Seeking a “second opinion” from different doc - overstepping?

[deleted836128]

Apologize if this is a weird question to be asking on this forum.

My opinion is that there’s no room for egos in medicine and if you have concerns about a patient care approach, speak up. However we all know that some people have egos and could potentially get offended if you question their approach and instead look to another person for a different take on a case. There have been only a handful of times when I’ve been in the position where I was uncomfortable with the plan from a doctor I consulted and felt the need to get a second opinion, but it always feels incredibly awkward...and it becomes even more complicated when I am a PA and therefore NOT the expert. I posted about one of these cases last year, when I had an ovarian cyst rupture patient that was anemic and passed out twice in the ER, and the gynecologist on call told me I should send her home. She was mad when I got my attending involved because I felt super uncomfortable with that plan. She was even madder when, after my attending physician had very reluctantly discharged the patient “because the specialist said so and it’s on her,” the patient passed out again, and we called the gyn back to tell her we would not send this patient home.

Today I had an old lady with head trauma a few days prior (no loss of consciousness) that came in with unilateral blurred vision, facial pain, and vertigo. She also had some posterior neck pain and stiffness. My first instinct was just to get a CT head, CT cervical spine and a CTA head/neck (concern for dissection) but - I’ve been told I order too many tests so I talked to my attending physician and he said to just get a CT head and cervical spine because he felt a vertebral artery dissection would be unlikely. I initially agreed that was a good plan but then felt weird about it so quickly asked another attending’s take. I do love having talks with different docs because they all have such different approaches and i learn something new every time. When I was doing so the other doc walked by and heard me getting a second opinion. It was a cringe worthy moment. Especially because this other doc totally agreed with me. Doc number one didn’t say much but I could tell he was a little miffed. Later on I apologized for my approach, and he was nice about it and said ultimately if I am that worried to just get the test. Hopefully I didn’t do too much damage but it’s hard to tell.

What do you guys think is the best way to handle this type of situation? Part of me thinks I am overthinking it - but I also never want to disrespect or overstep one expert’s opinion for another’s.

Note: I should be clear that in my ER I don’t have to staff most cases with an MD. In this case, it was optional. I can also choose which doc I staff cases with, usually whoever happens to be around at the time. I would never NOT get a test an attending wanted me to get. Or send home a patient an attending wanted me to admit. In these cases I am talking about ordering more tests or doing more for the patient than what the attending recommended. Hope this makes sense.

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[GeneralVeers]

Note: I should be clear that in my ER I don’t have to staff most cases with an MD. In this case, it was optional. I can also choose which doc I staff cases with, usually whoever happens to be around at the time. I would never NOT get a test an attending wanted me to get. Or send home a patient an attending wanted me to admit. In these cases I am talking about ordering more tests or doing more for the patient than what the attending recommended. Hope this makes sense.

I'd be pissed if you are working with me and ask another attending for their advice on my case. You are working with me, and ultimately need to follow my orders. You can certainly make suggestions or point out something that I've missed, but the liability is mine.

You aren't staffing "most" cases with an MD? I think that's a mistake. I want you to staff EVERY patient with me, even if it's just a 10 second blurb.

 

[GonnaBeADoc2222]

Yeah that would be the last time that mid-level staffs a patient with me. You can't ask Dad cause you don't like what mom says. Now you can present all patients to the other attending.

 

[Birdstrike]

For starters, if you discharge a hypotensive, hypovolemic, who's fainting repeatedly (because they're in hypovolemic shock!), hiding behind, "No worries. It's on them," feels like it should work, but it doesn't. Ultimately, it's on all of you. You're all involved, you're all jointly and individually responsible. It doesn't fly if you're sued. You all will get sued. Lawyers love nothing more than to name a dozen docs and PAs and pit them against each other. Once the providers start blaming each other, that's instantly seen by the jury as a confession that someone screwed up. The lawyers will start to smile at that point, because they know the case is won, and the only work left is running up the award amount.

