not just nurses who can be prescient, although I would never discount their hunches. As a paramedic, I have had the same sense of my patient's true condition and often that perception was accurate even before final testing. In the case of medics, we see the patient in their native environment or the location where an illness or trauma occurred, which can give us a unique insight. I have more than once pegged a brain bleed or other pathophysiology before testing could be initiated.
There is one irony, however -- in my experience, it is nurses who are most likely to discount these observations from other medical licenses. Normally doctors and other clinicians are very receptive to these hunches. The fact is, everyone in the chain of treatment has experience and observational skills and, yes, intuition that can prove crucial for the best outcome for patients.
6
Over my many years as a bedside nurse, I had a number of gut feelings that had subtle but solid evidence to back them up. Most doctors took me seriously and some did not. I was not always right, but there are a number of docs out there who know I was crucial to saving the lives of their patients. As for the ones who did not listen, they just did not care. I retired with no regrets and a clear conscience that I always did everything I could for my patients.
4
Please do not try to quantify a nurses' gut feelings in the name of justifying such. I refer you to the seminal works of Carper, BA,"Fundamental Patterns of Knowing in Nursing" and Belenky, Clinchy, Goldberger, & Tarule, "Women's Ways of Knowing". The phenomenon you are describing belongs in the qualitative paradigm.
2
@Kathy R. Higgins, PhD, RN
And how do male nurses fit into that?
2
As a female pediatrician, I too had gut feelings about patients. It might LOOK to the casual observer that this was female intuition, but it wasn’t, really. For the nurse here, it was good observation. She picked up on SIGNS.
Imagine a patient who complains of a stomach ache. That’s a “SYMPTOM.” If you see his belly is distended, that’s a “SIGN.” So is his fever and elevated heart rate. If you press on his belly and he winces, that too is a sign,
Most patients getting into trouble give off subtle, but real, SIGNS. In the essay here, garbled speech is sign. A big one. What seems like gut feeling is good nursing ... or good doctoring.
A patient becomes less communicative. (Are they in pain? Is something wrong with their brain?) Their heart rate ticks up, as does their blood pressure. (The body’s making sure to get blood to the brain.) Their urine output falls. (A body in crisis shunts blood to the brain and heart ... screw the kidneys.)
The more TIME you spend with a patient, the easier it is to pick up subtle signs. TIME is a huge factor in medical care. What’s in the shortest supply today? TIME.
There’s no substitute for paying close attention. After all, a life is at stake ...
11
I've been a registered nurse for over two decades, all of it at the bedside, mostly in intensive care units. I've developed a very good feel for when there's something seriously wrong with my patients. I trust my gut feeling.
Different hospitals and doctors respond quite differently to a nurse's feeling that something is wrong. In my current job, the doctors and the nursing leadership are very willing to listen and respond appropriately to a nurse with concerns about their patient. I wish this had been the case in every job and every hospital. It has not been.
My current hospital also responds in a very remarkable way when something goes wrong. Doctors, nurses and management sit down to a serious discussion: What went wrong, why did it go wrong, what can be done to fix the problem so that is will not happen again?
I live in a very big city. I choose to drive 25 miles each way to and from work at this hospital, where nurses and their gut instincts are valued and honest serious efforts are undertaken when problems inevitably occur. It's worth driving past a dozen other hospitals on my way to and from work.
I am happy to see that someone is making some effort to scientifically validate nurses gut level feelings. I am not sure, though, that any set objective data can corroborate my instinctive feelings for when there's something wrong. And I very much fear that attempts to do so will simply lead to another page on my already massive electronic charting duties.
7
How about differentiating between CNAs, LPs and RNs. My observation has been that it is mostly the first two doing the hands-on patient care.
Just spent five hours in the ER attending a 19-year-old who's been experiencing chest pain on and off for four dang months. We've see four doctors and spent way too much money trying to figure out what on earth is wrong with him. We've had diagnoses ranging from gas to displaced ribs to anxiety to skeletal deformity, along with 24 chiropractic treatments, massage, and anti-anxiety meds. Nobody, but nobody has been able to tell us why an otherwise healthy 19-year-old cannot sit upright in a chair or get through a day without feeling pain in his chest. All of his tests - blood panel, urine, stool, x-ray, CT scan - are normal. He has a slight heart irregularity (early polarization), but nothing, just nothing else
Still, he insists it is not in his head. He insists he feels real, physical pain -- but no medication or doctor has been able to help him. MY gut tells me that it is emotional pain, but he refuses to even consider that as a possibility. I wish I were a nurse, just so he might take my gut feeling seriously. But I'm merely a mom with no medical qualifications at all, so my intuition is worth nothing to him. Can I get a nurse over here to tell him that he ought to agree to see a therapist?!
29
@Anonymou
Definitely see a therapist as the anxiety related to his chest pain does not mean "it's all in your head" but finding ways to cope with symptoms, prevention of panic attacks. This is a way to be proactive, giving one peace of mind and I would highly recommend nurse practitioner specialized in this type of situation. I have been a nurse for 39 years and tell my patients there is so much more we do not know than what we know.
9
@Anonymous
Any pediatric nurse will tell you to always listen to a mother's concerns. The mother knows their child the best. If a mother senses something is wrong, any experienced nurse will listen and alert the healthcare team.
13
Has he seen a cardiologist? A pulmonologist? A gastroenterologist? A psychiatrist? He’ll need to see all of them to get this figured out. It’s always a mistake to blame mental health problems for physical symptoms until all relevant specialists have ruled out physical causes.
If his chest pain was from anxiety, the benzodiazepines should have reduced that symptom.
2
I’ve had these feelings several times throughout my nursing career. I had feelings of concern where I was more vigilant and checked a little more often on a patient but didn’t raise alarms. It was usually because of some objective number or result. Then there were times of nagging unease and a sense of urgency that I couldn’t put a finger on because there wasn’t anything objective for the basis of my concern. It was this feeling I learned to never ignore and I can’t remember a time it was inaccurate.
58
Nurses have given us crucial advice many times in the 20 years since our severely disabled daughter was born. Their advice sometimes conflicted with the doctors' advice but I can't think of one incident when they were wrong. Sometimes nurses helped us avoid unnecessary intervention when doctors were being too aggressive. Our newborn daughter was about to be sent home with a breathing monitor. The nurses who were tending her thought it was unnecessary. They could see that even though the monitor indicated otherwise, she was fine.They said that if we brought the monitor home it would beep frequently and we would be be up all night checking her and worrying. We said no to the doctors. Our baby was fine. We love nurses.
41
AS a physician I see the ultimate irony here which is "my experience based judgment and hunches are valid but yours are not" attitude many of my peers may have. The "informal" training I received in Residency and Fellowship was that taking cues from nursing staff was both efficient and wise. We Physicians use similar anecdotal and "sensing" every day. The only difference is that since we make the calls on interventions, we trust our judgment but are less likely to take "subjective" advice from others. The truth is that when it comes to diagnosis, hunches from nurses should always be taken seriously and followed up with objective testing. That is because we are dealing with an individual patient's data. Ironically, when it comes to therapeutic options, Physicians are happy to use "anecdotal" evidence in the selection of treatment modalities on the basis that in their experience, drug x or procedure y is what they are comfortable with irrespective of the scientific evidence available. Together, such arrogance undermines the team-based approach to patient care AND the quality of care provided.
81
I practiced Nursing for 45 years and YES, that "gut feeling" is alive and well and always has been. It is not newbie-jeebie stuff is is a human connection that relies not on anything provable (at the time) but a sense that this other human is experiencing something that is not right. It is a sensitivity to another being. It is not unique to women as many of the males I worked with also had the same deep sense of impending problems that could not be identified by labs, MRIs, x-rays or other tests. We were almost always correct. I worked in a place that had many NP's and they listened well to us when we raised the "gut feeling". Some of the MDs did as well but then we always had those who poo-pooed anything we told them relying only on labs and other tests. Rothman Index or not, there will always be the guiding gut, it is what makes some of us Nurses. I have to comment that I am so glad Ms. Brown writes about elderly who are afforded life saving/sustaining treatment. Even some one with a "No Code" order deserves treatment for problems that while not life saving can be treatments that keep them comfortable. I have read one of her books and will read more.
4
Our son was a premie, and spent six weeks in the neonatal intensive care unit. Every day when the neonatologist made rounds, she would go from baby to baby and ask the nurses, tell me about the baby. I asked her about that one day, and she said that these nurses had worked neonatal for many years, over a decade in the case of the newest nurse in the unit, and they had developed a very finely honed awareness of how the babies were doing. She said they spotted things long before the tests and measurements would. A wise doctor.
14
Theresa Brown is not only an exceptional and experienced nurse who has a complete and varied background, but she is a nourishing and informative writer, which Times readers have known for many years.
Yet it takes both of these skills, combined with not a little humility to articulate what is not so easy to simplify. A commenter, Ricardo from Baltimore, who identifies himself as a physician…I say, with tunnel vision…explains that Theresa Brown is merely recounting anecdotal information, not the result of a 360 degree exercise of professional competence, and the Rothman Index is an indicator of what every physician knows…but all to often is too busy, or overscheduled or egocentric…but fails to acknowledge or order appropriate treatment.
These failures to act should be regarded as malpractice. Too often, they are not. Some treatment is applied, the patient is shipped out and dies.
In fact, as perhaps at least some patients have experienced, where there are competing diagnoses, one is considered more pertinent, but when that proves not so important, the other problems are not always addressed. Maybe the patient will recover sufficiently to complain again and even demand to see a specialist, again, and will have at least one of the remaining diagnoses treated, successfully. But the original erring physician will never be called to account for an incorrect decision because, at least he or she tried.
How pathetic for one who holds a life's quality in balance.
5
I hate the hostile, nurses-versus-doctors narrative. It has some truth, but misses far bigger aspects - like the relentless pressures of for-profit health care to limit time spent on actual patient care.
And why the sexist use use of pronouns - “she” for nurse and “he” for doctor?
Ricardo Ismach, MD, MPH
VA Portland
OHSU
Casual Dog Productions
10
@Ricardo Ismach
I agree with you on all points. Nurses "gestalt"is valuable, but it is just one piece of soft evidence. We, as physicians, must gather all of the piece of evidence, soft and hard, and make the difficult decisions about what, if any, interventions are appropriate for that individual patient.
2
Years back (about 1973 when I started medical school) a patient's medical chart would contain a section called Nurse's Progress Notes.
I noticed physicians who impressed me with their care virtually ALWAYS read those notes on their patients.
The physicians who didn't were, as I remember, the "my way or the highway!" type, and with whom you never shared your questions, doubts, or "gut feelings."
Nowadays, a nurse confiding any worrisome information with patients' families is more likely to be called in by HR...
8
As an MD, I find the observations of an experienced nurse invaluable. If someone "looks funny", I take that very seriously!
6
Lemme see if I get this clinical anecdote straight.
A patient had been admitted with a disease that "put her at risk for spontaneous bleeding, but at the start of her third day in the hospital a treatment plan still wasn’t in place". Ms. Brown had a "nagging sense" that "we were moving too slowly". The medical team didn't share her "sense of urgency" and the patient "died the next day".
Based on a ? for-profit company's modestly validated index, "There’s now solid evidence that when a nurse says she’s got a bad feeling about a patient, the entire care team needs to listen."
How is this "I told you so" clinical anecdote helpful or even remotely related to the Rothman Index?
5
We, NPs MDs PAs Staff nurses must revisit and improve our assessment skills . The cardiac tamponade may have been picked up with that stethoscope we wear around our necks. Notes too often are chronically copied and pasted in the hospital. A recent patient’s serious murmur was never documented as each note said the same thing no murmur. Nurses keep speaking up . Advanced Practice Providers and MDs we all need to do a better job with our eyes ears and our hands. The best tools we have. MBeck DNP RN GNP
8
Dr. Judith Effken wrote on this topic years ago. It is the expert (science) and caring (art) in nursing that evidences intuition in nursing care.
https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1365-2648.2001.01751.x
1
As a repeat patient several times over I have come to hold the nursing profession in the highest regard and respect. This is not to demean doctors.
Doctors keep the fuel injection, driveshaft and transmission systems functioning but the equally important, if not more so, jobs of gassing up, oil changing and tire inflation fall, minute-to-minute, to nurses.
Plus, nurses have unparalleled human interactive instincts and are typically fun to be with. Whenever I hear the word "nurse," I immediately associate the word "hero."
6
I am not a nurse; I am an occupational therapist with a PhD. I have worked in health care for over 30 years.
There's more here than quantfying a nurse's gut feeling. There is also the communication that goes on in a health care team.
Many of the safer hospitals utilize TeamSTEPPS ( https://www.ahrq.gov/teamstepps/index.html ) a set of communication and safety tools to ensure that no one member of a treatment team ignores the gut feeling of one of the members. If everyone agreed to follow up on the intuition of this nurse, the outcome may have been different. Who knows.
2
Gut instincts can be good, but it is unlikely that they are as good as we think they are because we suffer from confirmation bias. Harvard Business Review has a good article on this. https://hbr.org/2010/05/your-gut-is-overrated-really
2
This also can apply to technicians. From the beginning of my pregnancy I had sharp, intense pain on my right side every time I ate. I don’t have a gallbladder, so it wasn’t that. I was sent for an ultrasound and the technician closed the door and said, “They are going to tell you the scan shows nothing, but woman to woman, something is clearly wrong. Don’t give up.” There was something wrong that wasn’t diagnosed until one week before she was born. But the technician’s woman to woman talk gave me the assurance that I wasn’t just being a crazy pregnant woman.
6
As a newer nurse in the 80s, I felt a combination of guilt and bravado over my nursing"gut". Guilt because I didn't think I was applying science; bravado because I was usually correct. Through education, experience, and mentorship, I learned that I was using science all along. If only a nurse had developed such a brilliant tool--but would it have been medically accepted if it were?
5
The one thing missing here is an argument that the "Rothman Index" indicators should include subjective hunch-style data gathered at regular intervals -- it's an interesting idea but is it happening? Should it?
This column is great because it presents both a problem and a solution.
The problem is that health care professionals sometimes say after a bad event: "I had a vivid premonitory dream that this thing would happen!".
The solution is to write down the dreams in advance and measure them.
(1) What percentage of the time do you think "something's not right" and indeed something was wrong?
(2) What percentage of the time do you think "something's not right" and everything was okay?
(3) What percentage of the time do you think "everything feels ok" but in fact something was wrong?
(4) What percentage of the time do you think "everything feels ok" and everything was okay?
If you can prove with data that these hunches offer useful predictive power then by all means please use them. If the data show that these hunches distract you from hard-to-see problems that could be detected another way, maybe focus on that detection instead.
3
As pointed out by @glorynine, these anecdotes are colored by huge recall bias. Where are the tales of the patient who looked great and coded, or the patient who looked terrible and did fine without a lot of fuss? Really, this is so silly, as is the implication that somehow only nurses have clinical intuition (i.e., not physicians, who are evidently hide-bound, non-intuitive, stuck with book learnin', and devalue nurses--none of which reflects the reality that I have experienced in a long career as a physician). As far as the Rothman index, I suppose it is nice to have a reminder of what every clinician already knows are important features of a patient's status. It would be a miracle if the elements of this index didn't correlate with outcome; this is not exactly a breakthrough.
5
I taught students going into 7 health professions as well as medical students, for more than 30 years. My areas were psychology, social science, and ethics, with some courses specially tailored to students in health care.
In general, nursing students were very smart, sensitive to others, and empathetic. There were very few exceptions, but when you taught one who had none of these qualities, it was scary. Fortunately, most of those flamed out or were dismissed before getting to the point they could do serious damage.
As a group, in or outsides the classroom, nursing students appeared highly conscientious, whatever the assignment or task, and I saw them take personal responsibility and exercise diplomacy in a number of times in sometimes difficult situations.
They know they must be diplomatic when questioning physicians, esp. some MDs, but they do not back down or turn their back, which is a gift to their patients, as comments here testify.
These observations were more than confirmed when I was treated for cancer for 2 years at the academic medical center where I taught--oncology nurses, night nurses, nurse practitioners.
For years Gallup's annual poll shows nurses have been ranked consistently as the profession that is viewed the highest in honesty and ethical standards.
In the 2017 poll, 82% rated nurses as very high or high in ethics. Only 11% rated Members of Congress as high or very high.
https://news.gallup.com/poll/1654/honesty-ethics-professions.aspx
5
There are so many aspects to nursing care, even nurses sometimes have difficulty describing exactly what they do. While the activities include everything from the basic hygiene to making complex, life & death judgement calls, the most important care activity in an acute care setting is monitoring the patient. This entails collecting and analyzing patient data, interpreting signs and symptoms to determine if the person is following the expected trajectory, knowing the appropriate response for that change and taking the necessary action. And yes, some of those signs can be subtle. But the nurse is reacting to something he/she is observing in that patient. While it may or may not turn out to be significant, it should never be ignored.
1
This is a great article. As a former nurse, I had many such encounters. You learn to observe and touch the patient to pick up early clues. In a busy ICU, there is lots of activity and noise that cause distraction. It takes strength to advocate for your patient. It was also the best thing I have ever done in my life. Cheers to all the great nurses out there.
10
In a sense, the article is "re-inventing the wheel" in terms of clinical management. Intuition has always been a keystone of medical and nursing care and probably out-distances "logic". And it does not need to be "quantified" to be germane. None of us are as rational as we think we are. "Patterns" and "suspicions" inform much health practice and have always done so. As artificial intelligence plays an increasing role in care, one hopes there will be software that allows our computer colleagues to stammer out "you know, this reminds me a lot of a case I saw years ago in training-- perhaps we should get a .."
6
Nurses are seen as inferior to attending physicins but it is the nurse who is physically with the patients over long shifts and countless crisis. The physician makes quick rounds; sometimes every other day and has Physician Assistants who document by pull-down electronic data in an EMR (Electronic Medical Record). Once rounds are completed it is off to the office and then on to the golf course, the gym, dinner out with spouse and or seasonal coctail parties and all the while may or may not be available in crisis by phone which is frequently answered by the prasctice's on-call who knows nothing about the patient. Apparently in our convulated and pricey health care delivery system what may be best for the patient is totally ignored. Afterall the doc gets paid for intervention while the nurse receives an hourly salry devided over 8 or more patients.
5
Ms. Brown's comments are fascinating in as much as they seem so dated. For years, virtually every Hospital in the country have had teams that have responded urgently to among other things, a "worried nurse"; these teams come to a patients bedside and evaluate the "objective data" and the patients clinical condition in person. Unfortunately, sometimes things are still missed or overlooked and a remarkable computer algorithm like the Rothman index can be of assistance. It is disingenuous, to say the least, of Ms. Brown to trumpet this technology as an I-told-you-so to Doctors. In modern medicine, the goal is team building and collaboration and attitudes like Ms. Brown's are no more constructive than a male, or female, Doctor who is disrespectful of a Nurses clinical opinion.
5
@Chris Clark
I worked in nursing 35 years. She is telling the truth, plain and simple.
3
Unfortunately I do not see this improving anytime soon.
Most hospitals and emergency rooms are severely understaffed.
And nurses are spending too much time on the computer and not enough time with the patients, as Hospital Administrators think that the better use of a nurse is typing notes.
