calling consults

[sese]

so i had to call consults on two stable pts that i didn't feel comfortable calling about at 2 a.m.. i thought they could most likely be worked up as outpts, but the attendings wanted the consults. needless to say, i didn't make the most enthusiastic and convincing "sales pitch" for the consults to come in at 2 a.m..

for veterans:
...what is the best approach to call consults on pts you don't feel need consults?
...how do you resolve personal opinions to make convincing arguments to the consulting doc to take the case seriously?
...is calling consults always the best care for patients?

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[JkGrocerz]

so i had to call consults on two stable pts that i didn't feel comfortable calling about at 2 a.m.. i thought they could most likely be worked up as outpts, but the attendings wanted the consults. needless to say, i didn't make the most enthusiastic and convincing "sales pitch" for the consults to come in at 2 a.m..

for veterans:
...what is the best approach to call consults on pts you don't feel need consults?
...how do you resolve personal opinions to make convincing arguments to the consulting doc to take the case seriously?
...is calling consults always the best care for patients?

This is a good question. I'm just an intern and still trying to perfect my sales pitch. some hints from our seniors would greatly be appreciated.

 

[EctopicFetus]

so i had to call consults on two stable pts that i didn't feel comfortable calling about at 2 a.m.. i thought they could most likely be worked up as outpts, but the attendings wanted the consults. needless to say, i didn't make the most enthusiastic and convincing "sales pitch" for the consults to come in at 2 a.m..

for veterans:
...what is the best approach to call consults on pts you don't feel need consults?
...how do you resolve personal opinions to make convincing arguments to the consulting doc to take the case seriously?
...is calling consults always the best care for patients?

I too am an intern. We have a few attendings who are notorious for weak admits. As such you are there to learn and in the end their will is the way.

Q 1) consults as in admit? If it is just for an opinion you can simply say here is what I see but my attending is concerned about x,y,z. Dont make it sound too weak on the phone but once there you can apologize (if you want), usually the "my attending wants this" is more than enough. If they dont like it I invite them to discuss it with my attending face to face.

2) see Q1.. you just tell em how it is, what you are worried about and what you hope they can do.

3) Consults of course arent always the best. But keep in mind in the ED we cant do all things. Consults are needed when you are out of the field of your expertise.

 

[EctopicFetus]

I too am an intern but IMO I shouldnt have to apologize to anyone for asking them to do their job.

Remember they are on call... it is their job. If they dont like it they should have thought about it before they chose their field. I chose wisely if they didnt thats not my problem.

 

[WilcoWorld]

I'm just a second year, perhaps some more senior folks have more refined tips, but here are some lessons I've learned about calling consultants:

1) Be succinct. When a consultant gets called at night he or she has ONE question that he/she wants answered; Do I need to come in? So lead with that. Don't give the consultant a full case presentation either. Diagnosis, treatment & disposition usually suffice. In cases with some grey area add a chief complaint & some diagnositics, but not much else. The more you talk, the less they'll listen.

2) Be more polite than they are. This one is tough to do sometime, but its merits speak for themselves, so...

3) Have a plan, and tell them what it is, then allow them to refine it. You saw the patient & you know what the initial work-up/management should be (or you should look it up before calling), so don't just call them & say "what should I do?" Specific questions are acceptable, such as asking the cardiologist it he/she wants eptifibatide or not, etc, but you don't need to ask if the doc wants nitro on the CHF'er with a systolic of 180 or antibiotics for that pneumonia, etc.

4) In non-emergent cases when you're calling to establish follow-up or for courtesy calls you can often wait until the morning to call. Call 'em at 6am when you're getting ready to leave, rather than at 2 am. They'll appreciate it.

Here are some examples of how not to do it & how to do it, in my opinion.

"Hey Dr. Bone, it's Johnny from the ER. Remember when I rotated on your service in April? That was sweet. Aaaaaaanyway, we got this lady here. She's really nice, and has a history of arthritis, asthma, and mitral valve proplapse. Tonight she fell down four or five stairs, she can't quite recall how many, and her son doesn't know either. She complains of left leg pain, as well as right wrist pain, and back pain. We did some labs, which showed a slightly elevated WBC, probably just due to stress, here 'lytes are OK, and we scanned her head, since she's old and fell, even though here neuro exam was non-focal, and there is no bleed. But she has a broken leg. Do you want to come take a look at her?"

vs

"Hello Dr. Bone, It's Dr. Me from the ED at ABEM General. I'm sorry to wake you, but we need you to come in. We have a 60 year old woman with an open tib/fib fracture - type 2. She's got distal pulses & sensation intact. Do you want us to give her a dose of Ancef now, or just have it on call to the OR?"

 

[The White Coat Investor]

4) In non-emergent cases when you're calling to establish follow-up or for courtesy calls you can often wait until the morning to call. Call 'em at 6am when you're getting ready to leave, rather than at 2 am. They'll appreciate it.

?"

The problem with this approach is that if they are residents who are up and working all night doing cross-cover they are even more tired and more stupid at 6am than they are at 2 am AND you left your ED bed full for an extra four hours. The alternative is wait until 7 or 8 am and call the next day's team, but then you end up staying late because you don't want to dump that call off and besides that day's team is busy rounding so they don't make it down until noon. I quit showing mercy. I did my time on call so I called at 2.