Even if blaming a consultant for a bad outcome you knew was going to happen, worked, it's not the right thing to do. All it takes is one person to do the right thing. And if you all herd towards the wrong end point, with each and every one of you pointing to the one to your right, everyone loses, patient included. Does that make it any easier to get your fainting Gyn patient admitted? No, because we lived in a very flawed world and system. But that's what you needed to do, and although it was messy, that's ultimately what you did. Next time, you're be that much more prepared to do it more efficiently.

Regarding the head injury patient, the head injury is likely* enough (notice I said "likely" enough, not "definitively" enough) to cause the neuro and c-spine symptoms alone. The CT Head, CT c-spine and admitting the patient due to the neuro symptoms, regardless of the presence or absence of CT abnormalities likely* has you covered. That's probably what 99% of EM attendings would do. Is a carotid or vertebral artery dissection likely? No. But could that patient have one? Absofrickinlutely, they could have one*. That diagnosis is rare, it presents weird and you won't see enough in your career to have a good feeling for when a patient has one or not. The only way to find them is to have a high index of suspicion. That means you're going to order more negative scans, than positive. In 10 years in the ED, I saw, I think maybe 3 (?) of these. Each time, they presented like a typical patient that just had some extra weirdness about them. Weird non-specific neuro (or other) symptoms that sometimes initially make you think maybe they're just nuts or dramatic. So, it absolutely would not be wrong to order the CTA. And you can bet you arse if you missed it, every cost-savings choosing-wisely academic in the USA that you thought was your friend and mentor will gladly line up to be paid $1000 per hour to give a deposition, chest all puffed up, arrogantly looking down over low slung glasses, saying "YES, he should have ordered the CTA. YES, I would have ordered it. Have you seen my resume? I'm amazing and this guy's an incompetent jerk. Gross negligence! I say. Gross negligence!"

An yes, if I was a PA, you can bet your first born that every single chart would have, "Case discussed with and approved by Dr. _____." Every single damn chart, from CTA patients down to a baby-butt pimple. Even if it's a 5 second conversation and Dr. _____ says, "I've heard enough. Do what you want. Go away." Put someone else's name on the chart. Because again, if you don't, and there's no attendings name on that chart, they're going to name whoever your default attending is and at lawsuit time the first thing he's going to do is say he never saw the patient, you acted alone and try to blame you for not discussing it with him. CTA patients you're worried about may turn out to be fine, and patients you thought had only a butt pimple can turn out to be flesh eating bacteria, nec fasc, smiling in your presence and bounce back septic in 2 hours, and dead in 4. Always hedge your bets. Think, "But if I'm wrong, then what?"

In bad outcome situations, it's sad, but there is no honor and no courage. Everyone tries to blame everyone else even though it never works. The ship just sinks, everyone goes down and the rats you thought would be strongest are the first to panic-jump off the ship to save themselves. And the only ones that win are the lawyers. Your lawsuit is their payday.

That being said, should you make a habit of shopping more than one attending for individual cases just because you like one personality or practice style over another? No. That's going to piss people off unnecessarily and waste people's time. But absolutely, if your radar is going off and you think someone is too busy or not invested enough in your case to sense that something's being missed, you may have to do it on occasion. That's just a reality. Not all attendings are going to be right, all the time. Nor will you.

 

[deleted836128]

I'd be pissed if you are working with me and ask another attending for their advice on my case. You are working with me, and ultimately need to follow my orders. You can certainly make suggestions or point out something that I've missed, but the liability is mine.

You aren't staffing "most" cases with an MD? I think that's a mistake. I want you to staff EVERY patient with me, even if it's just a 10 second blurb.