In addition, most doctors are notoriously arrogant in their treatment of nurses, in addition to the patients. I have had first hand experience with this, several times. I have had to intervene on behalf of family members and friends who had no family to advocate for them.
Until the Health Care industry is brought to its knees with more regulation of how many patients a nurse can safely handle in order to give quality care to patients, it will continue.
Also, the Insurance Industry needs to be better regulated. All they care about is the bottom line, not patient care.
When will hospitals, the Insurance industry, State and Federal Governments get their priorities straight?
12
This article conflates several issues.
Every experienced MD knows to ask the patient's primary floor or ICU nurse for their input. Or to come running when a nurse calls to say something is "off". And yes, everyone on inpatient care teams makes a huge contribution and all inputs are important. But it strikes me as naive to think that "gut feelings" from bedside assessments can be crystallized in a single composite score.
Most of the modest literature on the Rothman Index is in second-to-third rate journals; as such, they aren't available through my med schools's library. Most of the papers are in the Orthopedic literature, for very well-defined procedures (versus say, "shock"); for a number of reasons, tremendous effort is expended by hospital systems to specifically improve outcomes on Orthopedic procedures. With the caveat that I can only read the abstracts, I can't find any prospective trial that proves that using the Rothman Index improves Ortho or other outcomes. And I wonder, how much more input into the EHR by RNs is involved in this index? More clicks and more typing isn't good.
I'm sure that PeraHealth is ecstatic that their index is the subject of an opinion piece in the NYT; this is great PR for them. Just as they and Ms. Brown tout that Yale New Haven - not exactly a high volume center - uses the index. But meh, it strikes me as yet another button on the EHR that will be ignored by experienced providers who rely more on bedside evaluations.....
6
@Limo Wreck
Every experienced MD knows to ask the patient's primary floor or ICU nurse for their input. Or to come running when a nurse calls to say something is "off".
Limo Wreck, I am approaching the 30 year mark in my nursing career. All of it spent at the bedside, mostly in critical care. How I wish, Limo, that the above statement were true. It is not. Replace the word "experienced" with "really good" and you might have a shot at it.
If I had a dollar for every time an "experienced MD" made rounds on a patient without speaking a single word to the bedside nurse, I'd be retired now.
6
Documentation seems the mainstay of nursing time - not training. My observations on a three day stay in hospital. I fell on the street yet no one cleaned the dirt and gravel: I did not eat for 12 hours because the doctor’s instructions were not time coded, my treatment focused on a fracture not the infected hand abrasion that I treated later at home, the tetanus shot was never administered, the walker was the wrong height, the male nurse did not know how to assemble the trapeze on the bed, This was a highly rated hospital more intent on prescribing half a dozen medications, including an opioid, prescriptions I never filled or needed. The nursing staff was kind and considerate but clearly had little input in my basic care.
7
Kudos to these brothers! I have a close friend who was an RN at a nursing home. Early one evening, one of the residents looked "off" enough for her to ask permission to send the patient to the hospital. The responsible doctor did not agree. Two hours later the patient seemed worse and my friend spent the next 40 minutes in a verbal wrestling match trying to get the doctor's OK for an admittance, which was finally granted. Later that night the patient died. Of course, the blame for that had to be laid at someone's door, and it was my friend who got the pink slip for, "not arguing forcefully enough for the patient."
12
I wish in the field of education, we would return to the days when teachers were able to experiment with different pedagogical strategies in response to a feeling that students were not getting it. In today's data driven classrooms, teachers, like the medical profession, are spending too much time staring at computer screens with all kinds of test "data," and little time actually talking to students, reading their papers, and making those adjustments in lessons that align with these minute by minute interactions with students. Not in today's classrooms, where reams of data and programmed responses overrule the intuitive feel for whether a lesson is working or not.
8
Many of the comments state " the judgement and gut feelings of nurses" and "experienced nurses". When that experience is diminished by retirements and nurses leaving due to frustration, care is diminished. I recall a patient, admitted with uncontrolled atrial fibrillation. A treatable and fairly common problem. He was started on one anti arrhythmic medication after another on the same day. One of my colleagues walked by his room and looked in (never entering the room). She then went to the patient's nurse and said "I would keep a very close eye on him. He looks dreadful." The man coded and died an hour later. The lesson; you won't get that kind of insight to recognize "dreadful" even in passing without experiencing "dreadful" many times. When hospitals started following the business model, they viewed nurses as interchangeable, and did not try and keep experience because they could get a replacement for a lot less money (and every hospital will say "We don't do that here", but they do), they made the calculation that other aspects of treatment could make up for that experience. Another example: if your loved one "crashes and burns" in the regular part of the hospital, look at the chart. There will undoubtedly be no documentation of what led up to the transfer to ICU. I can't tell you how often my colleagues and I said to the nurse calling "report"... "Just bring the patient over, we will figure it out here." The question becomes who is going to figure it out?
14
@Walking Math Thank you for bringing up such an important aspect of how patient care is suffering with the way hospitals are currently run. I'm 7 years into my nursing career and am finally beginning to feel like I've got a solid amount of experience to make me feel confident in most situations. At the beginning of the summer my hospital started offering to buy out the contracts of the longer term nurses on each floor. The want to replace the experienced nurses with younger cheaper nurses. This financially motivated brain drain is such a loss to our ability to provide care--I learn something new every day from my fellow nurses, but especially the ones who've 'seen it all'. And in the end it will be the patients who suffer the most.
4
I am a cardiac surgeon in practice for 28 years. There is very little patient care data that I value more than the observations of the bedside nurse. There is little that I value less than the majority of what we are all forced to document in the EMR. With the emergence of guidelines and evidenced based care it feels like clinical judgement is being “regulated” out of medicine. We are being incentivized to all think the same way. Clearly there is tremendous value to guidelines and iliminating expensive and unjustified variation in care. But - few patients fit neatly into guidelines. I applaud the author for calling attention to the value of observation, experience and judgement. It is also a reminder of why we all went into health care in the first place.
30
Does the Rothman Index create another piece of documentation for nurses? Documentation takes so much time away from the bedside!
9
For people who work in the judgment and decision making field, one of the more important statements in this article is that gut feelings aren't " feelings at all -- they are agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment."
Ms. Brown is referring to intuition that is built much like she says. I've never seen it expressed better.
We call them "gut" feelings because they are largely inaccessible to analysis. We can't break them down just like we can't return a cake into flour, eggs, sugar, and other ingredients. As Ms. Brown indicates, observations and experience are the ingredients that later become intuitive judgments. But there is (up to now) no way to dissect the judgments to find the observations and experience, that is, to test their validity through analysis.
Such judgments can be wrong for different reasons, including an array of cognitive biases. But it is unwise to ignore the intuitive judgments of seasoned experts in favor solely of quantifiable and articulable measurements. Ms. Brown's argument has broad application to every field in which knowledge is the basis of action.
17
With todays so called organizational procedures, it seems when you end up in a hospital, your slotted into a set of standard drill as I would call it. Gone are the days when your local GP, would spend a day visiting his or her patient, in the Hospital, the professional who knows their patient best. As in where are those records ? Dr.'s amaze me, how their profession accepts the norm, how over worked they are . Any wonder the nurse is so key in all of this.
7
What most nurses know is that the body has very subtle ways to compensate for a deteriorating body function. For example, lab tests do not pick up on occult blood loss until the hematocrit (percent red cells in a volume of blood) has been sufficiently diluted by the plasma to be considered 'low.' In fact, decreased effort tolerance, a rapid small weight gain (1 pound of water retention in 24 hours), and increased heart rate, often precede the drop in hematocrit. To note this, you have to watch and TALK TO the patient. I could give many examples of subtle changes in functional measures that precede detectable changes in lab values and Xrays. Nurses know how to zero in on subtle changes in functional status--and know some physiological measure is about to change.....
21
There are several types of early warning systems. It appears that the Rothman Index is better than one of the other more common ones (MEWS): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4321057/ ("Measuring the modified early warning score and the Rothman Index: Advantages of utilizing the electronic medical record in an early warning system," published online Dec 2013).
On the other hand, it is important to recognize that subjective experience does not consistently equate with judgement accuracy: https://www.ncbi.nlm.nih.gov/pubmed/19739881 ("Conditions for intuitive expertise: a failure to disagree," by Kahneman and Klein, Sept 2009).
I am reminded of Richard Feynman's oft-quoted comment: "The first principle is that you must not fool yourself, and you are the easiest person to fool."
4
@JSK I'm surprised this is the only reference to Gary Klein's work in either the article or comments. He wrote a great series of articles for psychology today on the subject. They're worth reading if anyone is interested beyond the content of this article.
Teachers also use “gut feelings” to identify learning or emotional issues with students. Years in the classroom, watching and learning and accumulating understanding about young humans, makes teachers able to identify when “something” is going on with a student. Alerting clinical staff, getting testing done, is how to help the humans learn strategies to overcome those issues: data to back up the gut feeling.
13
In ICU we got to know the physicians very well and they would trust your gut instincts. Often I was aware that a patient was in trouble and could not quantify it. My gut never failed me. Years of experience give you the ability and sensitivity to note slight changes that mean the patient is failing.
23
I wonder how many "gut feelings" were NOT followed by any problem with the patient. This is recall bias. We don't remember the false positives.
20
@glorynine
You are right, we do miss. And I don't know that anyone really forgets the burning embarrassment you felt when your gut feeling made you call the doc in to see a patient who turned out to be just fine. It's amazing how a brief withering stare can be etched into one's memory forever!
But I can live with the embarrassment of making a big deal over nothing. It's the times when I should have been louder that haunt you.
4
I’m just wondering why on the 3rd day there’s was still no treatment plan in place. Isn’t it that RNs initiate the first care plan on admission?
Nurses cannot do anything the doc hadn’t ordered. Some docs feel threatened if someone else questions the treatment they ordered, or in some cases non-treatment.
11
Nursing care plans are not ordered by physicians. They cover things that relate to supporting the patient’s well-being well beyond the doctor’s orders.
4
@Fernand I think she meant a medical plan of care, not a nursing care plan.
I regret my patient died and no Doctor's listened to my concern. He was 71 years old intubated at home due to acute respiratory failure. The next morning he was extubated off the ventilator. His labs xray ABG were all normal and he looked ok. His Doctors cleared him for transfer out of ICU that morning. I held on to him because i was concerned I knew something was not right. His breathing was not right at times and he still did not have an echo complete. At 4pm my Manager questioned why he was still there and I had the Doctor examine him again and i explained my concerns. All his vital signs were ok. My Manger told me it was not my decision to make and move him NOW out of ICU. 1 hour later I heard code Blue on the Telemetry unit and sure enough it was my patient who was found unresponsive and he expired!
I was so upset for my patient and his family and so disappointed that i wasn't heard! I've worked in Critical Care for over 25 years but soon after I left that job!
That Manager was well aware of what happened but never acknowledged her error, the Doctor was in shock and did apologize that he didn't listen to my concern. It's the very subtle changes that the Nurse sees and we should be heard!
34
The difference is nurses see the patients throughout their shift while doctors zip in for 30 seconds and leave. This is trend analysis. No big mystery, it’s used in aircraft maintenance and is the best indicator of the health of a complex system.
Why is it that methods that are well known and widely used in many industries are unknown in medicine? I suspect a lot of the problems in the medical industry can be traced to doctor hubris.
25
“Gut instinct” is not a good indicator... but trend analysis has a more scientific basis (and should be possible to demonstrate to a doctor). Yes, doctors don’t always listen when they should, but then they are also under pressure to clear up resources for new cases. How many times were they right when you wanted to keep someone in? Confirmation bias is a tricky thing to identify in ourselves. Generalizations are not always helpful.
6
I'm an MD with 30 years experience attending in both community and academic hospitals. A big part of my job as a clinical chief is representing my department in "Patient Safety" and "M&M" reviews. I am also a busy malpractice witness. I spend a lot effort determining whether avoidable errors have occurred, using chart review and - when available - interviewing providers.
One thing I've learned is that many, many other providers think that they understand my sub-specialty enough to opine with authority when a mistake "clearly occurred". The reality is a lot more granular and they are usually wrong. A junior faculty recently remarked to me that to me that "everything seemed a lot more obvious when I was a fellow and an attending made the decisions".
Ms. Brown doesn't give details here, but let's say that her patient had acute promyelocytic leukemia (APL), which is prone to a severe coagulopathy before or after treatment. I may think that I know enough to criticize management of APL, but ultimately I'm not a hematologist. Were I to criticize the management of a patient with APL I'd likely be exhibiting the Dunning-Kruger effect - I know a dangerously small amount about APL, enough to have an opinion but not enough to have an accurate one....
I question whether Ms. Brown's "gut feeling" that something was preventable in her patient's case is an example of the Dunning-Kruger effect in action, rather than an outcome that the Rothman Index might have prevented....
19
It's precisely this tendency to compartmentalize medicine that causes so many problems.
Gone are the days of a caring GP/Primary that had a relationship with the patient. That, if I can claim it exists at all, falls to nurses due to them having spent enough time with the patient to pick-up on deviations from the norm.
Shuffling complicated patients from one walled-in specialty to the next, attempting symptom management, isn't working well for the many that suffer from idiopathic ailments.
This isn't Dunning-Kruger. This is a nurse that has enough training and direct experience with a patient to see that something is wrong. Your response, erroneous ellipsis and all, is an attempt to shove everyone back into their compartments, absolving doctors of accountability and putting a nurse in her place.
Anyone that has spent any time in a hospital setting knows this is tradition.
25
I had a different read on the article than you. What I understood from the article wasn't that the nurse had a "gut feeling" that something was preventable, but rather that something was wrong. As I read it, in her piece, the author is arguing the the observations and experience of a nurse should be used by the physician as a tool to support the treatment of the patient, not be dismissed as irrelevant. It may not change the outcome, but why not use all available tools? How many doctors subject patients to expensive, painful and ultimately useless operations, tests and medications based on their belief that there is "a slight chance" that it would have a positive outcome? The patient deserves the choice to take that chance. Why deny them this chance?
10
@Limo Wreck
Where is your compassion and caring for both the patient and the nurse. If I were a nurse you would be the last doctor I would want to work with.
1
Does your facility have a rapid response team? Different than a code team. A team of MDs, RNs, RTs and pharmacists who will respond to your "gut feeling" when you believe that the primary care team is not acting with enough urgency. They will assess the patient and make recommendations. No questions asked if the patient is ok, no blame, no charges, no repercussions. These teams are highly effective in hospitals and definitely save more lives than a code team.
40
In my daily experience as a physician, nurses have been removed from their core mission of engaging with and advocating for patients. There is no opportunity for gut feelings and human connection because nurses are busy clicking and entering mindless information.
31
Despite this this a well articulated article, the title is misleading. Nurses do not have a 'gut feeling,' especially well-trained and experienced ones.
To named this experience and training as a 'gut-feeling' diminishes the great work of nurses and healthcare workers perform around the world. Despite the nurses are not trained to diagnose patients, their training is rightfully directed at assessing the status of a patient, independently of the cause.
The Rothman Index appears well-constructed (being commercial the calculations are not open), and it is based somewhat on the experience of well-meant, well-trained, and experienced nurses on the care of patients. There are several other Early Warning Systems around based on nursing data.
Hopefully more people would be inclined to enter nursing based on the content of this article.
MD
6
Deja vu! I was fortunate that a physician listened to my concerns, and appropriate medical care was given.
8
As a nurse for 39 years, I find most physicians are very open to our assessments and recommendations. Some of this is related to the documentation and potential legal issues when we document why we called and the physicians response to our concerns.
Electronic Medical Records are now a double egded sword as nurse's are NOT at the bedside as much as they must be. Patients are so much sicker when they are admitted to the hospital, your primary physician brings in so many consultants and patients are lost in a system trying to get them out of the hospital as soon as possible. This too is a double egded sword as facts show longer hospital stays increase risks of infection, debilitation and "Post Hospital Syndrome".
We need to empower nurses to speak up, go up the chain of command while knowing we all all partner with the goal of making patients better. Health care is just awakening to the fact that we are an industry, serving the public and have an obligation to respond and answer to those we serve. Over the past 39 years, I have witnessed a tremendous collaboration with physicians and other professional peers as the "titles" and "degrees" are not viewed as leading to the best outcomes for patients, family, community and our organizations.
16
As a patient a nurse recently commented on a slight abnormality she found with a simple test; this abnormality could explain the majority of my symptoms.
Yet when I brought it up to the physician (who had been highly recommended as a researcher, but just began her practice) who examined me during that visit, she dismissed it just as she dismissed all of my symptoms.
That was the first and last time I will see her
25
Even even when an experienced pathologist with the tissue at the microscopic level makes a diagnostic decision, the tougher ones are the product of instinct or an intuitive leap of faith. People cross this bridge, when it is done truthfully and knowledgeably with their instincts. That is true of the poet, the scientist, the journalist, the humorist, the essayist, the novelist, the physician, the attorney, the editor, the CEO and the nurse. On the other hand the corporate board is effective because in the crossfire of group debate subconscious biases are minimized. Ideally that nurse should meet with several caregivers including intuitive physicians to catch problems early. Personally, I have never seen software make an intuitive leap. Nonetheless I am open to that kind of artificial intelligence.
3
As a veterinarian, I learned long ago that you miss more by not looking than not knowing. Good practitioners observe. A lot.
56
@MTP: BINGO! You've hit the nail on the head.
1
One of the nursing profession’s greatest advantages and obligations is that the RN, PA, Nursing Assistant or other title has hands- and eyes-on patient contact over the course of each tour and will notice changes in the patient’s condition well before the Medical Students, Interns, Residents or Attendings show up again. This is especially – and critically - true in the extended care milieu where MDs may not see the patient every day.
My thoughts are based on experience of decades as a hospital administrator, an operational and management auditor and consultant in the domestic and international hospital and healthcare fields and, perhaps most tellingly, as a patient.
7
Interesting that the comments focus on nurses. My takeaway is quite different.
We have spent a large fortune on EMR - Electronic Medical Records, but no real use is made of them. Yes, they may (or may not - if printed) save paper, and they may make the data more readily available, but that should not be their primary benefit.
If the data in medical records is useful to a physician or nurse, then is should be possible for the computer to be programmed (as it has with the Rothman Index) to recognize trends that are not obvious to clinicians. And again, if data are useful to clinicians, then computers, as masters of data manipulation rather than merely storage, can be great aides in diagnosis.
I submit that is the true benefit of electronic medical records. All else is commentary.
Watson, let the programming begin.
15
I trust humans over computers any day. Software is created by non clinical humans. There is always a bug.
4
It is observation, experience, assessment, taking time with the patient, asking the question and listening, that results in those "gut feelings" alerting us something is wrong. Not sure that the advertisement and promotion of the Rothman Index can replace that. The art of just being with the patient has been lost and has been replaced with the skill of how many patients can you see in a day and sometimes with the unnecessary ordering of labs and imaging studies just because there is not enough time to be spent at the bedside. I heard a doctor said the other day, "I do not do physical assessment, that is what imaging does for me." End of story.
20
Lets compound this problem. I use a VA hospital in Manhattan that is staffed by residents. These residents are forced labor not serving in their area of expertise but just doing a rotation. Some are very good some are very disinterested. Our nurses are beyond the best and are obviously frustration by the lack of experience by the residents. The supervising doctors are invisible and never show up.
