Dealing with Difficult Consultants

[zeitgeber]

kind of lost my cool the other day with a consultant... maybe it's just my institution, but some of the consultants, almost invariably surgeons, think that they can talk themselves out of a consult. Inevitably they huff and puff, talk to you with a condescending tone that gets my blood pressure shooting up 40 points, slam the chart down as they state "there's no surgical issue here" and leave. I usually bite my tongue during these situations and pick my battles, but sometimes can't help but calling them out on their ridiculous behavior. Any thoughts on how to deal with difficult consultants? Any good stories out there? How do we change the perception of surgery that we are triage nurses/incompetent doctors? My institution has some serious cultural issues that have been simmering for a long time... you'd think that we'd be accepted after a decade!

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[EctopicFetus]

kind of lost my cool the other day with a consultant... maybe it's just my institution, but some of the consultants, almost invariably surgeons, think that they can talk themselves out of a consult. Inevitably they huff and puff, talk to you with a condescending tone that gets my blood pressure shooting up 40 points, slam the chart down as they state "there's no surgical issue here" and leave. I usually bite my tongue during these situations and pick my battles, but sometimes can't help but calling them out on their ridiculous behavior. Any thoughts on how to deal with difficult consultants? Any good stories out there? How do we change the perception of surgery that we are triage nurses/incompetent doctors? My institution has some serious cultural issues that have been simmering for a long time... you'd think that we'd be accepted after a decade!

Ill bite.. look I assume that this is the residents but in the end it doesnt matter. I deal with them by being nice, telling them why I need them, stroking their egos and then going home at the end of my shift. I think at most places surgeons are miserable and thats their choice. I wont let them bring me down. Im sure someone will have more substantive info to give you soon.

 

[beyond all hope]

Which you won't fix. You just have to deal. Surgery residency sucks and that's the way it is. This is true for all consultants you call in an academic center: they're all overworked residents/fellows.

Don't let annoying/arrogant consultants get the best of you. And DON'T gloat when you're right. And thank the Gods above that you'll be going home in a few hours when their call just started...

Agree with prev poster: be nice. Realize that they're overworked. Realize that some are just jerks. You can help your consultants by only calling them after all of the info is back, but sometimes that bites you in the butt because they take forever to finish their c/s.

 

[anonymousEM]

You hear stories of those places that surgery gets mad and decides they just want to handle all of the belly pain themselves and to be called for every one....that last for about 1 day when they realize how many we don't call them for. The key here, as they've said, is to be professional. If you're making an appropriate consult after an appropriate workup there's not much else for you to do except smile and be glad you didn't choose surgery.

In general, I find calling consultants with a specific question or a one line of I have an 65yr old with acute cholecystitis who I need you to come admit rather than a longwinded story is usually the best way to start...then give them additional info as they need. This is especially true when interns and students are talking to admitting attendings on the phone. Be direct and to the point and tell them why you need their assistance. It saves a lot of whining from everyone.

 

[8744]

Hey, I'm doing a medicine rotation right now and if there's one thing I've learned after my twelfth admission of the day, it's that it's much better to give than to receive.

 

[EctopicFetus]

funny but one of my fellow residents told me that this whole nutty thing went down over a pt. Guy with his 1st stone, popping percs q1 hour, has a fever, white count and the CT shows obstruction. Uro says we wont even consult on this patient. This then became a chair to chair thing. Nuts.

Am I missing something? Clearly this is a Uro emergency and def a Uro consult is appropriate. I think it is important to realize that dealing with consultants is a pain in the butt and they are overworked and try to punt things that are often right in their field.

 

[wook]

I will say I've had some very interesting consults. With that being said, I had a consult today where the surgeons were outstanding. There was a social issue involved and they were very willing to help the patient out. It depends with whom you are dealing. In the end, hopefully we are all trying to do what is sensically (ooooh did I must make up a word?) best for the patient (within reason of course).


Wook

 

[f_w]

funny but one of my fellow residents told me that this whole nutty thing went down over a pt. Guy with his 1st stone, popping percs q1 hour, has a fever, white count and the CT shows obstruction. Uro says we wont even consult on this patient. This then became a chair to chair thing. Nuts.

Am I missing something? Clearly this is a Uro emergency and def a Uro consult is appropriate.

It's actually an interventional radiology emergency.

(All the plumbers will do in this situation is to put the patient on the floor, tank them up with fluids and a random assortment of antibiotics and call us.)

 

[roja]

this is such an age old issue. Its one of the 'downs' for EM.... in an academic setting (I think you will note that most in the private world will give you a different story because 'EM consults = money" for privates.) IN academics,a nd with residents the ER=more work.

Be professional, be nice and recognize that you get more flies with honey than with ... whatever.

 

[Amgen1]

How do we change the perception of surgery that we are triage nurses/incompetent doctors?

A few basic tips for ER docs to prevent consultants from being annoyed:

1) See the patient YOURSELF
2) Examine the patient YOURSELF
3) Take a history from the patient YOURSELF
4) Know the patient's vital signs/ hemodynamic status
5) Have the pertinent lab values/studies to the consult you are calling
ie you are calling a acute chole consult, then know the WBC, LFTs, US,etc

Can't emphasize enough how often these basic principles are ignored (esp the first 3) . . .

