How to (im)properly ? receive an ophthalmology consult.

[FrankMD]

This is a story that happened to me today that made me a little uneasy, so bear with me since this might get a little lengthy.

Please bear in mind that I’m currently doing an internal medicine prelim year and will be entering ophthalmology training in 2008. It’s been literally 2 weeks into my internship and this is the first ophthalmology consult I called this year.

We had just admitted a 40’s yr old HIV+ female in the AM with asthma for SOB but she was complaining of some swelling and pain in her left eye. During our lengthy attending rounds from 9pm to 12am we discussed the possibility of preseptal vs orbital cellulitis in this women and decided to hold off the consult until we have a CT scan of the orbit available which was scheduled for later in the afternoon. All housestaff was required to attend a noon conference (which they actually keep track of us by making us sign in) and after the conference was over at 1pm my resident comes up to me and says that the attending paged him and asked him to call the ophthalmology consult because he was more concerned about this eye swelling to be an orbital cellulitis.

So at 1pm trying to be a good intern and remembering what tidbits of ophtho I can remember from medicalschool I tried to get all the necessary info including pupil reflexes, extraocular movements, conjunctiva, etc…unfortunately I didn’t have a Snellen chart with me and remembering one of my old ophthalmology tips from a resident I asked the patient to read off a newspaper print at arm’s length using one eye then the other.

So now the time is 1:20pm and I think I’m ready to call the consult. I page the person on call for consult wait for theme to call back and I let them know that I have a consult for them, identify myself and starting to spew off the pt name, MR number and the location of the patient….

Then the rest of the conversation went like this…

Oph res: (in an angry/very frustrated tone of voice) “Do YOU have ANY idea what TIME it is?”

Me: err…1:24pm?

Oph res: (same tone of voice…it doesn’t change for the rest of the conversation) “Well you should know that you should call your consults EARLIER. I have a FULL clinic down here and it’ll take AT LEAST an HOUR to see the patient.”

Me: Well, my resident just asked me to call the consult and we just got the patient this…(I get cut off here)

Oph res: Well TELL me about the patient.
Me: Well this is a 45F with HIV who came in this AM with asthma exacerbation but also complaining that she started having eye pain and the team is concerned about orbital cellulitis.

Oph res: WELL is this AN EMERGENCY?

Me: Errr, I don’t know. We are concerned that it may be an emergency…

Oph res: What’s her visual acuity?

Me: I didn’t have a Snellen chart, but she was able to read a fine newsprint without problems with R as well as her L eye, although she is complaining of some blurry vision in her Left eye.

Oph res: You should really have the visual acuity of the patient before you call the consult. If you don’t have a chart you should have asked around your team to get it from SOMEONE. (additional 5 minutes of angry rant about importance of VA goes here, I wasn’t quite paying attention) Then she asks for the rest of the information..

Me: (I provide the rest of the information including EOM, Pupil reactivity and description of her affected eye.)

Oph res: (asks the same question in different way)

Me: (I provide same answer)

Oph res: (Goes on another 5 minutes about importance of VA and how to properly call an ophtho consult)

Me: (occasion yes and reassurance)

Oph res: Well you have to bring her down RIGHT NOW in an WHEEL chair to the clinic…and you said you’re an INTERN right? Call a proper ophthalmology consult next time.

Me: sure thing. (hangs up the phone)

So after all this, I speak to my resident about the consult and he says “Yeah, ophtho residents hate medicine residents.”

When I heard that I felt a bad for the medicine residents, but I felt worse for our ophthalmology community. In your opinion do you think this is any way to treat another colleague? It was my fault for not having the perfect visual acuity but I think it’s unprofessional that she yelled at me for calling a consult at 1pm to ruin her clock out time at 5pm. I realize that many of us enter ophthalmology because it gives us the ability to balance the rest of our lives with medicine, but I felt very let down by a future colleague I spoke to today.

I just wanted to share that with you guys and wanted to know what everyone’s thoughts are regarding my own actions as well as the reactions of the oph resident.

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[DiveMD]

This is a story that happened to me today that made me a little uneasy, so bear with me since this might get a little lengthy.

Please bear in mind that I’m currently doing an internal medicine prelim year and will be entering ophthalmology training in 2008. It’s been literally 2 weeks into my internship and this is the first ophthalmology consult I called this year.

We had just admitted a 40’s yr old HIV+ female in the AM with asthma for SOB but she was complaining of some swelling and pain in her left eye. During our lengthy attending rounds from 9pm to 12am we discussed the possibility of preseptal vs orbital cellulitis in this women and decided to hold off the consult until we have a CT scan of the orbit available which was scheduled for later in the afternoon. All housestaff was required to attend a noon conference (which they actually keep track of us by making us sign in) and after the conference was over at 1pm my resident comes up to me and says that the attending paged him and asked him to call the ophthalmology consult because he was more concerned about this eye swelling to be an orbital cellulitis.

So at 1pm trying to be a good intern and remembering what tidbits of ophtho I can remember from medicalschool I tried to get all the necessary info including pupil reflexes, extraocular movements, conjunctiva, etc…unfortunately I didn’t have a Snellen chart with me and remembering one of my old ophthalmology tips from a resident I asked the patient to read off a newspaper print at arm’s length using one eye then the other.