Of course, now that I am an attending working with attendings, I frequently hold off until 6 am for non-critical patients. But I am calling people in from home, not an in-house resident.

As far as the OPs question, if you think your attendings admit is soft...hammer it out with him before you make the call. Make him convince you the patient needs to be admitted. Ask him all the questions you know that consultant is going to ask you. (Why can't we do this as an outpatient? Isn't this patient low-risk enough to just check a 2nd trop and get an oupatient stress? How about sending them home with a 12 hour repeat abdominal exam?) It is a hell of a lot easier to sell an admit if you believe they should be admitted (or at least completely understand the attending's reasoning.)

 

[WilcoWorld]

Of course, now that I am an attending working with attendings, I frequently hold off until 6 am for non-critical patients. But I am calling people in from home, not an in-house resident.

Absolutely. I meant that suggestion to apply to calls to home. The house officers are already working at 2am (usually), so I don't worry about waking them up as much as I do with, say, the on-call ENT attending. S'pose I could've been more clear about that.

 

[sese]

thanks, everyone. it's nice to hear that others have a hard time with this, too, and that it's a skill one can learn. i'm a 4th year med student now looking forward to getting better at this!

 

[doctawife]

Sometimes the answer to this question depends on the consult service in question.

For heme-onc patients I usually call regardless of the hour. Most of the time the h/o patients have already called the h/o doc on call who told them to come in to us in the ED. Then, after talking to the patient, the h/o on call often forgets to call us to tell us to expect the patient. 99% of the time the heme-onc doc on call appreciate the call.

Our hospital has ortho residents in house, so I always call them. They're up anyway.

For GI patients it depends - if they are liver patients (ie have severe liver disease or are s/p orthotopic liver transplant) then I call them. If the patient is a standard IBD patient who is sick... but not complicated sick, then I'll wait until the morning (actually admit or obs him/her and then have the resident call in the morning.)

Renal attendings always want a page at my institution if s/he is a known patient. A new diagnosis, if stable, can usually wait until morning.

Endocrine always wants a call. Usually it doesn't change our management even a tiny little bit, but they get pissy if we don't call. One day, I swear, I'm not gonna call on a DKA patient, do exactly what I know they'll want ('cause it never changes - the protocol is freaking set in stone!) and then see if I get called on it. I kinda hope I do. Just to see if I can get people to examine this particular policy. If we have a protocol - one that doesn't change - why do I have to call and confirm it every time? Sheesh...

Neuro is a 'call in am' kinda consult most of the time. Then again, I'm in the pediatric world, so that's probably a little different than the adult world.

Rheum is almost NEVER a 3am call. Then again, I have only rarely (like once in three years) called rheum from the ED.

So that's my short list. The ID service sometimes gets consulted from the ED, but they never really put up a fight. But basically, I ask my attendings to explain if I don't understand the reason for consult. Sometimes the reasons are a bit spurious, like, "ID should always be consulted in a child with osteo" and sometimes the call makes much more logical sense. Not always, but sometimes.

 

[EctopicFetus]

Sometimes the answer to this question depends on the consult service in question.

For heme-onc patients I usually call regardless of the hour. Most of the time the h/o patients have already called the h/o doc on call who told them to come in to us in the ED. Then, after talking to the patient, the h/o on call often forgets to call us to tell us to expect the patient. 99% of the time the heme-onc doc on call appreciate the call.

Our hospital has ortho residents in house, so I always call them. They're up anyway.

For GI patients it depends - if they are liver patients (ie have severe liver disease or are s/p orthotopic liver transplant) then I call them. If the patient is a standard IBD patient who is sick... but not complicated sick, then I'll wait until the morning (actually admit or obs him/her and then have the resident call in the morning.)

Renal attendings always want a page at my institution if s/he is a known patient. A new diagnosis, if stable, can usually wait until morning.

Endocrine always wants a call. Usually it doesn't change our management even a tiny little bit, but they get pissy if we don't call. One day, I swear, I'm not gonna call on a DKA patient, do exactly what I know they'll want ('cause it never changes - the protocol is freaking set in stone!) and then see if I get called on it. I kinda hope I do. Just to see if I can get people to examine this particular policy. If we have a protocol - one that doesn't change - why do I have to call and confirm it every time? Sheesh...

Neuro is a 'call in am' kinda consult most of the time. Then again, I'm in the pediatric world, so that's probably a little different than the adult world.

Rheum is almost NEVER a 3am call. Then again, I have only rarely (like once in three years) called rheum from the ED.

So that's my short list. The ID service sometimes gets consulted from the ED, but they never really put up a fight. But basically, I ask my attendings to explain if I don't understand the reason for consult. Sometimes the reasons are a bit spurious, like, "ID should always be consulted in a child with osteo" and sometimes the call makes much more logical sense. Not always, but sometimes.

This is true.. very service dependent.. My experience is Renal ALWAYS wants to know whats doing with their people.

 

[Apollyon]

For heme-onc patients

Endocrine always wants a call.

Rheum is almost NEVER a 3am call.

The ID service sometimes gets consulted from the ED, but they never really put up a fight.

Even if we didn't know you, this post would give you away as Peds.