It is all about money. If i had a nickel for every time I heard that my labs were good and then I got worse I would be a rich Veteran.
24
When a nurse calls me about a patient I listen! They are the ones at the bedside and with a lot more contact with the patients to see subtle changes. However both examples in this article are a bit unrealistic. The first person has a blood cancer that can cause bleeding. There may have been things that could have been done but some of these leukemia’s cannot be controlled. The other example is an 87 year old patient. Yes the patient was seen 4 days before and she was stable. How do you predict all that could happen to a patient? Do a CT, MRI, echocardiogram for all patients who have some kind of malady?
17
@Jaime you are right it might cost money to help a patient.
2
As a neonatologist, I absolutely confirm that a nurse’s experience and gut feelings are invaluable. They’re at the bedside constantly and are aware of the slightest change. For the best patient care we need to work as a team and the RN needs to be treated as a valuable team member. Thank you Nurses, for all that you do.
77
I just had this experience as a patient. A 20-year experience nurse will be always more knowledgeable than a resident or fresh doctor. Education is good, but the experience counts a lot in health care.
During my wife's delivery the most knowledgeable help to pass through a difficult delivery came from a nurse. Unfortunately, hospital hierarchy did not allow her to be heard, and we end up having a very complicated delivery and horrible experience.
This should be managed with a lot of care, - its health care - but currently doctors are mini celebrities and nurses not allowed to speak up.
24
@S Ferreira
Bravo, well said! I worked in L&D for 10 years, as a staff nurse/assistant head nurse...and later taught high risk and complications of pregnancy, labor and delivery for 10 years at a college of nursing.
During my years in the field, I found some physicians were excellent, good listeners to nursing concerns re. our pts. In fact, they totally depended on seasoned nurses to keep them informed of their patients progress. This often enabled them to get another period in at the hockey game...or another inning in at the ball park before they had to show up for the delivery.....However, some physicians certainly were not good listeners or respectful of nurses at all.
50% of all complications during pregnancy happen during L&D, and when they happen, they happen fast, with two patients to consider, not just one. Fast thinking and critical nursing skills, are of paramount importance. When I once questioned a L&D physician, he told me, “I’m paid to do the thinking, you just do what I tell you”. He obviously forgot or didn’t care that my license was on the line as well. Not to mention our number one concern, the patient! When consistently short staffed, and I explained how we needed another RN on the evening shift, I was always told, “just make do”....when I quit, they hired 2 RNs in my place.
3
I can relate so much to this story. As a nurse I too had these experiences. It was the unwillingness of doctors at the time to believe my gut feelings. Several patients that I had identified as “something “ wrong died or had strokes. Happy someone is listening.
17
I became a Nurse Practitioner so I would be able to use my nursing knowledge and experience (23 yrs, critical care, home care, public health, ER, etc...) along with the ability to make more diagnostic and treatment decisions. Best of both worlds for my patients and myself.
24
@Kristan Thompson
You are so right as I have been a nurse for 39 years and have found our bedside experience is worth in ways that can not be measured.
6
If the hair on the back of your neck stands up - pay attention. Something's going on; whether or not you know exactly what that is, is irrelevant for the moment. Pay very close attention and follow through. Place your professional experience and your integrity before the egos and feelings of the medical staff. That said, if you as a nurse (or any other non-Attending title) feel that you lack sufficient years of experience, go to the charge nurse or your supervisor and lay out your case logically and convincingly. If necessary, present your concerns in writing. “If it isn’t in writing, it didn’t happen.” In today’s world, documentation is everything.
A major question concerning the Rothman Index is whether or not insurance will pay for the time, expense and expertise required to properly evaluate the data and the expense of the necessary treatment course. The concept of intervention before a crisis hits is well known and has been proven over the centuries in professions as diverse as medicine, the military, diplomacy and plumbing. The fact of insurance requiring pre-approval to determine whether or not intervention is allowable is also well known and has been proven over the recent years at the cost of many lives. Don’t be cowed. This article gives you understanding enough to realize that you don’t want to share Ms. Brown’s apparent regrets at that patient’s outcome.
CONTINUED
10
if we go back to the sixties seventies and 90s the nurses were extraordinarily involved with the patient and some of the rationale was the frequent handling of the nurse was extremely valuable in assessing change. But that has changed and while good nurses are invaluable a great deal of time it is only the nurses assistants dealing with the patient. I could fill a page with extraordinary nurses intervening and being their intervention that saved the patient. A good nurse is often the only protection a patient has when complications arise suddenly.
21
This is a good piece but the premise is off target. There is no evidence that the model necessarily agrees with the nurse's gut instincts. Suffice it to say, it would be even better if the model was able to pick up something that the nurse was not able to see, or to recognize it even earlier. Like MOST ICU physicians, I have a ton of respect for nurses and rely on them to be first to recognize that the patient's status has worsened. That said, there are still countless examples of physicians dismissing their warnings and this needs to change.
14
Nurses are front-line first responders and difference makers on countless occasions. I trust nurses more than doctors, and a good nurse is worth their weight in gold. Underpaying them is criminal!
24
My dear friend was very sick in The ER. The oncologist told me her labs were normal, she was not dehydrated. I pleaded with him to give her IV fluids. “Please look at the patient and not her labs results”. After several liters, she perked up and she was able to go home. He later thanked me for advocating for her.
21
My cousin had been near death and was finally much better. He then took a slow downhill slide. I'm a Medical Technologist and he approved me to look at his lab results. I immediately saw that his hemoglobin and hematocrit were much higher than I would've expected. I immediately thought he was hypovolemic. Upon googling it he had nearly every symptom. The concerned nurses insisted I talk to the doctor who explained to me that I who spent hours a day with him had no idea what I was talking about. I told him I knew these were new symptoms and CBC changes didn't make sense. He ended the conversation, but gave him blood and fluids in the AM and his condition improved quickly. I'm glad I was as to make the doctor look at changes in laboratory results he had missed or ignored. I would've felt awful if he had died with nobody really assessing his condition.
12
Nurses need to be recognized as essential members of the diagnostic team. In this case, the nurse’s ‘gut sense’ that something was wrong was the lost key to making a more timely diagnosis of cardiac tamponade. The #1 recommendation in the National Academy report on “Improving Diagnosis in Healthcare” was to improve teamwork in the diagnostic process, and this means, foremost, the nurse and the patient. I’m guessing Mrs Rothman’s sons had the same gut sense as the nurse in this case.
Speaking on behalf of our Society to Improve Diagnosis, I am proud of our new special interest group focusing on nurse engagement in diagnosis, headed up by Becky Jones at the Pennsylvania PSA and Kelly Gleason at Hopkins. Members of this group have recently authored papers on the need to increase nursing engagement. We are also in the process of recommending a new curriculum on diagnosis and diagnostic error that would be part of the training of every healthcare professional, including nurses.
Of the many recommendations on how to improve diagnosis, involving nurses (and patients) offers a clear path to fewer errors.
Mark
Mark L Graber MD FACP
President, SIDM www.improvediagnosis.org
Senior Fellow, RTI International
Professor Emeritus, Stony Brook University
27
Mark,
We’re huge fans of nurses and understand their contributions to the care team. Let me know if you’d like to talk about how we’ve helped nurses have found a voice.
Michael
[email protected]
6
As a 36 year pilot for a major airline, I learned that if a flight attendant told me that something didn't sound right in the back of the plane, I'd better send one of the pilots back there to check it out. The F/A's know how things are supposed to be in their part of the plane, and while they can't diagnose a problem, they do know when something is wrong or different. Nurses are the same, so docs, better listen up and pay attention!
42
The nurse knows but is often afraid to articulate. Very timid. The doctors are into their status, not team players, a hierarchical setting. Arrogance and incompetence are deadly combinations. Culture slow to change. Engineers prove what I've know for 30 years. Listen to the nurse. Also listen to the patient.
Nurses are being transformed into data entry specialists serving the computer. We need documentation to justify our outrageous billing.
The patient should bring an advocate to each important visit. It's essential.
25
Like anything else there are competent and not so competent practitioners, both nurses and physicians. And although physicians are blamed for outsized egos, I've also met my share of nurses who overestimated their expertise.
In multiple specialties it's crucial to have a sense of whether a patient is "sick" or not. And not based on lab work but on clinical judgement. For both nurses and physicians.
In the ER a good example of this teamwork is a triage nurse's assessment that a patient can't wait to be seen by the physician. And a physician's assessment that a patient is well enough for discharge. Both are clinical judgements that are made multiple times in a shift.
Sometimes someone gets it wrong. But both physicians and nurses rely on this informed instinct.
14
@LC As a hospice physician and long time family physician, I am absolutely certain of my own gut feelings. In fact, one of my radiology mentors in residency, when reading a simple chest X-Ray, he taught us to first and foremost ask, is this CXR normal, or not? When walking into a room with a pediatric patient, we do the same. Anyone who sees kids know, essentially immediately, whether the child is sick or not. The question really is what to do, when to intervene, how much of the sparse medical budget to spend investigating a hunch, even when we know consequences can be devastating. A CT scan of the brain on an end-stage Hospice patient may not have been the most appropriate intervention in the case of Ms. Brown. Most important I think is to trust nurses and colleagues, and then discuss appropriate management, and sometimes watchful waiting is the best way forward, knowing that humans do not own crystal balls- wish we did!
10
All good nurses have this "sixth sense"; the best nurses articulate them. I would always prefer to have a nurse with a history of "arguing" with the doctor, who spends much less time with the patient than the nurse.
31
Most people's "gut feelings" are just condensed, compressed experience that has been encoded into their hardware (nervous system) from their software (thoughts, perceptions, and experiences), which lets the information be processed more quickly -- until it seems instantaneous
33
This article will be posted as required reading by my undergraduate aspiring nursing students. When they complain I am too tough I reply that it's the nurses who have the greatest contact with their patients and are best positioned to detect changes in condition. And to be know and communicate the significance of these changes they have to study and learn. Oh, geez.
19
@Em
Bravo! I wholeheartedly agree. I had very fair but tough nursing instructors and we students often complained about the amount of work we had assigned. One third of my class dropped out following the first clinical rotation. Less than half of my starting class survived to graduate and take the boards, 99% of us passed the first time thanks to those tough instructors. That was 37 years ago. Wow!
Keep up the pressure, there are no do-overs in the real world. New GNs need to be able to handle whatever comes their way even if it was never experienced in school. A great education will guide them in making critical decisions and alert them to know when to seek guidance.
11
The question of our times: should we attempt to quantify all phenomena? After we've reduced a complex cognitive phenomena to a set of calculations, what do the resulting numbers mean? All front-line healthcare staff are familiar with the ways care and patient outcomes are reduced to a numerical value and tracked. But I believe there is still some value to the mystery of intuition that can't be easily reduced to an algorithm. Despite the systems in place run by management theory and actuarial-driven hospital administrators who try to maximize cookbook medicine at the expense of clinician initiative, experienced physicians rely on intuition as much as nurses. The difference is that nurses have far less autonomy to act on their intuition, sometimes watching with frustration at the bedside as their patients deteriorate. But the good physicians will heed nursing intuition as no less valuable than their own.
33
I’m not trying to invalidate nurses’ six sense. I agree that nurses who work closely by patients bedside must have a good sense of what conditions patients in. However, we need to be mindful of cognitive biases. Many of us have experienced hindsight bias: the inclination to see past events as being predictable. The bias ultimately is motivated by wanting to need for control. We want to able to cheat death and have a feeling if us human are in control of our lives, and our deaths. It’s likely the nurse only remembered a few incidences where her “gut feelings” are in the right track, but maybe, she doesn’t remember the times that her “gut feelings” are not valid? Memory sometimes plays tricks that we don’t aware. I’m not sure how useful to depend on six sense and gut feelings, instead develop more accurate measures to monitor patients are a much better approach.
9
@Miss feisty
“I’m not trying to invalidate nurses’ six sense.”
Yet your entire statement does just that.
I can assure you nurses and doctors remember the times we were wrong. Those times keep us up at night. Our “hindsight” is not biased, it is a process meant to identify how we could have done better.
Save your psychobabble for those who don’t have a sense of self, and are unable to separate self from the reality of using sound nursing or medical judgement to provide care.
16
@BMUS
I respect healthcare providers who are able to do retrospective analysis, and as you said, identify the ways that can provide better care to patients.
I'm a psychologist by training and I can assure you, my "psychobabble" arguments are not based on my "gut feelings" as an experienced psychologist, instead, it has solid empirical evidence.
Cognitive biases are not peculiar to
the medical domain but, rather, are manifestations of suboptimal reasoning
to which people are susceptible in general. Be mindful of cognitive bias helps us, including health care providers, to make better decisions. Unfortunately, cognitive biases do not discriminate. It happens to the best of us. I believe many of us also have heard stories where health care providers made suboptimal diagnostic and treatment decisions based on their judgments/gut feelings. I, once, was a victim of a medical decision based on a doctor's gut feelings. I think it is beneficial for health care providers to acknowledge these biases and make optimal decisions for patients. As psychologists, we have the responsibility to develop specific strategies to help healthcare providers make better decisions.
With today's technology, including big data and machine learning, maybe there is a way to transfer/code all the "gut feelings" into data, then we can develop scientific and falsifiable models help to build a more accurate monitoring system for patients.
are nurses somehow different from everyone else? peer reviewed science shows we have tendencies to forget the times we were wrong, just as the poster you responded to said. this is not intentional, and no one is saying it is. But if we acted on intuition, it could very well lead to unnecessary and invasive testing, which is already a major problem that leads to a decline in the condition of patients.
1
I went to theb emergency with a high fever and just feeling sick all over. I had been this way for several days. I was seen by a GP who said he had no idea and sent me to the Emergency.
I was seen by a couple of doctors who had no idea , the nurse came Back and said she thought she knew what was wrong and went back to convince the doctor to do more tests.
She was right I had some variation of flesh eating disease, I was soon in the care of specialists and receiving special medication.
There is no question that nurse saved my life.
The sad part of this story is that the politicians cut back on the nursing staff in all our hospitals and wasted the money on other things.
47
Much of the “intuition” nurses have are described by the nursing theorist Benner, who shows that proficient and experienced nurses simply can no longer explain why they do what they do or know what they know. It might be worth a medical doctor’s time to google Benner and read her theories.
19
Our fundamentally analog wetware processes channels of sensory information by finding similar patterns. A nurse’s intuition or a physician’s is that process applied to understanding what is often a complex medical situation. This intuition, which doesn’t ignore physical measurements, but rather integrates them, is one of medicine’s most powerful tools.
10
I just finished one of my final papers for my BSN on this very topic. My thesis ended up being that after years of nursing trusting my “instinct” was valid. That gut is curated and refined after years of experience. While it can’t always be articulated it’s there. Every good nurse I know, they have it.
20
This doctor listens to nurses and their "gut feelings". When all studies are within normal limits and a nurse tells me about his/her worries about a patient, I listen. It is same gut feeling whether it is a nurse or a doctor, a nurse spends more time at bedside than any doctor, it will be crazy not listen to a team member who spends more time with a patient than any doctor/consultant.
34
I am a former trauma nurse and retired nurse administrator. During my years of work we read/taught our staff a great deal about Patricia Benner's research/book: Novice To Expert.
I hope you have read and studied this outstanding research. A nurse, over years of practice, develops an expert 'intuition' in her/his care of patients that needs to be recognized, honored, taught and listened to in all healthcare settings. It can save a patients life.
28
I don’t understand why Ms. Brown’s columns always pit healthcare professionals against one another. Doctors and nurses work together as a team: neither would function without the other. I’ve learbed so much from nurses in my career, and know that will continue, and I have much to offer them as a physician.
The real problem with this column is that “gut feelings” are not secondary but are the cornerstone of artful medicine. Underlying these feelings are experience and knowledge. Honing these feelings—and being able to reason through them—is the goal of medical training. I always listen to nurses when they think something is wrong and investigate, but I don’t always agree with them. Having that conversation is in the patient’s best interest, but to denigrate the physician piece of this equation —again, forming clinical judgement is the goal of medical training—is ridiculous. Nurses are definitionally the front lines, and they’re essential. But this is not a zero sum game, nor should it be when it comes to patients’ lives.
34
@Jessica Almost every interaction I have had with attending physicians, fellows, and chief residents about a "gut feeling" has been with much mutual respect for each other's perspective, expertise, and instinct, even if we didn't agree in the end. At a teaching hospital, however, a nurse is often required to first contact the intern who as a first year physician is still learning so much about how to manage the numbers and put the big picture together. Some are harder to "sell" your concern to than others and it's a fine balance between helping them to develop their own instinct and going up the chain of command to protect the patient. Some of the frustration occurs because mostly the nurses stay in one place and every July have to start over with new interns. Smart residents learn as interns that it's not a one man/woman show and we rely on each other to make the whole thing go round.
16
@Jessica and Jenna,
I agree with both of you. Doctors and nurses need to corroborate on patient care. Each profession brings a different perspective to caring for our patients, something we all need to keep in mind.
Jenna,
Kudos to you. I didn't last very long working in the ICU of a well known teaching hospital. My last nerve frayed while attending a patient an intern was attempting to place a subclavian line in while four others looked on hopeful for a turn. It felt as though they all forgot there was a patient under that drape. I went back to the OR, my first love, and eventually became a RNFA. Nursing is great, there are many specialties from which to choose.
3
Brava. Nicely put.
AS long ago as 50-60 years, my father, a doctor, said that nurses, because of their day to day, hour to hour, care of the patient, are better qualified to judge the patient's condition than are doctors. He said nurses should be authorized to order medications without seeking a doctor's approval.
17
My female relative gave birth with perfect scores. Then she showed signs of temp., delirium, sweating, glazed look, and pain after 24 hours. I was staying by her side the whole time and I kept telling the nurses and doctors it looked like a classic case of shock to me, a non medical person. Doctor said it was highly unlikely. After 18 hours of these five classic symptoms, they took it seriously and she went to the ICU. Diagnosis - septic shock with hysterectomy outcome. This was a leading hospital for gynecology and obstetrics.
17
Nurses and women's intuition! Unbeatable combination and all nurses deserve our gratitude, nonpareil. They seldom get the thanks they deserve, male or female!
Another one is aortic dissection. Boom! Gone.
6
@Positively
1. Thank you!
2. "Another one is aortic dissection. Boom! Gone."
Not always. I witnessed many patients survive due to skilled surgeons, nurses, and surgical techs working in unison.
1
A nurse saved my friend’s life by diagnosing an aortic dissection.
3
I still remember 45 years ago as a 3rd year medical student standing at the bedside of a patient fresh from surgery who was having trouble breathing. Gathered at the bedside were the attending surgeon and chief and senior residents. As they watched the patient's distress my fellow MS3, who had been an ICU nurse, whispered to me--"He's going to arrest." He did.
18
Thank you. I can't help thinking that "gut feeling" is a phrase that displaces to the intestines something that happens in the brain. In other circumstances, it is called "judgment," and rightly valued.
19
And therefore, rightly, the gut is called "The Second Brain"!
3
God Bless all of you Nurses out there. The unsung heroes.
I forgot doctors should never be questioned, never because as we all know they are always right. (NOT)
8
@Margo Channing
Over a long career as a physician, I can count on one hand the number of doctors who think they are always right and should never be questioned. In my experience, doctors are well-aware that nurses provide valuable complementary expertise.
