Guest Post: A change in perspective may help build better physician relationships

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

I’m an old (and I do mean OLD) ICU nurse. As a working nurse, my relationships with physicians usually centered on getting them to listen to my assessments: Yes, you need to get out of bed and come see this patient who has stopped breathing! And getting them to do what they should to care for the needs of their patients: Yes, I could really use a new central line for the 17 vasoactive infusions you’ve ordered!

I respect their level of education and their place on the food chain, but each physician operates on an individual plane of competency and personality for which I sometimes had to make adaptations in my approach.

When I worked in ICU, there isn’t much I wouldn’t do for a nice, polite doctor who showed respect to me and the patients. I knew how hard it is to become a doctor, and how really hard it is to become a good doctor, so I used to try to help the physicians by writing out a verbal order and having it ready for his or her signature. I would try to have all the necessary supplies ready ahead of time and if something additional was needed, I’d be the first to run to get whatever else was needed. Nice physicians got to sit in my space to write their progress notes. I even shared my Twizzlers.

Conversely, if you were a mean, crotchety doctor who didn’t show respect to nurses or patients, I wouldn’t be necessarily unkind but I certainly wouldn’t go out of my way to make your day better. I probably wouldn’t have your orders written and ready for your signature, I would show you where the supply closet was rather than get your materials ready for you, and I’d most likely not let you use my spot at the nurses’ station to write your notes. And no, no Twizzlers for you.  Ever.  Because you have to be a nice person, first and foremost.

In 2008 I left ICU and became a CDI specialist. Nobody knew what that meant, least of all the doctors. They just knew that I left on Friday wearing a white uniform and stethoscope and came to work on Monday in street clothes, pushing a computer on wheels.

When I was no longer running cardiac outputs or sending off specimens for C.difficile, they could no longer comprehend my new role against their earlier vision of who a nurse is and the role nurses play in patient care. I had to create a new identity and that meant redeveloping my existing relationships.

My biggest surprise came from a doctor I’ll call Raquel (since that’s her name). Raquel is a wonderful, hard-working physician who always seems to get the most difficult cases. She works too many hours. She eats standing up to save time. When I was an ICU nurse, I was always happy to have Raquel taking care of my patient, and she seemed just as happy to have me as her patient’s nurse. We got along very well. So I was unprepared for the way our relationship changed when I changed roles.

I quickly learned that she really, really hated the idea of clinical documentation improvement.  She refused to be educated on coding or documentation standards. If I asked her a question, her usual response was: Give me the chart and tell me what you want me to write!

I tried to reassure her that she had the right disagree with something I’d asked and that I would never pressure her to document anything she couldn’t stand behind, but she would roll her eyes and say, “Whatever.”

Physicians are frequently pushed to discharge patients approaching or exceeding their anticipated GLOS (geometric length of stay). Over time, however, physicians learned they could buy their patients more hospital time if the patient had additional comorbidities. Under such circumstances, the physician’s documentation could change the DRG assignment and therefore the expected GLOS.

So, Raquel would brandish the census report at me, and demand I tell her what to write to help increase her patient’s length of stay. From a compliance standpoint, of course, I couldn’t give her that information. Instead, I tried to help her understand how to document the different diagnoses that accurately fit the patient’s presentation.

I clung to the fact that she knew me and respected me as an ICU nurse. I tried to build on that previous relationship and eventually learned how to work around Raquel’s displeasure. I even learned that she preferred KitKats to Twizzlers and made sure I always had enough to share.

There were other difficulties to face regarding Raquel’s clinical documentation. Her handwriting is abysmal. It is probably the worst doctor scrawling I’ve ever read, not a good thing in a hospital without an EMR. The director of HIM threatened to require her to dictate her progress notes; that didn’t work because the transcription company complained that her accent was so strong they had trouble transcribing her dictations. I was faced with progress notes I couldn’t read and dictations that took at least an extra 24 hours to transcribe.

Almost every day one of the coders asked me to help them decipher something in Raquel’s notes. A surgeon who requested a consult from her became upset when she couldn’t actually read the information in Raquel’s report.

You may think all this would be enough to cause Raquel to change her ways but any mention of difficulty reading her handwriting, no matter how delicately phrased, would lead instantly to an angry, defensive, and hostile encounter. I once asked her to help me understand a line in her progress note and she stopped talking to me for three days.

Finally, I came upon a solution. If she didn’t want to be bothered writing out extensive notes and lengthy reports maybe simplifying the process would work. Maybe checkoff boxes could help. If she had choices that required less writing, perhaps she could be more careful with the words she did have to write.

I developed a personalized progress note for Raquel that met all the requirements for physician documentation and billing purposes. I asked several physicians for their input and review, and it was approved as a hospital form.

Raquel hugged me and thanked me. Eventually she had the highest positive response rate to my queries of any physician in the hospital.

Perhaps I need to rethink that earlier ICU nurse’s viewpoint. Perhaps mirroring the physician’s attitude isn’t the best method to build relationships. Maybe it’s better to figure out the best way to help an individual and work on building a relationship from there. And sharing Twizzlers—or KitKats—always helps.

Editor's note: At the time of this article's original release, Brown was an independent CDI consultant based in Carrollton, GA. With experience in critical care, nursing education, disease management, case management, and long-term care, she has worked as a CDI specialist, educator, director, and consultant. She is a frequent writer on topics involving clinical documentation and published her own "The Case Manager's Quick Guide to Diagnostic Related Groups" in 2013.