Consults- Memorable/Dismal/Ridiculous/Unique

[Pir8DeacDoc]

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Guess you are at a quiet hospital or not looking hard enough. There are a bunch of urologic emergencies and patients who need admission, plus we usually have a relatively big inpatient census. As a resident, I am in the hospital almost every call night (q2-4) at our busiest hospital. Our attendings have to come in about a third of that to operate. Not to mention that even when I am not coming in I am fielding calls from ER and floor nurses all night, none of which even gets recorded as duty hours. Home call sucks. I miss my post call days a lot.

Well each place is different. I've got four friends from med school who are urologists. They would echo what I'm saying. Usually a very large coverage pool such as VA, pedi, county, etc means a large resident pool. So call could be bad but happens every two weeks or so. Or call is split by service and you may be on more often but cover only one hospital. Hard to imagine you are on call q2-4 and come in all the time and carry that schedule all year. To have that much call volume you should have big resident classes.

I'm not trying to minimize what you do. I'm sure you work hard. It just amuses me slightly to see a urologist complain about consults to general surgeons. I worked probably 70 hrs per week average in residency. It wasn't easy especially with airway emergencies and train wreck cancer pts trying to die or withdrawal from ETOH. But I'd never gripe to my buddies in gen surg about it. They pushed a lot more hours than that. Anyway sorry to derail.

 

[cpants]

Well each place is different. I've got four friends from med school who are urologists. They would echo what I'm saying. Usually a very large coverage pool such as VA, pedi, county, etc means a large resident pool. So call could be bad but happens every two weeks or so. Or call is split by service and you may be on more often but cover only one hospital. Hard to imagine you are on call q2-4 and come in all the time and carry that schedule all year. To have that much call volume you should have big resident classes.

I'm not trying to minimize what you do. I'm sure you work hard. It just amuses me slightly to see a urologist complain about consults to general surgeons. I worked probably 70 hrs per week average in residency. It wasn't easy especially with airway emergencies and train wreck cancer pts trying to die or withdrawal from ETOH. But I'd never gripe to my buddies in gen surg about it. They pushed a lot more hours than that. Anyway sorry to derail.

Welp, I'm not trying to have a pissing contest about who has harder call. You're the one who says you've never even seen a urologist in house at night. That seems hard to believe. I know that my general surgery colleagues have a lot of respect for GU call because they rotate on service, and they know it is pretty terrible.

 

[DoctwoB]

Well each place is different. I've got four friends from med school who are urologists. They would echo what I'm saying. Usually a very large coverage pool such as VA, pedi, county, etc means a large resident pool. So call could be bad but happens every two weeks or so. Or call is split by service and you may be on more often but cover only one hospital. Hard to imagine you are on call q2-4 and come in all the time and carry that schedule all year. To have that much call volume you should have big resident classes.

I'm not trying to minimize what you do. I'm sure you work hard. It just amuses me slightly to see a urologist complain about consults to general surgeons. I worked probably 70 hrs per week average in residency. It wasn't easy especially with airway emergencies and train wreck cancer pts trying to die or withdrawal from ETOH. But I'd never gripe to my buddies in gen surg about it. They pushed a lot more hours than that. Anyway sorry to derail.

It's worth remembering that Uro programs are tiny in comparison to gensurg. A 2/year program (with interns off-service on gensurg) leaves 2 juniors, 4 seniors, and 2 chiefs to cover every hospital every night.

 

[Pir8DeacDoc]

It's worth remembering that Uro programs are tiny in comparison to gensurg. A 2/year program (with interns off-service on gensurg) leaves 2 juniors, 4 seniors, and 2 chiefs to cover every hospital every night.

Pretty similar to ENT in terms of program size. I'm not sure but I imagine two per year would be on the smaller to average size for programs. What is the most a program can have? Four?

If you're coming in every night as a surgical specialist then you are covering a huge hospital(s). So I would imagine 3-4 per year in such a setting. Let's say 3 to be conservative. That's 12 people to cover call. Like I said earlier, about every two weeks of an awful night/weekend or split services by call (i.e. pedi resident takes pedi call) and you would surely be less busy at night just covering one hospital.

 

[StritchMD2011]

Looks like my difficult foley consult page stirred up a lot of conversation.

I agree that "difficult foley" consults generally make urology residents start having a nervous twitch. It's mainly because many of the medicine services think of us as a foley catheter service. The sentiment mentioned above by bostonredsox is way too pervasive amongst many medicine residents/attendings. "Well the nurse couldn't get it, so why should I be able to," is a comment I hear about once or twice a week. The resident or attending won't even see the patient, but will automatically call a consult, or even worse - tell the nurse to call us.

As mentioned above, the reason a foley is difficult and what was tried previously is very valuable information, as it does give us some information about what the problem is. A morbidly obese guy with a buried penis is very different from a guy who had prior prostate CA and had a radical prostatectomy. I just get angry when the physician taking care of the patient can't even tell me these things.

I'm more than glad to come in at 2am to place a foley if the patient truly needs it, but it's frustrating when the person responsible for the patient's care doesn't even attempt to address the problem first.

We cover 5 separate hospitals and about 30-75 primary patients and consults when we're on call. I don't think my time is more valuable than others, but we're not in house at all hours. Driving in at 2am to place a foley that was deemed "difficult" and being able to throw an 18F coude catheter in from the doorway gets frustrating after awhile.

The moral of the story is - an 18F coude catheter and a urojet is a successful combo about 80-90% of the time.

 

[Bostonredsox]

I do, though most of the time the nurses can get them. But if an outtie suprapublic cath rolls in, I'm it. And I'll jam viscous lido into that stoma and squirrel a Foley in there so I do not have to call a urologist at 3am. And if I have to call them, I can honestly say that I tried before calling. They appreciate that.