Honestly, at the "major medical center" I trained at, the only endocrine and rheum people I knew had been IM residents prior (and ID, also). I got a chuckle out of the "rheum" part - for adults, take out the "3am".

Just noting - I mean, it was a TOTAL coup to get derm one morning to see a pt in the ED (and, truth be told - this guy doing derm at Duke has to be - bar none - one of the absolute sharpest, smartest, smoothest docs I've EVER seen - like, future Nobel prize-winner, HHS Secretary stuff).

 

[doctawife]

Even if we didn't know you, this post would give you away as Peds.

Honestly, at the "major medical center" I trained at, the only endocrine and rheum people I knew had been IM residents prior (and ID, also). I got a chuckle out of the "rheum" part - for adults, take out the "3am".

Just noting - I mean, it was a TOTAL coup to get derm one morning to see a pt in the ED (and, truth be told - this guy doing derm at Duke has to be - bar none - one of the absolute sharpest, smartest, smoothest docs I've EVER seen - like, future Nobel prize-winner, HHS Secretary stuff).

Yes yes yes, I'm soft and cuddy and sweet.

But I'm one of them meanest peds people ever, so there! pbbt! 😛

(Okay, only to the parents.)

(Okay, maybe not even to them.)

(Well, only to the ones who deserve the evil eye!)

 

[Apollyon]

Yes yes yes, I'm soft and cuddy and sweet.

But I'm one of them meanest peds people ever, so there! pbbt! 😛

(Okay, only to the parents.)

(Okay, maybe not even to them.)

(Well, only to the ones who deserve the evil eye!)

As I was prone to say as a resident:

"You want to round at 5pm with surgery? You send the med student to tell everyone at 4:58 that they have 2 minutes to be there.

You want to round with peds at 5pm? You start getting people together at 4pm, and then it's like herding cats."

 

[spyderdoc]

I think the OP is asking when you want to send a patient home, coutesy call the PCP to let them know their pt was in the ED, and they ask to get a consult bfore you give the pt the big boot...
If I think the pt is stable to go home, it is unlikely that they actually need some poor consultant to come and see them at 3AM. I would just tell the PCP as diplomatically as possible that I don't think that a consultant needs to emergently see the pt at 3AM. I would ask that the PCP see or call the patient in the AM and refer the pt to whatever specialist they feel the pt should see. I don't think it would be appropriate to have, say a surgeon come in at 3AM to see a biliary colic pt who is stable to f/u as outpatient....

 

[beyond all hope]

As an ED attending, I call consultants for only three reasons:

1) Admit
2) Procedure I can't do myself - GI: Scope, cards: Cath, Surg: OR, etc
3) Dangerous condition that I can't figure out myself (the softest of all consults, and in general should be avoided. As an ER doc I should be able to treat dangerous conditions and send everything else home)

So, when you call a consult, you have to convince yourself that it's one of the three above, and then convince the consultant with the same logic.

 

[turtle md]

As an ED attending, I call consultants for only three reasons:

1) Admit
2) Procedure I can't do myself - GI: Scope, cards: Cath, Surg: OR, etc
3) Dangerous condition that I can't figure out myself (the softest of all consults, and in general should be avoided. As an ER doc I should be able to treat dangerous conditions and send everything else home)

So, when you call a consult, you have to convince yourself that it's one of the three above, and then convince the consultant with the same logic.

Great Advice!

 

[Roadie9]

Just a quick couple of cents from the "other" side of a consult. I'm a 2nd year IM resident, trying to get into EM this year, by the way.

Do not exaggerate a patients symptoms because you want us to admit him/her.... It doesn't take too many "soft" admits to brand an ER doc as incompetent. We have a Dr. "Smith" here. I swear his patients get poorer care, simply because they are "Smith" patients, ie. not really sick etc.

Don't call someone "really interesting", when you simply don't know what to do next.... 🙁

Don't lie. I had an ER attending tell me he had called cardiology on a patient. We admitted said patient, who turned out to be having an STEMI. The guy hadn't called cardiology...... 🙁

Don't be insulted when we tell you we want to see the patient before we accept him as an admit. It's simply an issue of seeing things from a different angle. The inpatient world is no wonderland. If someone has pre-renal ARF, you can keep him for a few hours of IV fluids and send him home.

And don't forget........ As much as it hurts to wake up someone at 3 a.m., it's worse for the guy/girl being woken up. Why do you think I am switching to EM? 🙂

 

[southerndoc]

Do not exaggerate a patients symptoms because you want us to admit him/her. Don't be insulted when we tell you we want to see the patient before we accept him as an admit.

You guys get the option of refusing admissions?

Where I am, we call the residents and tell them a patient is coming to them, give them a brief summary, and then ask if there are any questions. The admitting residents can't demand additional labs, consults, etc. If they request a lab and we agree it's a reasonable thing to do, then we can send it. There are many times that I've used the "Request Denied" stamp for lab tests that have no business being ordered in a busy emergency department. Yes, urine lytes are great to work up that renal failure, but if it's busy in the ED, I'm not taking a nurse away from a critical patient so she can send a urine specimen. That can be done on the floor. Lactate schmactates when the patient has no clinical indication for a lactic acid (no SIRS criteria, not hypotensive, appears well but has other reasons in addition to their infection that warrants an admission).

