Consultant Conundrums

[HoosierdaddyO]

Im all about teamwork… was military, and D1 wrestler before my days of medical school etc. so I always try to place nice in the sandbox… but what’s peoples limits on when enough is enough in regards to consults and documenting their incompetencies or lack of teamwork in your note!!!

ie the cardiologist who is on call who you need to consult but doesn’t pick up the phone for 3 hours, or the surgeon who won’t even look at the CT scan and says admit to medicine I’ll deal with it tomorrow. Or the urologist who blatantly says “are you going to put my name in the note… bc if so, I’m not going to give you any formal advice, only off the record” because they are too lazy to pull up the scan from their end!!!

I say fudge it… document it all or else it never changes 🤷🏼‍♂️lol?! Others thoughts/opinions?!

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[emergentmd]

Im all about teamwork… was military, and D1 wrestler before my days of medical school etc. so I always try to place nice in the sandbox… but what’s peoples limits on when enough is enough in regards to consults and documenting their incompetencies or lack of teamwork in your note!!!

ie the cardiologist who is on call who you need to consult but doesn’t pick up the phone for 3 hours, or the surgeon who won’t even look at the CT scan and says admit to medicine I’ll deal with it tomorrow. Or the urologist who blatantly says “are you going to put my name in the note… bc if so, I’m not going to give you any formal advice, only off the record” because they are too lazy to pull up the scan from their end!!!

I say fudge it… document it all or else it never changes 🤷🏼‍♂️lol?! Others thoughts/opinions?!

Bump it up to your director/chief of EM. All of the Er docs are dealing with it.

If this is the culture and nothing will change, then either deal with it or find another job.

There is no reason to let it make your job miserable. Seems like the medical staff culture is one of animosity and little respect.

 

[Porfirio]

Im all about teamwork… was military, and D1 wrestler before my days of medical school etc. so I always try to place nice in the sandbox… but what’s peoples limits on when enough is enough in regards to consults and documenting their incompetencies or lack of teamwork in your note!!!

ie the cardiologist who is on call who you need to consult but doesn’t pick up the phone for 3 hours, or the surgeon who won’t even look at the CT scan and says admit to medicine I’ll deal with it tomorrow. Or the urologist who blatantly says “are you going to put my name in the note… bc if so, I’m not going to give you any formal advice, only off the record” because they are too lazy to pull up the scan from their end!!!

I say fudge it… document it all or else it never changes 🤷🏼‍♂️lol?! Others thoughts/opinions?!

I would document the amount of time to reach the cards consultant. I would document talking to surgery and they rec hospitalist admission and no surgery at this time. I would document the urologist recs and remind the urologist no conversations are off the medical record when it comes to patient medical care.

 

[elanmorin]

Right, there's no such thing really as "off the record." Anyone can go back and see who was the specialist on call, even if you don't document the name...

 

[Rendar5]

Curbside consults should actually be off the record otherwise it defeats the entire point of it. If it’s a curbside consult I tell them up front it’s a curbside consult and I’m not going to put the conversation in the chart. In fact I won’t mention in the chart that I spoke with anyone. I do this sometimes when I need a small bit of management advice from a specialist or need a radiologist to double check a radiology read (usually an outside study already read but without an attached report )

If it’s an official consult the entire conversation goes into the chart. The consultant should actually assume any calls are of this type of call unless explicitly informed otherwise.

 

[Rendar5]

For consultations that aren’t timely it is not always the consultants fault. I’ve directl called people on their cell phones after waiting too long and they were surprised they hadn’t even gotten paged yet. Other times it is their partner who is actually on call. I document delays only when I can’t reach them on their phone. If you guys don’t have their numbers you should set up a list of contact #’s. I also try and make a habit of getting numbers into my cell of reasonable consultants

 

[Candidate2017]

Im all about teamwork… was military, and D1 wrestler before my days of medical school etc. so I always try to place nice in the sandbox… but what’s peoples limits on when enough is enough in regards to consults and documenting their incompetencies or lack of teamwork in your note!!!

ie the cardiologist who is on call who you need to consult but doesn’t pick up the phone for 3 hours, or the surgeon who won’t even look at the CT scan and says admit to medicine I’ll deal with it tomorrow.

Don't hate the player, hate the game.

This is a systemic/hospital problem not a consultant problem. You don't know what's going on from the consultant's end. Maybe they are in the OR or cath lab. Maybe they don't get paid anything. Maybe they've negotiated 1 page per night, which the hospital is keeps violating.