21
@Margo Channing
First, thank you.
Second, incorrect, in my nursing career I’ve met very few doctors who didn’t value the input of nurses. There’s no need to denigrate one profession in order to uplift another.
17
Gut feelings or intuition is not nonsense. It is a buildup of past experiences culminating into a conclusion. One problem here is likely that RNs/NPs input is not what it should be, which is a waste, since nurses are front lines in any hospital.
11
this is a nice article but good doctors trust their guts too, not just numbers and other tests as this article implies, because a different word for gut is experience. it's very true that nurses do not receive adequate respect for the enormously difficult and important job they do, but the implication that doctors are drones who just treat numbers is both foolish and wrong. and of course the insurance companies are the ultimate arbitrators of medical treatment and they are gutless money-grubbers..
18
This intuition is a tool requiring time with the patient, to get that 'sense' of well being. it is also a skill very well used by us midwives...sitting for hours with a laboring patient, walking with her, soothing her, listening to the fetal heart rate, we often get that sense that the birth will be fine, or might be difficult. Perhaps that is one of the many reasons why outcomes with midwives are often so good, in terms of route of delivery, maternal outcome, fetal outcome, and patient satisfaction.
6
It has been my experience as a Licensed Practical Nurse for 22 years, that when I get the "feeling" that something is off, it generally is. Getting a doctor to listen is a different story. No one wants to listen when you report that the patient's vital signs are good, and that you find no definitive abnormalities in your assessment, but you know something is cooking...
The fact that I am an LPN and work in a nursing home appears to be even further cause for scepticism, but I can tell you, yes, I may have missed a problem, but my "feeling" has never been wrong.
17
@Evie
I could not have said it better myself. And if you manage to get them to the ER they just sent them back.
One of my residents was "off" one day. I sent her to one ER, and when they sent her back I sent her to another one. They ended up keeping her for about ten days with pneumonia. Plus she has renal failure and cardiac issues, so I knew something was getting ready to happen. That was one of the rare times when the gut feeling was actually validated.
And BTW my work partner is an LPN and one of the best nurses I have ever worked with. And I've been an RN for 25 years.
10
LPNs are the unsung heroes of the nursing profession.
It is a great stepping stone.
The best Nurse Practitioners began their careers through the educational backdoor.....
1. In high school..... certified nurses’ aide
2. Post high school technical school .... Licensed Practical Nurse Program
3. Associates Degree in Nursing
4. Bachelors Degree in Nursing
5. Masters in a Specialty
6. APRN
7.PHD in Nursing.
Don’t let the uninformed kid you!
Nurses have just as rigorous a career ladder in their profession as physicians. Our perspective might be different.
We consider ourselves the progeny of ancient healers.
But by the early middle ages we were relegated to being “ witches”. Intuition is in the realm of the female gender historically.
1
Been a nurse for almost 30 years. Most millennials and those that follow don’t have gut feelings, a sound knowledge base, anything resembling a work ethic or any desire to be in uncomfortable or stressful situations.They mostly just feel entitled to a fairly decent wage and job security...or to seek a DNP or CRNA after a year or two of experience working in acute care. It’s a world of relatively inexperienced 24-26 year olds “training in” 22 year olds. There are none of the crusty highly experienced diploma nurses left who used to show young nurses the ropes or when needed, demanding discipline and ethical behavior. God help us all.
19
@Willie From Madison
Diploma nurses are the best. I've worked with several and thank God for that. I got a BSN years ago and had no prior training in health care. If it hadn't been for nurses like you I would have probably lost my license a long time ago.
Right out of school I went to work in psych (I already had a bachelor's in general psychology). I don't think I killed anybody but I probably made a few wish they were dead.
5
Medicine has and probably always will be an art and not a science because of the issues mentioned in this article. Yes, medicine makes impressive use of science. But until the art of medicine can eliminate the "intuition" that seems to be present in observations to minor to create statistical data, it will always rely on the art of the medical professional.
4
In 1982, at 9:30 PM on a Friday evening in the Coronary Care Unit, I noted something wasn’t right and called the unit medical director at his home, telling him something was wrong with the patient despite “good numbers.” He thanked me for the call and was at the bedside 10 minutes later. 10 minutes later the patient was in the Cath Lab for pacemaker repositioning; the lead wire had migrated through the wall of the heart. The variable in this was the nature of the relationship between the unit staff and the attending physicians, irrespective of the ages of the involved staff. My experience has been that, generally, surgeons are less likely than internists to listen to a nurse express a gut feeling. Additionally, my female peers noted the attending physicians were more likely to listen to me as a male RN.
I have seen this improve over the intervening years; however, there is still a long way to go. I would also note that conversion to the EHR has not been as beneficial as hoped. Nursing documentation is still largely disregarded – except by lawyers.
18
The following article also helps to describe the uncertain medical environment prevailing when doctors and nurses must make fateful yet instantaneous decisions in ICUs. It is from The New York Times Magazine (May 16, 2018) and Dr. Abraham Verghese wrote it. Its title is: "How Tech Can Turn Doctors into Clerical Workers."
The following extract from this article, citing his brother, a professor at MIT with a current interest in biomedical engineering, is particularly apt and relevant to today's discussion. The article states:
"A blizzard of monitors from disparate manufacturers display EKG, heart rate, respiratory rate, oxygen saturation, blood pressure, temperature and more, and none of this is pulled together, summarized, and synthesized anywhere for the clerical staff to use." The article continues: "What these monitors do exceedingly well is sound alarms, an average of one alarm every eight minutes, or more than 180 per patient per day. [(1 alarm/8 mins) x (60 mins/1 hr) x (24 hrs/1day)] = (180 alarms/1 day). What is our most common response to an alarm? We look for the button to silence the nuisance because, unlike those in a Boeing cockpit, say, our alarms are rarely diagnosing genuine danger."
[JJL 8/10 12:06p Greenville NC]
9
Called “alarm fatigue”. Another interesting monkey wrench thrown into the lives of nurses is something called CPOE... “ computerized physician order entry” which should be a great idea but instead slows physicians to beam patient orders to units at irregular intervals from anywhere in the hospital of even from home without consulting with the nurses and thus not knowing what the situation is on the ground, as it were. Terrible effect on work flow and a huge time waster especially in July in teaching hospitals as new residents bombard nurses with inappropriate orders from afar. In the old days on had a good chance of detecting doctors on the unit writing orders which would allow discussions or even...teaching moments.
5
@John Joseph Laffiteau MS in Econ
I was in the ER with tachycardia--heart rate about 180 but--and for two hours lay on a cold bright table with a loud and urgent beeper going off over my head. Note to ER, don't put people with tachycardia there. A quiet room with an easy chair and reruns of Modern Family would've helped. Or just for God's sake lose the beeper. It really hurt my heart's efforts to calm down.
7
I have been a nurse for 32 years and I can say with certainty that when I didn’t listen to the nagging feeling I had about a pt that I could not put into words, I regretted it. Bedside nurses know.
30
@Elizabeth
No. I do not
My moment was when I walked into the OR room to relieve the circulating nurse. The case was done, the patient had been transferred to the bed, anesthesia was getting ready to extubate, and the surgeon was in the RR writing post-op notes.
To this day I can’t tell you exactly what made me suspicious that something was “off”. I pulled on a glove and slid my hand under the patient’s neck, when I pulled my hand out it was covered in bright red blood though the dressing looked dry and intact. A suture placed in the carotid artery had ruptured. I grabbed the first surgeon I saw and gave him a clamp...
The next day I came in by way of the ICU to see the patient doing well. What a great feeling it was to see such a positive outcome.
30
@BMUS
Just pure lack!
@Antonio Vargas Heredia
"Pure lack"?
No. Pure intuition based upon the knowledge gained from caring for numerous patients peri-op and post-op prior to to this case.
I hate to think about what would have occurred if I had ignored my intuition. This occurred over 30 years ago and is one of my most vivid memories. I never ignored my intuition as a nurse, it was almost always right.
5
40 years ago, as a medical resident in an inner city hospital, I learned the importance of listening to a nurse's gut feelings. When a nurse tells you something is not right about a patient, even if it's not backed up by "hard" data, you had better go and take a good look for yourself. An important corollary to this is that you should never criticize a nurse if it turns out to be a false alarm. The next time he or she might be reluctant to call you.
By the way, cardiac tamponade is diagnosable at the bedside. Patients almost always have very disended jugular veins, as well as other physical signs. Physical diagnosis is a lost art these days.
50
I always pay serious attention to patient reports of impending doom...something they don’t always report to doctors
5
I believe that there is a gender issue overlying Ms Brown's excellent essay. It starts with her use of "gut feelings." An equivalent is "women's intuition." Both terms take the rational conclusions that result from the amalgamation of experiential data and turn them into an emotion. On the other hand, a doctor (man) more frequently will use the term "clinical judgement" when presenting the same data.
It is an archetype that is thousands of years old and thus tough to break. Think of Cassandra warning her father about that horse the Greeks left in Troy. She was ignored with tragic results.
To help fight this human failing, our hospital has instituted daily interdisciplinary bedside rounding in which every member of the team from the patient to the attending physician has a voice. It has helped in improving nurse's confidence in their analysis and in physician's taking it in as clinical data-not irrational emotions.
23
The nurses have that “ female” intuition mainly because they actually spend time with the patients and get to know them but also, they actually get a feel for what’s called “the human reaction to illness.” That’s s why nursing is sometimes described as “the last defense for patients against the heartless for profit medical industry.” Also, having experienced “nursing led interdisciplinary rounds” I’ve watched them quickly devolve, first into physical led rounds and then watched the nurses on the outside of the group find that no one wants to know anything from them save a brief synapsis of any of the previous night shifts negative incidents , if any. Actual talk of gut feelings or attempts to humanize patients quickly become discouraged. And this from the teaching hospital I work at, is consistently awarded “ best hospital in the trump state area”
4
The experiential intuition learned by intelligent, interested professional in any field is invaluable in evaluating any human affliction and developing and applying an effective solution. Medical doctors, as opposed to those educated in the Osteopathic tradition, are trained in a strictly linear method of collecting and evaluating patient information and become focused on a very limited amount of evidence. Nurses, most of whom are still women, come to medicine with a non-linear, whole-person view of their patients and therefore are able to access information and see events outside the strictly linear approach. Their experienced "feelings" are really a highly developed intellectual sight that allows a more accurate assessment than a strictly linear approach--the "art" of the professional healer, if you will. Any true medical breakthrough in treatment of a disease process has been accompanied by a scientist who sees beyond the linear "scientific" tests into the broader relationships of the phenomena he or she encounters, thereby opening up the non-linear mind to all the facts and their relationships of the particular phenomenon under observation and ambition to develop a solution.
Any lawyer doing good plaintiff medical malpractice work knows that the real facts are in the nurses' notes.
13
Jonah Lehrer's excellent book "How We Decide" really aided my understanding of, and thinking about, the nature of gut feelings and the ways they represent long term accumulations and integrations of experience, as did this thoughtful essay. Once, 33 years ago, when a medical trainee glibly wrote off something I had observed about my daughter's physical adaptations to a disability, his doctor/mentor admonished him immediately and told him that a parent's constant experience of a child was one of his best diagnostic tools. I was very grateful for the encouragement this gave me to be a forceful advocate for my child in a medical establishment that tended at that time to dismiss me as a "nervous mother."
18
@Sue Ann Dobson
Indeed, "a parent's constant experience of a child" is a critical piece of the diagnostic process. I, and I am sure many of us, have had the experience of insisting our child be seen (or pushing the M.D. to look deeper) because the child's otherwise subtle symptoms raise big red flags to those of us who know their every state. In this way I've caught many a strep throat, allergic reaction, sepsis, pneumonia and mono that had been dismissed as something less. The same is true of our constant experience of our spouse or other loved ones - valuable insights and red flags can gleaned from these careful observations we provide. Rather than writing us off as "nervous" or "anxious", an observant and experienced nurse can often put it all together, saving lives and alerting M.D.s to impending problems. Good healthcare professionals of all kinds, teachers, parents and others use their experience and go beyond the numbers to direct their care. I am always grateful for an experienced nurse who knows how to listen.
9
With all due respect to nurses, are we referring to perception bias here?
While there is little dispute about mother’s instincts, or perhaps in this case there should be little dispute about nurse’s instincts, is this essay really a commentary about a lack of respect felt by nurses from some doctors.
This disrespect may stem from the hierarchy seen in the medical system, as well as in part due to sexism from predominantly male doctors to female nurses. But with steady progress these days, medical organizations emphasize teamwork and “flattening” the hierarchy, and the younger generation of doctors and nurses often embrace respect for all regardless of gender.
As a counter point, I have heard many stories about older nurses giving new doctors a hard time (I.e. lack of respect), almost to the point of hazing. It goes both ways. This is not to sensationalize problems between doctors and nurses, but to highlight we are all people with insecurities and emotions. How we understand ourselves better for the benefit of patient care will be challenge, not using a scoring system. (Technology is great for sure! But I wonder how we will truly digitize human care. Is that even possible without changing its essence?)
If we want to go back to stats and a scoring system, how many times were nurse’s gut feelings wrong? Doctor’s too. See recent op-ed from Dr. Sekeres piece from Aug 7.
We are human, no one is perfect. But we all should take the time to care for one another.
14
@A Doc
Well say!
I will add that too much emphasis in team work and collaboration may delay the decision making process that it is critical with patients
2
Nurse here, 40 yrs of practice in multiple settings. What a "gut" feeling is actually the knowledge and experience to note subtle changes in a pts condition. Skin color, resp rate, lung and heart sounds, mental status...all the little things that go into assessing the whole pt. This includes listening to what the pt says about how they feel and what family say. I learned how to do this in nursing school 40 yrs ago. Part is science, part is the art of any healing profession. Ignore a good nurse at your peril, for sure.
33
Amen to that (doc with 40 years of experience).
5
My granddaddy was in the hospital, in bed but waiting to go home that day after a minor procedure. The family was visiting that morning, talking and cheerful in that somewhat hyper hospital-room way. Some were leaving on a trip, some were making plans for later that day, a nurse was coming and going at the time. And Granddaddy said softly that his arm hurt. No one seemed to hear in the noise going on. I was right by him, and I heard. I repeated, "He says his arm hurts." But no one heard me. As the nurse leaned over him, I said it again. It was strange, but no one paid any attention at all. And I let it go, and Granddaddy let it go. I guess you can figure out the rest. The call came that afternoon, just as we were expecting to hear he was back at home. A massive heart attack, and he was gone. Years later, I learned that pain in the left arm is a precursor of heart attacks in men, and well, it was a hard thing. Even now, old myself, I feel guilty sometimes for not making more noise, not yelling or whatever I could do. But this is true, and I've seen it since: people pay least attention often to the very person who knows the patient best, and that's the patient himself or herself. In that role, you seem to become invalid, I mean not valid, anymore. We need to guard against that, all of us. That person is valid, and should be heard and responded to with respect.
24
@jb I’m so sorry you had this experience. I’m an intelligent woman who is good at noticing and does not “awfulize.” I cant tell you how many times my valid observations have been dismissed. Or that I’ve been offered a prescription for antidepressants for what turned out to be an actual physical issue (it just took a more in-depth look — often one that I had to initiate myself). It’s no wonder so many of us try to steer clear of mainstream medicine any more. Dismissiveness is epidemic!
3
problem is the age-old idea that (to quote something I don't believe in) "The nurse is handmaiden to the doctor". Nope: not true, if indeed it ever was. Smart docs know that the RN or LVN is your most sensitive patient monitor, and best pay attention to him or her as well as, if not more than, the various 'scopes and 'ometers. And I think most of the time that's the way it is. It's about teamwork, folks; and regrettably, some of us docs aren't good team players.
13
@G Ingraham MD
Sure Doc, team playing is key but i want to pick my team players, to make sure they follow my decisions diligently and do not delay or suggest a second or third opinion or having this people on board, etc, etc
1
As of five years ago when I retired, electronic nursing records are making this situation much worse! They should have improved our process, since they offer the possibility of analyzing trends and setting criteria, but the ones I've seen don't come close.
6
@Dottie Davis I agree. It seems to me the purpose of electronic notes is to shield hospitals and physicians from nurses articulating deviations from plan of care. The automated notes make it difficult for the nurse to note anything different that may have happened. I participated in an adverse events study and institutions that had automated notes had no place where nurses could note what really happened
9
@Dottie Davis
Agreed. The more "high tech" we get, the more alert we need to be. As a long term burn nurse I have had to teach many new nurses that we nurse the patient, not the machine. Just because an alarm is not going off, that doesn't mean that everything is fine.
7
As a physician/patient, I was appalled to experience the New medical efficiencies: no MD took my history- that was relegated to nurse practitioners, no bedside RN was assigned to my hospital care for more than one shift, vital signs were methodically charted by aides, labs were automatically drawn at 5am- but only the electronic health record held any continuity of 'observation' as the MDs, fellows, residents, nurse practitioners and physicians assistants dropped by - in a parade of fragmented care. The opportunity to enhance clinical awareness that is crucial for complex acute conditions was lost as no one saw me over time- seeing me well vs failing.
Yes the Rothman Index is useful, but a structural change would help as well: promote continuity of clinical management. Assign RNs to a patient for the duration of the hospital stay. (In some hospitals, hospitalists replace tiers of trainees and can also provide a longer term view.)
It is appalling to see the computer record undermine sound clinical skills and watch MDs, usually swamped and goaded by administrations to worry about the profit margin, aim for quick discharge as though that was the new gold standard of professional competence.
48
I have been a nurse for 34 years in both acute care and academia. I was lucky to work in several facilities where the nurses' judgments and intuition were trusted by the physicians, and we were given latitude to order tests and to ask the docs to see a patient STAT. One was a small community hospital ER, the other an ER at a big city ER, and the other a medical clinic for the homeless. As an instructor, I saw the decline in the ability of new nurses and students to even have an opportunity to develop the assessment skills and time to spend with patients to develop intuitive skills. Time is spent documenting a "head to head" assessment and clicking check, check, check. They spent their time administering medications and looking at monitoring equipment rather than at the patient. At the same time, experienced nurses are retiring -- those that I learned from as a new grad. Many new nurses leave the profession within 5 years, disillusioned with the reality of nursing in acute care settings.
19
These are multinomial probability distributions. A nurse is making simultaneous assessments of multiple factors in real time and is therefore gaining more information than measuring a single factor like heart rate or blood pressure. Humans are very good at assessing complex situations real time. As a Process Engineer I saw the same effect occur repeatably over 30 years. I would really love to see how these Engineers created their solution.
8
Thank you for putting patients' well-being first.
In addition to listening to the nurses, Doctors should also listen to patients' loved ones.
At the end of my father's life, he was hospitalized after having severely low blood sodium. Those numbers improved somewhat with treatment, but other problems soon developed. My father made incoherent and hallucinatory remarks. Breathing was difficult. He was deappetized. But the Doctors were stuck completely on his one improving sign and moved him from the ICU to a regular room, where he received nominal attention. We pleaded with a Doctor who had been treating Dad not to move him away from the stronger care structure and were told, dismissively, that it was a team decision.
My father died less than three days after being moved. We have some peace because he was late in life when that happened. But that won't be true of everyone. Families know when something is amiss. We may not have medical titles, but we should be listened to when we describe our gut feelings.