I figured this is what you guys would say - that you would be pissed. The worst part is the other doc said loudly in front of the other “you should absolutely get the CTA.” This is why I posted about this at 4 AM - couldn’t sleep because I just felt terrible. Any suggestions for damage control? I don’t know if the doc is pissed; he didn’t seem like it. I did pull the doc aside later and say “Hey, I wanted to apologize about asking Dr Z as well about the case. Our work up sounded good and then I was having terrible anxiety about not getting the right test and I wouldn’t sleep tonight if I didn’t just get it. In the end you right right and the CTA was fine.” He was nice and said “You know, if you’re really worried about something just get the test.” Somehow based on your responses about being “pissed” I might need to go a step further than that apology. Email? Not sure what to do but I love this doc and don’t want to damage the relationship. The most important thing right now is that I fix this.

And yes, the doc would have liability but the liability is mine as well. Because I saw the patient, ordered the test and sent her home. If I talk with a doc it doesn’t make me less liable.

I will be honest, one of the hard things about being a PA is not just that I have less knowledge and experience but I know that when I talk to a doc he or she will have a completely different approach than another. So when I do a work up based on what that doc told me, the past advice of other docs screams in my mind “you did that?!” Or “you didn’t do that?” Sometimes they tell me to do something that is flat out wrong (Once I was told to send a febrile, tachycardic 45 year old patient with raging PID, a bandemia, and possible TOA on ultrasound home with antibiotics without talking to GYN and was yelled at when I suggested a few times that if we are really sending this patient who is septic home, maybe we should call to at least follow up for this patient as we didn’t have GYN on call at the time). That part is rough.

With the exception of dumb stuff like URIs, lacerations and dental pain, I WOULD LOVE to staff every case with a doc. Safer for the patient and would help me learn a hell of a lot. Sadly the docs wouldn’t want to be bothered for every case (If I see around two an hour that’s just too much) and don’t seem to have time for that. So I reserve my questions for tricker cases like the ones above. I also discuss with them any patient who is super sick or unstable in some way, or if it’s a case that has a high risk of missed diagnosis or bad outcomes (all newborns, significant trauma, potential tendon injury or retained foreign body, belly pain without a clear diagnosis especially in an old person, anyone with weird neuro symptoms, etc.) I guess everything in the ER has potential to turn into badness but my strategy is I look at all charts and ask myself if the patient came back, is my work up defensible and should I have talked with a doc about it?...and if it’s not absolutely bulletproof in some way I get a doc in on the loop.

Anyway, damage control. Ahhhh... any suggestions?

 

[deleted836128]

For starters, if you discharge a hypotensive, hypovolemic, who's fainting repeatedly (because they're in hypovolemic shock!), hiding behind, "No worries. It's on them," feels like it should work, but it doesn't. Ultimately, it's on all of you. You're all involved, you're all jointly and individually responsible. It doesn't fly if you're sued. You all will get sued. Lawyers love nothing more than to name a dozen docs and PAs and pit them against each other. Once the providers start blaming each other, that's instantly seen by the jury as a confession that someone screwed up. The lawyers will start to smile at that point, because they know the case is won, and the only work left is running up the award amount.

Even if blaming a consultant for a bad outcome you knew was going to happen, worked, it's not the right thing to do. All it takes is one person to do the right thing. And if you all herd towards the wrong end point, with each and every one of you pointing to the one to your right, everyone loses, patient included. Does that make it any easier to get your fainting Gyn patient admitted? No, because we lived in a very flawed world and system. But that's what you needed to do, and although it was messy, that's ultimately what you did. Next time, you're be that much more prepared to do it more efficiently.