The only guaranteed thing you know is the hospital is too cheap to make it worth the consultant's time. The consultant isn't a grunt or D1 athlete who blindly sacrifices and follows what the institution tells them to do, for free. The consultant did their time in sweat and blood, and is now the equivalent of a Blackwater contractor or an athlete in the big show asking for due compensation.

 

[doctalaughs]

I know you guys don’t consult dermatology very often, but here’s a good example of hospital being stupid. I enjoy derm issues that might come up in the ED or inpatient so offered to be on staff for several nearby hospitals.

Having done this before - I know typically the volume would be probably just 2-3 calls a week and mostly could give good advice over the phone if a photo was sent to me. Asked them to waive the credentialing fee and a very small stipend (just to break even on the time, as I could make much more just seeing a few more outpatients).

Universally was told no. Pretty sure no one asked anyone clinical (much less an ED doc) if it would be helpful.

 

[southerndoc]

I know you guys don’t consult dermatology very often, but here’s a good example of hospital being stupid. I enjoy derm issues that might come up in the ED or inpatient so offered to be on staff for several nearby hospitals.

Having done this before - I know typically the volume would be probably just 2-3 calls a week and mostly could give good advice over the phone if a photo was sent to me. Asked them to waive the credentialing fee and a very small stipend (just to break even on the time, as I could make much more just seeing a few more outpatients).

Universally was told no. Pretty sure no one asked anyone clinical (much less an ED doc) if it would be helpful.

Interesting. I've consulted dermatology once in my 4 years of residency and zero times in my 13 years of practice. Not sure what can't be referred as an outpatient except maybe SJS and a few other things. EM docs should know those.

 

[Vandalia]

The only guaranteed thing you know is the hospital is too cheap to make it worth the consultant's time. The consultant isn't a grunt or D1 athlete who blindly sacrifices and follows what the institution tells them to do, for free. The consultant did their time in sweat and blood, and is now the equivalent of a Blackwater contractor or an athlete in the big show asking for due compensation.

If they are being consulted, it is almost certainly because they have hospital privileges. In return for the privilege - the root of the term - of being able to utilize hospital facilities to perform procedures, a highly lucrative concession, it is expected that in return they will agree to provide call coverage.

The compensation is the access to the facilities. It is tough to do a cardiac cath or a TKA in your garage.

So I don't buy the "uncompensated" part.

 

[Porfirio]

We all give the hospital a pound of flesh.

 

[doctalaughs]

Interesting. I've consulted dermatology once in my 4 years of residency and zero times in my 13 years of practice. Not sure what can't be referred as an outpatient except maybe SJS and a few other things. EM docs should know those.

Seems like this varies a lot but I believe dermatologists do offer a lot to the ED and inpatient settings. I know your job is mainly not miss true emergencies (of which there are few dermatologic in nature) and administrators aren’t interested in reducing admissions but there’s a good body of evidence expert dermatologic consultation:

1) can reduce admission (and more importantly re-admission
2) improve outcomes (this is probably more once they are admitted).

A few example are:
- distinguishing cellulitis from mimics. I can’t tell you how many patients I’ve seen in the ED who would have been admitted but really have bad stasis or something else (LDS is probably 2nd place).
- distinguishing early SJS/TEN from other items to save admission (90% of things with a rash and mucosal involvement are not SJS)
- helping identify infectious rashes that require prompt correct treatment (such as disseminated zoster or deep fungal infections)
- identifying and treating serious drug eruptions that are not SJS (like DRESS)
- identifying vasculopathies that often end up inpatient like HSP, calciphlaxis, small vessel emboli etc.

Dermatology Consultations in Patients With Inflammatory Skin Diseases

This study investigates the association of dermatology consultations with outcomes of hospitalized patients with skin diseases.

jamanetwork.com

Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis: A Randomized Clinical Trial - PMC

Does early consultation with dermatology specialists improve outcomes for hospitalized patients with a presumed diagnosis of cellulitis? In this randomized clinical trial of 175 hospitalized adults, the length of intravenous antibiotic use was ...

www.ncbi.nlm.nih.gov

In any case, I think many hospitals don’t have a dermatologist on staff because a) yes, it’s not essential even if it might lead to better patient care and b) they don’t want to bother making it remotely worth any dermatologist’s time, even if the cost is minimal to them.

