Constant push back

[MSUSpartan642]

Mid-way through my intern year here. Just want some advice regarding admitting patients. At one of our hospitals it feels as though every admission is a constant struggle. Its not even that the IM doctors are attempting to teach but they are flat out trying to not have the patient admitted.
For example: From today. 51 y/o F (HTN/smoker), syncopal episode while walking back to bed at night fell through a f'ing door with her head and was found by BF. Work up was negative (Blood work, ekg, CT, orthostatics, etc.). In my limited experience I felt this patient warranted at least an ECHO, as she has never had one before. I tried to make my case for this and all I got was grief about how the patient should have came in immediately after the syncopal episode and why they wait until today for evaluation.

I wondering if its just this hospital or is it like this at many other institutions cause man-o-man is it draining. Thanks for any advice.

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[namethatsmell]

Mid-way through my intern year here. Just want some advice regarding admitting patients. At one of our hospitals it feels as though every admission is a constant struggle. Its not even that the IM doctors are attempting to teach but they are flat out trying to not have the patient admitted.
For example: From today. 51 y/o F (HTN/smoker), syncopal episode while walking back to bed at night fell through a f'ing door with her head and was found by BF. Work up was negative (Blood work, ekg, CT, orthostatics, etc.). In my limited experience I felt this patient warranted at least an ECHO, as she has never had one before. I tried to make my case for this and all I got was grief about how the patient should have came in immediately after the syncopal episode and why they wait until today for evaluation.

I wondering if its just this hospital or is it like this at many other institutions cause man-o-man is it draining. Thanks for any advice.

Exertional syncope portends badness. Without knowing all the details of your case, I bring these patients in 99% of the time (especially if pt has not had prior workup for it).

Hospitalist being cranky is an unrelated (though obnoxious) issue--it may improve as you become more of a known quantity and your presentation skills improve with time. Did they end up admitting?

 

[MSUSpartan642]

Patient was eventually admitted.

 

[Rendar5]

Honestly, I would consider that a soft admit. Normal v/s, normal hct, normal lytes, NSR EKG w/o concerning or even nonspecific changes. Not even sure it warrants a head CT unless the patient's at risk for a head injury. It's a relatively low risk d/c IF you can give them cardiac f/u. Not sure syncope while walking down a hallway counts as exertional syncope.

 

[Rendar5]

by the way, the pushback does get less the further along you get just to let you know. I wouldn't necessarily admit that patient depending on the circumstances, but I wouldn't get any significant pushback in a community setting.

 

[DO3]

Fellow intern here who can relate to your struggle. One thing that's helped me is telling the consultant/admitting service why you want them to see/admit a patient up front. My opening line is always something along the lines of, "I've got a patient that needs to be admitted for <insert diagnoses>." Most of the time their response is, "tell me the story." You already have their attention, and you are the one taking the lead. It gives you the opportunity to tell them all the things that support your diagnosis and paint your picture. If you start with, "I've got a 56 yo female who came in with <insert complaint and big long story about their entire ED workup and course>..." and wait till the end to give your admitting diagnosis, they will either have ignored 3/4 of what you said, interrupted you 10 times, or thought of 10 reasons why the patient does not need to be admitted. Taking this approach has really helped me. Another thing that's helped is to look over old notes and ED visits. For example, if I have a chest pain/CHF patients, I look to see if they have a previous echo or cath. If they have had a past cath with known CAD or an EF of 15%, I make sure the cardiologist or IM doc knows that info upfront. If they haven't had any studies, I highlight the risk factors. Makes it really hard to decline an admission. I'm definitely no expert by any means and still have a longggg way to go, but after watching my upper levels, I have quickly realized that we can paint whatever picture we want. Just takes awhile to get good at it.

 

[namethatsmell]

Not sure syncope while walking down a hallway counts as exertional syncope.

Depends on the protoplasm.

 

[GeneralVeers]

Head CT is part of the non-scientific workup in IM for all syncope even without neuro symptoms or head trauma.

