S1E5: Working With Physicians

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Kati Kleber, MSN RN CCRN-K – Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, speaker

Melissa Stafford, BSN RN CCRN SCRN – Highly experienced and currently practicing nationally certified neurocritical care nurse

Elizabeth Mills, BSN RN CCRN – Highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center

Examples of advanced practitioners

Physicians – terms to know
- Attending physician: main MD who calls the shots
  - Frequently a hospitalist, internal medicine, or critical care MD
- Consulting physician: only brought in when the attending physicians feels it’s necessary and they have an MD to MD conversation to “consult” someone from another service line
- Residents: people who went through their undgrad, graduated medical school, is a physician, and now matched into a residency program… which is typically 2-3 years and residents acquire more responsibilities as they progress in their program
  - Intern: in their 1st year of residency
    - **FYI, residents have a very difficult transition into practice, just like nurses do. School is very theory/big picture focused (again like nurses) so their learning curve is very steep and abrupt as well. Please be gracious and kind to residents.
- Chief resident: in their last year
- Fellows: people who have completed their residency and are receiving specialized training (like pediatric cardiology)
Advanced Practice Providers
- Nurse Practitioners, Physician Assistants, CRNA’s, and so forth
- Current acceptable term is “Advanced Practice Providers” – NOT midlevel provider

When does call start?
- Typically at 1700 daily, weekends, and holidays
- Call is when the physicians are done for the day, and the on-call physician is who you will talk to with any needs that must be addressed before the regular physician is back the following day (typically around 0700 or 0800).
- Physicians rotate who “takes call” so they are able to have some time off
Who to call?
- You may call MD directly, or they may want you to call their advanced practice staff first (like the NP or PA)
- If you’re working in a teaching facility, make sure you know which resident to call – if you’re not sure, check and see which resident has been writing notes on the patient each day
- The “on-call” doctor is not always your patient’s doctor, it may be one of their colleagues. Therefore, use your critical thinking to decide if it’s truly necessary to call and clarify something in the middle of the night
  - Keep in mind, you’re probably waking a physician up, so if it’s a non-urgent question that will not change the immediate plan of care and/or is something that would be best addressed by the patient’s main physician, then consider waiting
  - Know your institutional policies on when to notify and when to wait

Practice paging first before doing it for real the first time
Know where the phone numbers are, have frequently used ones in your badge
Try to get normal, routine needs taken care of during the day – by the attending – before call starts
Be considerate and consolidate calls if possible
Save non-urgent needs for rounds, if medically appropriate
- Just because this was a “notify MD” situation doesn’t mean you always have to notify them immediately. Use your critical thinking skills to identify if it is a situation in which you can update them during rounds.

Examples of service lines
- Cardiovascular surgery, cardiology, cardiac electrophysiologist
- Neurology, neurosurgery, neuro radiologists
- Internal medicine, family medicine
If you’re calling about an existing order, look to who ordered it to know who to call
If you’re calling about a new issue, typically calling the attending who can let you know if they would like you to notify one of the consulting MD’s

Typically the attending or resident will lead rounds and discuss the patient’s situation
Each member of the health care team will discuss the plan of care from their unique perspective, how the patient is currently responding, and how they are planning to progress the patient
It is essential that nurses participate in these – some facilities have nurses lead them
Helpful to save non-urgent questions for rounds so they entire team can hear needs and offer input if needed

Use PRN meds only for indicated use
Use PRN’s first before calling if needed
Be prepared when calling (fresh set of vitals, have the chart readily available, anticipate questions)
Be able to quantify things (instead of saying “they’re in a lot of pain” try to say “they were rating it at an 8, I gave 2 mg of Morphine and they’re still moaning and in distress”)
Try to stay professional even if you become friends with any advanced practitioners while you are at work

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