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Pride and Prejudice at the Bedside

It was nearly thirty years ago, but I clearly remember the woman who came to my care in the CCU. She’d been languishing on the medical floor with ill-defined respiratory issues that worsened over the twelve hours since she’d been admitted to the hospital. She was one of the quiet ones, the kind of patient who doesn’t complain, a stoic woman of modest, rural upbringing. To this day, I neither understand exactly why her myocardial infarction (heart attack) was missed nor why no one noticed her arterial blood gases indicated metabolic acidosis from cardiogenic shock (medical jargon meaning her heart couldn’t pump well enough to feed her cells.) Ten minutes into assessing her condition, reading her lab reports, and looking at her twelve-lead EKG, I knew all the clues had either been overlooked or ignored. Possibly both. It’s the quiet ones who get ignored. It’s quiet women especially who are overlooked.

I approached the cardiologist on call as she was passing through the unit and explained my patient was in trouble and to expect she’d be called in on the case. An hour later, the cardiologist had indeed been asked to consult. We conferred, both arriving at the same conclusion. Intervention was far too late to effect a positive outcome. All we could do was give supplemental oxygen, put her on several intravenous medications to improve cardiac output, and hope for the best. Pray for the best.

The woman’s son worked at the hospital as a custodian, also a quiet individual, meek in demeanor. I explained as best I could what was happening to his mother, that she was not doing well. He nodded, eyes sagging, and barely made a comment. I wanted to tell him what I knew; his mother had not been given good medical care and, in fact, her heart attack had been missed by the doctors who should have caught it, both the ER physician and her family practitioner. When I showed the woman’s physician the changes on her EKG that indicated cardiac damage, he lifted his chin and deflected responsibility, saying he didn't read twelve-lead EKGs. He never again would look me in the eye. The case still troubles me.

Nurses frequently face this type of conundrum. We are the ones who pick up the pieces when things go badly for a patient. We are the ones who have to break the news to the family who is standing outside the room with uncertainty and fear written on their faces. We are the ones who have to confront the doctors when they miss a crucial clue. We are the ones who are sniffed at and told if we want to practice medicine, to go to medical school. Yeah, it really happens exactly like that. Sometimes, pointing out an issue a physician has missed, even if done in the most ego-assuaging, non-critical manner, will result in the patient getting even worse care. It’s ugly and unethical.

Allow me to digress from the case at hand and expand to the psychology of highly educated people who refuse to admit when they are wrong. In an ideal world, egos would be checked at the door before any provider was allowed to give medical care. Arrogance leads to misadventure and poor outcomes. Even now, we witness territorial posturing preventing the use of safe therapeutics to treat SARS CoV-2. There are a number of physicians who have been treating patients with a combination of therapeutics and are having startling success. Instead of adapting these regimens, the medical establishment resists. Physicians using combined therapeutics are being ostracized and, in some cases, subjected to discipline and dismissal. What could not be more clear to me is that those who resist safe, creative, and novel approaches to treating any illness have more interest in maintaining their entrenched belief system than curing patients.

As further proof of this type of entrenchment, let’s consider Australian internist Barry Marshall. Dr. Marshall suffered scathing criticism when he attributed gastric ulcers to Helicobacter pylori. “The medical elite thought they knew what caused ulcers and stomach cancer. But they were wrong — and didn't want to hear otherwise.” Discover, April 8, 2010, (author’s emphasis.) Marshall courageously persisted. H. pylori is now commonly accepted as the cause of gastric ulcers. It takes courage to step outside the establishment; courage, unfortunately, is in short supply. Pride never is.

Most nurses enter the profession to give bedside care. It’s not the physicians who become intimate with the patient. It’s not the physicians who see the subtle changes that harbinger trouble ahead. It’s the nurse at the bedside. Astute physicians rely on this input, especially in the critical care setting. I was fortunate to work with a handful of collegial physicians during my practice who, once they understood I wasn’t blowing smoke up their kilts, appreciated my input. There were others, though, who took exception to my using the good brains God gave me. When I worked in interventional radiology, I read a patient’s history and discovered she had a condition that contraindicated the treatment a radiologist had planned for her. The doc wasn’t happy with me when I told him. In fact, it got his day off to a distinctly bad start. Later, he said in so many words I’d done the right thing. Well, heck yeah, but I didn’t do it to save his sorry butt. I did it for the patient.

Despite our best efforts, the woman in the CCU bed continued to spiral downhill. By the time my shift was over, she’d taken on a gray pallor. When I reported for my shift the next morning, I was told she died during the night while I was safely asleep in my bed. She was only in her sixties, which I now am as well. Over the years, I’ve pondered how her death could have been prevented. I came to the sad conclusion that had she been a man, had she been vocal, she likely would not have died.

It’s not uncommon for women to be treated differently than men by male physicians. I’ve personally experienced the arrogant dismissiveness of a physician at a well-known medical center concluding my condition was mental in nature when subsequent intervention uncovered a serious surgical failure. Determined it never happen to another woman, I wrote a pointed letter to the hospital review board which was responded to in a diplomatic manner. Maybe it did good, maybe it didn’t. I’ll never know.

What I do know is this kind of male physician/female patient phenomenon results in sub-standard care. My hopes that the problem has been resolved in the years since I left nursing in 2002 is sadly not the case. Consider this from the Harvard Health Blog, 2017: “Researchers publishing JAMA Internal Medicine reported that older adults admitted to the hospital fare better if under the care of a female physician rather than a male physician. More specifically, the patients in this study were less likely to end up back in the hospital, or die, in the 30 days after discharge if cared for by female physicians than similar patients cared for by male physicians.” Additionally, read the following conclusion, published February 2021: "Female physicians have better patient outcomes compared with their male peers, while female patients are less likely to receive guideline-recommended care when treated by a male physician, according to a systematic review from ACC’s Cardiovascular Disease in Women Committee published Feb. 22 in the Journal of the American College of Cardiology."

An in-depth review of the literature is beyond the scope of this blog. I have no solution to the problem, but awareness seems a good place to start, for both the patient and the provider. Whether poor treatment is due to a provider’s pride or arrogance or simple inattention, it behooves women—as well as men—to advocate for themselves when seeking medical care.

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Jun 20, 2023

I can testify to the pride and prejudice at the bedside. Even I, after years of no one noticing or seeming to care about a rapid, but regular heart rate, almost encouraged ignoring it post op. The small intern, female, said, “I can’t blow this off.” Ordered CT scan of my lungs, which revealed two large pulmonary emboli. I wasn’t short of breath. No chest pains I noticed. I could hardly believe it. I’m glad that woman didn’t go down the path of the men before her.

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