So now the time is 1:20pm and I think I’m ready to call the consult. I page the person on call for consult wait for theme to call back and I let them know that I have a consult for them, identify myself and starting to spew off the pt name, MR number and the location of the patient….

Then the rest of the conversation went like this…

Oph res: (in an angry/very frustrated tone of voice) “Do YOU have ANY idea what TIME it is?”

Me: err…1:24pm?

Oph res: (same tone of voice…it doesn’t change for the rest of the conversation) “Well you should know that you should call your consults EARLIER. I have a FULL clinic down here and it’ll take AT LEAST an HOUR to see the patient.”

Me: Well, my resident just asked me to call the consult and we just got the patient this…(I get cut off here)

Oph res: Well TELL me about the patient.
Me: Well this is a 45F with HIV who came in this AM with asthma exacerbation but also complaining that she started having eye pain and the team is concerned about orbital cellulitis.

Oph res: WELL is this AN EMERGENCY?

Me: Errr, I don’t know. We are concerned that it may be an emergency…

Oph res: What’s her visual acuity?

Me: I didn’t have a Snellen chart, but she was able to read a fine newsprint without problems with R as well as her L eye, although she is complaining of some blurry vision in her Left eye.

Oph res: You should really have the visual acuity of the patient before you call the consult. If you don’t have a chart you should have asked around your team to get it from SOMEONE. (additional 5 minutes of angry rant about importance of VA goes here, I wasn’t quite paying attention) Then she asks for the rest of the information..

Me: (I provide the rest of the information including EOM, Pupil reactivity and description of her affected eye.)

Oph res: (asks the same question in different way)

Me: (I provide same answer)

Oph res: (Goes on another 5 minutes about importance of VA and how to properly call an ophtho consult)

Me: (occasion yes and reassurance)

Oph res: Well you have to bring her down RIGHT NOW in an WHEEL chair to the clinic…and you said you’re an INTERN right? Call a proper ophthalmology consult next time.

Me: sure thing. (hangs up the phone)

So after all this, I speak to my resident about the consult and he says “Yeah, ophtho residents hate medicine residents.”

When I heard that I felt a bad for the medicine residents, but I felt worse for our ophthalmology community. In your opinion do you think this is any way to treat another colleague? It was my fault for not having the perfect visual acuity but I think it’s unprofessional that she yelled at me for calling a consult at 1pm to ruin her clock out time at 5pm. I realize that many of us enter ophthalmology because it gives us the ability to balance the rest of our lives with medicine, but I felt very let down by a future colleague I spoke to today.

I just wanted to share that with you guys and wanted to know what everyone’s thoughts are regarding my own actions as well as the reactions of the oph resident.

Jerks everywhere!!!!!!

 

[JMK2005]

Don't let that ophthalmology resident bother you. Hopefully, she was just having a bad day and that's not how she really responds when a consult is requested usually.

 

[DrEyeBall]

I would say this was an excellent learning experience for you. I will also say that too often this is how consults are handled.

I basically expect no information about the eye exam when called. I like to know the reason for the consult (so I know what question to answer) and background medical history. I am going to do the exam and what a non-ophthalmologist tells me about his/her exam is rather meaningless.

This is the type of behavior that gives ophthalmologists a bad name. Other services already think we are overpaid and do not work hard (they may also have no idea how busy our clinics are). However, this is the impression we continue to give with this type of behavior.

The proper response was to say "thanks for calling we are happy to help you with the management of your patient".

Remember this interaction for the rest of your career. You are actually lucky to have experienced it now.

 

[orbitsurgMD]

This is a story that happened to me today

She must not be that senior a resident. Sooner or later, you learn not to abuse your referring doctors, and she obviously hasn't got the message yet.

And no, it isn't your job as the requester to do the eye exam for that resident. It seems you provided more information than any reasonable consultant would have expected you to obtain. I have trained ophthalmology residents and ran a consultation service for six hospitals during my fellowship. Generally it is the ophthalmology resident that does the eye exam.

As others said, jerks everywhere.

 

[V05]

You did a great job on requesting a consult.

I do not usually expect too much- the best consult I received was:
Medicine- We have a deaf patient here who seems to have an eye problem.
Me- What is the problem?
Medicine- We do not know, we cannot speak to her?
Me- But I cannot speak to her either, is it an emergency?
Medicine- I cannot speak to her so I do not know, why don't you just see the patient.

As you see, it goes both ways.

I agree with many of the posts here- it is important to treat your colleagues with courtesy and respect. I am always happy to do consults (unless it is for an "emergency refraction"). Don't let this one incident throw you off. You should continue to request consults when needed and continue to provide the most amount of information to the best of your ability. I hope you will have a more positive experience as the internship continues.

 

[Haptic]

I would report that resident to his/her program director. Aren't we supposed to be "professionals?" That's really unprofessional behavior and I wouldn't let that pass no matter what service the resident was from. If you can't be nice to colleagues, I wouldn't want to be their patients!

