Consultant insists on [insert possibly harmful test here]...

[namethatsmell]

How do you guys handle the scenario of a consultant who demands something you think is excessive and/or possibly harmful to a patient before they will accept an admission?

I recently had a case where a consultant simply refused to admit a patient until a 2nd CT was done so a specific type of contrast could be given as he felt the original CT was "inconclusive." The diagnosis was pretty classic based on the patient's presentation and was called by radiology on imaging...and the consultant was basically trying to overread the radiologist. I expressed my concern of increased radiation to the (somewhat youngish) patient and the consultant basically said it wasn't his problem. Admit to medicine for serial exams was not really an appropriate option. Consultant was at home and I almost insisted that he come in to see the patient before repeat CT but he gave me the line "I can be in the ED in 5-6 hours." Patient agreed, the repeat CT stated the obvious, and the patient ended up getting the care they needed but...anybody have any tips for circumventing situations like these?

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[Birdstrike]

Radiologists are usually very good, but they have been know to over-read things. I've also picked up things they've missed more than once and they've had to amend dictations. That's being said, context is key.

If you trust the consultant, and you think their plan is reasonable even though you may not agree with it 100%, then you can go along with it the majority of the time.

If it's some BS they're pulling at shift change, wanting you to order a test to stall, get out of work or blatant malpractice/incompetence then you have to put your foot down.

Just don't pull the "I demand you come see the patient and discharge/order test yourself!" card too many times or you'll burn bridges and make your own life harder in the future.

Also, keep in mind specialists can be excellent at imaging studies in their narrow field, sometimes better than radiologists because they have years of clinical correlation backing their interpretations, whereas radiologists don't have that advantage.

When they write, "Clinical correlation recommended," that translates to,

"I have no clue if this finding absolutely normal, a horrendous acute problem or something in between, but if I had thirteen seconds with the patient, a simple yes/no question answered could tell me or you more than 5 years learning radiology in a dark room."

 

[TooMuchResearch]

"Hi, Dr. Radiology? I know this study wasn't optimized for x, but I was wondering if you could evaluate for x? The surgeon wants another CT..."

 

[Groove]

I need more information... Was this a neurologist? CT surgeon? If it's a specialty where there is plausibility that an alternate study would ultimately change the disposition... i.e. admit to their service, then I don't think it's unreasonable. I rarely have a specialist successfully hold a pt in the ED simply for a glorified work up. If you found yourself in that situation, could you not have admitted to medicine for the specialists' "other" tests? I agree with Birdstrike that you don't want to play the "You've been consulted...B*TCH!" too many times. However, if it's not a simple case and you need a bedside evaluation before doing something that you consider "at risk", then by all means request it. "I can't be there for 5-6 hours" doesn't cut it as most hospital bylaws dictate that they be at bedside within ~30 mins after a formal consult.

Ultimately, it's unacceptable to board a pt in the ED for that many hours without a good reason. The way to escalate things like that is to get your director involved who should know how to involve the other department and/or tie in hospital administration in such a way as to voice "concern" for inappropriate holds in the ED that potentially have a deleterious impact on throughput and ultimately pt care in the ED. They can contact the dept's chair and make sure all the right people are contacted and dealt with appropriately. That's assuming that this was really something out of the ordinary but I can't tell by the lack of details. I mean, everyone has a few outlier cases.

Alternatively, if you are feeling particularly mischievous and are say... changing jobs in the next 6 months then by all means play the "You've been consulted B*TCH...see you in 30 or I call hospital administration on your punk ass!" card followed by a request for a peer review witch hunt on this particular consultant. Then go walk into HR and say something like "I'm really worried that <insert name> specialist is hurting patients. I had this case...." Blah, blah. They'll involve risk management and the whole thing will turn into a s*** storm really fast. It will provide immense entertainment to your colleagues.

 

[Birdstrike]

and the whole thing will turn into a s*** storm really fast. It will provide immense entertainment to your colleagues.

I ️ a good s*** storm. Gives me the warm-and-fuzzies.

 

[Apollyon]

When they write, "Clinical correlation recommended," that translates to,

"I have no clue if this finding absolutely normal, a horrendous acute problem or something in between, but if I had thirteen seconds with the patient, a simple yes/no question answered could tell me or you more than 5 years learning radiology in a dark room."

Ouch! My radiologist says that, and he is the sharpest doc I've ever met - bar none, and that includes Duke people. He's 72, and you would think 50 if you saw him. Plus, on top of that, he's a genuinely nice guy.