 

[southerndoc]

Thankfully not where I am. Only about 20% of my syncope patients get a head CT.

 

[WilcoWorld]

I agree that syncope is not an indication for a head CT, but the patient the OP describes fell through a door head-first.

 

[Birdstrike]

Mid-way through my intern year here. Just want some advice regarding admitting patients. At one of our hospitals it feels as though every admission is a constant struggle. Its not even that the IM doctors are attempting to teach but they are flat out trying to not have the patient admitted.
For example: From today. 51 y/o F (HTN/smoker), syncopal episode while walking back to bed at night fell through a f'ing door with her head and was found by BF. Work up was negative (Blood work, ekg, CT, orthostatics, etc.). In my limited experience I felt this patient warranted at least an ECHO, as she has never had one before. I tried to make my case for this and all I got was grief about how the patient should have came in immediately after the syncopal episode and why they wait until today for evaluation.

I wondering if its just this hospital or is it like this at many other institutions cause man-o-man is it draining. Thanks for any advice.

There's two sides to this. One is that you're getting hella pushback with enough admits to make you feel drained. That sucks. You're getting caught in the middle between what your ED attending wants admitted and what the internists don't want admitted. When it's your own struggle, you're in charge and you've had more experience with admission sales strategies, it'll be easier to do.

The other side of it, is that in-patient syncope workups, even when the cause is life potentially threatening, generally don't turn up much. If this patient walks into an internists office, 99/100 aren't going to send that patient to a hospital for inpatient care, if their exam and vitals are normal. That being said, if such a patient leaves Dr. Outpatient's office and drops dead of V-Tach, which can cause paroxysmal syncopal episodes, the family is much more likely to say, "Oh...we love Dr. Outpatient. We know him and he's so nice. He said there was nothing that could've been done," and accept what happened. On the other hand, when someone leaves the ED and drops dead, the assumption always, "This should never have happened! That doctor said 'There was NOTHING WRONG!' I KNEW there was, that's why we took her there! He was trying to save MONEY for the HOSPITAL!!'" or something to that effect. This makes it harder for an EP to blow off syncope in patients with cardiac risk factors, age included.

Therefore, syncope is a classic setup for a head-banging admit conversation, because most of the time there's nothing wrong, or found, but when there is in the very few cases something's found it can be very bad. Keep your chin up. This stuff gets better as you get along in training and get to know your hospitalists (and they know you) in the real world. Also, before you make any phone call for admission, ask yourself, "What's the clincher?" That is your quick answer to the question, "Why can't this patient go home?" for any admission. Be prepared ahead of time, to answer that question for all admissions. For syncope, it might be, "The patient's father died suddenly in their fifties, I suspect a malignant arrhythmia, "We walked the patient and she got dizzy prior to discharge," or "We discussed possible discharge and she and her husband are uncomfortable with that. They insist on admission." It's much easier if you have your "clincher" ready, rather than get caught off guard, shocked that an internists want to discharge someone you thought was a slam dunk admission. As you get more experienced, you'll be able to pull these out by second nature, and the internists will be like, "Damn, he got me again." Lol

 

[dchristismi]

Yep. Like the syncope I admitted this morning. "Healthy 60 yo was at work, suddenly felt dizzy and just passed out. I managed to catch about 8 seconds of the VT on the EKG, wanna see it? Yes, I already talked to cardiology and he approved a CIU bed."

Practice young padawan. And it gets MUCH easier the longer you do this.

 

[dotcb]

Agree – this definitely gets easier as you go along. It's very important to know the specific reason for admission, and be prepared for resistance in advance.

Thinking back to residency, the times I had trouble admitting someone were usually times when I didn't necessarily agree with my attending, or I didn't really understand what the benefit of an admission would be…

In this case, it sounds like it comes down to there being certain high-risk features associated with syncope that would make you want to admit a patient. Some of these include – being really old, having an abnormal EKG, having more than one event in a short period of time, some way the patient describes their story that is particularly concerning, etc.