 

[turkeyjerky]

Stuff OP is describing is not okay. 3 hrs for a callback from cards? Dude is either drunk or asleep, isn't carrying his pager, or the system is broke. What if it's a stemi? Of course you document that. It's not my responsibility to know his cell phone # (and if that's how they want to be contacted, they should give it to the HUC). Uro doens't want a phone call documented? If he's on call, he should know that he is responsible to either see the patient or offer recs. Frankly, with the way most systems operate, I don't think curbsides should be a thing anymore.

That said, there is definitely truth to the notion that sometimes these responses are the result of inappropriate/unnecessary consults. Most patients getting admitted can wait a few hours to be seen and it's not really neccesssary to wake someone up at 2am just to let them know about it.

I would definitely appreciate having derm on call, although 99% of the time it would be to give the patient a name for f/u.

 

[TheComebacKid]

I would document the amount of time to reach the cards consultant. I would document talking to surgery and they rec hospitalist admission and no surgery at this time. I would document the urologist recs and remind the urologist no conversations are off the medical record when it comes to patient medical care.

This does very little to protect you. If your patient has a surgical issue and they die on the hospitalist service, you can still be held liable for this, especially in cases where the surgeon did not come and physically evaluate the patient and write a note. Documentation of phone recommendations, curbsides, statements such as "I'll see them in the morning" do not protect you.

These issues are effectively EMTALA violations. If you have a specialist on call and they refuse to see the patient, or significantly delay the patients care, CMS can crush the hospital financially, and the hospital can lose various accreditations. The conversations, when they get to the CMO level of the hospital, start to get really serious, really fast. I say, escalate through the appropriate channels, starting with your medical director.

One time when I was a resident, my attending made me transfer an orthopedic patient to another facility that the resident refused to see (after trying to escalate to the ortho attending and being unable to get a hold of them). It caused A LOT of issues, once the hospital realized our level 1 trauma center accreditation was suddenly in jeopardy. All of a sudden I noticed how much nicer the ortho residents were...

It's a pretty gutsy move to transfer some of these patients especially if you have the specialist available, but still, if you escalate through appropriate channels and things are still not getting done, it's on the table.

 

[Tenk]

I’ve never met any of these consultants but I’ve somehow met all of them…

 

[Siggy]

Short of something completely outrageous, I just document what they said. If it's truly outrageous then I'll start going up chains of command. I don't look at it as throwing people under the bus... I'm just documenting the fact that they've laid down under the bus. If the recommendation is reasonable (even in the "no surgical intervention, case is futile" situations), then there's no bus to speak of despite what is essentially the same documentation.

 

[DoctwoB]

If they are being consulted, it is almost certainly because they have hospital privileges. In return for the privilege - the root of the term - of being able to utilize hospital facilities to perform procedures, a highly lucrative concession, it is expected that in return they will agree to provide call coverage.

The compensation is the access to the facilities. It is tough to do a cardiac cath or a TKA in your garage.

So I don't buy the "uncompensated" part.

It all comes down to the local market and supply of specialists vs. hospitals.

As a surgical subspecialist, I am well paid to cover ER (and hospital) call. It comes down to us being the only group in the area, and if they want ER coverage, they pay for it. If they make unpaid call a condition of having privileges, the hospital 5 miles away would LOVE to have our elective cases. Or maybe we open a surgery center. At big name places/academic centers you take call as part of the deal for the privilege of being credentialed at said center. In competitive markets where there is a saturation of specialists, you might take unpaid call to have access to the referral source to fill your clinic. An other system I've seen at salaried places (hospital employed specialist) is that call is not paid for, but you're guaranteed to be paid for X number of hours if you come in.

As to the other topic, If I'm getting a call from the ER I just assume that it is being documented unless told otherwise and act accordingly.

 

[Vandalia]

Sure, you can debate the amount of "compensation" and the amount of work required.

If a physician feels the benefits of privileges are not worth the call coverage requirements they can make the decision to resign their privileges.

However, it is incorrect to say, as I believe the individual I quoted said, that physicians provide call "out of the goodness of their hearts." There is in fact a benefit received. Often a very lucrative benefit.

In a way it is similar to GME: Residents can argue that they should be paid more, or should work less, or should receive more educational benefits. What they cannot argue is that the education/training is in fact part of their compensation.

 

[michaelrack]

Sure, you can debate the amount of "compensation" and the amount of work required.