The lack of these basics will often lead to frustration/hostility

 

[deleted109597]

A few basic tips for ER docs to prevent consultants from being annoyed:

1) See the patient YOURSELF
2) Examine the patient YOURSELF
3) Take a history from the patient YOURSELF
4) Know the patient's vital signs/ hemodynamic status
5) Have the pertinent lab values/studies to the consult you are calling
ie you are calling a acute chole consult, then know the WBC, LFTs, US,etc

Can't emphasize enough how often these basic principles are ignored (esp the first 3) . . .

The lack of these basics will often lead to frustration/hostility

I find it rare that the person asking for the consult isn't the person that evaluated the patient. Even I have called consults as a 4th year, because the attending implied that I knew the patient better than he or she did, because I spent more time with the patient. They only got involved when dickhead consultants either refused to listen to a student, or didn't want to come down because they didn't feel the consult was necessary. If the attending wants a consult, they're going to get one eventually, or you'll have to send your attending down to discharge the patient from the ED. That's how it works.

 

[Dr. Will]

A few basic tips for ER docs to prevent consultants from being annoyed:

1) See the patient YOURSELF
2) Examine the patient YOURSELF
3) Take a history from the patient YOURSELF
4) Know the patient's vital signs/ hemodynamic status
5) Have the pertinent lab values/studies to the consult you are calling
ie you are calling a acute chole consult, then know the WBC, LFTs, US,etc

Can't emphasize enough how often these basic principles are ignored (esp the first 3) . . .

The lack of these basics will often lead to frustration/hostility

Ohhhh...that's how it works. If I know a patient is coming in with abdominal pain, the first thing I do is call the consultant without any information. I mean, I'm just triaging them, right?

 

[Amgen1]

1) See the patient YOURSELF
2) Examine the patient YOURSELF
3) Take a history from the patient YOURSELF

These comments are more in relation to the consulting ER physician relying on 2nd, 3rd, or 4th hand information to call a consult . . . .

 

[Dr. Will]

These comments are more in relation to the consulting ER physician relying on 2nd, 3rd, or 4th hand information to call a consult . . . .

Hey in this instance, I agree with you. I've had similar experiences as Dr. McNinja, with consultants giving students problems requiring someone else to step in. Unfortunately, as I hand the phone over to the Attending or Senior, they may not have the opportunity to fully evaluate the patient, but the appropriate workup is available.

 

[endo]

My experience in Cincinnati (4th year EM) has been quite good with general surgery. I have a lot of respect for the general surgery residents and try to do the most I can for them on consults. They, more than most any other service, will "suck it up" and do the right thing for the patient when other services (who may be more appropriate) don't want to do the work. They can be abrasive at times, but if I had to do their job -- err, who am I kidding. I couldn't do their job. When I moonlight in a nearby city, I've noticed the same thing with the surgical residents there. General surgery residents, in my experience, have more pride in their specialty and work than others I have interacted with. Your experience may be different.

 

[The White Coat Investor]

Ill bite.. look I assume that this is the residents but in the end it doesnt matter. I deal with them by being nice, telling them why I need them, stroking their egos and then going home at the end of my shift. I think at most places surgeons are miserable and thats their choice. I wont let them bring me down. Im sure someone will have more substantive info to give you soon.

Do the words "pleasantly persistent" mean anything to you?

 

[The White Coat Investor]

A few basic tips for ER docs to prevent consultants from being annoyed:

1) See the patient YOURSELF
2) Examine the patient YOURSELF
3) Take a history from the patient YOURSELF
4) Know the patient's vital signs/ hemodynamic status
5) Have the pertinent lab values/studies to the consult you are calling
ie you are calling a acute chole consult, then know the WBC, LFTs, US,etc

Can't emphasize enough how often these basic principles are ignored (esp the first 3) . . .

The lack of these basics will often lead to frustration/hostility

This is good advice, and also the reason I try to let the student/intern/resident call the consultant. When I try to help them out by jumping on the phone because they're in with another patient I invariably don't have a piece of information the consultant deems important, simply because the resident didn't mention it to me (and didn't really need to, since it didn't affect my decision-making process.) When I am seeing patients without residents I am occasionally asked for information I don't have (didn't order whatever random lab the consultant wanted or didn't ask about a trivial piece of history) and I offer to put them on hold while I ask the patient if they would like. They usually say don't bother, since "I'm coming in to see the patient anyway."

When working with residents, sometimes the place simply becomes too busy for me to see all the patients who need a consult/CT/whatever prior to ordering the consult/study etc. I have to decide who I need to see immediately and who I can lay eyes on immediately prior to discharge. I recall one shift a few weeks ago where for 3-4 hours straight I was seeing 12-15 patients an hour (with 2 very competent residents and two interns). Do the math. That's the amount of time I can spend with a patient, and don't forget the time writing my note and walking between rooms.