15
This is an example of the shortfalls of technology and lab ranges, many of which are faulty. Clinical impression and judgement, along with the experience of the clinician, matters most when it comes to the health and vitality of the patient.
7
Health care is a science, but it is also an art, which benefits from strong intuition, based on experience. I have used my intuition all my life, and it has served me very well.
8
After 20 years working in health care as a P.T., I am convinced that the floor nurses are more in touch with the patients under their care than the physicians who are in charge of treatment. I hope that physicians would give more weight to nurses' observations.
13
@Joan Erlanger
You are absolutely correct. As a physician (internal medicine) I may have up to 20 patients under my care and a floor nurse generally has no more than 6. She spends hours with her patients and I breeze in for a few minutes in the morning and unless something changes I may not see them until the next day. I need the feedback and reports of the floor nurses and PT's and ayon else on the team to help me care for the patient.
12
6 is 2 too many with today’s complex “general care” patients, but then that would cut into profits which are the prime driver of the medical industry in America.
4
Part of the problem is that the American health care system is more of an assembly line than it is care. Hospitals cut back on skilled staff that deal with patients. The tech who takes the blood from a patient isn't going to know if something is going wrong. The nurse who is busy doing paperwork may not have the time to look in on a patient more than once a shift. And the doctor, who is in charge of the whole deal, definitely isn't looking at the patient more than once a day.
Our hospitals are like factories. The care is impersonal. Patients are complained about if they expect too much or require too much. Rather than being run for patients, hospitals, like our entire health/wealth care system are run for profit and convenience. That doesn't leave much room for inefficient care where patients are listened to and cared about.
16
My understanding of rules for admission to hospice require the patient to be within a short time of death. The nurse’s instinct would have prolonged that period & perhaps increased discomfort for a dying person.
My niece, who lives in England & was born in France, once said, “ Americans believe that dying is an option”.
8
Hospice care generally does not require the patient to be in extremis or even likely to die within the year. It can simply require a change in care from cure to paliation. Interestingly this change in the goals of care result in prolonged life.
3
About time. Nurses have a much better sense of a patient's condition than the doctors, who see the patient maybe once or twice a day, and must rely on pieces of paper and numbers on a monitor.
Now let's pay attention to family members gut feeling. They often have an even better sense of a person's condition. Small shifts in behaviour, not enough to trigger clinical concern, are too often early warning signs.
11
As a MD, I try my best to always listen to my nursing staff. They are usually on to something I might not yet realize.
I am much more skeptical of tools like the Rothman Index. Many of these tools only see to increase cost of care without much benefit - like obsessing over patients with mild bumps in their lactic acid because the might be septic or thinking that every patient who meets SIRS criteria is nearing death.
12
This is not about nursing, but intuition. I used to drive into NYC at least weekly. Occasionally the idea would pop into my head to try a different, sometimes unknown route, which I always disregarded until I realized that when I did ignore the idea, I ran into traffic problems that made me late. I decided to start paying attention to my intuition and was never late again. Since then I have paid close attention to my intuition, and it has never steered me wrong. Those who discount intuition are depriving themselves of one of our most powerful ways to understand our world and how it works. There are many kinds of knowing, and scientific knowledge, while valuable, is quite limited. When we recognize that we are much more than merely rational beings and that our conscious understanding of how the universe works is partial at best, we may be able to begin to realize our full potential.
10
@J Shanner
Please understand that this is NOT about intuition, and I object strongly to the term "gut feelings." I have been an RN for nearly 50 years, and my most important professional skill is observation. Just by shaking someone's hand I know something about their circulation based on skin temperature, state of hydration if their skin is a bit dry, muscle tone, range of joint motion, presence/absence of a tremor, and more. With continued observation I can notice subtle but real changes that may indicate something significant.
Fortunately for me and my patients, I have worked most of my career with other health care providers, including MDs, who trust and value my observations. Too many providers now days rely too much on "the numbers." Physical examination and clinical observation are becoming lost skills -- to the detriment of patient car3e.
10
@ shanner: no this is about Nursing. No one does when you’re late to work. Your thoughts would be more valid if you were a professional traffic engineer who followed his or her “ intuition”
2
I could have written this based on my experience but I learned to collect the data an present it as objective not subjective information. Unfortunately I experienced the doubt and irritation on the other end of the phone. I also learned to document clearly when "the team" did not respond appropriately and have seen these cases reviewed in peer review. Nurses, make yourself a credible communicator.
13
I experienced my first so called stint in a hospital for 5 days. All in all, can't complain about the care, and diagnosis. I did come away with some observations of todays medical procedures. Doctors order the drug regime and frequency, and in my case of drawing blood going to the lab . Am sure this all gets plugged in a database . The circumstance that popped up was, nurses as expected are on shifts, handing off care to their replacements. A doctor only comes by once a day, and I had no way of knowing, with how busy doctors are, if through the course of a twenty four hour period, he or she, has time to look at data plugged in, or blood work results. A doctor on my floor probably saw 20 patients during the rounds.
1
I am in awe that the Rothman sons channelled their grief into developing this tool. They could have looked for who to blame or sued the hospital. Instead, they honored their mother by trying to prevent this from happening to other mothers. Bless you Rothman sons, your mother is very proud.
285
@Redsoxshel
Yes their involvement is inspiring.
However, the use of a "multifactorial" tool becomes a blunt force instrument which will lead to other missed diagnoses because the patient did not meet the Rothman criteria and therefore were not thought to warrant more investigation.
Like The fall risk assessments, the skin breakdown indices, the risk assessments for delirium, etc., the medical record will be replete with derived data of specificity and sensitivity which varies depending on the characteristics of the presenting patient, and when used on all comers will lead to misclassification. Which the malpractice lawyers will utilize to further dilute the effectiveness of each health care dollar spent.
1
@Redsoxshel The Rothman index is a commercial venture. The Rothman sons license their proprietary software to hospitals. The cost to a hospital can be as much as $500,000 per year.
Another term for “Gut Feelings” is “pattern recognition:” The patient is somehow not fitting an expected pattern. Something is wrong. Identifying abnormal patterns, analyzing them, discerning their significance; obtaining additional information if needed is the fundamental skill of clinical medicine. Information from disparate sources has to be pulled together quickly to do this task.
The recent introduction of the electronic health record (EHR), instead of making this task easier, has created information silos that impedes information gathering and analyzing patterns from disparate data types.
The most obvious problem is that healthcare providers now type into a computer instead of talking to each other. Questions are not asked and abnormal patterns are not recognized.
Important observations are buried inside mountains of boilerplate text that is segregated into different sections that are clumsy to navigate making comparison and pattern recognition much more difficult. To even look at vital signs, you have to log into a computer and click past 3 or 4 menus and then scroll through columns of poorly labeled numbers in order to identify an abnormal pattern. It is usually impossible to look at and scan through vital signs, lab reports, imaging reports, nurses notes simultaneously. You can only look at one data type at a time.
The regulatory and bureaucratic burden now imposed on healthcare is overwhealming+absurd. We don’t need Rothman indices. We need simplification!
31
@ Stasiak: thank you, yes!
@J. T. Stasiak well put!
So many defensive doctors here.
3
Not saving any lives, but prolonging deaths.
4
@Generallissimo Francisco Franco
Who are you to decide what is best?
3
As bob Dylan famously said: “ he is isn’t busy being born is busy dying.” Too many Americans die either kicking and screaming or while so incapacitated that the families are the ones kicking and screaming. It is not up to the caregiver to decide but there have been scoring systems that consider quality of life, the likely outcomes of procedures on quality of life but also on longevity. An example would be Gretchen Schwarze’s tool for judging whether more complex peripheral vascular surgical procedures are worth submitting to.
2
Nurses I work with can call 100 out of 3 close catastrophes.
2
Any physician who ignores or, worse, denigrates a nurse for phoning because a patient “just doesn’t seem right”, is a fool.
22
While I fully agree that close observation and communication can be as important as lab results and vital signs, I just want to point out the greater value of the latter over the former.
In recent years, I have been hospitalized twice, once in allergic shock, and once with sepsis. Each time, a doctor has commented that I looked and mentated much better than my lab results and vital signs would have predicted.
2
Anything that will improve medical care by anybody is positive.
The patient should always be the concern and not the caretaker's ego, be it nurse, doctor or whatever. Machinery has no ego, but the people who run it and interpret data do.
Alas the human caretakers are just that: humans and everybody makes mistakes and screws up for more reasons than can be counted.
9
When it comes to medical care, 'gut' feelings should always be ignored in favor of medical tests and diagnostic readouts. You might as well toss out the thermometer and diagnose a fever based solely on a hand to the forehead!
Doctors go through rigorous training, years of medical school, years of residency, and years of diagnosing patients based on hard data. Nurses should stick to their guns and do what they've been trained to do: listen to the doctor, and care for the patient's basic needs. Leave the diagnosing for the people who have been trained to do it.
2
Nonsense, Michael. Doctors are “trained” to memorize facts and interpret data points, all of which give a limited glimpse into the infinite complexity of a biological system and really doesn’t help much when newly confronted with a sick patient. The best health providers are those, while adept at the engineering aspect, are able to discern when the limited data points deviate from the status of the patient...the so-called “art” of medicine. This requires experienced intelligence combined with the instincts of an artist. The case cited in this essay (in which the final diagnosis should have been suspected by deteriorating vital signs and heart auscultation) is a perfect example of a fairly common event, where the data points inconveniently may not fit the patient’s status. There is a morbid medical joke which refers to a patient dying with all normal laboratory results. And, yes, it’s perfectly fine to include a hand on the forehead when suspecting a fever.
14
@Michael
This is why I object so strongly to the phrase "gut feelings." We need to recognize when we are observing subtle but real changes in a patient's condition and articulate them clearly. "Gut feelings" play no part -- careful observation does.
3
You've got to be kidding me! If you're a patient in the ICU you'd better have confidence in your nurse. The physicians certainly do I can tell you!
2
Nurses do incredible work.
9
@DallasGriffin
Thank you from an RN.
3
Skilled and experienced ICU Nurses are the reason I didn‘t kill anyone in my Intern year. They offered guidance and limitless patience with us „Baby Docs“. Can‘t thank them enough. I still bring cookies.
48
87 year old heart valve replacement? Good god our expectations are insane. What kind graphic can change that fact? That being said good nurses are amazing people, absolutely amazing. There just aren’t enough of them.
16
@hbit It doesn't matter how old you are! You deserve the best care possible EVERY TIME unless you specifically say you don't want it. Your comment is an example of ageism at it's worst.
3
One should have whatever one thinks one should have, but doctors ( and surgeons and oncologists in particular) have a duty to fully describe benefit vs risk, but also what to reasonably expect as an outcome in terms of quality Of life. An 85 year old who gets his or her chest cracked for a bypass or thoracic aortic aneurysms repair is quite likely to survive it today, but also quite likely to wake up with a delirium they will never fully recover from. I’ve seen that sort of surgically driven cognitive decline waaay too many times.
2
Overall agree with article. But it’s a gross oversimplification. Also, I know plenty of nurses that do speak up. It’s called a professional. Lastly, I’m suspicious of this nurses attitude. It’s kind of a “ the medical community is evil and I the Nurse was the savior” mentality. Often medical people with this attitude ironically do not work well with others.
13
@Primary care doctor
MDs have ego problems that get in the way far more than nurses behavior.
2
@ primary: while I don’t really know what it’s like to be a doctor I can tell you what it feels like to witness multiple “failure to rescue” situations ( what we’re actually talking about) as a RN. it always seems like the doctors have a much easier time shrugging off preventable deaths than nurses do. Every one steals a little (or a big) part of a nurse’s soul. Nurses are a patient’s last defense against a cruel and pitiless health care INDUSTRY. I’d rather be wrong or come off divisive than be unable to save a save-able life of someone I may have even formed a modest therapeutic relationship...
4
Well come on now. Let's have perspective. Example one was a patient with blood cancer admitted to hospice. The other was an 87-year old.
You are a hospice nurse. People die. We need to be careful not to create an overwrought culture that lives do not end. They end. Sure you might make it a few days longer, a week, or even a month. But at what quality? What is the need to prolong it? Who does it serve? Quantity over quality is not always the best goal. "wondered if their mother’s death could have been avoided" - she was 87. The answer is "yes", but actually it's "no", no it wasn't. She was 87, and that is always close to death. We Americans need to accept death as a thing and stop trying to imagine we are immortal. People die.
118
@Matthew
The author states that this case occurred years ago. Most nurses work in a variety of fields over the course of their careers, and based on the information in this article about the patient's course of care, she was not a hospice nurse at the time. More than likely she was working on an oncology acute care floor, which makes her regret over the outcome absolutely appropriate.
1
@Matthew
Hey Matt...better remember your own words when you get older. At what age do people become disposable?
2
God, you have missed the entire point of this article. It's about the" OBSERVATIONS"! I agree with you in that we are a culture denying death as a part of life, but this article is not about that. Trust me, I was a Labor & Delivery nurse and many a baby was saved because the nurse at the bedside saw what others did not. Put that soapbox away for now.
2
Spot on Theresa. Thank you for putting your nursing and narrative expertise together. Again!
4
As nurses become “ expert in their field”......this intuitive sense we develop is extremely useful in our practice.
This isn’t science ; it is experiential intuition.
89
@Nurse Jacki
And experiental intuition is the sum total of remembered data from prior clinical encounters.
It is of high value when the intuiter is an inquisitive, analytic clinician who reviews clinical events and catalogs them in an logically sound and etiologically consistent manner - for such a clinician it is science, though not rigorously complete.
Often, we see the intuiter who is uninterested and has developed route thinking. Such a clinician "knows" that the patient has such-and-such diagnosis without corroboration or consideration of the differential diagnosis. The results are not pretty.
1
When I was in nursing school, and during my early years at the bedside, we called this "nursing judgment". It was widely respected and accepted by both doctors and nurses, and may have saved many lives. No longer. If it cannot be quantified by a clinical value or imaging study no one accepts or appreciates it. Tbere are many reasons, including nurses spending less time at the bedside and more on documentation to satisfy clinical reviewers. But fundamentally it is a loss to good clinical care and militates against the professionalization of what we do as nurses. All the degrees and certifications in the world won't teach or replace nursing judgment, and that is everyone's loss.
13
So many key takeaways from this story:
- Nurse's gut feelings rather than "intuition"
- that the people who spend time with a patient have an insight that a couple of minutes a day can't equal
- that EMRs shouldn't just be complicated spreadsheet-like lists of data, but the data can be analyzed to spot potential trends. The time entering into an EMR shouldn't be thought of as time away from the patient, but as feed a data rich view of the patient over time.
5
Agree. As a retired pediatrician with 40 years under my belt, I decided that numerical coding of clinical illnesses and symptoms, in the interest of billing, was the beginning of a dumbing-down of the clinical process, culminating in the wretched EMR systems that have turned providers into data-entry clerks, and which have nothing to do with patient care nor useful record keeping. I suspect that these systems were designed by the same folks who create furniture kit assembly instructions.
7
Our health system is so strongly based upon profit and money that my first thought after reading this is that it is just a commercial for the Rothman Index product.
Why we grasp onto our current health system so tightly when other countries public systems show us the way to a better quality of life is beyond me. Having a truly public health system geared towards care and outcomes rather than bottom lines would go a long way in curing me of my excessive cynicism towards essays like this.
7
I recently had the opposite experience. All the years of nursing experience told the nurses that my induction would take many many hours - even a day. I went from pretty easy contractions to fully dilated extremely rapidly, and when the nurses came in and asked my pain level, I said "8? 9?" The nurse said "or maybe 5? Don't forget how much farther you have to go!" I gave birth about 30 minutes later. As they wheeled me to recovery, the nurse said "if you do this again, make sure to tell the nurses how this all happened." I HAD told the nurses that my mom had me and my sister in both about an hour of labor...I don't know what else i could have said (how about "my pain is level 9"?!). Anyway, I think sometimes experience and gut feeling works against outliers.
16
When my husband was hospitalized for 10 days for pancreatitis, he had the same nursing team in the AM and PM. These wonderful, compassionate, alert and observant women and men spent quality time every day with my husband. Their unique position afforded them to evaluate his symptoms, overall health concerns and ascertain if anything was amiss. My husband’s doctor was extremely skilled, capable and knowledgeable but it’s the observant nurses who had been medically eyeballing my husband for days. They would be the first responder to catch anything that began to go sideways.
Somehow, if a nurse tried to explain to my husband or myself that she/he was making a determination about something based on her/his particular “agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment” we would have stopped listening right then and there. Perhaps in many cases “gut feelings,” actually aren’t feelings at all but most patients and their family members understand, recognize and have experienced “gut feelings”.
While I truly appreciate and respect the logic and justification for the differentiation of the term “gut feelings” in this article, I’m going to stick with my own “gut feeling” and trust the nurses whom I would encounter on a daily basis should I ever end up in the hospital. They see everything, every day. The doctor merely gets the highlights and “cliff note” version of my condition once a day, if that.
16
@Marge Keller. as an ICU RN of 42 years, I've experienced the gut feeling many times. You are correct that it's years of training, education & experience that just tells you that "something is wrong" even though everything on paper says differently.
I called a new surgeon one night saying his patient's vital signs & lab work were all normal, but I just had a gut feeling something was wrong. He told me he'd be right in because his mom was a nurse & always said to run to your patient whenever a nurse called you with a gut feeling. The patient crashed quickly after he arrived & we were able to save her.
Many other examples throughout the years.
14
@pat
Such a priceless comment Pat.
While many a physician has the education and credentials, it's the nursing staff that truly has the day-to-day pulse of the patient and instincts to know something is off, especially when their "nursing radar" begins to beep.
Thank you for being the kind of nurse and caregiver the medical field continuously is in need of. You are a wonderful role model and inspiration to all nurses and patients. Thank you for speaking out when you thought it was imperative.
I don't know you, but I love you and your heartfelt compassion for your patients.
1
I am so grateful, as a nurse of many years, to see this article. I have a story that involves phone triage, a child who as a teen seems just too ill to have simple gastro enteritis and when brought in was found to have meningitis. He survived. Something kept me on the phone with that parent long enough to sense the urgency. The physician I worked with understood and valued my judgement. I was supremely lucky there. That was over 20 years ago and I do strictly telephone triage where critical thinking and the nurse's 'sixth sense' is highly valuable. But it is still questioned frequently by providers. I have not seen this index or used it, but if it can really quantify what goes on in my head it is invaluable.
16
It takes quite a few years for nurses to develop these “gut feelings”. Unfortunately, hospitals hire many young nurses to save their bottom line & don’t reward bedside nurses for stAying @ the bedside. Many of us don’t want to go into administration or management but it seems it’s the only way to make more money. 8 hour shifts should also be available to the older nurse who wants to stay @ the bedside.
Patrice Katsanevakis, RN
17
First, we need a health system whose engine doesn't run on money but the actual caring for patients. Yes, we have all this incredible technology but that shouldn't negate the importance of intuition. After all, it's our own intuition or that of a parent who feels something just isn't right, that gets us to a hospital or a doctor in the first place. Alas, health care now operates on the business mandate of time is money with little or no time for team consultation let alone intuition. Like a restaurant, they want to get you and get you out and turn that table over if their going to make money.