If a physician feels the benefits of privileges are not worth the call coverage requirements they can make the decision to resign their privileges.

However, it is incorrect to say, as I believe the individual I quoted said, that physicians provide call "out of the goodness of their hearts." There is in fact a benefit received. Often a very lucrative benefit.

The situation could be that the hospital worked with a major insurance company to make hospital privileges at that hospital a condition of being on that insurance panel

 

[Dral]

"- distinguishing cellulitis from mimics. I can’t tell you how many patients I’ve seen in the ED who would have been admitted but really have bad stasis or something else (LDS is probably 2nd place)."

Got an inpatient consult one day after admission from the ED. Bilateral upper extremity cellulitis. Within 2 minutes of being in the room, the husband pulls a bottle of lac-hydrin out of his wife's bag and tells us she started using it a few days ago on her arms. Contact derm. That was the only reason she was admitted.

 

[RustedFox]

"- distinguishing cellulitis from mimics. I can’t tell you how many patients I’ve seen in the ED who would have been admitted but really have bad stasis or something else (LDS is probably 2nd place)."

Got an inpatient consult one day after admission from the ED. Bilateral upper extremity cellulitis. Within 2 minutes of being in the room, the husband pulls a bottle of lac-hydrin out of his wife's bag and tells us she started using it a few days ago on her arms. Contact derm. That was the only reason she was admitted.

LDS?

Lipodystrohy syndrome (s-word that I can't find in my brain?)

 

[Vandalia]

The situation could be that the hospital worked with a major insurance company to make hospital privileges at that hospital a condition of being on that insurance panel

Same idea. They receive compensation by being on the insurance panel.

 

[Dral]

LDS?

Lipodystrohy syndrome (s-word that I can't find in my brain?)

Lipodermatosclerosis? If so, yep, that's a mimic of lower extremity 'b/l' cellulitis. I think of that entity as related to stasis. It usually occurs due to a similar mechanism (venous insufficiency, obesity, etc).

 

[Jabbed]

LDS?

Lipodystrohy syndrome (s-word that I can't find in my brain?)

Lipodermatosclerosis, which may or may not be the same thing as stasis dermatitis.

@southerndoc I frequently wish that I could text a dermatologist some photos for identification. Outpatient derm referral takes MONTHS in my major metro area. While these may not be high mortality diagnoses, they still have morbidity. I can confidently say that this ardorous truncal dermatosis in my 2nd trimester pregnancy patient isn't a life-threatening emergency, but I also have no idea what it is and it's certainly going to get much worse before they follow-up in 6-8 weeks. Last shift I had a patient that I'm 70% sure had early pyoderma gangrenosum, but I wasn't confident enough to start any specific treatment. She was having significant pain and there's high likelihood of progression given that she'll have a delay in diagnosis and treatment. Life-threatening? No. But I really would've appreciated a 30 second conversation with a dermatologist.

 

[RustedFox]

Lipodermatosclerosis? If so, yep, that's a mimic of lower extremity 'b/l' cellulitis. I think of that entity as related to stasis. It usually occurs due to a similar mechanism (venous insufficiency, obesity, etc).

That's the term I was looking for. I wasn't sure what you meant when you typed "LDS", but that was my best guess.
You can easily see how we in the ER aren't interested in this condition.

Only reason I know this term is because I had a plucky med student who was applying derm rotate thru my community ED several years back, and this was at the top of her differential when she presented the patient.

 

[Dral]

That's the term I was looking for. I wasn't sure what you meant when you typed "LDS", but that was my best guess.
You can easily see how we in the ER aren't interested in this condition.

Only reason I know this term is because I had a plucky med student who was applying derm rotate thru my community ED several years back, and this was at the top of her differential when she presented the patient.

Lack of interest is 100% fine by me (it's obviously the antithesis of an emergency), as long as the ED doc can tell it's not cellulitis or something that needs an admit.

 

[doctalaughs]

Yep, lipodermatosclerosis (basically a type of stasis with fibrotic changes).

It can be difficult because often it can be acute, unilateral, painful, and erythematous/hot like cellulitis. I can see why it’s often mistaken (acute LDS, although have also seen multiple admits for chronic LDS) for cellulitis although a dermatologist should be able to tell fairly easily.

 

[RustedFox]

Lack of interest is 100% fine by me (it's obviously the antithesis of an emergency), as long as the ED doc can tell it's not cellulitis or something that needs an admit.