I had a STEMI EKG brought to me by a nurse while the resident was in evaluating the patient. The nurse told me chest pain, there were 3 mm of ST elevation in contiguous leads, and I paged the cath team attending. Naturally, he asked me a few questions, none of which I knew the answer to. Of course I felt dumb, and I'm sure it annoyed the consultant. So maybe the next time I'll let a few more myocytes die and wait for the resident to be available to talk to the consultant.

 

[kungfufishing]

Do the words "pleasantly persistent" mean anything to you?

exactly.

And sometimes, how about just "persistent". I'm the nicest guy I know, but at some point you are choosing patient care vs. consultant ego/comfort.

 

[Lola713]

I agree...sometimes it is just so frustrating to argue with people, for the amount of time that we sometimes spend on the phone going over labs, vitals blah blah blah they could have already been down to see the patient instead of us just sitting on phone arguing. Obviously they are not going to get out of the consult so just do it!
I once had a guy that came in less than 24 hrs s/p inguinal hernia repair (with foley placement!!) who had called surgeons office b/c he couldn't urinate and was told to come in, and he had a moderate postvoid residual and I called surgery to come see him and they hung up on me after telling me that obviously "it wasn't a surgical issue".
i think sometimes it just helps, if the arguing continues to just cut them off and say in a calm voice "I would really appreciate it if you came to see the patient. Thank you." that usually scares them.

 

[NinerNiner999]

I had a STEMI EKG brought to me by a nurse while the resident was in evaluating the patient. The nurse told me chest pain, there were 3 mm of ST elevation in contiguous leads, and I paged the cath team attending. Naturally, he asked me a few questions, none of which I knew the answer to. Of course I felt dumb, and I'm sure it annoyed the consultant. So maybe the next time I'll let a few more myocytes die and wait for the resident to be available to talk to the consultant.

Exactly - there are several "slam dunk" diagnoses that don't need many details, or even labs, to get the consultant to the bedside. Off the top of my head, these include (very incomplete):

STEMI
Stroke
Open Fracture
Compartment Syndrome
Sepsis in the Elderly
Pneumo/Tension Pneumo
Globe Rupture
Evisceration

Sure, you may need to wait for some of the final details to determine where in the hospital these patients need to go, but these presentations alone should make it safe to call the consultant.

I have found in my community practice that if I call the patient's PMD when they arrive with x complaint, the PMD will accept them 50% of the time, and another 40% with basic labs. Plus , they like to be informed about their patients...

 

[WilcoWorld]

Grrr....

Diabetic female with strong family history of early MI's complains of chest pressure + SOB with exertion. I ask Cardiology to consult, and they say that because she didn't rule-in 2 months prior that she did not need a Cardiology consultation, or any further evaluation, and that she should be discharged. I asked them to write that in the chart, seeing as they were in the ED and all. Surprise! Once they were forced to write something in the chart they determined that the patient actually did need further work up. What's more, after basically telling me that I'm an idiot who doesn't know how to work anything up, they recommended that the patient get a GI, Pulmonology and a Neuro consultation to work up her complaints!

 

[TheBlueBlazer]

man... couldn't you have waited a couple of weeks to bump this for its 5 year anniversary of the last post!

j/k. SOLID thread-zombie-ing.

 

[TrumpetDoc]

This is a great thread to resurrect.
I would second way earlier post, particularly when starting off in a site be it academic or prvt.
Be succinct and definitive I your impressions. "pts has X an I need you to Y." of course I have all the background stuff ( age, RFs, imaging, labs, etc). And if I don't/didn't order something I am nice and professional about it, and tell them "why" I didn't.
I work mostly in pvt EM. It sometimes in a university program and ther is a HUGE difference!
Just go with what is RIGHT and your set.
I good thing I do and bierce in is being real with them.
I will say " hey, I could be wrong, you may disagree, but this is what I have. And if you think otherwise il be happy to discuss it an you could maybe show me what you are talking about, etc" or something to that effect. I don't let used be swayed over the phone in ANY circumstance. You're just asking for trouble there!



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[BJJVP]

I have to agree that in the community setting, consultants are a little easier to deal with. It's probably because we don't call them to the ED that much.

However, they are not really happy to help as others have stated either. Yes, hospitalists may be incentivized for # of admits but they can also be overworked & scrutinized by admin for appropriateness of admission as well. And honestly, some are just simply lazy, condescending, arrogant, jerks.

I've experienced similar things Wilco. I'm the idiot that can't figure out anything and I want to admit the 70 yo that "just vagaled." But when she gets admitted, EP and neuro are consulted.

Intractable back pain should just get a medrol pack and be discharged. She can't walk due to the pain? Give her IV solumedrol because that will fix her faster. I finally show them the light...she can't walk. Now, they want me to ask what ortho/spine wants to do with her.

Trauma can be bad as well. If a pt is admitted for a liver lac for example, I get asked about what did facial surg say about the orbital fx's, or spine about their tranverse process fx.

 

[Khaos]

I get this a few times also. Now I have decided to default to the statement, I just don't feel comfortable and would like you to come see the patient (since they are at home and telling me to send the patient home). The response that follows is usually "give me the nurse so I can give orders."