4
Thank you for this piece. As a care provider, I have certainly had this kind of experience as well as the regret when I a bad outcome might have been prevented if I had only acted on impressions I had before the event. I'm especially enthusiastic about the index that includes these impressions in a read out of risk. This has the potential to save lives but also offers an opportunity to evaluate the impact of a human tendency to attend to only two of four critical pieces of evidence: 1) gut alarm goes off and something bad happens; 2) gut alarm doesn't go off and all is well. What we tend to ignore are: 3) gut alarm goes off and nothing bad happens: 4) gut alarm doesn't go off and something bad happens. Only by calculating the full range of evidence - as the index described would - can we judge accurately if these gut feelings are truly adding predictive value. I would be fairly certain that there are some cases that a gut reaction, taken seriously, would save a life but I'm less certain that its a reliable value for a large number of cases with varied outcomes. Glad someone will examine this.
4
An acute change in mental status and garbled speech have absolutely nothing to do with "gut feelings". They are ominous symptoms of a stroke and or intracranial hemmhorage. Also, these are hospice patients, meaning that they have agreed to forego any type of aggressive treatment.
5
My daughter just started her second year as a nurse in the cardiac care unit of a major university hospital. Because all of the patients are in critical care, she is legally not supposed to be caring for more than 2 patients per shift (although that is regularly violated). She has authority to do things like titrate nitroglycerin doses by herself. A bad calculation can kill the patient. She is meticulous and regularly picks up minor changes in condition which she reports up the line because she realizes that these minor changes can portend bigger problems. For the most part, her observations are taken seriously and acted appropriately upon even if the answer is that the higher ups will simply monitor the patient more closely. Often the families point out issues that they think might be critical. The nurses have the ability and authority to bring these issues to the treatment team which is another way in which having more eyes on the patient can be very useful in restoring the patient to health.
7
Most of the doctors I know do listen to nurses, and why wouldn’t we? We know just as well as others that nurses spend more time with our patients than we do. And we have gut feelings that need to be reckoned with, too.
This is a complex topic that lends itself to oversimplification, but my advice, particularly for young physicians, is to do what the nurses tell you to do. This means you should always ask their opinions. It will keep you out of a lot of trouble.
33
@Franz Reichsman
I would not follow your advice at all. One should never, ever just do what the nurses tell you to do. Patient care requires a team approach. Getting input and information from nurses, and coming up with a care plan together is not remotely the same as doing what they told you to do. Doing what they told you to do is no better than ignoring them.
3
Working as a physician beside nurses in my career, I could see their dedication and their skill. I had my own opportunities to see the green shoots of emerging trouble just breaking through the crust of the patients whom I was entrusted to care. Often a nurse might nudge these thoughts upon me and I was smart enough to recognize their contributions and act on them.
We are dangerously straying from the art of medicine at the bedside into an over reliance on technology. Even the codification of the Rothman index itself depreciates insight while suggesting it can highlight it. Just because a tumor is below the detection size of current technology does not mean it does not exist.
I remember a discussion between a colleague and his newly minted residents-in-training.
Residents: We have a problem with a patient.
Teacher: What's wrong with her?
Residents: She has abdominal pain and she is too obese to fit into the scanner.
Teacher: Have you examined the patient?
In our professional lives, we all will face limitations in what we can bring to the bedside. The test is not available at this hospital. The patient cannot afford the test. The insurance company will not pay for it. The patient refuses the offered test. And on and on...
Pushing the envelope of clinical skill is equally if not more important than pushing the button of the latest instrument or device if our desire truly is helping patients.
18
@Douglas McNeill
Finally the Art of Nursing and the Art of Medicine known as the Laying On Of Hands at the bed side. The importance of the physical examination cannot be over emphasized. I practiced for many years as a Visiting/Homecare nurse where we did not have all the bells and whistles as the hospital based professionals did. Many times it was my call to the doctor with the results of my examination of our patient and review of medications that resulted in immediate changes to the care plan keeping the patient on course or sending them to the ER. Our educated judgements were always respected and welcomed.
1
Agree 100%. Doctors may swing by for a few minutes when you are hospitalized, but it is the nurses who can keep you alive. Doctors love their labs and their numbers, but few develop that INSTINCT based on years of close contact and observation that a good nurse develops. Subtle shifts, not yet discernible in tests, but clear to the nurse that a turn has been taken.
When you are hospitalized -- pray for a good, competent, nurse. Your life may depend on it.
29
@Atikin,
I’m a retired OR and Home Health RN. I must disagree with your conclusion that only nurses keep patients alive. While nurses are at your bedside they are working closely in collaboration with physicians.
Physicians most certainly develop and follow that “instinct” you only want to credit nurses with having. That “gut feeling” is not so much instinct as knowledge gleaned from experience.
If you need a cardiac catheterization (heart cath) or surgery it will be a cardiologist or surgeon who’ll be doing the procedure, not a nurse. Hopefully you’ll value their years of experience and their “instincts” to get you through the procedure. As someone who had a heart cath I can tell you I’m thankful my cardiac interventionist was exceptionally skilled, got the catheter in on the first attempt with minimal discomfort, and made the entire experience more pleasant than I anticipated.
10
Research shows, sorry citation not at hand, that delirium is misdiagnosed as dementia (or worse—psychosis particularly in Parkinson’s patients) by doctors 90% of the time, despite the fact that nursing notes showing an important change or changes in status—any of which could be a red flag for a proper diagnosis are not read by the doctors. This often leads to improper prescription of medications and often leads to death. Dehydration or an infection is common in the elderly and causes delirium. Hydration, hospitalization, dim lights, and an antibiotic for an infection would resolve those cases. Another primary problem is the failure to evaluate medication interactions leading to delirium and often to death. I once heard a hospitalist say: “I have a patient who is going sour.” To me that meant that there was an electrolyte derangement that, had it been caught early enough, the patient would have lived. Jeanne Hannah
2
I could cite many similar episodes in my career. However, lets step back and look at the big picture: what provides such "gut feelings" is experience. Years of encountering patients and recognizing when something is not right. The experience of hands on care is being replaced by younger, far less experienced nurses who are directed more by technology than by face to face, hands on care. I started my career where specialists and nurses rounded together on the patients. Nurses were taught and mentored by those physicians. Now, time is money. Physicians don't have the time to spend teaching what they know. They used to do it because the nurses became their eyes and ears when they were not available. That model has changed. No more family doctors in the hospitals. Because of computerization, far more patients per nurse per shift. No one with whom the patient has any relationship. And the patient has no knowledge of whether the physician is good or not. The next step is right around the corner: a computer will be wheeled into the room. The doctor will be in a room nowhere near the patient and will conduct the examination and interview from a video screen. All the "necessary" data on an adjacent computer. And will rely on nurses with but a few years of experience. Perhaps what will be needed is the "MYGUTFEELING" app. Remember when you used to take manual blood pressures. Ah, the good old days.....
6
I retired from nursing after 45 years in various positions, lastly VP of Nursing for a nursing home management company.
When I was in home care, more than 30 years ago, I went to see a patient who'd just been discharged. I cannot remember why she'd been in the hospital. However, this was my first visit ever with her. Her vital signs were all good but she kept telling me she "just didn't feel like herself." She said she was afraid and had no reason to be afraid. I called her doctor who gently said, "Send her to the ER." I did.
The next day, when I was still in the office, I received a phone call from this doctor. "Well, Mitzi. I want to know when you're hanging out your shingle. Mrs.___ was having a silent heart attack."
It's not just the nurses we should be listening to...
33
@Mitzi Reinbold
Your closing sentence is one that should always be respected. Ten years ago, I was being treated during an acute phase of ankylosing spondylitis by means of a sulfide medication. All of its side effects, some of them quite hair-raising, were explained away with "That's part of the symptoms." To make a long story short, I needed nearly two years of treatment to get my blood back to standard, and the ischemia caused by acute anaemia caused (fortunately) reversible brain damage. Only ten years until that was 'repaired'. And all that because that doctor refused to take my observations seriously.
4
Now, let's look at the flip side: how many times did the nurse have a "nagging feeling" and it turned out to be nothing. My guess is that false "nagging feelings" occur far more often than positive ones. Despite popular belief, gut feelings are notoriously unreliable in the majority of decision making endeavors.
7
@Francis , Since as another commenter mentioned, "the nagging feeling" is really the result of experience, it might be more accurate to term it intuitive ability, based on experience. I'm not sure that it has been or perhaps can be quantified, since most evidence is anecdotal. so is "notoriously unreliable" supported by studies?
4
@Francis
I would rather a "nagging feeling " be fully explored and only then dismissed as "not much", than ignore it outright and be wrong, FrancIS (if you get my not-so-subtle hint.)
1
Thanks for your article. It angers me that doctors refuse to act unless some unrealistic metric is met.
I have nearly died several times due to this mentality and due to plain stupidity of doctors. If you think they don't pay attention to nursing staff, you should realize they don't seem to listen to patients either.
Most recently I went to a new internal medicine doctor at a highly regarded university medical center, gave him my medical records, including a summary of surgeries, allergies, meds, current medical issues, and the like. When I logged on to my patient portal, I discovered that they did not post three conditions that could compromise my life should anyone there not be aware of them. (Two require daily medication.) This was deliberate, I am sure. A competing university medical center is handling one of them (as they are the country's leader for this particular problem), he had mocked the doctor who treated me for another one because he doesn't believe I have the condition (never mind that he never saw test results and has no working knowledge of it), and apparently he simply isn't familiar enough with the third one to even believe it's real versus something I conjured up. Just because something is uncommon doesn't mean that a patient doesn't have it!
11
What is the "solid evidence that when a nurse says she’s got a bad feeling about a patient, the entire care team needs to listen"? Has the Rothman Index been validated and shown to be better than current practice? How exactly are nurses concerns quantified? And how much are the Rothman's charging for their tool?
2
@Jeff I was wondering the same thing. I looked it up on Pubmed and there have been some studies showing that this index can predict who is at highest risk of ICU or or hospital re-admission. It uses a several data points from the electronic medical record. Many of these data points are part of the nursing physical assessment: bowel sounds, oral intake, incontinence, etc. as well as lab results and vital signs. So the tool makes a prediction based on quantitative data not a gut feeling.
2
The problem today is most everyone on the entire 'care' team really doesn't care. They're too busy or distracted or whatever, looking forward to their next break or end of shift. The doctors just wander around and look/act important after glancing at notes. None of these people are truly in charge nor know what the heck they're doing. Deep down we all know this. They're just practicing crisis management or reactionary medicine. The well being of the patients is of course secondary right after billing.
8
@Lee As I lifelong healthy person who has recently encountered a serious condition which has involved hospitalizations and many, many doctors visits, I can tell you this is not true -- not even a little bit. Of course individuals' level of commitment, exhaustion, distraction varies. But as a group, they are people who are working very diligently for the health and wellbeing of their patients, sometimes at the cost of their own. They don't always know what is going on -- they can only surmise, based on what they observe -- but to say they don't care is wildly inaccurate and unfair.
10
@Lee
I once took care of a critically ill "neuro" patient on whom minute-by-minute intervention, observation, and in-room computer recording were required to track any subtle changes over time. This included Subjective as well as Objective observations, all critical in understanding the unfolding events. The arrogant young Resident approached me as I was diligently working and asked what had happened over the course of the shift and when I said that it was all detailed in the nurses notes that he should have read just before coming into the patient's room, he said, "You know we never read nurses' notes."
I had everything I could do to keep from telling the arrogant little snot to go pound sand. And to please send in a doctor who actually cared about attending this patient.
4
So gut feelings are really just a conglomeration of bits and pieces of objective facts pulled together into a hunch.
This is why many hunches shouldn't be ignored.
Disasters can be avoided by paying attention to hints from real behavior.
Those who knew Tony Bourdain was a depressed individual who had talked about wanting to end it all and then behaved for several days in a down beat attitude could surmise that he was in danger.
A direct intervention with him by asking if he was thinking about hurting himself might have averted his suicide and got him treatment. In actuality, he needed to be hospitalized with a suicide watch and antidepressive treatment until he was out of danger.
This is a valuable lesson learned from losing Tony so tragically!
6
Nurses spend much more time with patients than doctors .
Their gut feeling is the result of experience, not something born out of nowhere.
15
It is the “nurses spend more time with patients” that makes the difference. Nurses have the opportunity to see sudden changes in status—what was a sharp patient, for example” become confused. It’s not enough to order the lab tests—someone has to read the results and look for important changes. A good assessment begins with a good answer to the question: “what happened (changed) and when did it change?”
Of course "well-honed clinical instincts matter". If "it’s hard to get a doctor to listen", then it seems to me a nurse should be able to access some type of urgent review process...
5
As a now-retired psych liaison clinical nurse specialist on the medical units of an academic medical center, I don't know how many times I worked with distressed nurses who were trying to get the doctor's attention for a patient whose status had changed.
Although they mentioned "gut feellings" and I got it, that would not fly with the data-driven residents. So, we reframed it in words they could understand. So, Ms. Brown's feelings about her patient would best be dellivered exactly as she says: "[Dr, your patiend] ha(s) grown confused and her speech (is) garbled."
According to Patricia Benner, author of "From novice to expert", the expert, having seen a particular situation many times, no longer relies on a list of characteristics to explain her/his assessment. In the end, nurses at the bedside are the ones who shape doctors' reality and learning to be bi-lingual is helpful.
And if there is a trend toward what KA mentions, it has to do with nursing lowering its entrance to practice instead of raising it.
7
This column makes no mention of the opposite problem: nurses who dismiss patients’ concerns and symptoms and rely on a different kind of “gut instinct” when they should be reporting those concerns to a doctor. Too much of medical treatment is handed over to nurses who overestimate their abilities. In my experience, the care described by this author is the exception when it comes to nurses.
8
What we need to be careful about here is that we all remember when we were right and everyone else was wrong, but we don't remember when we were wrong and everyone else was right. When a doctor responds to a nurses hunch that something is wrong but she doesn’t know what it is not only is he spending resources to try to figure out what she is sensing, which may be nothing, but he also can not be working on other patients where he may know what is wrong with them and is trying to fix it. I certainly don’t know what the correct balance
6
Here in Canada more than half of all all medical graduates are female and we have lots of male nurses too. Not sure what your situation is, but imagine it is likely similar.
Speaking as a physician, I take the hunches or bad feelings of nursing staff seriously, because there is no downside clinically and it contributes to heuristic learning. In our frequently over extended clinical settings, communication is critical and always at risk.
Also, I’ve had those bad feelings too. I trust them as an invitation to pay closer attention. Sometimes when we work backwards from that ‘little warning bell’ and ask ourselves why something seems off we do identify objective findings that explain it. An otherwise well-looking baby boy with an unusually high heart rate who just seemed off (and who nurses actually weren’t worried about) turned out to have necrotizing fasciitis (flesh-eating disease). Moving him to the ICU before that became clear saved his life.
A last thought about the idea of another logarithmic tool to broach the divide between nurse and doctor: it sounds like it may be worth trying. It would not be a substitute for communication and teamwork.
8
A valid point, although it would be more compelling without the archaic gender roles of doctor = he, and nurse = she.
1
I believe in evidence-based medicine. However, it seems that the root problem here is not taking seriously the judgement ("gut feelings") of trained and experienced professionals.
Somewhat analogously, the software industry is full of quantitative sorts who want experienced and expert opinions (about software quality, e.g.) converted to numbers before they will take them seriously, even though the act of shoehorning a valid gut feeling into a number is usually painful and often largely meaningless.
5
Patricia Benner's excellent book "From Novice to Expert"- a classic when I was a young nurse ( possibly before the invention of paper)- articulately identifies the almost unique capabilities nurses have to detect, process and manage information that leads them to the same conclusions that this author is describing. It is a process of evolution for nurses, however. They don't graduate this way but there is something about how they accrue this information over time (becoming expert) that develops an analytical thought and action process, directing them to make some computer-like predictions about their patients which is different than acting on information in the present, such as in an emergency.
Interestingly, pilots, professional poker players and money traders (if memory serves) are the other groups that share these spitfire analytical capabilities. Note that doctors are not included on that list. Family members bring a different and equally valuable perspective of knowing what's different. There's a role for everyone to play in the care of a patient.
40
Family members can be a very important member of the care team—especially if they can articulate concerns in a way that helps medical team to be alert to things like (1) “Mom got really confused yesterday. She talked about seeing monsters and hearing voices and being afraid.” Team member: “Was she like that yesterday?” Or “Does that happen often?” “No.” Now the physician has good information to go with—sudden onset vs. gradual onset. This makes all the difference between a proper diagnosis of delirium (and proper treatment) and an improper diagnosis of dementia and improper treatment.
@Marney Prouse
Thank you. I have been thinking of this book since the first sentence of this article. I am a nurse-midwife and years ago wrote my dissertation using Benner's theory. I was trying to discern how faculty determined nurse-midwifery students were ready for "safe beginning practice." As soon as I saw "gut feeling", I thought Benner.
I hope nursing students and faculty are still reading it.
Family Doctor with 30 yrs experience here.
What the RN describes in this article I like to refer to in practice as the "maternal instinct".
Mothers will often say that something is just not right with their child too.
The key is to communicate it directly verbally to the treating provider(eg not the medical assistant) , and be persistent, and trust your instinct.
21
@CTMD - What tips do you have for patient who does communicate directly to provider but is still ignored, belittled, discounted, whatever you want to call it? The arrogance of many doctors I've encountered over my years is beyond belief. Because they seem to feel threatened by patients who expect to be believed and treated as a human, I have come to believe these are the doctors who don't know what they are doing, and they are covering up by playing mind games with patients.
1
@CTMD
So true
1
The author is correct about the difficulty of articulating such subtle cues as are noted by the bedside RN, as well as the wall that may be encountered when attempting to make oneself heard to the doc on call when, on paper, things may not look so bad. We are encouraged and required to supply EVIDENCE for our clinical opinions--and sometimes telling the doc,"She doesn't look right," just doesn't cut it. The Rothman Index can help, but so can a bit of practice in writing down and rehearsing ways to say such things in a calm, plausible manner: "The patient's affect & responsiveness to others has changed significantly over the last 12 hours. She appears almost obtunded, although her vitals have been stable and her labs haven't changed. I'd like you to have a look, please." The nurse/doctor relationship is now at its most collegial and professional than it has ever been before--and a good doc will listen & respond to the report of the bedside RN. We both have to do our parts to improve communication, use all the clinical tools available to us, and to allow ourselves the confidence to approach the MD with our opinion. Finally, I think it's incumbent upon experienced nurses to nurture and support the new nurses under our preceptorship and guidance, so that their communication & confidence flowers from the very beginning in rich soil.
62
While I agree with this article, in general, I echo some sentiments from other commenters. The first is that articulation, or communication, is key. The tagline of this article is “But I couldn’t articulate it”. Good communication is essential to patient care. The best nurses articulate their concerns promptly and clearly. Physicians with long patient lists are entirely dependent on nurses at bedside for changes in clinical status and for their assessment on how urgently evaluation is needed. I would argue the vast majority of doctors would not ignore a request for urgent evaluation. What really gets doctors is pager fatigue- a steady stream of pages regarding non urgent lab results or orders. Any concerns or changes should never solely be documented in a note, buried within piles on piles of notes I will never have time to dig through. Secondly, I want to emphasize that due to shift work, a given patient may have a different nurse every day- this lack of continuity is not given adequate mention in this article. Last, I am a young physician and already I am seeing those trainees younger than me spending even more of their day treating the screen rather than the patient. An additional “index” on the EMR is not the solution. We need to bring patient care back to the bedside and to do that, we need to free up time spent wallowing in superfluous documentation. A good first step would be streamlining and reducing EMR redundancies and having universal access to medical records.