 

[Birdstrike]

Ouch! My radiologist says that, and he is the sharpest doc I've ever met - bar none, and that includes Duke people. He's 72, and you would think 50 if you saw him. Plus, on top of that, he's a genuinely nice guy.

It's not a criticism of radiologists, and I respect their skills, just think of this example. No matter how good they are at picking up, let's say, a 10% vertebral compression fracture in an osteoporotic 80 yr old, no amount of radiologic expertise tells them as much as asking, "Does your back hurt Mabel? How about right here?" Thump thump on L1.

They can't really tell you if the patients back is broken or not without that "clinical correlation." Then comes the inevitable, "consider mri if acute fracture is suspected," where ultimately they'll be able to see bone edema to assess acuity.

 

[Birdstrike]

@totalbodypain Why no posts since 2012?

 

[namethatsmell]

I need more information... Was this a neurologist? CT surgeon? If it's a specialty where there is plausibility that an alternate study would ultimately change the disposition... i.e. admit to their service, then I don't think it's unreasonable. I rarely have a specialist successfully hold a pt in the ED simply for a glorified work up. If you found yourself in that situation, could you not have admitted to medicine for the specialists' "other" tests? I agree with Birdstrike that you don't want to play the "You've been consulted...B*TCH!" too many times. However, if it's not a simple case and you need a bedside evaluation before doing something that you consider "at risk", then by all means request it. "I can't be there for 5-6 hours" doesn't cut it as most hospital bylaws dictate that they be at bedside within ~30 mins after a formal consult.

Ultimately, it's unacceptable to board a pt in the ED for that many hours without a good reason. The way to escalate things like that is to get your director involved who should know how to involve the other department and/or tie in hospital administration in such a way as to voice "concern" for inappropriate holds in the ED that potentially have a deleterious impact on throughput and ultimately pt care in the ED. They can contact the dept's chair and make sure all the right people are contacted and dealt with appropriately. That's assuming that this was really something out of the ordinary but I can't tell by the lack of details. I mean, everyone has a few outlier cases.

Alternatively, if you are feeling particularly mischievous and are say... changing jobs in the next 6 months then by all means play the "You've been consulted B*TCH...see you in 30 or I call hospital administration on your punk ass!" card followed by a request for a peer review witch hunt on this particular consultant. Then go walk into HR and say something like "I'm really worried that <insert name> specialist is hurting patients. I had this case...." Blah, blah. They'll involve risk management and the whole thing will turn into a s*** storm really fast. It will provide immense entertainment to your colleagues.

Concern was for infected renal stone. Pt story/presentation was solid, urine was dirty and bloody, rads called stone in ureter with hydro. Urologist insisted the stone we were seeing could have possibly been a calcification extrinsic to, and compressing, said ureter...in which case urologist would not take pt. The uro wanted a special phase study with IV con. It was community setting so I did not want to pull the "come in bi*atch and see the patient now" play. Pt's vitals were still stable (which can obviously change rapidly with pus under pressure) but I was concerned that admit to medicine would have likely meant pt would have sat there until pt went over cliff into septic shock land. I tried to invoke occam's razor and it fell on deaf ears. Lead me to believe this doc has either seen this once before and has crazy anchoring bias or was stalling for time. Probably the latter.

Would you have just ordered the 2nd CT or would you have attempted to find a compromise? If so, what and how?

 

[TooMuchResearch]

If it looks and smells like infected stone and urologist refuses, I'd probably load up the antibiotics, admit to medicine, and advocate to medicine why you think the scan isn't indicated, then let medicine probably just obtain the scan and consult urology anyway.

Or maybe patient gets lucky and another urologist is on call by the time the medicine admission happens.

 

[WilcoWorld]

Concern was for infected renal stone. Pt story/presentation was solid, urine was dirty and bloody, rads called stone in ureter with hydro. Urologist insisted the stone we were seeing could have possibly been a calcification extrinsic to, and compressing, said ureter...in which case urologist would not take pt. The uro wanted a special phase study with IV con. It was community setting so I did not want to pull the "come in bi*atch and see the patient now" play. Pt's vitals were still stable (which can obviously change rapidly with pus under pressure) but I was concerned that admit to medicine would have likely meant pt would have sat there until pt went over cliff into septic shock land. I tried to invoke occam's razor and it fell on deaf ears. Lead me to believe this doc has either seen this once before and has crazy anchoring bias or was stalling for time. Probably the latter.

Would you have just ordered the 2nd CT or would you have attempted to find a compromise? If so, what and how?