 

[Jokestr]

I wouldn't go straight to reporting her....But, after she's had some time to simmer down, I might try to go talk to her and let her know that you were unhappy with her response to your consult. I do not think you did a bad job. Having VA is nice, but if the patient can read news print that gives enough detail to determine near vision anyways. If u go and speak with her, she might not be such a B@#$%% next time since she will have a face to put the consult to. But, if she's still a jerk, then you might try going above her to help improve ehr behavior. All in all though, I wouldn't worry about it. If she continues this behavior in private practice, she won't make very much $ as consults will be at a minimum. We all get what is coming to us in the end.
Good luck and enjoy Intern year

 

[bulldoc]

out of curiosity, are you entering your PGY-2 year at the same program? I wonder if she'll be your senior next year...

sounds like you were pretty well prepared for the consult, respecting the consultant since you are entering ophtho next year...don't let it ruin your PGY1 experience!

 

[Free Radicle]

It is interesting that this post popped up today. Our class got together and decided how to handle consults, ER calls, etc. And we basically came to the census that if someone is asking us for our opinions, then we gladly accept it. All this with the caveat that it is triaged appropriately, if it is for something like the above orbital cellulitis then we see it right then, if things are busy and it does not sound like an emergency and can wait a few hours then so be it. As someone else said, learn from it and never act that way yourself.

Good luck in your prelim year

 

[JMK2005]

Though I don't expect too much eye exam findings from the primary team, I do expect them to give me enough information to triage correctly. If it is something that you want the consultant to see sooner rather than later, it's your job to give supporting history and physical.

If I get a consult request form the unit secretary for "blurry vision", I will put it lower on my list after my clinic day. If the primary teams takes the time to call me directly and gives me a good story for orbital cellulitis, I'll make it a priority to see if it's truly that and take care of the patient.

 

[FrankMD]

out of curiosity, are you entering your PGY-2 year at the same program? I wonder if she'll be your senior next year...

sounds like you were pretty well prepared for the consult, respecting the consultant since you are entering ophtho next year...don't let it ruin your PGY1 experience!

Bulldoc, fortunately, I'm definitely NOT going into ophtho program at the place I'm doing my prelim. I actually didn't even apply to this program since I was looking to go to the "best" program for me.

 

[rubensan]

1PM! That's early! Usually, the medicine/peds flurry of consults come between 2-4. They finish rounding, have lunch/conference and THEN page ophthalmology. I agree with all the above posts. Now you know how NOT to handle consults next year. In the real world, when you get inpatient or ER consults, they pay well.

Sure, VA is important when the primary team is asking you to evaluate "blurry vision," but there are certain consults that you see right away irrespective of VA: ruptured globe, orbital cellulitis, CC fistula, pupil involving CN III palsy.

Bulldoc, fortunately, I'm definitely NOT going into ophtho program at the place I'm doing my prelim. I actually didn't even apply to this program since I was looking to go to the "best" program for me.

 

[schistosomiasis]

one tip for those of us on the receiving end of consults- our chief requires us (and I'm an attending) to say "we will be happy to see the patient..." to anyone who requests a consult. It is meant to put the consulting physician at ease and to let them know that I am taking them seriously. After I began trying this, this really does work. Of course, I usually end the sentence with ".... tomorrow morning" or "next week"

 

[ckyuen]

The resident you consulted will get her's when she goes into practice and has no business because she is do difficult to deal with. You must respect your consults, my pcp's show me a lot respect for basic things they see everyday when I consult them for preop H&P. They never make me feel stupid. Unless that resident ends up at kaiser or another closed system, they will be hurting for business. If someone calls it's b/c they don't know and the need help. I remember seeing 30-40 pts a day doing consults, and thinking this is pretty tough. Now on a good day I see much more than that, do surgery, and cover several hospitals. And if you want to know who the ER guys send their non-emergent consults to to be followed the next day look no farther. Same with the internist. If I have 40 patients for a 3.5 hour clinic and one of my pcp's calls me at noon when I have 30 or so patients in the afternoon at my satellite clinic, I say send them right over. Just don't eat lunch, I'm much to plump anyways.

 

[Eyescan]

We, as ophthalmologists, provide a service. We should strive to deliver the best service.

Consult to remove a contact lens? Thank you.
Consult to check visual acuity? Thank you.
Consult to fill out driver's license form for a hospitalized patient? Thank you with a disclaimer that a clinic exam is more accurate and may be the difference between getting a license or not....patient opts for clinic appointment when blood sugar is stable.

In return, we, as ophthalmologist also ask for stupid consults. As a resident, the attending's neck is on the line so that person's judgment is given weight in calling for consults.

Don't we fault airlines for poor service even if the plane arrives on time? The same is true with ophthalmology. Technically good cataract surgery but also good personal service should be our motto. Today's Wall Street Journal has an article comparing optometry chains. They said the ophthalmologist had poor service as they were unable to give an appointment for several (?) months.

 

[DrEyeBall]

one tip for those of us on the receiving end of consults- our chief requires us (and I'm an attending) to say "we will be happy to see the patient..." to anyone who requests a consult. It is meant to put the consulting physician at ease and to let them know that I am taking them seriously. After I began trying this, this really does work. Of course, I usually end the sentence with ".... tomorrow morning" or "next week"

My theory is that you are just as busy next week.

Now or as sson as I can get there is the best time to see them.

We are often disgusted by the behavior of professional athletes who are paid so much and never seem to really acknowledge it. We too easily forget that the person bagging your groceries would be very happy to receive the consult fee for the time it takes to do that consult. He/she will work all week to make that.

More importantly, this person hopefully became a doctor to help people. I am sure she would not have felt the same if it were her grandmother.

Not everyone changes in practice and many times it is advertising more than skill or professionalism that dictates the volume of patients in your waiting room.