At the end of the conversation, if you're still in a rut, request that the person come down to the department and perform history and physical. If they still feel the same way and have an alternate plan, I'm always open to discussing it with them. It's much easier to hide and be unprofessional over the phone.

 

[Old_Mil]

Depends where you work and the culture there. Hospitalists, just like every other specialty has its good, its bad, and its lazy.

Just had the argument the other day about admitting a guy with melena and an INR of 5 that the hospitalist wanted to send home because the "vitals were normal" and his "h&h looks fine" (he was only "mildly" anemic). But we have a particularly bad "take the patient" culture here for a community hospital.

 

[engineeredout]

Not sure syncope while walking down a hallway counts as exertional syncope.

Walking down the hallway is probably the most physical activity that a lot of my patients have experienced in a long time.

 

[The Buff]

It does get easier to admit, but dont forget the admitting docs also have that many more years of learning how to block you. It is a constant arms race.

 

[Arcan57]

Blocking docs are a huge pain in the rear. That being said, you've got to learn the game somewhere and it's better to get smooth in residency when you always have an attending to back you up then cruise through residency admitting hangnails and then be bullied into sending home decompensated CHF or elderly pneumonia with no access to outpt care. It also helps to have a plan for the inpatient doc. "This pt has x. I want to admit her for treatment y and diagnostic test z." Unless the flagrantly disagree with your plan, it usually makes the sell easier because they can go in focused and not have to spend a lot of mental energy figuring out what category the patient falls under.

 

[Groove]

Although medicine admissions during residency can be painful, they ultimately will better prepare you for your future practice. You'll likely get the most push back throughout your career during training. Medicine admissions where I trained were frequently malignant. Here's a few rules of thumb:

• Know why you're admitting the pt.
• Know why you're admitting the pt. - Seriously. Don't rely on "Well my attending thought they needed admission, so that's good enough for me." Take a few minutes to think about it and understand why they need observation or why they need further ancillary studies, etc.. Syncope is bread and butter EM. We admit it all the time. Some you can send home, some are slam dunk admissions and some are on the edge where you need to be able to argue the admission with an element of facile and finesse. The "soft admits" are where you have the best opportunity to learn your medicine because those are the cases where you will be expected to argue your rationale. Take syncope for instance... You should know San Fran Syncope rules, Boston syncope rules, etc.. down cold and the risks in discharging a pt meeting any of those for starters. I even have quoted the OESIL study on occasion for pt's where your gut tells you to admit but they don't meet any of the classic criteria although other studies support my decision. Obviously, syncope is broad... but you get the point.
• Practice your "sell". Admission consults are an art. You will get more smooth and used to the typical "blocks" as you get further along to where you barely have to think during the conversation and have heard it all before and know exactly what to say and how to defend your position. I've often thought that our jobs as EM docs as far as telephone consults go... prepares for a great career in politics.
• Anticipate having to tell the admitting physician what to do with his/her pt. I'm not going to say that the IM doc doesn't know what to do, but sometimes you're catching him with 5 admissions pending, a 2 minute conversation about a new admission and he seriously just doesn't know what to do with the pt. Help them out. "It would be a good idea to get studies 1,2,3 and consult X, Y, Z, etc.." During residency I figured out that many times when your'e getting a tremendous amount of push back, the admitting physician just doesn't know why they should admit or what to do with the pt. That could be from bad communication on your part, brevity of the discussion with lack of context, etc.. You get the picture. (Not a slam on hospitalists.)
• Practice. This stuff gets ALOT easier with time and you won't have to deal with it as much after residency. You'll get the most when you start work at a new hospital as the internists are trying to get to know you but once people realize that you now only know your **** but are willing to go toe to toe on difficult admissions, you won't get much after that. I very rarely get push back these days and most of it is with new hospitalists and the hum drum usual fencing match that I've experienced thousands of times.