Regarding the head injury patient, the head injury is likely* enough (notice I said "likely" enough, not "definitively" enough) to cause the neuro and c-spine symptoms alone. The CT Head, CT c-spine and admitting the patient due to the neuro symptoms, regardless of the presence or absence of CT abnormalities likely* has you covered. That's probably what 99% of EM attendings would do. Is a carotid or vertebral artery dissection likely? No. But could that patient have one? Absofrickinlutely, they could have one*. That diagnosis is rare, it presents weird and you won't see enough in your career to have a good feeling for when a patient has one or not. The only way to find them is to have a high index of suspicion. That means you're going to order more negative scans, than positive. In 10 years in the ED, I saw, I think maybe 3 (?) of these. Each time, they presented like a typical patient that just had some extra weirdness about them. Weird non-specific neuro (or other) symptoms that sometimes initially make you think maybe they're just nuts or dramatic. So, it absolutely would not be wrong to order the CTA. And you can bet you arse if you missed it, every cost-savings choosing-wisely academic in the USA that you thought was your friend and mentor will gladly line up to be paid $1000 per hour to give a deposition, chest all puffed up, arrogantly looking down over low slung glasses, saying "YES, he should have ordered the CTA. YES, I would have ordered it. Have you seen my resume? I'm amazing and this guy's an incompetent jerk. Gross negligence! I say. Gross negligence!"

An yes, if I was a PA, you can bet your first born that every single chart would have, "Case discussed with and approved by Dr. _____." Every single damn chart, from CTA patients down to a baby-butt pimple. Even if it's a 5 second conversation and Dr. _____ says, "I've heard enough. Do what you want. Go away." Put someone else's name on the chart. Because again, if you don't, and there's no attendings name on that chart, they're going to name whoever your default attending is and at lawsuit time the first thing he's going to do is say he never saw the patient, you acted alone and try to blame you for not discussing it with him. CTA patients you're worried about may turn out to be fine, and patients you thought had only a butt pimple can turn out to be flesh eating bacteria, nec fasc, smiling in your presence and bounce back septic in 2 hours, and dead in 4. Always hedge your bets. Think, "But if I'm wrong, then what?"

In bad outcome situations, it's sad, but there is no honor and no courage. Everyone tries to blame everyone else even though it never works. The ship just sinks, everyone goes down and the rats you thought would be strongest are the first to panic-jump off the ship to save themselves. And the only ones that win are the lawyers. Your lawsuit is their payday.

That being said, should you make a habit of shopping more than one attending for individual cases just because you like one personality or practice style over another? No. That's going to piss people off unnecessarily and waste people's time. But absolutely, if your radar is going off and you think someone is too busy or not invested enough in your case to sense that something's being missed, you may have to do it on occasion. That's just a reality. Not all attendings are going to be right, all the time. Nor will you.

Thank you so much for this.

I agree, the “it is on them” argument didn’t sit well with me because it is absolutely my responsibility as the PA taking care of the patient to ensure a safe discharge. This doc who said “it is on them” happened to be the same doc in question I “overstepped” yesterday and I guess I just realized maybe I don’t trust him in some way. That’s bad but maybe it’s the truth behind overstepping him. Anyway, in the case with the ovarian cyst rupture, yes, I am a PA with limited knowledge but I obviously was getting TERRIBLE ADVICE from my attending and the GYN. So it’s like - what the heck do I do? If I don’t “overstep” the patient could have a horrible outcome.

Interestingly enough, I think the reason I wanted the CTA is in my less than four years as a PA I have caught FIVE vertebral or carotid dissections. Yes, FIVE. One of them was caught by accident because she actually presented like a subarachnoid hemorrhage and I did a CTA on her (this one was a 30 year old migraine patient that came in with a sudden, unusual headache for her with facial pain). The two vertebral artery dissections were vertigo and severe headache after an MVA. Then the other two were carotid dissections after chiropractic. I think we all have a diagnosis we think about a lot because of past near misses or misses and this is one of mine. Now, despite this I am not ordering a ton of CTAs of the neck. Maybe a handful per month. But I still think about it and in this lady I just had to get it.

And yep, if I had it my way I would have much more doc involvement but they’re too busy to deal with my two patients per hour on top of theirs.