 

[PDT4CNV]

It sounds like that particular resident did not act appropriately on the phone. That particular resident was a jerk or having a bad day, plane and simple. But really, that has nothing to do with ophthalmology.

As I'm sure you know, whenever possible, it is courteous to try to call in consults as early as possible regardless of whether it is for ophthalmology or another service. Ophthalmology residents can be busy in the OR or bogged down in an overbooked, understaffed clinic where simply leaving to go see another services patient at their convenience is not an option. Remember, there are a LOT less of ophthalmology residents than IM residents

My opinion is that a basic exam on the part of the consulting service is expected (pupillary exam and acuity at a minimum). This is no different than, for example, listening to the chest, checking vitals, and getting an ekg before a cardiology consult, as would be expected by the cardiology fellow. Last time I checked, med students still learn basic exam techniques for the eye which are still covered in Bates and Degowin, and Cecil and Harrisons still have chapters on common ocular disease as do ER texts like Tintinalli.

Ophthalmology residents can also get defensive because the majority of the consults they get are absurd and without merit and the consulting service usually makes no effort to even question the patient on his/her visual symptoms or even do a basic exam.

Certainly, it sounds as if the resident you spoke to acted inappropriately. But the implication that this is specific to ophthalmology is out of line. Housestaff and attendings in virtually ever specialty are at times less than pleasant on the phone, particularly regarding consults from other services at academic centers. And if the consult comes in the afternoon, its worse.

And just for whoever is reading, the most inappropriate thing to do is to consult ophthalmology for an exam just prior to discharge. Inpatient consults are to assist in managing inpatient problems, not to satisfy one's curiosity or because the patient needs new glasses.

 

[greenwitch]

Hey Frank,

I had the exact same thing happen to me when I called an ophtho consult! It might have been the same person... made me want to stay an undercover ophtho person during my prelim year (at least to the ophtho department here).

 

[odieoh]

I have a co resident who used to badger the medicine people about getting a good vision and a thorough pupil and motility exam and he would question them endlessly about what they did and didn't do and how they probably did it wrong and on and on and on. My take on that is--what an incredible waste of time. Mainly because, even if they did a very complete exam you can't beleive a single word they tell you. I've had consults where they've told me the pt was seeing 20/400 or light perception and they end up being 20/30 or better. Conversely I've had them tell me patients are "seeing fine" and they are 20/400 or worse. So basically I've learned to not even ask, I want the pt's name and room number and the basic story so I can triage, but I don't usually ask them much about the exam, I'm going to have to do it myself anyway so whats the point.

Part of the problem is that taking a good vision really is a skill that you have to practice at. When I started as a resident I would consistently get a certain vision, and then the senior resident would come and push the pt and end up getting several lines better. Learning to push them to reading the lowest they possibly can is something medicine/ER residents just haven't learned and I don't really expect them to.

 

[rubensan]

i definitely agree with a lot of points that you have made in your post. as i stated earlier in this thread, there are a few consults where pts should be seen ASAP regardless of Va or whether it was checked. for r/o diabetic retinopahty in an inpatient, i think it it is good practice (and common courtesy) for the consulting intern/resident to check a vision. you are correct in stating that we repeat it when do a formal consult, but a cardiologist repeats the cardiac exam when he/she sees the consult and the general surgeon repeats the abdominal exam when they see a consult. does it mean that i am as good as a cardiologist when i ausculate a murmur? no. does that mean that i should not at least find a stethoscope and listen to the heart before i call? absolutely! i think the point that some are making on this thread is what makes calling an ophthalmology consult any different? i agree that the way the ophthalmology resident acted in the scenario this thread was based on was INAPPROPRIATE and poor FrankMD went ABOVE AND BEYOND before calling ophthalmology. but people are absolutely correct in stating that this behavior is NOT limited to ophthalmologists. I remember being raked over the coals my 2nd or 3rd week of internship when i called a nephrology consult for acute renal failure without checking ins and outs a post void residual and urine lytes first. residency is different from private practice. we are all here to learn and we are compensated the same whether we call consults correctly or not. we should ALWAYS be respectful and helpful to our colleagues. however, as an intern, if no one pushes you to learn and be a more complete physician, then you won't. okay, gotta go r/o ectropion ASAP for a pt with icthyosis, because the "attending wanted me to call the consult."

I have a co resident who used to badger the medicine people about getting a good vision and a thorough pupil and motility exam and he would question them endlessly about what they did and didn't do and how they probably did it wrong and on and on and on. My take on that is--what an incredible waste of time. Mainly because, even if they did a very complete exam you can't beleive a single word they tell you. I've had consults where they've told me the pt was seeing 20/400 or light perception and they end up being 20/30 or better. Conversely I've had them tell me patients are "seeing fine" and they are 20/400 or worse. So basically I've learned to not even ask, I want the pt's name and room number and the basic story so I can triage, but I don't usually ask them much about the exam, I'm going to have to do it myself anyway so whats the point.

Part of the problem is that taking a good vision really is a skill that you have to practice at. When I started as a resident I would consistently get a certain vision, and then the senior resident would come and push the pt and end up getting several lines better. Learning to push them to reading the lowest they possibly can is something medicine/ER residents just haven't learned and I don't really expect them to.