More than half the admissions go upstairs before an admitting resident sees the patient. The unit secretaries page the admitting residents when the patient gets to the floor.

The only residents that can refuse admissions are ICU residents (MICU, CCU, etc.). In order to do so, their fellow must personally evaluate the patient and deem him/her not needing a unit bed.

 

[boston]

I too am an intern but IMO I shouldnt have to apologize to anyone for asking them to do their job.

Remember they are on call... it is their job. If they dont like it they should have thought about it before they chose their field. I chose wisely if they didnt thats not my problem.

This type of self-righteous attitude is not really necessary and only engenders bitterness and lack of understanding between EM and consultants. There are such things as inappropriate consults.

Excellent posts by desperado, wilcoworld, and beyond all hope -- right on the money! If I may offer my humble 2 cents as your surgical resident colleague to try to change the tradition of animosity between EM and surgery. I myself have been in the position of calling inappropriate consults because my surgical attending insists (on covering his own ass). For example, I've been told to "call a cardiology consult" on stable floor patient who is mild tachycardia postop day 1, likely from a SIRS response. When the attending won't listen, I call the cards fellow and say, "look, I'm sorry. this is a non-emergent inappropriate consult that my attending is insisting on for 'tachycardia of unclear etiology'. (give concise appropriate relevant details - pt is HD stable, not dry, good urine volume, EKG unchanged from preop, no new meds, no cardiac history, sending a TSH). you don't need to see the patient now, this can wait until the afternoon." in these cases, the cards fellow will generally appreciate the honesty.

fwiw, even if you have to call the grumpy surgical resident for a questionable consult at 3am, it is easier to take if you just come straight out and say it without trying to be confrontational. (can't we all just get along? i know surgery residents are on the whole probably more guilty of this than EM residents) it's also nice if some workup / treatment for working diagnosis has been initiated, e.g. consult for equivocal r/o appy w elevated WBC, the CT has been ordered, abx hung, etc. honestly, i do understand that i chose this job and this lifestyle so i try not to complain about appropriate consults even if i am get hammered -- it just goes with the territory i believe. but usually at 3am, i'm not sleeping, i'm seeing 2 other consults or some unstable icu patient so please understand if i am asking for a concise accurate story. on my part, i promise to try not to belittle or get upset and be good-humored. 😳

 

[MasterintuBater]

This is a great thread with a lot of helpful posts from seniors and attendings. I'm a second year so I have little to add except:

In the situation of an attending requesting a "soft" consult which you do not feel is necessary, it is important to NOT undermine your attending with your conversation with the consultant. You should try to "sell" your patient as if you are the attending (without, of course, embellishments). You'll eventually get burned if your phone conversations with consultants reflect that you disagree with your attending. I, too, am developing my tight rope walking skills with that balance of politeness, firmness, and succintness over the phone. But I try to establish a tone and attitude over the phone that I know what the heck I'm doing with the patient, I have a plan, and I've done my part. When you sound like you are on top of your game, the consultant on the other line will likely feel the need to be on top of his.

 

[EctopicFetus]

This type of self-righteous attitude is not really necessary and only engenders bitterness and lack of understanding between EM and consultants. There are such things as inappropriate consults.

Excellent posts by desperado, wilcoworld, and beyond all hope -- right on the money! If I may offer my humble 2 cents as your surgical resident colleague to try to change the tradition of animosity between EM and surgery. I myself have been in the position of calling inappropriate consults because my surgical attending insists (on covering his own ass). For example, I've been told to "call a cardiology consult" on stable floor patient who is mild tachycardia postop day 1, likely from a SIRS response. When the attending won't listen, I call the cards fellow and say, "look, I'm sorry. this is a non-emergent inappropriate consult that my attending is insisting on for 'tachycardia of unclear etiology'. (give concise appropriate relevant details - pt is HD stable, not dry, good urine volume, EKG unchanged from preop, no new meds, no cardiac history, sending a TSH). you don't need to see the patient now, this can wait until the afternoon." in these cases, the cards fellow will generally appreciate the honesty.

fwiw, even if you have to call the grumpy surgical resident for a questionable consult at 3am, it is easier to take if you just come straight out and say it without trying to be confrontational. (can't we all just get along? i know surgery residents are on the whole probably more guilty of this than EM residents) it's also nice if some workup / treatment for working diagnosis has been initiated, e.g. consult for equivocal r/o appy w elevated WBC, the CT has been ordered, abx hung, etc. honestly, i do understand that i chose this job and this lifestyle so i try not to complain about appropriate consults even if i am get hammered -- it just goes with the territory i believe. but usually at 3am, i'm not sleeping, i'm seeing 2 other consults or some unstable icu patient so please understand if i am asking for a concise accurate story. on my part, i promise to try not to belittle or get upset and be good-humored. 😳

Lets be serious everyone knows G Surg residents are about as self righteous as it gets.. well ill get back to this later

 

[Homunculus]

Lets be serious everyone knows G Surg residents are about as self righteous as it gets.. well ill get back to this later

maybe so, but his post was pretty dead on.

I too am an intern but IMO I shouldnt have to apologize to anyone for asking them to do their job.