74
WOW!! What you said!
Yes the EMR is a pathogen
2
EMR is definitely a two edged sword. No 47 pounds of paper med records arriving on the unit along with the patient nor trying to read hand written H&Ps that are unreadable d/t poor penmanship...but it is true that healthcare has become fraught with useless data entry followed by useless cut and paste workarounds in order to get the actual work of caring for humans done.
Well said. Ms. Brown. I often tell my nursing students that people stay in the hospital because they need NURSING care. The instincts and observations of an experienced nurse are critical to the patient's welfare. We are the ones who spend 24/7 at the bedside. I am not trying to diss physicians...they are a critical part of the team. But just as I listen carefully to the physician, they need to listen to the nurse who is actually there, full-time, at the bedside. We are a team.
44
General impression is a better description than gut feeling. Much clinical accumen seems like it is not data based, but it is. It is the rapid evaluation and decision of signs and symptoms that experienced and talented medical professionals acquire as they work. It seems like a “feeling”. However, the clinical picture sets in motion rapid recall of past experiences that lead to a sense of the possible course of events for a patient. It is not hocus-pocus. It is real expertise telling you the possible and likely future course of events. It is based on what has been seen.
12
The same is true when family members have observations and concerns. Those who know the patient best and have experience with him or her, and who may well also listen more attentively to that person should be heard and heeded. Too often the professionals who come and go, with many things on their minds, or perhaps not respecting lay people, don't do that. And very bad outcomes can follow because of it.
20
@jb or even the patient him/herself, may sense something is wrong and yet cannot communicate it or describe it.
2
Yes! I was just thinking that! Sometimes the person least listened to is the greatest expert on the patient--the one lying in that bed.
This is a series of anecdotes. We are hearing about the times that this feeling was followed by deterioration in the patient's condition. It is certainly important that if a nurse feels that something is not right with her patient she convey that to other health care providers. What is not known is the denominator - how many times a nurse has this feeling and the patients condition remains unchanged.
10
@Tom True, nurses can make mistakes. But the value of a nurse's experience is the ability to observe subtle signs and changes. I have also learned to listen when a family member says that something about the patient is different, and I never ignore that information. I would rather find that nothing has changed than miss something important.
17
“Change in status . . .” Well-communicated to a doctor can make the difference between a great diagnosis and a terrible one.
One problem with reading nursing notes is that the recorded thoughts of the nurse are very often buried in long sets of tables filled with numbers. It's often hard to find that meaningful narrative that a nurse records. One has only so much time when rounding. It would help if systems put the most meaningful information front and center and not bury it in the back
18
@Dan Urbach This is a problem with the EMRs. Computers prefer quantifiable numbers and charts, and narrative is seen as less valuable. As you state, the nursing notes should be easy to access and readily available. EMRs are generally designed by IT people, and not by the health professionals who need to use them.
25
@EthicalNotes
Your comment reminds of something that happened years ago. The hospital I worked at was building a new OR and RR without input from the staff. When we finally received a tour during the finishing stages, a Recovery Room nurse said, “where do you plan to put the monitors?”
The architect and designer did great with the esthetics but failed to take into consideration the equipment and where it needed to go.
1
I learned early in residency to take nurses' concerns very seriously and I've never regretted pursuing a nurse's recommendation when they think a patient is looking sick. As a nurse or doctor or other provider your gut tells you a great deal and you should learn to trust it despite normal test results. In morning report it was hammered into us to judge how the patient "looks". It's a gut feeling that is honed by experience in medicine and with long acquaintance with a given patient, if you're lucky enough to have it. About the patient you say haunts you, while you haven't said much about her condition, preventing bleeding in the brain is usually not possible in the acute setting. I doubt very much that there was anything you could have done to prevent it.
26
Doctors, nurses, and health care aides have so many patients and so many charting responsibilities that it affects patient care. This is why it's so important that one family member stay at all times with the patient in the hospital. If the family member can see something is not right, and holler about it, a lot of people working in the hospital will get irritated. But, it may save the patient's life.
19
@TH
Exactly correct. A strong and ever-present presence with a family member can dramatically improve outcomes. If you help staff with care by comforting the patient, assisting with more menial tasks that do not require expertise and engage with everyone to be kept involved, the patient benefits. It always ok to ask what is happening, what medications are being given and where is the patient going and for what test. Learn the names of all support personnel. Be engaged. Not only will things turn out better, but you might learn something. Errors do occur, be nonjudgmental. Your presence is a major positive and you can help accelerate recovery.
11
Great article. Really you are not only talking about having acute clinical skills but also acting as an advocate and activist for your patient. These are the keys to a great nurse in my estiimation and what I have always tried to do.
15
I’ve practiced medicine in an acute hospital setting for over 40 years. If a patient’s family member or any of our staff, whether nurses or not, tells me that something seems off with a patient, I go talk to the patient and/or gather additional information. I value the input and experience of each of these individuals and also value the assistance we can get from technology such as the Rothman Index.
Despite this I always find myself getting annoyed whenever I read This author’s columns. I don’t think I’ve ever seen her say something nice about physicians and it’s always easy to cherry pick experiences (like this) where ones instinct was right and someone else’s was wrong. I’ve had nurses be very astute but also had one call me frantically saying the patient was having a stroke. When I got there, after leapingbftom the on call room bunk, hitting my head on the ceiling and falling flat on the floor, the patient said he’d fallen asleep with his head on his hand and his hand went to sleep. I’ve also had times where my instincts (and direct written orders) were ignored by nursing staff with adverse outcomes as a result. Fortunately that has been rare, but it’s fairly common that nurse administrators refuse to allocate crucial staff and patients suffer.
In the end, we’re all humans trying to do the best we can to help patients with the resources we have. The more we can use creative technology to help, the better!
46
@NY MD
I feel the same way about her columns and wish she’d channel her platform into a force for good rather than the same tired nonsense every single time.
3
I spent 48 days in Acute Care at one of the great hospitals in Boston this past winter.
The biggest thing I came away with was that the nurses are the backbone of the hospital. They know their patients better than anyone. I am alive and well today in large part due to their observant, astute , kind and yet firm care. They are the best.
54
That was my experience as well at MD Anderson in Houston, Texas. I was there for over 100 days and I found the nurses to be knowledgeable, caring, compassionate, etc. I thank the universe every day for these professionals.
4
This op ed is a great wake up call because doctors, most regrettably, really are the weak link in health care. Their egos are so tied up in always being right that they'll far too often recoil from any suggestion that they may in fact be flat wrong in their initial diagnosis. And while it may be true there's a placebo effect to placing one's faith in the infallibility of doctors, one probably shouldn't indulge in such willful self deception without bearing it in mind that when it comes to cause of death malpractice and/or rank incompetence on the part of doctors is right up there with fatal road accidents and suicide. And in the case of the near elderly and the elderly doctors yield to no competition when it come to satisfying the grim reaper other than congenital heart disease, advanced dementia, and debilitating physical injuries of the kind that result from a serious fall.
3
I'm confused why a hospice patient was admitted to ICU instead of receiving comfort care.
14
@Susan Lemagie. She may not have been a hospice patient but ultimately it is because this is America. There are $ to be made and no one has the guts to have the conversation required. I saw a patient last week who wanted to be worked up for lung cancer. He has end stage rheumatoid lung disease, nothing to indicate any further issue, and has a prognosis that wouldn’t be altered by addressing a cancer if he has one. Admittedly I may not be the most tactful person but ultimately the answer is “you’re gonna die.”
2
@Susan Lemagie Perhaps the author was not a hospice nurse at the time the incident with this patient occurred. She said it was years ago.
1
@Susan Lemagie
Thanks. Question I wanted to ask.
I have been a nurse for 41 years. Nurses are responsible for so many autonomic system functions-- so subtle and yet so important separately and taken together-- balance, blood pressure, elimination, swallowing, energy, breathing, cough, mobility, appetite, color,motility in various systems, temperature regulation, plus mental attributes of memory, strength and coordination, hearing, vision, taste, orientation, mood, interaction, judgment, pain, planning, motivation,optimism, anxiety, sleep, attention, consciousness and so much more. When you have taken care of many patients, you come to notice the ones that are a little different from the usual or a little different from their usual. "Gut feeling" is not unscientific nor uneducated, but it is a way to enlist more help and mobilize more attention. I recall a young woman who arrived in our epilepsy clinic who just did not seem right in a difficult to describe way-- she was in absence status.
The converse presentation of a gut feeling is also true in its power--when a nurse assesses that a person is doing better or is making tiny steps of progress. I think patients derive a great deal of comfort to sense from their nurse that what they are experiencing is not unusual, or can be managed and helped, or is showing a little improvement from earlier. My patients study my face as much as I study theirs. The communication of honesty, empathy, and unwavering attention takes the science of biology and transforms it into help.
26
Beautifully expressed.
3
NYT, you have failed me in a particularly annoying and, frankly, stupid, way that I do not expect. This is an article about the Rothman Index as a key tool for patient care. The Rothman tool is a graph.
There is no illustration or photograph of a Rothman graph in this Opinion piece.
What was the point of publishing this story without an example of this graph?
12
@Jzzy55, I think most of us understand without it.
@jb I don't know who you mean by "most of us." Just how well does a vague written description explain a quantitative data display? There's a whole body of science developed around visual displays of quantitative (and qualitative) information. I worked in sci-tech publishing for years. Whenever possible one uses visual examples because they are much more readily understood, retained and recalled. And anyway, this is an article about patient care that hinges on the existence of a key patient care graph, without an example. WTH.
I am a physician and although the author seems to believe it is only nurses' notes that doctors ignore, in fact doctors also ignore other doctors' notes.
When I do consultations on patients I always make sure that if there is a serious issue that needs to be addressed that I speak to the referring doctor or team as I know that they may often not even read my note.
Similarly, I expect nurses to tell me and colleagues to talk to me about any problems they detect that they believe to be of significance in our patients as so much of what they are expected to put into their notes are routine things.
Both these things take time from busy people but as lives depend upon us doing things right, it's worth doing them.
89
Put a place in that Index for warnings from family members, too -- and from patients themselves.
20
Years ago, my sense that something wasn't right saved a child's life. This boy, a doctor's son, had been admitted with unexplained injuries (parental abuse suspected). I decided to check him just before I went to lunch, even though I'd done so a few moments before. Examination revealed that one of his pupils was largely dilated. The neurosurgeons took him right to the OR, and the boy did well following surgery.
This happened in one of the best known children's hospitals in the US. When a clinician thinks something may be wrong, chances are that it is.
33
The same thing happens to observant nurses as happens to observant doctors. We have gut feelings that something is not right, and some of the time we are correct. Observant nurses of course are the same, and can play a role in alerting everyone and beginning the diagnostic process to figure out what’s wrong. Who would argue otherwise? Is there someone out there (in real life, not a TV show) that doesn’t think that nurses can observe their patient and tell when something isn’t right?
That is not to say that everyone’s hunch is correct, again the same with doctors, nurses, or anyone else that is around the patient. Lots of things turn out to be the opposite of our hunches, and staying open to that possibility also is prudent. Not every hunch is a catastrophe waiting to happen.
I guess my overall reaction to the article is: of course all this is true. Therefore we remain vigilant, and consider all factors, and observations of everyone. So what is the point of the article?
11
@Doctor The point of the article is that I'll bet very nearly every nurse out there can point to an instance where s/he brought a "gut feeling"-type concern to the medical team, they squinted at the numbers in their computers for a bit and decided nothing was wrong, and then the patient suffered a negative outcome related to the concern that was not acted upon. The point of the article is both to illustrate a tool that has been developed that highlights the value of quality clinical assessment, and to emphasize that it matters that the bedside nurse be able to catch and call attention to the minute changes in patient status that unfold over a 12-hour shift.
29
@Doctor
The point is, a nurse spends at least 200x's the amount of time with a hospitalized patient than a physician does. This article is not about a doctors hunch, it's about a nurses hunch. You can't always be vigilant on your own. That's what we are here for. Why do you feel the need to bring your own perspective in to everything. Ugh. Something tells me that you are the kind of "doctor " I dread having to talk to.
Not everything is about you.
@JustANurse
please please don’t EVER call yourself “just a nurse”. Nurses are too important for “just”.
During the long declines of both my aunt and then my mother, I saw too much of the attitude that "something will get her soon" that seemed to stifle action.
My mother rallied for another year and a half after we had "the meeting" with two doctors telling us to give up, that she very likely would never wake up.
During that extra year and a half, her grandkids spent long days with her doing 24/7 care, not too demanding but needed for her to stay at home. They bonded. It seemed to be a real pleasure to all, and the kids grew and benefited in ways clear still. It was one of Mom's last great accomplishments that she listened to them so well, and was heard when she advised them.
The doctors were wrong to counsel "do not revive" and to accept, giving up.
Later one of the rehab nurses told her that, "we had given up on you." Mom was a bit shocked to hear that, and repeated it a lot.
End of life comes, but it does not always come when expected, in either direction. We mustn't assume what we can't know.
24
This is such a thoughtful and important post. I had to fight hard with hospital doctors who had only just met my mom, also family, who all bluntly told me that my mom didn’t have the RIGHT to decide if she could be given a chance to live. Not one doctor even asked the patient. So much easier to just let her die when it was (others) poor medical care that caused the emergency! They finally backed down and she was treated and then sent to rehab. She lived another 2 1/2 years. During that time, though frail and in a nursing home, she touched many lives for the better and resolved her life’s loose ends so when she did pass on, it was on her terms and peacefully. Treat the patient with dignity and listen to them, as you hope to be treated when your time comes around.
1
Effective communication between clinicians with different observation vantages provide the care coordination that might make a difference in the types of cases reviewed in the article.
Two continuing trends in present day acute care medicine make such communication less and less likely. The first is the EHR [electronic health record] as currently constituted. First of all the cutting and pasting and slotting in of results leads to bloated documentation which includes [often inaccurate] miscellany from throughout the hospital course and before in each progress note, making the small daily clinical shift essentially impossible to detect by review of the chart. Additionally the data entry screens of the nurse, doctor and every other clinician is different, and the printed chart is indecipherable to all because its formatting is even more arcane, so that each discipline is effectively more locked in isolation.
The other factors which preclude doctors from paying attention to other clinicians is their training and reimbursement. Because the training remains hierarchical, young insecure physician trainees are commanding experienced nurses and other clinicians. To emotionally gird themselves, they become intolerant of criticism and input, and now communicate only by EHR. Finally the reimbursement and measurement of their "quality" is also only based on the care of the EHR not the patient. The system will only deteriorate if we allow current trends to continue.
33
@TVCritic
By "trainees" do you mean medical students, interns, residents and fellows?
@Brad C
Yes.
Most hospitals now have a system in place to deal with minor changes in a patient that cause concern, or even to act on a nurse’s instinct or “gut feelings.” Nurses who notice subtle shifts in a patient’s vital signs or condition, or who just feel that “something “ is wrong, can call a “rapid response .” This alerts a special team including a doctor and usually an ICU nurse to come and evaluate the patient. Nurses are told not to worry that they might be wrong, but to call and let the Rapid Response team figure it out, with the hope being that patient deterioration can be caught earlier, before it becomes critical.
23
@Bernadette
In my experience rapid response teams are more geared to unstable clinical parameters, not sufficient to call a code, but certainly more overt than the findings in the cases described.
The subtle changes noted fall back to the primary physician and other clinicians who follow the patient over the hospital course.
1
My first child turned out to be in a double footling breech presentation. It wasn't my (excellent) obstetrician who determined that; it was the shift nurse who had concerns about the progress of my labor and suspected that something was amiss. She took it upon herself to get me to imaging to confirm her suspicions, at which time my obstetrician was called to perform an unscheduled Caesarean.
My daughter was partly named for that nurse. And I will always be glad that I gave birth in a facility and era that could create a good outcome for an unforeseen double footling breech.
84
Like Mrs. Brown's feelings here, but it's hard to state if chemo earlier would have saved that acutely presenting patient. It's just too difficult to tell. As a physician, I wish pieces like this one would have used examples that were more clear cut. There often might 2-sides to the story and we didn't hear that of the "slow-moving" physicians. Even in the case of Mrs. Rothman itself -- it's hard to tell if the tamponade didn't happen later (after discharge), if it could have been prevented or even treated if caught in the hospital. As for the Rothman Index -- great - let's use it -- but, if it proves better than a nurse's gut in a head to head study. That being said, we should listen to caring nurses -- their extinct is hard earned and well honed. They are trying to care for the sick, just like physicians.
13
@beskep (instinct)!
I have been a nurse, an ER nurse, since 1995, I've been an ER ARNP since 1999.
As someone firmly situated between the staff nurses and the Md's I am in a unique position to see both sides of the fence-so to speak.
In my current ER practice, I find that all of the providers put great value on the nurses Gestalt, that sense that something is amiss, I'll even go as far as to say that we rely on the nurses to notify us that there has been a change in a patient's status. We have to, because oftentimes we are multitasking both the critically ill patient and the "my ear has been hurting for a month"
I hesitant to say that another algorithm, another form-as helpful as it may seem-only keeps the nurses in front of the computer and away from the beside where they want to be, and where they belong.
77
Exactly, if you operate as a team and not a hierarchy then you provide the best care for patients. That means valuing all the team members experience, education and responsibilities on behalf of the most important person , the patient.
The arrogance that it takes to think you have the most important role and voice is mind boggling. Nurses in hospitals are the primary care givers of patients, they know the drill and their patients. Listen to them as valuable members of the team
15
I would see the first case a little differently. A skilled nurse noticed a significant amd crucial change in the patient's mental status, a finding which will frequently not be reflected in changed vital signs or lab tests until too late. The medical team chose to ignore this critical observation because it was made by a nurse.
Nurses' observations are critical patient care information. Unfortunately, in the electronic medical record they are very hard to find without a special effort by the doctors to review them. Placing nurses' notes in the same place as physicians' noted would make a difference.
It sounds like the Rothman Index might help, but as long as doctors ignore nurses' observations due to lack of respect it won't help enough.
Jack Kashtan MD, FACS
83
I learned early on that you listen to nurses. It took a while longer to appreciate listening to patients. “Gut feelings” aren’t gut feelings they are observations we make that we can’t quantify or adequately put into perspective. That certainly doesn’t mean they should be ignored. Instead, like everything else they must be put in context. The alternative is to ignore subtle observations until they fully declare themselves. We once talked about the art and science of medicine. The most brilliant physicians I have ever worked with were the artists and they had the best “gut”
27
I agree wholeheartely and think the Rothman Index is crucial to good patient care, but just as important, I believe, is continuity of care, and in our local hospitals that is difficult to find. When my sister was recently hospitalized as a result of a hemorrhagic stroke and was in neuro ICU, she had only one nurse who saw her three days in a row; in the remaining 20 days in ICU she had 9 different nurses on day shift alone, and as a result, no one knew what her 'normal' was so were not aware of the minute changs that her family could see. I realize that staffing shifts is difficult, but I believe unless nurses monitor and get to know their patients, these minor danger signals will comtinue to go unnoticed and perhaps result in unnecessqry deaths.