 

[odieoh]

Hey Rubensan-

Yeah, probably 80% of the consults I get are "because my attending wanted the consult." One attending in particular is driving me crazy, she is an ID doc and she calls an ophtho consult to "rule out fungal retinitis" on pretty much EVERYONE. If the word candida is mentioned anywhere in the chart she wants a consult. I did one yesterday on a pt with fevers who had a culture positive for candida from an abdominal wound in 2004. 2004!!!! No visual complaints, no eye issues, but call ophthalmology STAT! I am averaging about a consult a day from her, sometimes two. Very annoying.

 

[snoopy brown]

Interesting thread. I'm not an optho person, but it's a question that all services have to deal with. What's the right thing to do? I understand that you as a consultant are the person who is answering the question and the person who is asking obviously is asking for help because they don't know. But isn't it also the case where it's unfair for you to field inappropriate consults? Most people defend it by saying, well, in practice you make money off those inappropriate consults and you'll learn to love them, but that sounds silly.

For example, in Medicine we get consults from ER people who will say stuff like, well the patient doesn't look right to me. I can totally see where someone would go like the resident in the story above and just grill them on the patient. Sort of like if you want me to work then you have to do some work too. And I've been on both sides, where I called a neuro consult for example and the person wanted me to do a complete neuro exam first, including tine testing and caloric checks in their ear. If I could do their job, why am I calling them? Just for their signature?

I think the best way we can handle things is to at least make an effort and that seems to have been done. I once called a cardiology consult and, even though I wasn't an expert, I had done "enough." I had looked at the EKG, I knew the cardiac history of the patient, some basic risk factors, and I had a reasonable question. The person started out by ripping into me, but once I walked them through all that they immediately calmed down and were extremely helpful! It's little things like that which allow us all to work together.

In contrast, if someone just "dumps" stuff on me without thought I refuse to take the always-say-you-love-it-and-want-more attitude. Why is it that physicians feel they need to act like everyone's slave? I know you guys make your money on consults, but still.

 

[DrEyeBall]

i definitely agree with a lot of points that you have made in your post. as i stated earlier in this thread, there are a few consults where pts should be seen ASAP regardless of Va or whether it was checked. for r/o diabetic retinopahty in an inpatient, i think it it is good practice (and common courtesy) for the consulting intern/resident to check a vision.

I would disagree with that. It is not a skill they know or will ever use in practice.

In our clinic, we do not even have the consulting service talk to us unless they feel the need to give us information that is needed.

To stop clinic, pick up the phone and take an exam from somebody who is not able to do one, makes no sense. To ask questions of the intern or resident about what exam they did or did not do is a total waste of time. I could have been done seeing the patient I was seeing.

Our protocol is that the clinic receptionist tells the consulting doctor to send the patient to clinic as soon as they can for the consult. The doctors rarely triage anything. The extra effort is a waste of time and energy.

 

[odieoh]

I would disagree with that. It is not a skill they know or will ever use in practice.

In our clinic, we do not even have the consulting service talk to us unless they feel the need to give us information that is needed.

To stop clinic, pick up the phone and take an exam from somebody who is not able to do one, makes no sense. To ask questions of the intern or resident about what exam they did or did not do is a total waste of time. I could have been done seeing the patient I was seeing.

Our protocol is that the clinic receptionist tells the consulting doctor to send the patient to clinic as soon as they can for the consult. The doctors rarely triage anything. The extra effort is a waste of time and energy.

While I agree that its a waste of time to grill medicine people about their eye exam, I don't think most places are set up like wherever you are where you can just see everyone in clinic. Where I am, and I assume it is the same most places, you take consults from inpatient services including the ICU/CCU/SICU and a lot of them are way too sick to go down to clinic. So you kind of have to get a basic idea of what the problem is and triage, but that usually takes about 10 seconds. For my aforementioned fungal retinitis rule-outs I usually just interrupt them after they've told me about two paragraphs of the long, drawn-out medical history and ask them if this is a rule out fungus. They say "yes" and I say "ok I'll get there eventually" and we both hang up and I stick that pt way down at the bottom of my list and go about my business and see it when I get to it.

 

[Tux]

Interesting thread.

I'm in my first year of ophtho, and I have to say that I'm amazed, surprised and often very pissed off at what I see is being referred to us.

Consults from neurology: "patient admitted with x symptoms, CT shows brain tumour <insert location anywhere in visual pathway>. Requesting ophthalmology consult due to vision problems." No eye history, no VA, didn't even take the time to perform Donder's.

And the killer I received a few days ago: pt referred with bacterial conjunctivitis of 2 wks. duration, no improvement, this was third time he was at his GP for the consult, after which he ended up at our place.
me: *thinking I caught a glimpse of his eyes with contacts on*: you dont wear lenses, do you?
pt: yes, I do.
me: youre wearing them now?
pt: yes
me: have you had them on for the whole period you've had symptoms?
pt: I've taken them off for the night like I always do.

God oh mighty. If I ever get to speak to that GP again...
This is remarkable. As ophthalmologists, we're sometimes amazed people don't know the difference between us, and an optometrist. We deny optometrists the privilege of surgery, and like to consider ourselves as fully qualified MDs. Yet a neurologist or GP or IM is not able to perform BASIC eye examination and take history. And, vice versa, majority of ophtos just ditch patients over to IM once ocular pathology has been excluded. Yeah, grabbing a stethoscope is frightening...