Remember they are on call... it is their job. If they dont like it they should have thought about it before they chose their field. I chose wisely if they didnt thats not my problem.

i'll do my job, but remember you should be doing yours as well. 😛 "weak consults" to me falls under the "not doing your job" category. i've consulted for "what is this rash", "i auto-consult on kids under 3 months", "he drank a bottle in 5 minutes and threw up so he failed his PO challenge", "his g-tube came out" etc. i have no problem seeing patients, and yes, it is what i chose. i don't mind admissions or consults (and honestly i think admissions are easier). but if i get a weak consult, i don't want to be mislead. if your attending wants a BS consult, call a spade a spade. it let's me prioritize things. is it something i can send an intern or second year for? can i run down, check them out, then leave, or is it going to be a long drawn out consult?

Dont make it sound too weak on the phone but once there you can apologize (if you want), usually the "my attending wants this" is more than enough. If they dont like it I invite them to discuss it with my attending face to face.

like i said, as a consulting service i prefer not to be mislead just to get me there. if it's weak and you know it's weak, an apology can go a long way toward reducing any negativity. at least with me it will.

--your friendly neighborhood consulting's not insulting (most of the time) caveman

 

[southerndoc]

Lets be serious everyone knows G Surg residents are about as self righteous as it gets.. well ill get back to this later

Actually our surgery residents are really cool. We get along very well with them. It's the CT surgeons that are self-righteous at my institution. All the other specialties (especially trauma and general/emergency surgery) are pretty cool.

 

[waterski232002]

I'm lucky as well.... We have admitting privledges to General Medicine, HONC, Cardiology, and Neurology. So if I call them, the conversation starts with "I have an admission for General Medicine...". They can not deny admission. There is no such thing as consulting General Medicine or any of its subspecialties (I have never heard of anyone ever calling Rheum, ID, Endo, Pulm, etc). The exception is GI if there is a catastrophic GI Bleed, or esophageal FB impaction... but this is for a procedure, not medical advice). We make all our own decisions for admit vs d/c on our own, which I think forces me to think a lot harder about my dispo's...

Once in awhile I will page the IBD fellow for a crohns pt, cardiac tx fellow for an orthotopic heart pt. But its basically for some over-the-phone input.... at times they'll offer to come see the patient or suggest we admit the pt. It's more of a courtesy that we call them, and they appreciate being able to hear about their patients in the ER... I think it's a great working atmosphere.

The ICU's can deny or turf admission (CCU can say "call MICU"... or MICU can say "stable for floor"). Of course, we consult all the surgical specialties, and they make their own determinations for admission vs turf to gens.

 

[EctopicFetus]

Actually our surgery residents are really cool. We get along very well with them. It's the CT surgeons that are self-righteous at my institution. All the other specialties (especially trauma and general/emergency surgery) are pretty cool.

Well I guess this is institution dependent. My experience N=3 hospitals tells me this. Most of the GSurg residents are nice people on a one to one basis but my experience is that they get all pissy when you consult them for ANYTHING other than one of their surgical boo-boos.

I called them on a patient with severe hidradenitis (that they CHOSE to admit) and while down there I told them "Hey I have this other patient too".

The senior loses his ****. I said its an acute appy he was all pissy and stormed off like a little kid.

Im guessing this had nothing to do with me since that was about the full extent of the exchange. Let me be clear I have a good working relationship with most of the surgeons and other consultants cause FWIW as an intern I am probably more interested in booting people from the ED than admitting people but if I call you should come down and not bitch and moan about it.

We have some attendings who are known to consult/admit for everything I usually call and say hey this is Fetus calling for Dr. Ectopic (code word for long day). They usually reply with we'll be down in 2 -3 hours.. I say thats cool dont sweat it.

 

[southerndoc]

Well I guess this is institution dependent.

I've yet to see a surgery resident in the ED refuse a consult or start whining about consults. Maybe it's because we only consult when needed (appy, cholecystitis, etc.), or maybe it's because the R-2's and higher do the consults (no interns allowed to do consults in our ED).

Our surgery residents are very gungho about surgery. Maybe that's why they're pretty cool (the program screens them, who knows). Maybe it's the 2 years off for required research that lets them chill out a bit.

 

[The White Coat Investor]

I've yet to see a surgery resident in the ED refuse a consult or start whining about consults. Maybe it's because we only consult when needed (appy, cholecystitis, etc.), or maybe it's because the R-2's and higher do the consults (no interns allowed to do consults in our ED).

Our surgery residents are very gungho about surgery. Maybe that's why they're pretty cool (the program screens them, who knows). Maybe it's the 2 years off for required research that lets them chill out a bit.

Unbelievable. I can only think of 3 surgical residents that I have ever met (in multiple institutions) that didn't whine about a consult at some point. Many surgical residents are downright cranky and act put-out about anything you ask them for. They're tired and overworked so I look past it most the time (as long as they eventually get around to doing what is right for the patient, which they usually do) but to suggest they don't ever whine is would be untrue.

 

[Apollyon]

Unbelievable. I can only think of 3 surgical residents that I have ever met (in multiple institutions) that didn't whine about a consult at some point. Many surgical residents are downright cranky and act put-out about anything you ask them for. They're tired and overworked so I look past it most the time (as long as they eventually get around to doing what is right for the patient, which they usually do) but to suggest they don't ever whine is would be untrue.