I 100% agree. Unfortunately for us, nobody cares besides you and me. When these patients are incorrectly sent to the ER by "Doctor Jenny McJennyson, NP" for "admission and stronger antibiotics" it puts us in an unwinnable situation because satisfaction is king, and us not meeting the incorrectly set expectations of the patient is a sin in the eyes of administration.

 

[doctalaughs]

I 100% agree. Unfortunately for us, nobody cares besides you and me. When these patients are incorrectly sent to the ER by "Doctor Jenny McJennyson, NP" for "admission and stronger antibiotics" it puts us in an unwinnable situation because satisfaction is king, and us not meeting the incorrectly set expectations of the patient is a sin in the eyes of administration.

I hear you for sure. Same thing with the 50% of consults I see sent from Jenny without consulting their supervising doc.

Fine - I’ll take the $125 for 20 seconds of my time to tell them it’s another SK. Too bad for the patient’s deductible and healthcare system cost in general (another myth that midlevels are “cheaper”) but I can’t change that.

 

[RustedFox]

I hear you for sure. Same thing with the 50% of consults I see sent from Jenny without consulting their supervising doc.

Fine - I’ll take the $125 for 20 seconds of my time to tell them it’s another SK. Too bad for the patient’s deductible and healthcare system cost in general (another myth that midlevels are “cheaper”) but I can’t change that.

SK?

Seborrheic keratosis?

 

[doctalaughs]

SK?

Seborrheic keratosis?

Yep sorry too many thousands of dictated notes with scribes or auto replace.

 

[RustedFox]

Yep sorry too many thousands of dictated notes with scribes or auto replace.

Look... I'm learning.

 

[turkeyjerky]

I 100% agree. Unfortunately for us, nobody cares besides you and me. When these patients are incorrectly sent to the ER by "Doctor Jenny McJennyson, NP" for "admission and stronger antibiotics" it puts us in an unwinnable situation because satisfaction is king, and us not meeting the incorrectly set expectations of the patient is a sin in the eyes of administration.

I'm sorry, but this is one situation where I just throw the other person under the bus.

 

[RustedFox]

I'm sorry, but this is one situation where I just throw the other person under the bus.

Oh, I'm well in front of you in the line to throw MLPs under the bus for their generalized *******ery.
Unfortunately, that just gets complaints.

 

[thegenius]

LDS?

Lipodystrohy syndrome (s-word that I can't find in my brain?)

lipodermatosclerosis? That's got an "L", a "D", and an "S" in it.

I learned that from you, RF from one of your prior posts. I'm a slightly better doctor as a result.

 

[thegenius]

I hear you for sure. Same thing with the 50% of consults I see sent from Jenny without consulting their supervising doc.

Fine - I’ll take the $125 for 20 seconds of my time to tell them it’s another SK. Too bad for the patient’s deductible and healthcare system cost in general (another myth that midlevels are “cheaper”) but I can’t change that.

Yup it's all about kicking that "risk can" down the street to some other doctor.

 

[RustedFox]

lipodermatosclerosis? That's got an "L", a "D", and an "S" in it.

I learned that from you, RF from one of your prior posts. I'm a slightly better doctor as a result.

I learned it from that med student.
I couldn't remember my own remembery.

 

[dchristismi]

I just had a hospice patient with that. She died from her kidney failure after a "heck no, I don't want dialysis," but her legs were atrocious.
The "care" she was getting at her nursing home was only slightly less atrocious.

FWIW, I've consulted derm exactly once in my EM career, and it turned out to be Sweet's Syndrome, but it was a real WTF moment. I was in residency, and my attending decided this would be a good time for "rash rounds." So lots of people looked at it, but no one had any idea. It was a hell of a scary looking vasculitisy-thing though. I am pretty sure that patient got admitted, and a derm was gracious enough to come in, but it was also an academic medical center and also, daytime.

 

[e30ftw]

The only guaranteed thing you know is the hospital is too cheap to make it worth the consultant's time. The consultant isn't a grunt or D1 athlete who blindly sacrifices and follows what the institution tells them to do, for free. The consultant did their time in sweat and blood, and is now the equivalent of a Blackwater contractor or an athlete in the big show asking for due compensation.

Seriously cringe.

 

[Old_Mil]

I learned it from that med student.
I couldn't remember my own remembery.

I was going to ask him if he was Mormon.