My point: I expect the referring doc to have done a basic eye exam, just as he'll examine the pt. with chest pain or shortness of breath. Wanna play doctor, then do your job, simple as that.

 

[rubensan]

A very successful community ophthalmologist once imformed of the "3 A's" of a successful private practice: Ability; Affability; and Availability. Some even think that these are listed in increasing order of importance. I think DrEyeBall is touching on the importance of being available for consults. Once you are done with residency, the more available and affable you are, the more business will come your way. The optometrists learned this A LONG time ago.

Now, I happen to be in a program where it is not uncommon for the 1st year consult resident at the county hospital to receive up to 20 consults/day (in addition to the 20 or so patients that are already scheduled to see you) everything from people with pterygia that come throught the ER to ruptured globes from outlying ERs. If we saw everyone the same day, our system would break. The ER residents rotate through our clinics to learn how to triage ophthalmic cases. At the end of the year, they are pretty good at knowing if the pt needs to be seen by ophthalmology right then or if the pt sent from the outside ophthalmologist or optometrist with C to D ratio of .06 and IOP 15 can receive a follow-up appt in a few days when we are not AS BUSY. I don't agree with DrEyeBall in that when I am the consult resident, I am much busier that day when compared to 2 days later when I am not the consult resident. I am currently on a rotation at a more private hospital where we receive 3-4 consults/day and DrEyeBall is correct in that it is easier to see everything at lunch or after clinic. The attending is compensated, the primary team is happier with you, the patient is happy for being seen and everybody wins. It is much easier to be "available" in this tye of setting which I believe more closely approximates the real world.

 

[DrEyeBall]

Tux,

I think you need to re-evaluate those feelings.

There is absolutely no reason for the neurologist or GP to do any sort of an eye exam at all. This complaint is heard often in residency but nothing could be further from the truth.

When I consult another specialist, I do not listen to the lungs, look in the ears, take a BP, etc. I expect the expert that I am asking for help to do those things. I admit my patients to the gemeral medicine services for those physicians to do what they do best. I never feel like I am "dumping" on them. In turn, those doctors know they can call us about a consult for anything they need help for with their patients. If a patient comes to the hospital and needs a refraction, he/she gets it that day. The system works best when we provide the service we provide best. Our residents are taught to never ever complain about a consult for any reason. They learn this by seeing that the attending staff would never do such a thing. It is not because we get paid for those consults, it is because it is the right thing to do.

Rubensans - I see your point but there are ways to build a system so that the ability to see these patients can be included in the daily work plan.

There is no point complaining about death, taxes, consults or call duty. They are part of life and complaining about them serves no purpose.

 

[rubensan]

amazed, surprised and often very pissed off

ahh, 3 very common emotions to feel as a first year. It gets much better 2nd year.

 

[rubensan]

Tux,

I think you need to re-evaluate those feelings.



When I consult another specialist, I do not listen to the lungs, look in the ears, take a BP, etc. I expect the expert that I am asking for help to do those things. I admit my patients to the gemeral medicine services for those physicians to do what they do best. I never feel like I am "dumping" on them. In turn, those doctors know they can call us about a consult for anything they need help for with their patients. If a patient comes to the hospital and needs a refraction, he/she gets it that day. The system works best when we provide the service we provide best. Our residents are taught to never ever complain about a consult for any reason. They learn this by seeing that the attending staff would never do such a thing. It is not because we get paid for those consults, it is because it is the right thing to do.

Rubensans - I see your point but there are ways to build a system so that the ability to see these patients can be included in the daily work plan.

There is no point complaining about death, taxes, consults or call duty. They are part of life and complaining about them serves no purpose.

You have a great attitude and many of your points are well taken.

 

[DrEyeBall]

You have a great attitude and many of your points are well taken.

Thanks. I realize as I resident that there is not too much control over what happens in the clinic. More senior residents can help the junior residents by displaying the proper attitude. It makes the year go by alot faster.

Also, I fins that residents that work and act like they would in practice get treated like peers by the attending staff. These attitudes about patients and improper consults don't disappear when July 1 rolls around after residency is over...they just are justified by the money we make. Not a great way to practice medicine.

 

[Tux]

Tux,

I think you need to re-evaluate those feelings.

There is absolutely no reason for the neurologist or GP to do any sort of an eye exam at all. This complaint is heard often in residency but nothing could be further from the truth.

When I consult another specialist, I do not listen to the lungs, look in the ears, take a BP, etc. I expect the expert that I am asking for help to do those things. I admit my patients to the gemeral medicine services for those physicians to do what they do best. I never feel like I am "dumping" on them. In turn, those doctors know they can call us about a consult for anything they need help for with their patients. If a patient comes to the hospital and needs a refraction, he/she gets it that day. Our residents are taught to never ever complain about a consult for any reason. They learn this by seeing that the attending staff would never do such a thing. It is not because we get paid for those consults, it is because it is the right thing to do.

why is it the right thing to do? Take my example of the GP who didn't bother to ask a basic question - the patient be better off and it would be perfectly safe to handle the situation without an ophtho in the picture if the GP had taken a proper eye history on the first consult (granted, at the point where 2 wks had passed I'd obviously see the patient anyway).

The system works best when we provide the service we provide best.

