Radiation Oncology Call

[bob1988]

Just curious how busy call is for most folks. I'm a PGY2 and have gotten 8 consults and counting after hours (as late as 10:30 PM) or on the weekend this week - much busier than the norm. Some of these consults not necessarily appropriate for calling late at night or on the weekend, but our attendings always want us to lay eyes on patients when we get called. Mainly venting after working 73 hrs over 6 days and just about ready to smash my pager. I wish people who consult were more thoughtful about their consults.

---

Members don't see this ad.

 

[Neuronix]

Sorry to hear that. If it's a consult that clearly has nothing for us to do, we often just do a phone to phone to make recommendations without seeing the patient (i.e. go to neurosurg), negotiate seeing it the next day or after the weekend, kick it to the outpatient clinic, or ask for it to be cancelled. The attendings back us up on this. Maybe you could try to get that policy going at your institution.

Do the attendings actually come in after hours or on the weekend to see these patients? That's the real test to me. If the attending doesn't care to see the patient and is pretty sure that they won't have to come in before you even go to see the patient, then it doesn't need to be seen.

Yes, this is a very academic mindset. With this culture in place I'd say we average about 0.5 after hours or weekend inpatient consults per call with what they tell us is the third busiest cancer hospital in the nation. Private practice is very different (drum up business, maintain relationships).

 

[bob1988]

2/8 needed treatment (hemorrhagic brain mets with sudden vision loss and SVC syndrome) but the others were seen by attendings the next business day. These aren't so bad that we can kick it to outpatient (brain mets, cord compression that neurosurgery is planning to operate on), but clearly things we wouldn't treat at 10:30 PM and could be called in the AM. We definitely have a culture of keeping referring / consulting physicians happy and we cover a private hospital in addition to our academic site and a VA. As it is, we average about 3-4 inpatient consults per day during business hours. The amount of consults we get saying "we just want you on board" and "we just wanted to make you aware" is absolutely frustrating.

 

[evilbooyaa]

2/8 needed treatment (hemorrhagic brain mets with sudden vision loss and SVC syndrome) but the others were seen by attendings the next business day. These aren't so bad that we can kick it to outpatient (brain mets, cord compression that neurosurgery is planning to operate on), but clearly things we wouldn't treat at 10:30 PM and could be called in the AM. We definitely have a culture of keeping referring / consulting physicians happy and we cover a private hospital in addition to our academic site and a VA. As it is, we average about 3-4 inpatient consults per day during business hours. The amount of consults we get saying "we just want you on board" and "we just wanted to make you aware" is absolutely frustrating.

Regardless of the specialty, these are the most frustrating consults when they're put in after normal hours or towards the very end of the work-day. Agree with others that you should try to talk to your attendings and determine what needs to be seen ASAP vs what doesn't.

This may be an initiation to PGY-2, however, as the attendings may not know if you know what can wait and what can't, but after you present they know it's not serious?

 

[medgator]

"These aren't so bad that we can kick it to outpatient (brain mets, cord compression that neurosurgery is planning to operate on), but clearly things we wouldn't treat at 10:30 PM and could be called in the AM"

No one in pp is going to see that 10:30 inpt until the following day realistically. I'd touch base with the referring to find out whether it's really such an urgent consult that has to be seen then. Usually, it won't be

 

[xrthopeful]

you shouldn't be going in at 1030 PM. You wouldn't be able to do anything that late anyways.

You should clarify with your senior residents.

 

[Gfunk6]

When I was in your shoes (residency), I would also bemoan the useless, late night or weekend consult. Now that I am incentivized, my my how things have changed

 

[OTN]

2/8 needed treatment (hemorrhagic brain mets with sudden vision loss and SVC syndrome) but the others were seen by attendings the next business day. These aren't so bad that we can kick it to outpatient (brain mets, cord compression that neurosurgery is planning to operate on), but clearly things we wouldn't treat at 10:30 PM and could be called in the AM. We definitely have a culture of keeping referring / consulting physicians happy and we cover a private hospital in addition to our academic site and a VA. As it is, we average about 3-4 inpatient consults per day during business hours. The amount of consults we get saying "we just want you on board" and "we just wanted to make you aware" is absolutely frustrating.

If you're going into private practice, how you view those "we want you on board" consults will change completely once you're done with training.

Is there any competition around? If so, it makes sense for your attendings to want the pt to be seen. I see patients whenever referring MDs want, no matter the time/day/etc.

 

[xrthopeful]

What residency programs have competition for in-hospital consults?

and it's one thing to make referring MDs happy, it's another thing to make their interns who unwittingly place consults late at night happy.


common sense.

 

[Gfunk6]

If you're going into private practice, how you view those "we want you on board" consults will change completely once you're done with training.

Is there any competition around? If so, it makes sense for your attendings to want the pt to be seen. I see patients whenever referring MDs want, no matter the time/day/etc.