The reasons for "blocks" can be many. It can be due to a truly "soft" admit that you're scared to send home. It can be because the admitting doc leaves in 30 mins and doesn't want to stay late, census high, <30d readmission, personality, dump to medicine from a service that doesn't want to admit, you name it.

Keep practicing. You'll be seasoned in know time and this kind of stuff will get much easier.

 

[gutonc]

Although medicine admissions during residency can be painful, they ultimately will better prepare you for your future practice. You'll likely get the most push back throughout your career during training. Medicine admissions where I trained were frequently malignant. Here's a few rules of thumb:

• Know why you're admitting the pt.

Honestly, this is all I really need when I get called. I'm frankly horrified by the number of times the answer to "so what does s/he need to be admitted for?" is "s/he just does.". I get paid the same for bogus admits as I do for the real ones. Just tell me why.

 

[gman33]

Push back depends on the setting.
Academic site. Residents just don't want any more work. Understandable.

Community site. Does the patient have insurance and do they meet admission criteria for reimbursement.

Just anticipate the questions and have reasonable answers.

I don't take a lot of crap, but I try to be respectful of my consultants.
Simple wording changes can make a difference.
I have a patient I'd like to talk to you about admitting to your service.
I have a patient I could really use your help with.

This is tougher at an academic site where you may not know all the parties involved.

 

[The White Coat Investor]

It's a lot easier now for many reasons:

1) I'm no longer in training- I actually know pretty well now who needs admitted and why and who doesn't. Far easier to admit someone who needs to be admitted.
2) I'm no longer in training- I don't have to get patients admitted who my hyperconservative attending wants me to get admitted.
3) I'm not giving someone uncompensated work, I'm giving them money.
4) I know my hospitalists and they know me. Nobody is a jerk to their friends. Occasionally, they talk me into sending someone home and that's okay, especially if they have some information about them I didn't have when I decided to call them to admit. Occasionally I have to insist on an admit. But for the most part, it's "I want Mr. Jones admitted for PNA because he's 103, lives alone, can't walk, can't eat, and has sats of 70% without oxygen." The hospitalist says, "Great, I'll put orders into the computer."

 

[emergentmd]

Once you get out of residency, it will get easier. Where I work at, there is very little pushback to admit pts. In 15 yrs, I can remember very few times when there was some "discussion". If I believe they should be admitted, hospitalist will admit. If I think it is a soft admit, i will agree to discharge.
If we both are staunch about admit vs discharge, I just tell them, "can you see them in ED and give me a consult". That usually ends the discussion and pt gets admitted.

 

[deleted547339]

Honestly, this is all I really need when I get called. I'm frankly horrified by the number of times the answer to "so what does s/he need to be admitted for?" is "s/he just does.". I get paid the same for bogus admits as I do for the real ones. Just tell me why.

There only problem is that you have the patient and the consultant doesn't. Some people just have that look. They just look sick. They have normal VS and workup looks fine, but they can't go home. I try to be upfront about this and the admitting service is usually understanding. I usually try to follow up the soft admits. As a rule, anyone who I get significant pushback (e.g. why don't you just send them out?) end up staying for several days, lol.

Conversely, there's the guy who's numbers look terrible, but they look fine. I had a patient yesterday who's numbers looked absolutely terrible - AKI, elevated LFTs, bad anemia, hypotensive - but the guy was fine; he needed medical intervention, but he was rock-solid stable. Almost all of his issues were chronic. Admitting service wanted him to get seen by the MICU fellow before they'd take a look at him. MICU came down and immediately said to send him to step-down.

 

[Hair Police]

The "must be seen by X service first", and it's kissing cousin, "Must have X test first", are classic delay tactics. The former you get around by calling both services at the same time. If you know the guy's gonna go to tele, but his labs would make him 'ICU-able', tell the floor team the story as usual. You tell the ICU guy you have someone for tele but you know the floor team will make a stink, so you ask the intensivist to please come down and quickly eyeball the patient so the floor team feels more comfortable about taking the patient? At that point you can step back and let them duke it out.