Sure, but as MDs, we're all trained to handle a number of situations, be it gen.surg., IM, neuro, whatever. I recently had a pt. with the classic "decreased vision" problem, needed nothing but a pair of glasses. 6 wks. earlier discharged from IM where he was treated for pneumonia, previous history of heart failure, MI etc. Complained at my office of shortness of breath upon phy. act. It took me about 10 min. to take history, RR, auscultate, check for edemas etc. Made a call to IM attending with findings, I referred him to IM outpatient. When I told my attending, she said I should have just sent the patient off to IM. For Pete's sake, 10 min. for me, a situation I feel comfortable at handling, vs patient waiting for (potentially) hours at the hospital for an IM conult, with the exact same outcome. And I believe it goes both ways. At the very least do a basic exam, it'll take 5 min. tops and will help me prioritize.

 

[snoopy brown]

Sure, but as MDs, we're all trained to handle a number of situations, be it gen.surg., IM, neuro, whatever.

But isn't it also true that we're not all trained for stuff like optho? That's very unfair to expect an optho person to know about GP stuff and not vice versa, but it's true. You guys are talking about how ridiculous that the GP didn't "perform Donders." I don't even know what that is, sorry. I can use a Snellen chart and I can test oculomotor function, but I don't know much more. But I'm not avoiding doing it because I'm trying to be a jerk. OTOH, everyone who goes through medical school knows about SOB or chest pain and can use a stethoscope. I can bet a good percentage of people don't get much exposure to slit-lamps or putting fluoroscene in someone's eye.But to be honest most opthos or sub-specialists I know don't do anything outside of their field. It is admirable that you took time to deal with the SOB patient, but most sub-specialists would just refer them to the GP.At any rate like I said, consults are a tricky thing to give or receive. I know I'm no optho, but I hope you guys read my other post about the issue above.

 

[DrEyeBall]

why is it the right thing to do? Take my example of the GP who didn't bother to ask a basic question - the patient be better off and it would be perfectly safe to handle the situation without an ophtho in the picture if the GP had taken a proper eye history on the first consult (granted, at the point where 2 wks had passed I'd obviously see the patient anyway).
Sure, but as MDs, we're all trained to handle a number of situations, be it gen.surg., IM, neuro, whatever. I recently had a pt. with the classic "decreased vision" problem, needed nothing but a pair of glasses. 6 wks. earlier discharged from IM where he was treated for pneumonia, previous history of heart failure, MI etc. Complained at my office of shortness of breath upon phy. act. It took me about 10 min. to take history, RR, auscultate, check for edemas etc. Made a call to IM attending with findings, I referred him to IM outpatient. When I told my attending, she said I should have just sent the patient off to IM. For Pete's sake, 10 min. for me, a situation I feel comfortable at handling, vs patient waiting for (potentially) hours at the hospital for an IM conult, with the exact same outcome. And I believe it goes both ways. At the very least do a basic exam, it'll take 5 min. tops and will help me prioritize.

I would argue that your exam really did not add anything. The patient still needed to see the other MD. They were going to repeat the exam anyway. Nothing you did on your exam made their job any easier and it wasted 10 minutes of time for every patient sitting in your waiting room.

Again, this is a common complain among residents. I think this occurs because:

You feel overworked.
You are still close enough to medical school that the basics of a general exam are close to you and you feel since "you can do it" you should get the same in return.


But mostly it is about looking at the best interest of the patient, being professional and developing maturity about being a physician.

 

[DrEyeBall]

Let me add one more thought for you to think about:

Every patient you see gives you a chance to have a positive impact- for both the patient and the referring doctor.

When I was a resident, I was called by an OD on a weekend with what seemed like something fairly routine for me but not for him. I took care of that problem. The patient was happy and it made the OD look good as well. Several years after fellowship, I returned to the same city and he directed all his referrals to me because of that pleasant interaction.

You never know when that might occur. You never know when that "routine refraction" consult, rule out fungus, etc will be someone who can have a very positive impact on your career.

 

[Tux]

The IM attending didn't see the patient, I just called in to confirm that he shared my point of view, and referred him to the IM outpatient clinic instead of tossing him into the lap of whoever was oncall.

I'm not overworked, perhaps because this is my first year and they're limiting number of scheduled patients to 10 - 12 or so, plus whatever comes in.

Anyways, we seem to have different philosophies.

 

[Tux]

Let me add one more thought for you to think about:

Every patient you see gives you a chance to have a positive impact- for both the patient and the referring doctor.

When I was a resident, I was called by an OD on a weekend with what seemed like something fairly routine for me but not for him. I took care of that problem. The patient was happy and it made the OD look good as well. Several years after fellowship, I returned to the same city and he directed all his referrals to me because of that pleasant interaction.

You never know when that might occur. You never know when that "routine refraction" consult, rule out fungus, etc will be someone who can have a very positive impact on your career.

As much as I see your point, when I'm at work, I'm at work; not running in a popularity contest. I value courteous interaction with other docs, but that doesn't mean I shouldn't expect anything from them - ofcourse that goes both ways.

 

[DrEyeBall]

As much as I see your point, when I'm at work, I'm at work; not running in a popularity contest. I value courteous interaction with other docs, but that doesn't mean I shouldn't expect anything from them - ofcourse that goes both ways.