You hit the nail on the head. In my area, there is massive competition. You can't swing a dead cat without hitting an Oncologist. Therefore, if you get a consult you run (not walk!) to see the patient, write a note and "mark your territory."

 

[ReOxygenation]

You hit the nail on the head. In my area, there is massive competition. You can't swing a dead cat without hitting an Oncologist. Therefore, if you get a consult you run (not walk!) to see the patient, write a note and "mark your territory."

Can't wait to pee all over those Inpt charts. Back off chemosurgery!!!!!

 

[medgator]

Im in pp and have a hospitalist (ip) and pulmonologist (op) who send me primary oncology cases sometimes, sometimes even less, just "lung mass"

Not every case requires radiation. I provide the three "A's" and am happy to do so. Every so often, it turns out to be a lung abscess etc. Most of the time, I set up the appropriate biopsy to establish a tissue diagnosis. If needed, I then get a medical oncologist involved. Sometimes I consult hospice/palliative care. The palliative care specialist was surprised the first time he got a consult from me. Imagine how the med oncs feel. It proves to them and the community at large that we are not technicians, but rather oncologists who are capable of managing oncology patients. It also gets me involved early in the case for when a patient does eventually need radiation .

Those calls that may annoy you now will be the ones you are thrilled to get since they are the life blood of your practice. Unless you work at the VA... just kidding.

OTN and Gfunk both nailed it. In competitive areas, you're going to want to be the first one they call and the first one on the chart. You may in a situation where if you don't get that consult, maybe a med onc will (who happens to be partnered in with a different radiation center/rad onc).

 

[RadOncDoc21]

Agreed with the above posts, however during residency it really does serve no purpose other than for you to serve as a bridge for the attending. As I became more experienced, I started to make the management decisions for the attending in regards to seeing the patient right away versus pushing things off to the morning.

Let me warn you, I do not recommend this strategy approach as a pgy-2 or 3 and you should always communicate your plan with your attending.

PP is a whole different ball games, I'm fighting for scraps!

 

[BobbyHeenan]

Agree with other people. This is a totally different conversation between private practice (where I LOVE these "get you on board" consults) and residency, where I LOATHED them.

As a PGY-4 you can start effectively "triaging" these patients. I started to get to know the med onc fellows and medicine residents and they started just calling the on call resident to discuss cases before putting in orders for a formal consult. What they didn't understand is that in rad onc we have no "consult service," so we have to squeeze inpatient consults in after busy clinic days or at lunches. That was all news to them. Once we established a good rapport they just called the rad onc on call to get input prior to putting in for a formal consult.

Really all their attendings want is a good plan for their patient they're going to discharge, so they were often very satisfied with a brief rad onc note on the chart and calender date/time for a formal outpatient follow up. That way you could run up and introduce yourself to the patient briefly and tell them you'd discuss everything once they're an outpatient and can be seen in the clinic. This works especially well if they're local...not so much if they've got to drive a couple of hours back to the hospital/clinic though. This method was a great compromise to all of those "just wanted to get you on board" consults where you've got to do a full consult note, can't really discuss specifics because path/staging/etc isn't back, pray the family is as bedside so you don't have to make a million phone calls...then repeat the whole consult again as an outpatient closer to sim date.

Our attendings were comfortable with that as long as we set up an outpatient appointment and made sure the patients didn't fall through cracks. Where you run into problems with the compliance/bean counter folks is when a formal consult is ordered and no such consult (no attending) sees the patient. So you've got to get the referring fellows or residents (and their attendings) comfortable with these quick mini-consults where attendings don't have to see the patient because there is no formal written order for a consult.

 

[BobbyHeenan]

The other thing I didn't mention is that any time you or an attending is giving a lecture to other departments (OB/GYN, Gyn Onc, Medicine, Heme Onc, Surgery, etc)....end the Powerpoint with a slide called "logistics" or something and just explain in a few seconds the work flow of inpatient consults. Educating your referring docs is the best way to make sure the consults are timely and appropriate.

It's then that you can set up whatever work flow or system that will work best for you and the patients. Seriously - other services think a rad onc department has an inpatient consult service - they're often blown away that one doesn't exist. So throw up a slide with the on call resident pager and say any time you think you may have a consult but aren't sure, just page this number and we'll sort it out.

 

[medicineradman]

When you're early in residency it is hard to realize how big of a mobilization it takes to get someone on treatment for radiation, but its important to understand that so you can relate it to referring's as well. They certainly have no clue (don't you just push the button?!).

At the end of the day you do learn something by seeing these patients and you aren't really on call that much so take it as a learning opportunity. You really do learn a lot by seeing inpatient consults. The beginning of residency sucks bc you don't know what is and isn't important or emergent, and this is part of that. If the referring says specifically it is just a curbside to setup outpatient follow up just refer them to the number for clinic to set up an appointment but think through the case, it is good experience.