You don't want to call both teams for every admission. But you will learn which patients fall into this category and when to make the calls.

Remember that the important work is done - the patient is coming in and will get the care they need. The rest is a mix of politics and logistics.

 

[NinerNiner999]

There will always (I rarely use "always") be at least one admitting physician wherever you work who will be the "most difficult" doctor to admit patients to. They will have the unique ability to make you question life itself in their incessant desire to provide you education, ask every question, challenge every test, and analyze every decimal point before they accept the patient. Like Einstein said - this is relative to your position. When you get out of residency, your worst community attending will be equivalent to your average admitting resident, but seem like an outlier compared to his colleagues that say "thanks - I'll enter the orders."

It gets much better, but you will always have "that guy" relative to everyone else. There are admitting physicians who can't enter orders in faster - they literally start their CPOE orders while you are talking to them, without argument, and say "thanks". These are the ones who get it, and fortunately, they are the majority in the community.

 

[ccfccp]

I agree that it gets better as you get more experience. It also helps not having to admit to resident services who have no motivation for taking another patient because they get nothing out of it. At my academic job, I can't tell you the number of times that I as an attending had to argue with an intern that they needed to come see the patient. It was pretty irritating.

I also agree with above that you should know the inpatient process well enough that you should be able to propose at least a cursory plan (I would like to bring this patient in for cardiac obs and provocative stress testing in the morning... etc.) Also - learn some of the favorite IM indications for admission (i.e. - "well, they looked pretty good, but they are 70 and seem a little dry with some mild uremia, so I was concerned via "CURB-65" that they might be a keeper.") Also, don't be afraid to mention legitimate social issues to admitting docs. Most of them went into medicine for the right reasons and want to help people. "I don't feel safe sending our unsteady 80 year old patient with the dizziness home, because she lives alone and all of her family lives out of state. I can't set up home health to check on her at 3am and was hoping to get her obs'd to be evaluated for this and set up." Above all - what gutonc said... be honest. An admitting doc that's been doing this for any length of time will see though your BS before you finish the sentence.

Finally, every once in a while (like a few times a year) I will insist that if the admitting doctor wants me to send the patient home, that he/she gets off their duff and comes and evaluates the patient in the ED and that they can write a note and send the patient home themselves. I don't like doing this, because it's not really a great way to make friends with your consultants, but if you're legitimately worried about the patient, I think it's the right thing to do.

 

[Cerberus]

Pushback improves as your seniority and car salesmenship skills improve. As a low level resident expect a lot of pushback, this significantly decreases as your seniority increases(or should based on your intrahospital politics, relationship with other departments, salesmenship). My advice (learned the hard way as someone who has been described as an "dingus" by people who like me), is to be as friendly but firm as possible and know your medicine and criteria for admission like the back of your hand. Nothing frustrates an admission blocking hospitalist more than someone who can rattle off risk assessment rules for admission.

 

[e30ftw]

you just gotta learn the tools of the trade.

"gait disturbance"
"unable to walk"
"lives alone with no primary doctor"
"failed outpatient management"
"curb 65, timi score, etc"
"ekg is non diagnostic but history concerning for cardiac chest pain and needs provocative testing"
"intractable nausea and vomiting"
"patients right arm went numb for 5 seconds in 1976 and no history of stroke so needs mri/neuro consult/admission"

"I do not see emergent indication for GI consult/cardiology consult/surgery consult however I am happy to have them see patient upon arrival to floor."

"I am happy to order that whole body CT en route to the floor and I'll have the RN page you when patient gets to his bed."

These are jedi mind tricks which usually work to get patients admitted without keeping them in the ED for additional testing.

As mentioned above, there is always one insufferable hospitalist who no matter how straightforward the admission will ask you to describe every last detail and criticize your management, "I can't believe you didn't give kayexalate for the potassium of 5.4" "This patient with known CAD and typical angina same as his constant angina definitely needs a CT of his chest to rule out PE."

Smile and nod, then see the next patient.