I am afraid this attitude has become much more common among training physicians now. You are in many ways in a popularity contest. Your goal is to please and help both the patients and the people who send you those patients. That of course means giving them the best care but making them feel they made the right choice about coming to see you. Many people have a sense of entitlement about being a phsyician. That MD at the end of your name gives you nothing but the ability to see patients.

You will hear many people complain that they do not see enough patients, that the other doc must be doing unethical cataracts to be that busy, etc as to why one person does better than the other in practice. Most of the time they need to look at themselves as the source.

Think about it if it were your parent. Would you want the ophthalmologist to be trying to "teach" his/her doctor how to properly triage an eye patient?

 

[orbitsurgMD]

Hey Rubensan-

Yeah, probably 80% of the consults I get are "because my attending wanted the consult." One attending in particular is driving me crazy, she is an ID doc and she calls an ophtho consult to "rule out fungal retinitis" on pretty much EVERYONE. If the word candida is mentioned anywhere in the chart she wants a consult. I did one yesterday on a pt with fevers who had a culture positive for candida from an abdominal wound in 2004. 2004!!!! No visual complaints, no eye issues, but call ophthalmology STAT! I am averaging about a consult a day from her, sometimes two. Very annoying.

You won't mind the calls so much when it is your practice doing the billing and your paycheck depending on the referral. Get used to it. Lots of consults are pointless, and you will only hurt your reputation by saying so or by implying anywhere in the report that the consult was inappropriate. If you get a call "stat", call the attending directly and ask for the particulars and to know why the request is "stat" or whether within 24 hours would be acceptable. Be polite. Don't undermine the resident who called you with the request. Do that resident a favor and call him back to say when you hope to see his patient. Sometimes stat really means stat, and sometimes it is used because of a fear that you wont see the patient at all.

 

[odieoh]

You won't mind the calls so much when it is your practice doing the billing and your paycheck depending on the referral. Get used to it. Lots of consults are pointless, and you will only hurt your reputation by saying so or by implying anywhere in the report that the consult was inappropriate. If you get a call "stat", call the attending directly and ask for the particulars and to know why the request is "stat" or whether within 24 hours would be acceptable. Be polite. Don't undermine the resident who called you with the request. Do that resident a favor and call him back to say when you hope to see his patient. Sometimes stat really means stat, and sometimes it is used because of a fear that you wont see the patient at all.

I completely agree, although that seems to contradict my own post. Once you are in private practice it is a whole different game, I would love to do as many rule out fungus consults as they can throw at me, because they are easy to do and very straightforward and as you have indicated my paycheck would be depending on it. Thats often the difference between private practice and academic medicine. I did my intern year at a private hospital and it was great whenever we needed a consult because the private guys wanted the work and were willing to come in right away to get it done, no matter how stupid the consult might have been. Consulting a resident on the other hand can be a hassle because all the consult means to them is more work.

 

[DrEyeBall]

I completely agree, although that seems to contradict my own post. Once you are in private practice it is a whole different game, I would love to do as many rule out fungus consults as they can throw at me, because they are easy to do and very straightforward and as you have indicated my paycheck would be depending on it. Thats often the difference between private practice and academic medicine. I did my intern year at a private hospital and it was great whenever we needed a consult because the private guys wanted the work and were willing to come in right away to get it done, no matter how stupid the consult might have been. Consulting a resident on the other hand can be a hassle because all the consult means to them is more work.

If someone is happy doing the consult only because they are getting paid for it, then maybe they are in the wrong line of work.

To many of us, these are routine and seem like an annoyance. To the family, the patient and the referring doctor they are helpful and needed. They would not be askign for them if they thought they were "useless". I have found that the family is always relieved to hear that the eye is not filled with fungus. It is often a bit of good news in an otherwise very bad experience.

Enjoy giving the good news to the patient and family. Remember that what we take for some little issue may be very big for everyone else. People spend more time complaining about this then it takes to do the consult.

 

[shiro1]

Ahhh... consults. You love them and hate 'em when you're out in private practice. I'm extremely lucky in that my outpatient office is connected to the hospital in which I cover consults so that many can be transported to my office which is very convenient. It is very rare for me to have to drive in after hours or on the weekend for an inpatient consult as many consults can be safely done the following day, or even wait over the weekend until a weekday. This is good because I live 35 miles away from the hospital. However, it is still a little irksome to have a completely unwarranted consult. I mainly find it so because I feel for the patient if they have wasted their time and got an unecessary dilation. I feel this way for recent CVA's with visual field defects (duh!), sub-conjunctival hemorrhage (can I start Aspirin/Coumadin/etc?), headaches, conjunctivitis already being treated with vigamox,etc. I am always polite to my consultants, however, as I also have admitted patients directly to IM or hospitalists for cellulitis, uncontrolled HTN or cardiac arrythmias in the immediate post-op period after cataract surgery etc. and I have been surprized by what I thought was a b-s consult being completely warranted (a simple conjunctivitis consult being a corneal ulcer or iritis, etc.)

 

[Pastrami King]

so i eventually got the consult that i'd been waiting for with bated breath (and i thought it was an urban legend):

reason for consult: nonreactive pupil in an intubated patient
diagnosis: prosthetic eye

i would've laughed it off except that it was on the weekend and you can't believe just how many patients people at my program see each weekend (one person covers a major children's hospital, two major trauma/academic centers, and a VA, and we are encouraged to always be "affable and available.")