 

[hoot504]

Yeah that would be the last time that mid-level staffs a patient with me. You can't ask Dad cause you don't like what mom says. Now you can present all patients to the other attending.

This is basically the correct response.

If you were that concerned, ask the attending to go and examine the patient. There should be no issue with that.

 

[Birdstrike]

Think back to your residency. You never caught something an attending with greater training and experience than you missed or didn’t think of?

I bet you did, more than once. And the fact that they outranked you, and we’re irritated at your find, made you no less correct.

One time I caught a subdural hematoma in an infant, that was missed by an attending, and a radiology attending nonetheless. How the hell he missed it, I don’t know. And the fact that I saw it was dumb luck.

I pointed it out, and he agreed it was an epidural. If it hurt his ego for me to point it out because he outranked me by multiple years and board exams, I don’t know. But if so, so be it. I didn’t rub it in or brag about it, but at the same time I didn’t let any fear of bruising an ego stop me from pointing out what I saw.

The opposite has happened, also. One time I had someone with less medical training than me disagree with me and tell me what they thought the diagnosis was. I huffed and puffed and told them how it was basically impossible that they had what they thought they had. Then to appease them I ordered the test and it turned out they were right, I was wrong. This person not only had less medical training, they had no medical training at all. It was the patient. I sure felt stupid by being wrong but it taught me a lesson. Don’t let ego prevent you from hedging your bets.

None of us are infallible.

 

[Groove]

Humblebrag sympathy for second guessing an attending followed by "What do you guys think?!". I thought to myself......wait a sec, this sounds like ERCAT! I was right!

ERCAT, I have to hand it to you...if anything, your posts are 100% consistent and guaranteed to get the longest and most opinionated answers of any threads on this forum. If anything, you're a stimulating topic starter on here, lol.

So, did they have a vertebral artery dissection or didn't they?

 

[deleted836128]

Humblebrag sympathy for second guessing an attending followed by "What do you guys think?!". I thought to myself......wait a sec, this sounds like ERCAT! I was right!

ERCAT, I have to hand it to you...if anything, your posts are 100% consistent and guaranteed to get the longest and most opinionated answers of any threads on this forum. If anything, you're a stimulating topic starter on here, lol.

So, did they have a vertebral artery dissection or didn't they?

LOL, is this a good thing or a bad thing? What are you getting at here?! I guess it's a good thing I stimulate the dialogue but it's not if I am annoying everyone on this forum.

I tend do agree that in this case it's like I went to talk to dad because mom gave me an answer I didn't like. Guess I have to learn from it and move on.

They DID not have a vertebral artery dissection and I made sure to tell my attending he was right. With my tail between my legs.

 

[southerndoc]

The opposite has happened, also. One time I had someone with less medical training than me disagree with me and tell me what they thought the diagnosis was. I huffed and puffed and told them how it was basically impossible that they had what they thought they had. Then to appease them I ordered the test and it turned out they were right, I was wrong. This person not only had less medical training, they had no medical training at all. It was the patient. I sure felt stupid by being wrong but it taught me a lesson. Don’t let ego prevent you from hedging your bets.

None of us are infallible.

This. This should be advice to all residents and attendings. We may get aggravated because a patient has consulted Dr. Google or WebMD, but sometimes they are right. Never dismiss them. Explain to them why it can't be, why something says a test isn't indicated (Canadian head CT rules, etc.), or test for it if it's a possibility.

I've had plenty of patients come in with their diagnosis. The last shift I worked 3 days ago, a lady came in and said "I think I have a blood clot." Wells 0, PERC negative. I ordered a D-dimer anyhow. What did I have to lose if she was right? I had everything to lose if I missed it and she was right. That would be a huge lawsuit. Despite having a Wells 0 and being PERC negative, her D-dimer was 750. CTA showed large bilateral PE's. Later in her stay when she was about to be admitted, her HR went to 120. When I saw her initially she was Wells 0 and PERC negative, but when she was admitted she was Wells 1.5 and PERC positive. These are clinical risk stratification tools and aren't always accurate. I've seen quite a few PERC negative individuals who have had PE's. Some are taken during a snapshot and need to be reevaluated throughout their entire stay if you're going to use them to get out of testing (i.e., if they're Canadian head CT negative and start vomiting upon discharge, well they're positive now if they vomit >2 times; any HR >100 during their ER stay is PERC positive and adds 1.5 points to the Wells score).