Agree almost verbatim. Even as our surgery folks were nicer than any I've ever met (mostly), boy howdy, could they (and did they) bitch.

 

[EctopicFetus]

Unbelievable. I can only think of 3 surgical residents that I have ever met (in multiple institutions) that didn't whine about a consult at some point. Many surgical residents are downright cranky and act put-out about anything you ask them for. They're tired and overworked so I look past it most the time (as long as they eventually get around to doing what is right for the patient, which they usually do) but to suggest they don't ever whine is would be untrue.

👍

Even when I was a student all I heard them do was whine. It seems like part of the culture.

 

[BKN]

👍

Even when I was a student all I heard them do was whine. It seems like part of the culture.

I think it's a matter of leadership. I demand that my residents be as professional (and friendly if possible) and the Chair of Surgery does the same for his. Work gets done with a minimum of fuss. Sometimes a good time gets had by all.

Where the attendings don't get along or are dismissive of other services, thae attitudes become part of the institutional culture and the residents pick them up.

And remember, there are no interesting cases after 2 am. It's their job to come, but be understanding and cut them a little slack. but not a lot.

 

[RuralMedicine]

I'm lucky as well.... We have admitting privledges to General Medicine, HONC, Cardiology, and Neurology. So if I call them, the conversation starts with "I have an admission for General Medicine...". They can not deny admission. There is no such thing as consulting General Medicine or any of its subspecialties (I have never heard of anyone ever calling Rheum, ID, Endo, Pulm, etc). The exception is GI if there is a catastrophic GI Bleed, or esophageal FB impaction... but this is for a procedure, not medical advice). We make all our own decisions for admit vs d/c on our own, which I think forces me to think a lot harder about my dispo's...

Admitting privileges implies that you can admit the patient to your service (perhaps your program is unique and you can but then you wouldn't be calling yourself with the admission 😉 or I hope you wouldn't). From my perspective you decide disposition and then you call for an accepting physician. The physician you call may decide the patient is not in need of admission and can then explain this to you (in hopes that you agree with new information) or come down to the ED and see the pt. and discharge.

 

[waterski232002]

I guess a better way to put it is that we have admitting privledges "to Medicine, Cards, Heme/Onc, etc"... (not admitting privledges ourselves). We obvioulsy do not admit the patients and/or care for them on the floor. However, we invariably make the decision for admission ourselves, as they can not refuse admission.

In my experience, this is much different than the other 3 hospitals I have worked at where you must call the admitting service, give the story, then they will either agree or disagree (either over the phone or after seeing the patient in the ER). I have seen a lot of arguments at these other hospitals over "possible soft admisions" where General Medicine doesn't want to admit the patient, but the ER isn't comfortable letting the patient go home.... It can turn quite ugly.

Where I am now, because these services can not refuse admission, it takes arguing out of the discussion. And I don't have to worry about "selling" my patient.

 

[RuralMedicine]

I guess a better way to put it is that we have admitting privledges "to Medicine, Cards, Heme/Onc, etc"... (not admitting privledges ourselves). We obvioulsy do not admit the patients and/or care for them on the floor. However, we invariably make the decision for admission ourselves, as they can not refuse admission.

In my experience, this is much different than the other 3 hospitals I have worked at where you must call the admitting service, give the story, then they will either agree or disagree (either over the phone or after seeing the patient in the ER). I have seen a lot of arguments at these other hospitals over "possible soft admisions" where General Medicine doesn't want to admit the patient, but the ER isn't comfortable letting the patient go home.... It can turn quite ugly.

Where I am now, because these services can not refuse admission, it takes arguing out of the discussion. And I don't have to worry about "selling" my patient.

Just out of curiosity where are you? Not a specific institution but public/private/community/academic? Are you still in training or now an attending? If you're an attending dealing with other attendings I'd be interested in how your institution makes other attendings admit patients.

Hospital bylaws usually require physicians with admitting privileges to take unassigned call on some schedule and to practice in an appropriate manner but I think giving the EM provider (especially if they are hospital employees) the ultimate say somehow in the bylaws puts the hospital on a slippery slope in terms of compliance issues (is the ED drumming up bogus admits for revenue purposes is the fraud spin). The reality is that I see patients in our ED too often that get half a workup and the EM provider kind of bails out halfway through and requests they get admitted. When I can't figure out what the EM provider was thinking from our phone conversation I'll ask to see them in the ED and decide disposition. Often they do not need to be admitted but rather we need a targeted history and physical and a plan for followup. I document that arrange their plan and help them call their son for a ride. I bill it as a low level consult but often I think what I'm more doing is an E&M encounter (so in theory it should probably be rejected as duplication of services). I did very little of this as a resident but our EM residents and attendings were very competent so I'd agree with Homunculus that this can stem from EM providers not doing their job. (In our system I don't think it's an attempt at fraud.)

Personally as far as selling the patient please don't. Do the right thing and allow me to do the right thing. Don't tell me what you think is the magical thing to say to get me to admit or admit to the floor rather than insisting that you transfer the patient to another institution because our ICU is full. Once I've come in and seen the patient, placed that central line and started those pressors (which perhaps should have been done before calling me) then they aren't going to the floor.