On the one hand, "I can't be in for another 5-6 hours" is unacceptable. This should be taken up with hospital administration on Monday morning.

On the other hand, a Urologist requesting a CT urogram is not unreasonable, especially if you're asking the urologist to take a stable patient to the OR based on an iffy CT. This probably wouldn't be a case I'd "go to the mat" over (and I "go to the mat" more often than most of the docs I've worked with).

 

[slystalone]

One that I frequently see is with the medicine team demanding an ABG be done - literally every asthma/COPD admission - even in cases when a venous gas was done!

 

[Vandalia]

In this type of case I would probably go ahead and order the CT. The potential risk of radiation exposure from a 2nd CT in an adult is negligible when compared with the risk from a procedure or even an inpatient stay that is unnecessary. 2nd CT or ureteroscopy that turns out not to be needed? I think the risk factor goes with avoiding an unnecessary procedure.

I am not saying that this was the specific issue here, or that the urologist was not an idiot, but if it can be argued with a straight face that the imaging might significantly change the proposed treatment, then go ahead and do it.

I have also found this is not the time to fight these battles. Bump it upstairs when things have calmed down if you think it is necessary.

 

[Arcan57]

The treatment for infected stone rarely runs through a urologist. The veteran move is to get IR to put in the nephrostomy tube which buys you time to get the urologist on board.

 

[Birdstrike]

The treatment for infected stone rarely runs through a urologist. The veteran move is to get IR to put in the nephrostomy tube which buys you time to get the urologist on board.

I think this would be pretty site dependent, depending on how aggressive radiology is with these at a specific hospital, and whether or not a specific urology department would want to give first crack at these pretty sick patients to non-urologists.

 

[Arcan57]

I think this would be pretty site dependent, depending on how aggressive radiology is with these at a specific hospital, and whether or not a specific urology department would want to give first crack at these pretty sick patients to non-urologists.

Admittedly a small n but I've never worked at a hospital that had uro and IR where the urologist didn't talk to me like I was an ass for bothering them with an infected stone prior to calling IR. The usual algorithm seems to be nephrostomy tube by IR, sepsis resuscitation by Intensivist, f/u for definitive treatment of stone after resolution of infection. Now I'm not saying that's every septic stone or you shouldn't call uro on every septic stone but that there's more than one way to get a nephrostomy tube in the patient and most urologists will not operate/stent/lithotripsy a septic patient.

 

[namethatsmell]

On the one hand, "I can't be in for another 5-6 hours" is unacceptable. This should be taken up with hospital administration on Monday morning.

Thanks for the reply, I agree and it was.

On the other hand, a Urologist requesting a CT urogram is not unreasonable, especially if you're asking the urologist to take a stable patient to the OR based on an iffy CT. This probably wouldn't be a case I'd "go to the mat" over (and I "go to the mat" more often than most of the docs I've worked with).

Agree on not going to the mat on this as it was not technically emergent and the patient could have come in through medicine. This was also at a community site and I'm taking it as an exercise in picking my battles with consultants. Compared to dying from urosepsis a CT is not the worst thing in the world (although IMHO the rads exposure of 2 abd/pelvis scans in a younger person is not inconsequential)...it was the fact the radiologist was adamant that the first scan clearly showed a stone (his read of the 2nd scan referenced his read of the 1st read) and the patient story and exam was classic and yet the uro was calling shots from home.

Oh well, on goes the world, thanks for everybodys thoughts.

 

[Cerberus]

Ouch! My radiologist says that, and he is the sharpest doc I've ever met - bar none, and that includes Duke people. He's 72, and you would think 50 if you saw him. Plus, on top of that, he's a genuinely nice guy.

We bitch about radiologists hedging their bets a lot. We are pretty terrible at hedging ourselves. We are taught to document this way in residency to cover our asses, I'm not surprised other specialties do the same.

 

[Siggy]

We bitch about radiologists hedging their bets a lot. We are pretty terrible at hedging ourselves. We are taught to document this way in residency to cover our asses, I'm not surprised other specialties do the same.

Part of the problem, as mentioned, is that they can't see the patient. I just got done with a month on radiology and sometimes the information provided with the image is minimal, at best. There's nothing like looking at a set of foot x-rays and the only information provided is "fracture." Sometimes it's because the ordering physician only provides that information, sometimes it's because the clerk putting in the order decides that they don't need to type everything into the computer.

It's like providing a set of lab work and asking for a diagnosis based only off of the chief complaint and then having people get upset because you aren't specific enough with a diagnosis.