97
I call it Cultivated Instinct. A good RN has it... but it takes time to develop.
15
My MDs are highly trained newbie GPs and their supervisors in the setting of a most prestigious teaching hospital. Over the years these professionals spend more time looking at the lab results than at me. My body is hardly ever touched, my movements and gait never reviewed - I have basically become the dehumanized sum of my lab readings. In this context nurses are the only ones who see patients as people and who pay attention to all aspects of a patient's condition: skin color, breathing, coherence, sleep patterns, and such. These are not gut feelings but conclusions based on years of experience and training. One would hope that medical teams would pay attention to these invaluable insights, even if they are not always quantifiable.
99
Your grave mistake is giving in to the insistence that everything must be quantified in the first place. This "scientific" standard ignores human emotions, human experiences and human differences. And as "evidence-based" data have taken over human-based knowledge (even in mental health counseling), many patients have suffered. I finally convinced my primary care physician of 15 years that I'm not an algorithm. My care improved dramatically when he looked at me and listened to me instead of journal articles.
26
I learned the complementary lesson early on in my medical training. One night I was paged by a nurse who wanted me to place an order for a sleeping pill for a patient who couldn’t sleep. When I asked what the trouble was, the nurse told me that the patient was just anxious. As an new intern terrified of making a mistake, I decided to go and check on the patient. It turned out that she couldn’t sleep because she was in florid heart failure and struggling to breathe. She was urgently intubated and sent to the cardiac ICU. Acting on the “gut” assessment of the nurse would have killed her. The lesson I learned is that no one should base patient care on someone’s gut feelings. If you have a concern, go and evaluate the patient! This applies to nurses, doctors and every member of the care team.
215
@lrubin I am 72 and in excellent health. One of the worst things I can imagine is waking up in a hospital on life support. I wear a medical bracelet with the inscription: DON'T RESUSCITATE OR INTUBATE
1
@lrubin you might be missing the point. Sounds like you acted on your own gut feeling instead of the black and white report of that particular nurse. I guess, kudos to you for trusting your instinct... But I pray you are not the provider that ignores others instincts because you think only yours are valuable. Don't confuse a nurses "gut feelings" with their basic report of the events that are playing out.
Gee. I wonder what would have happened if that nurse never reported the patients difficulty sleeping in the first place....
Bleh I'm glad I don't work for many of these physicians.
1
@JustANurse Really? You "guess" that lrubin should get kudos for following her instinct? You seem to think we should be down on our hands and knees thanking you for following yours. This was a case of both doctor and nurse doing what was necessary, yet you want to keep bashing the doctor.
1
I am a retired hospital RN, and I can not put my finger on it, but there was many a case when my instincts prevailed over what was on paper. These involved not only insidious changes in a patient's condition, but also errors of my fellow co-workers. The latter, because of an unwritten code of professional courtesy, needs to be handled diplomatically. However, it can not be ignored, not at the risk of the very person whom we have an ethical responsibility to care for.
One commenter, and I thank him, mentioned how crucial nurses are in the healing and treating of the ill...and also how at times our assessments are not taken seriously by our doctors. I thought back at a time when I stood up to a head nurse's assessment and then the patient's doctor who was reluctant to heed by urgency. He did, and he later thanked me for detecting ventricular contractions which were life-threatening. As a final thought, I was taught to take notes on all my patients. Even if I did not have time to run to the desk to officially chart a situation, I took a few seconds to write down any red flag occurrences. Documentation is invaluable.
58
In my medical experience, insurance companies control the diagnostic system. Doctors know this. So no matter what your malady, you will be diagnosed based on insurance company directives, not on medical results. Nurses work under this flawed system. And obviously they may be frustrated because they can not change it. It is important to return medical diagnosis to practitioners and take it away from the insurance companies.
72
@Mark Hermanson. Can you explain further how diagnoses are based on insurance company directives? Thank you.
2
@allison: I think what he means ("nurses work under this flawed system.") is that without insurance you are unlikely to get a diagnosis and subsequent care. Of course, I'm just guessing and being a little hyperbolic. But, the system is flawed. It's why one of the first questions asked is "Do you have insurance?"
A few years ago my new young associate physician walked into our office at the hospital late at night and sat down to begin her overnight shift. She answered a page and then got up and headed for the door. I asked, “What is it?” and she said, “I don’t know, the nurse said to come right now.”
That’s the kind of doctor I want taking care of me when I’m sick.
303
I don't want one more machine to substitute for the warmth of a hand on mine or a kind word. Suppose the machine failed? Maybe a nurse who listens to her guts would be available?
18
We need to get rid of the phrase "gut feeling" when it comes to trying to make sense of a patient's changing status. It is not a phrase that communicates anything of value and is not respected by physicians (and it shouldn't be). Such "feelings," as the writer articulated, are not at all feelings but "are agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment." They need to be described as clinical observations with objective data. Physicians may still not take our comments seriously but let's start by getting rid of this idea that our gut is doing anything other than tell us when we're hungry.
102
If I am in the hospital, and a nurse has a gut feeling..I'll take her advice and hope doctors do too.
11
@lmsseattle
sorry, but 40 years of ER nursing, and it IS a gut feeling. I am proud to have kept my 6th sense intuition intact. hurray for the gut feeling!
6
Google " microbiome"
In 1991, my 3 year old underwent a complex heart repair. Among many of her post-op complications was one that she was unable to wean off the respirator for several weeks. It was frustrating and puzzling to all of her very fine,skilled doctors and specialists on her team until one of her ICU nurses noticed that her belly didn’t draw in evenly or bilaterally during breaths. This nurse’s keen and patient observation skills led to a diagnosis and another step toward my daughter’s recovery. Talk about ‘gut instinct’ (pun intended).
168
I find it incredibly hard to believe that the patient's hemorrhagic stroke didn't result in any focal neurologic signs. Rather, what I suspect happened, was this: The nurse paged the doc and and said: "The patient is confused and has slurred speech" ....and the physician responded with :"And so do 50% of hospitalized, critically ill blood cancer patients...." and so thought nothing much of it and attended to other more-urgent sounding matters first.....If, on the other hand, the RN had fully assessed the patient, she would have noticed (a) that patient's speech was not "garbled" - it was aphasic; and (b) that patient did not have "confusion" - she had an acute change in level of consciousness.... If those objective findings (aphasia and obtundation) had been communicated to the physician, I promise you that s/he would have come running!! Code strokes are taken very seriously, and have been since the late 1990s.
40
'If on the other hand the nurse had fully assessed the patient?'...Followed by guessing at the findings of the assessment and the doctor's response? What is the basis of your guess work? Clinical symptoms that are subtle may not elicit intervention. It doesn't mean that the nurse didn't do a thorough assessment.
16
@LM - I'm a stroke Neurologist and know from treating hemorrhagic and ischemic stroke patients every day that there _are_ focal findings on exam. Sure, I'm guessing about what those focal findings were in this particular case based on the colloquial descriptors used in the article but am certain they were present and would have been found if looked for.... This truism ( the presence of focal findings on initial clinical assessment) is the entire basis of modern acute stroke care, and it works!
1
Your points are good ones. However, if the physician knew the patient s/he would have known this was a change from the patient’s baseline.
1
Having been a nurse for 40 years I appreciated this article. I also appreciated some of the remarks from physicians acknowledging the value of a good nurse, both for them and for the patients. Most nurses give their all to provide quality care to their patients- long days with few bathroom breaks, if lucky, a short lunch, documentation demands ever increasing. The Rothman index is a good tool to quantify subtle changes in a patient. Sadly, staffing patterns often are insufficient to provide patients with safe, quality care.
150
The key word in the story and in all the comments is listen. I have a family member in the hospital with sepsis because nobody listened to her.
122
@Raven Senior
And Serena Williams could have died after childbirth because the hospital staff didn't listen to her at first when she felt an embolism coming on. A patient who has had previous health issues should be listened to.
I was a junior resident at UCLA. A patient I was responsible for had undergone a partial nephrectomy (partial kidney removal for a kidney cancer) earlier that day. It was about 02:00 a.m.. I had gotten home maybe an hour or so before that. I had been on call the night before and was whipped. I had just dropped into a deep sleep when I got a page from a nurse caring for the patient. When I called her she said that the "patient looked vague". I asked her what the patient's vital signs were, what the patient's urine output was and what his labs showed. All were normal. She remained insistent that the patient "looked vague".
I sensed her discomfort. I turned to my wife and said "I am going into to hospital to assess a 'vague patient'".
By the time I got there, the patient had turned from "vague" to profound hypovolemic shock. We resuscitated him and he walked out of the hospital upright rather than feet first. Were it not for nurse Gina recognising "vague" the patient would have died.
From that point on, I never questioned the insights of the nurses directly dealing with the patients. They have a sixth sense and are the best advocates for patients. I have beat this concept into my residents/registrars for decades since. God bless the bedside nurses/sisters.
608
@Aaron of London I have to add that this occurred in 1978 and it still resonates with me 40 years later.
28
@Aaron of London
Thank you. Though I’m now retired I am pleased to read your comment. I’m sure many nurses who are still practicing will be pleased as well.
2
You are to be commended. To leave the comfort of bed when exhaustion dominates is an admirable act. It would seem that males too have intuition.
1
Not a believer in "gut" feelings but attribute to a cognitive "sense" when a patient is declining. A good nurse notices very subtle changes: slight change in VS, color, mentition, etc. And then, the nurse needs to work in an environment where that "sense" can be shared, acted upon, not derided or ignored. The best physicians ask and listen. That's very rare. Preventing codes is boring. But, that has been my aim for 4 decades as a nurse. 100% successful to date.
122
I too have been fighting that fight for 4 decades . At least now we have “rapid response” teams. Usually the only way to get an ICU bed, instead of “watching” them until they arrest.
This idea sounds like another beeping machine to me, another way to convert the patient-doctor/nurse relationship into a patient-machine relationship. The other troubling thing is the idea that the metric for successful patient care is whether you can keep that person alive for a few days longer, which seemed to be the case in this article. What about quality of life in this new data driven way of managing patients? I am a person, not an automobile, yet it seems that medicine looks more like how my car is fixed these days.
5
Nurses spend more time with patients than doctors do. I would want my doctor(s) to listen to their “gut instincts” as indicators that need lab work, documentation, or further diagnosis. Doctors without nurses would be something like an oxymoron.
31
Also crucial to being an excellent nurse is the ability and inclination to listen carefully to the patient’s family member(s). Close family can sometimes pick up on the patient seeming “off” when medical staff cannot, and sometimes that family can articulate in what ways s/he is off. The nurse can then tune in to the signs and/or can intervene with the doctor on the patient’s (and family’s) behalf.
I cannot say enough about the ER nurse who listened to me this past spring concerning what I noticed in my supposedly fine-for-release family member.
Credit also goes to the doctor who then listened to the nurse, asked to speak directly to me, and emphasized how important the info I provided was. She admitted my family member. Within hours, my fm had a high fever and trouble breathing. The story ended well after a seven-day stay.
Again — the happy ending began with an excellent nurse who paid careful attention to what I was saying and then followed through ...
229
Wait -- where is the evidence that nurses' gut feelings and the Rothman Index are ever in line with each other? Have these gut feelings ever been tracked and shown to be accurate indicators?
This nurse is haunted by a single event that happened "years ago." How many times since then has she had a gut feeling of impending calamity that was not followed by calamity? Has she forgotten these times, or dismissed them because they're not so intense a memory?
If every nurse's gut feeling of impending calamity is followed to the end Ms. Brown proposes, will we have an even higher epidemic of over-testing, over-treating, and the resultant medical errors?
This article has only anecdata, when what it really needs is actual data.
20
@Capri
I am one of those nurses who has had that gut feeling and acted on it and fortunately for my patients, 2 specifically, the doctors listened and responded to the urgency I sensed and both survived thanks to the docs responding. One was a liver rupture which patients rarely survive in pregnancy and the 2nd was a patient headed for a rupture but was treated quickly enough that the liver had a hematoma that would have ruptured within a couple of hours.
78
@Capri
Logical Positivism died in the '70s.
Continuity of observation is real data. Years of experience is real data.
20
And if the goal is truly saving lives, why is this Rothman Index a commercial 'product' instead of something simply evaluated and then shared through medical literature?
1
I think that the problem here, is that when expert RNs have this feeling, and we get them often, we need the skills and education to analyze, and articulate our findings to physicians. It isn’t enough to “push here and there”. We need to be ready to to clearly outline our findings, and create a plan to protect the patient. Nurses need advanced critical thinking skills that are not taught in all nursing programs, and also the ability to communicate their findings in a way that physicians can hear them. And when that has been done, to no avail, nurses must be able and willing to advocate more aggressively for the patient. Nursing is the most difficult baccalaureate program to complete because it is a very demanding profession, and we wear many hats. But patients in hospitals are sicker, and it is only getting harder to do our job well. We do often save lives when we pick up early signs that a patient is starting to fail, and this is a gift when it works well, and a curse when we remember the ones we couldn’t save. We all have a few of those, and while painful, it makes us better the next time.
126
The patient is not "starting to fail." The patient was failing before she got there. That's why she is there.
3
I was with you until you said that nursing is the most difficult undergraduate degree to complete. First of all—where’s your data? As a second career nurse with a first BA in comp lit from an elite school and later returned to the same elite school for a BSN, the difference was laughable. The comp lit degree was MUCH harder and taught me critical thinking and writing skills that allowed me to ace the BSN program without really even trying.
1
Thank you for this piece. There are so many aspects of case taking and understanding our patients that are methodical and logical, happen in a predictable order and include a good clear review of systems. Care in and out of the hospital setting also includes nurses and doctors observation skills, being keyed into the kinesthetic parts of the experience with a patient. Our observations are so essential and of course they are most important because of the questions they lead us to ask. When I teach naturopathic medical students, we always include this aspect of being a health care provider. In our time of EMR which has providers noses in computer screens and less with the patient, this piece is a clear reminder that we must also prioritize connecting with the patient. So the Index described here and the use of AI based on big data is important. And connecting with our patients and honing our observation skills is also where we find the art of medicine.
9
@amy rothenberg ND Naturopathic? Do you mean osteopathic or allopathic? 'Naturopathy' is not a medical field, and 'naturopaths' are not doctors nor med students.
1
@John
Osteopathic physicians receive the Doctor of Osteopathic Medicine (DO) degree. Their education is comparable to a Doctor of Medicine (MD) degree. DOs and MDs have privileges at the same hospitals.
See osteopathic.org for more information.
The commenter seems to understand what you’re saying. Hence them asking if the OP meant “osteopathic or allopathic”, AKA a physician, as opposed to Naturopathic, AKA a shaman.
I value a nurse’s opinion in a visceral way I can’t deny. I thank them for their perspective constantly. Yet the general notion that an 87 year old woman’s failed procedure merits consternation may be more of the problem than the visceral information’s denial. Accuse me of a cold heart, or ask yourself what you say when articles percolate about the desperate plight of shore line property owners in the face of rising tides. I have both elderly parents and shoreline property, but a sober perspective is called for, as well.
19
@Boxengo OK, since you ask: You have a cold heart. Saying someone is 87 or someone is rich is not an admirable diagnostic tool.
2
When will we admit that death is not always the worst thing that can happen? Why should we expect an 87 year-old patient to live on and on? At 82, I dread the thought of being caught in the American health system, which will refuse to help me die comfortably of old age.
217
Thank you for this post. My mother just entered hospice at age 85. My heart aches and I want her to keep fighting but my brain says we need to let her go
29
@Joe. What are your mother's wishes? Has she raised you well? Can she look back on a life well lived with contentment? Are there conversations that still need to be addressed? Is she at peace being enveloped in your love and care? Best wishes to you and your family. Many of us are with you.
6
@jani
You're absolutely right. End of life decisions are difficult and often procrastination is the result. An Advanced Directive is a legal document in which you can direct how you are to be treated when you can't speak for yourself. Without one, the medical staff will decide for you.
5
Back in the days of no work hour limitations (36 on 12 off) I started my internship at Maimonides Hospital in Borough Park, Brooklyn. During orientation a second year resident gave us a word of advice. Listen to the nurse about the patient's condition. They spend more time with the patient and can pick up clues about the patient by their interactions.
Five decades later it is still good advice.
Dr Ruth Jacobson if you are still out there. Thank you
341
@Teaching Doc
Maimonides was a great place to train. Was Dr Grob your chief. Keeping the ratio of patients to nurses low and giving RNs time at the bedside is what results in great care. The quality of care and outcomes is heavily dependent on the nursing care. Smart docs listen to the nurse!
33
Dr Grob was the chief.
1
Well, this is timely. My brother has has two re-admits, with serious setbacks, following a 'successful' June 21 back surgery.
Fortunately, since last bounce-back to hospital, in mid-July, kept for another 3 days, he has managed to stay home.
But if anything goes haywire again, we will be asking: are you using the Rothman's Index?
21
How old is your brother? What comorbidities does he have?
1
During my career in Internal Medicine, starting when I was an intern in 1969, the first thing I did before going into the patient's room was ask the nurse how the patient was doing and ask her if she had any suggestions. I learned very early in my career that the nurse could save the patient's life and very often my reputation. Somehow, the nurse has never been high on the totem pole at the hospital. Doctors ignore nurse at their peril.
425
@Alan Feingold; Could not agree with you more. I credit nurses with a lot of my success as an internist, and welcomed their input on the wards and the ICU. On one occasion I was advised not to leave the unit for lunch just yet, even though the patient had seemed stable to me on morning rounds, and within minutes all the clinical signs one could want manifested in a crash. Always trust the senses of a good nurse.
165
Great essay. In the case of hospital admissions, nurses spend far more time with patients than physicians do. And even if they don't interact with the family of the patient, they observe these interactions.
In my time as a medical educator for a hospital system in the Mid-Atlantic region, I was -- quite simply -- astonished that interns and residents on rounds didn't ever ask nurses about the patients they were rounding. My role was teaching these novice physicians about the importance of communication skills -- what many refer to as bedside manner.
In healthcare, communication must forefront a systems approach and nurses are incredible resources that could (and often do) provide vast amounts of information that can't be gleaned from a chart.
140
Ms. Brown is right not only about nurses trusting their instincts and speaking up but also the need for the care team to listen. This collaboration worked as it should when we brought our coughing and feverish infant son to the emergency room at Morristown Memorial Hospital (Morristown, NJ) five years ago. After a careful exam he was diagnosed with a not uncommon case of Respiratory Syncytial Virus (RSV). After a consultation it was determined we could take him home and follow up with his pediatrician in the morning. When the ER nurse came in a short while later to help complete the discharge, her “gut” told her this case was on the serious side and, in her words, “she didn’t like what she was seeing.” With our discharge papers in her hand she brought the care team back in, talked them through what she was seeing, and they agreed that something wasn’t quite right. He was admitted right away and his condition worsened overnight as treatment intensified. Happily, after a scary few days, he rounded the corner and never looked back. We are always grateful to the nurse who trusted her gut and to the team that valued her instincts — even if was something they couldn’t quantify.
434