 

[Apollyon]

Personally as far as selling the patient please don't. Do the right thing and allow me to do the right thing.

Your position is not legion. You have MANY colleagues that will do/say anything to avoid adding to their service. Unfortunately, the sale is needed, often.

 

[southerndoc]

Agree almost verbatim. Even as our surgery folks were nicer than any I've ever met (mostly), boy howdy, could they (and did they) bitch.

Actually it's our hospitalists that bitch all the time. Residents don't admit after 1 am or after 5 new admissions + 1 ICU transfer going to the floor. The hospitalists wine about everything.

 

[docB]

Hospital bylaws usually require physicians with admitting privileges to take unassigned call on some schedule and to practice in an appropriate manner but I think giving the EM provider (especially if they are hospital employees) the ultimate say somehow in the bylaws puts the hospital on a slippery slope in terms of compliance issues (is the ED drumming up bogus admits for revenue purposes is the fraud spin).

Everywhere that I've been the bylaws say that when the EP and the consulting physician disagree about the disposition the consultant can either agree to the admit or come in and see the patient in a timely manner and dispo them himself. It's not a slippery slope. It just makes sense that if the EP wants to admit and the admitting doc doesn't the admitting doc should see the pateint, dispo the pateint and bear the liability of that decision.

The reality is that I see patients in our ED too often that get half a workup and the EM provider kind of bails out halfway through and requests they get admitted.

Yes that's what Emergency Medicine is about. Stabilize, get the basic work up started, determine if the pateint can go home or needs admission and call the admitting doc. If getting the definitive diagnosis will take more than 4-6 hours then the pt needs to be admitted. In my area consultants, especially the HMO hospitalists, frequently come in, refuse to admit but order a whole inpatient work up and try to leave the pateint in the ED for hours and hours. I can't run an ED with my beds full of people who should be inpatinets.

When I can't figure out what the EM provider was thinking from our phone conversation I'll ask to see them in the ED and decide disposition. Often they do not need to be admitted but rather we need a targeted history and physical and a plan for followup. I document that arrange their plan and help them call their son for a ride. I bill it as a low level consult but often I think what I'm more doing is an E&M encounter (so in theory it should probably be rejected as duplication of services). I did very little of this as a resident but our EM residents and attendings were very competent so I'd agree with Homunculus that this can stem from EM providers not doing their job. (In our system I don't think it's an attempt at fraud.)
Personally as far as selling the patient please don't. Do the right thing and allow me to do the right thing. Don't tell me what you think is the magical thing to say to get me to admit or admit to the floor rather than insisting that you transfer the patient to another institution because our ICU is full. Once I've come in and seen the patient, placed that central line and started those pressors (which perhaps should have been done before calling me) then they aren't going to the floor.

So it sounds like the EPs where you are are incompetent and probably dangerous. I suggest getting you med exec or oversight comittee involved.

 

[8744]

I had an interesting conversaton with my attending today. I am rotating on a pulmonary service and we get many consults during the day. I did a consult for an Asthma exacerbation and in my "Assessement and Plan" I wrote "Asthma Exacerbaton, agree with plan of care...," and so on and so forth.

The treatment plan already ordered was exactly what I would have done so I didn't feel there was anything to add except getting baseline PFTs at some time in the future.

My attending, on reviewing my consult, said that they wouldn't have consulted us if it was as simple as an asthma exacerbation and we had to dig a little deeper. He had a point of course, but I think people do call consults just to cover themselves even if they know what they're doing is the correct thing. I think these kinds of consults are what I'd call "weak."

 

[RuralMedicine]

Everywhere that I've been the bylaws say that when the EP and the consulting physician disagree about the disposition the consultant can either agree to the admit or come in and see the patient in a timely manner and dispo them himself. It's not a slippery slope. It just makes sense that if the EP wants to admit and the admitting doc doesn't the admitting doc should see the pateint, dispo the pateint and bear the liability of that decision.

This is very different than saying that your admitting physicians are required to admit as was stated/restated by Waterski. Personally I've never refused to admit someone I haven't seen. But I do reserve the right to see the patient decide they don't warrant admission, or warrant admission to a higher or lower level of care.

Yes that's what Emergency Medicine is about. Stabilize, get the basic work up started, determine if the pateint can go home or needs admission and call the admitting doc. If getting the definitive diagnosis will take more than 4-6 hours then the pt needs to be admitted. In my area consultants, especially the HMO hospitalists, frequently come in, refuse to admit but order a whole inpatient work up and try to leave the pateint in the ED for hours and hours. I can't run an ED with my beds full of people who should be inpatinets.

Oh I agree with this but in the quote you lifted decision making kind of doesn't really happen until someone else sees the patient. I'm all for a targeted history and realize it's paramount in the ED. I won't fault you for missing fine details (and if they are irrelevant I don't care either) but if you (not you specifically I presume you don't practice this way) have no idea why the patient is here or what to do after your 2 minute history that you scribbled on the t-sheet then perhaps you could go back spend another 2 minutes and then formulate a plan. The patients I send home from the ED don't languish for hours waiting for their workup to be completed.