 

[jw3600]

Massive blocks of texts aside, learn your role or go to medical school. It’s simple.

 

[thegenius]

To me it sounds like you were shopping for an attending to support your plan of care. I don’t mean to sound mean, that’s what I thought. Be mindful of who you ask in the future because if you do ask more than one attending their opinion on the same case, I as an attending would get annoyed.

By the way...these kinds of questions are purely judgement and based on a good history and physical. It's hard to summarize a case in 2-3 sentences and ask "Do you think they have a vertebral artery dissection? Should I scan them?" I'm not surprised you got different answers from different attendings. I do like what someone said to just ask the doc to see the patient. I usually don't get upset when my PA's ask me to see one of their patients.

 

[Rekt]

This. This should be advice to all residents and attendings. We may get aggravated because a patient has consulted Dr. Google or WebMD, but sometimes they are right. Never dismiss them. Explain to them why it can't be, why something says a test isn't indicated (Canadian head CT rules, etc.), or test for it if it's a possibility.

I've had plenty of patients come in with their diagnosis. The last shift I worked 3 days ago, a lady came in and said "I think I have a blood clot." Wells 0, PERC negative. I ordered a D-dimer anyhow. What did I have to lose if she was right? I had everything to lose if I missed it and she was right. That would be a huge lawsuit. Despite having a Wells 0 and being PERC negative, her D-dimer was 750. CTA showed large bilateral PE's. Later in her stay when she was about to be admitted, her HR went to 120. When I saw her initially she was Wells 0 and PERC negative, but when she was admitted she was Wells 1.5 and PERC positive. These are clinical risk stratification tools and aren't always accurate. I've seen quite a few PERC negative individuals who have had PE's. Some are taken during a snapshot and need to be reevaluated throughout their entire stay if you're going to use them to get out of testing (i.e., if they're Canadian head CT negative and start vomiting upon discharge, well they're positive now if they vomit >2 times; any HR >100 during their ER stay is PERC positive and adds 1.5 points to the Wells score).

Stories like these are always cute and fun, but I find it hard to believe she was asymptomatic beyond "I have a blood clot". CP? SOB? DOE? Fatigue? Toe pain? Why did she come in? Reported transient tachycardia aside, If she was asymptomatic, then was it really "bilateral PEs" or was it actually bilateral subsegmental PEs of questionable clinical significance?

 

[thegenius]

I had that thought, more-or-less, as well. Because if she was Low risk wells and then PERC 8/8 (or 0/8 depending on how you look at it), the probability of PE is so low the guidelines say don’t work it up. Regardless of what the patient says. In these trials there were a few people out of hundreds who had a PE, but it’s considered an acceptable miss rate (presumably because there was no consequence to those missed PEs?)

It’s fine to work these patients up as these are guidelines and not rules of ER life one must live by. But the guidelines are defensible.

It’s interesting she had large PEs and later became hemodynamically worse. She was probably continually embolizing them.

 

[southerndoc]

Stories like these are always cute and fun, but I find it hard to believe she was asymptomatic beyond "I have a blood clot". CP? SOB? DOE? Fatigue? Toe pain? Why did she come in? Reported transient tachycardia aside, If she was asymptomatic, then was it really "bilateral PEs" or was it actually bilateral subsegmental PEs of questionable clinical significance?

Sorry, was in no way implying that she was asymptomatic. She had shortness of breath. Not tachypneic, normal pulse ox.