As far as stabilization BP of 70/20 and poor perfusion is not stable so it would be nice to be at least start addressing this rather than hoping no one will notice and the patient can still go to the floor. In this case the patient sounded like they needed to go to the ICU over the phone I offered to come in and see the patient but suggested we would likely need to transfer because our ICU was full. I was going out the door to come back to the hospital when the nurse paged me because she thought maybe I wanted the real vitals so I gave verbal orders for boluses and came in and put in a line and we started pressors. When the patient was more stable I arranged for transfer to a tertiary ED for admission to their ICU. While all this happened the ED physician read a novel. (I think it was actually Michael Crichton but still....)

So it sounds like the EPs where you are are incompetent and probably dangerous. I suggest getting you med exec or oversight comittee involved.

Agreed! This issue has been to Med Exec already and we're readdressing it at Med Staff. The problem is our ED director is perhaps even more dangerous than the rest of the physicians so when you try to talk to him he doesn't get it that there is a problem. He's also a close personal friend of our CEO so I'm not very optimistic that things will change. Sadly after establishing roots in a community I'm truly thinking about resigning my privileges and moving just because I feel our current ED situation makes our hospital unsafe. It's too bad our hospital is the only one in a rural county and has a lot of potential. I truly believe this community needs this hospital but this community also needs this hospital to be safe.

 

[waterski232002]

Just out of curiosity where are you? Not a specific institution but public/private/community/academic? Are you still in training or now an attending?

I'm a resident at the University of Chicago. We are definitely at two very different ends of the hospital spectrum. I think one of the big reasons that they allow us to make the decision for admission is because medicine residents always want to send patients home (it means less work for them), and attendings are not in-house overnight (which is when 80% of patients get admitted). Even during the day, if the patients physician were actually in-house, he's probably in clinic or doing research and would rarely ever make it to the ER to see the patient. The only attendings we call are the cards/CHF/transplant physicians or GI/IBD physicians when they show up in the ER (they like to be involved, and they help us with dispo).

 

[RuralMedicine]

I'm a resident at the University of Chicago. We are definitely at two very different ends of the hospital spectrum. I think one of the big reasons that they allow us to make the decision for admission is because medicine residents always want to send patients home (it means less work for them), and attendings are not in-house overnight (which is when 80% of patients get admitted). Even during the day, if the patients physician were actually in-house, he's probably in clinic or doing research and would rarely ever make it to the ER to see the patient. The only attendings we call are the cards/CHF/transplant physicians or GI/IBD physicians when they show up in the ER (they like to be involved, and they help us with dispo).

I think this is a rather presumptive statement. I would like to think that most physicians want to do what is right for the patient and would not send patients home that need to be admitted just because it is less work for them. I did a dual residency so I was in residency for four years and while I did see different approaches to management (some physicians are just more conservative than others) I never saw this. I always see threads about lack of mutual respect between EM and IM residents, I didn't experience in the institution I trained. However, the EM residents did not approach things from your perspective and perhaps that allowed them to be part of the solution rather than part of the problem.

 

[RuralMedicine]

Your position is not legion. You have MANY colleagues that will do/say anything to avoid adding to their service. Unfortunately, the sale is needed, often.

It goes both ways though...if I trust you (and your clinical judgement) then I'm much more likely to just let you write some tuck in orders and send them to the floor, drop everything and run to the hospital to admit them, etc. If I have come to learn that embellishment should be your middle name then I may ask to see the patient in the ED prior to admission. You might want to give new physicians the opportunity to "be difficult" before you master your sales pitch with them. Who knows they might just surprise you and do the right thing.

 

[Apollyon]

It goes both ways though...if I trust you (and your clinical judgement) then I'm much more likely to just let you write some tuck in orders and send them to the floor, drop everything and run to the hospital to admit them, etc.

I see your point, but, just as a note, ACEP does NOT support EM docs writing admitting orders for admitted patients. If your username is true, this may be a little softer where you are (as there may be a longer distance or a snowstorm between you and the hospital).

 

[JackBauERfan]

I see your point, but, just as a note, ACEP does NOT support EM docs writing admitting orders for admitted patients. If your username is true, this may be a little softer where you are (as there may be a longer distance or a snowstorm between you and the hospital).

at where I am doing prelimary medicine, the ED has came out with to the hospital that they will not be writing admission orders anymore, and did not go over great at first, but seems ok with everyone now. Its definitely a liablity and not good for patient care for ED doctors to write 'skeleton' orders because you can not control how long before the admitting team sees the patient and your training is not meant for inpatient medicine/surgery and is not the greatest for the patient.

 

[RuralMedicine]

I see your point, but, just as a note, ACEP does NOT support EM docs writing admitting orders for admitted patients. If your username is true, this may be a little softer where you are (as there may be a longer distance or a snowstorm between you and the hospital).

Personally I'd prefer the ED physicians not write admitting orders on my patients (or any patients I aquire on unassigned) but since they are often desperate to move the patient out of the ED they volunteer to. My preference is that the patient is evaluated in the ED and admitted by the admitting physician in a timely fashion. However, what defines a timely fashion now as an attending in private practice and what defined it when I was a resident in the hospital are different things. That said when buying a home I intentionally selected one within less than ten minutes of the hospital I admit at and if it's the middle of the night it's probably closer to five. I'm also willing to walk away from a waiting room of patients if going back to the hospital is what I need to do.