They aren't worried about not getting the referrals ... they're the only uro group in town so they get it whether I refer to them or not.

As for IV's. Well, I'm actually better than some of the nurses, but that wasn't because of med school, but my previous medic experience. Sometimes throwing an EJ will make the nurses happy and avoid an unnecessary IJ.

I do quite frequently come up and throw in EJs. But I have found that in most patients the EJs don't last very long and I have on more than one occasion gone up Monday night and thrown in an EJ and then been called tuesday hey we lost that EJ and we still can't get anything else. If I know they're gonna be here a few days I throw in an IJ.

And to the post about being called for a patient I am covering that needs a foley and not knowing why they failed to get it, prostate ca etc.....at my shop we cover like 120-130 patients at night. I know almost nothing about any of them. Less than 50% of the pts are on the medicine resident day teams so I don't get signout on over 70 of the 130 pts nightly, yet I get called on all of them at night. I get, in the middle of a batch of 6 admits at once from the Ed, "random pt X on floor y needs a foley and 3 of us have tried including the MICU nurse" I say do they need one tonight (why do they need it)....they're septic and making no urine.....ok what have you tried thus far so I can give the urologist a call.

That's how both of the 2 ( in 2 years) URO consults for a foley have gone that I have called.

 

[SLUser11]

.....at my shop we cover like 120-130 patients at night. I know almost nothing about any of them. Less than 50% of the pts are on the medicine resident day teams so I don't get signout on over 70 of the 130 pts nightly...

That doesn't seem like very good care. It might not be your fault, but it seems inappropriate. You can't care for 70 patients you know nothing about, especially if some of them are critically ill.

Are you all alone, or do you have other doctors or physician extenders taking calls as well?

Why would you be asked to cover patients you are not consulted on? That seems like a liability nightmare for you and the primary team.

 

[Bostonredsox]

We are not the Consultants, we are the primary for everyone except maybe 15 or so Gen surg patients. It's quite inappropriate, but I'm an IM senior resident at a community for profit shop, the administrators care about one thing, dollars. They do not see the need for a second attending at night. So regardless of the census, 90 or of late, 120+, there is one hospitalist at night, one senior and a few interns. We started having a second senior to cover the ICU at night, which has helped some, but the rest of the house falls to the one attending and one senior. And our average admits from 7p-7a is around 17. High end is 22-24. So the majority of the night is in the ED. And the floor calls just keep coming. Throw in 2 floor codes and its just a horrible draining night. So things like we can't get a foley in end up being far down the totem pole for us.

 

[45408]

I would call you. I do not put in foleys. Lines, airways, chest tubes, and other physican performed procedures.. no problem. But I have never been one to put in foleys. I have maybe put in 3 in my life. If a nurse cant get one I tell them to call one of the MICU nurses. If the MICU nurse, who has more than likely put in >5,000 foleys in her life, cant get the foley in, there isnt anyway in hell I am getting one in. I tell them to call the on call urologist if we really need one that moment, otherwise slap a diaper on them and they can do it in the morning. And very few of my other IM collegue's have ever put in foleys. It is a nurses job. And If it is too difficult for the experienced nurse to put in, chances are they have some anatomical problem. I am not sticking a tube in them, easy uro consult. Never had a Uro attending holler at me for that. Usually they say hand the phone to the nurse, they give the nurse some orders and they come up and do it via cysto. Same deal with an IV. If 3 different competent nurses cant get a peripheral IV in someone I am not wasting my time dicking around trying to put an 18 into their antecub, there getting an IJ. There isnt time amidst the 400 floor calls and 600 f'n ED admissions to waste time with peripheral IVs, Foleys and other nursing procedures. Atleast that is my experience from a community shop.

The bolded comment is lame. If I'm busy, of course I'll prioritize a new surgical consult over placing an IV or a Foley, but in the last week, I did place a Foley (see below), and I put in an ultrasound-guided IV on a floor patient who had been stabbed repeatedly. I sank it in the first try. Like SLUser said, just give it a try.

However, it is virtually impossible to think that a medicine intern, resident or attending for that matter, who collectively, probably have placed a dozen foleys, as again, it is nursing procedure that is placed without difficulty 99% of the time, will have any better luck placing it then the experienced nurse. It is an exercise in futility and a waste of time for me to even come try. If it is a complicated foley, its getting a consult. Your a urologist. Come place the foley.

I love nurses, but you're putting too much faith in the nurses' abilities. I've seen several botched Foleys, by nurses who supposedly had more experience than me. Several don't seem to give a sh-t about sterile technique either. I ended up putting one in an obese woman last night, because I saw the nurse bury it in the vagina first and looked like she was gearing up to try again with the same catheter.

And to the post about being called for a patient I am covering that needs a foley and not knowing why they failed to get it, prostate ca etc.....at my shop we cover like 120-130 patients at night. I know almost nothing about any of them. Less than 50% of the pts are on the medicine resident day teams so I don't get signout on over 70 of the 130 pts nightly, yet I get called on all of them at night. I get, in the middle of a batch of 6 admits at once from the Ed, "random pt X on floor y needs a foley and 3 of us have tried including the MICU nurse" I say do they need one tonight (why do they need it)....they're septic and making no urine.....ok what have you tried thus far so I can give the urologist a call.

That's how both of the 2 ( in 2 years) URO consults for a foley have gone that I have called.

And to me, that really doesn't sound unreasonable for you to do that, it's just the mindset of "I don't do that" that caught most of our attention, I think.

 

[Dr.LeoSpaceman]

I honestly hate having to call one of my urology friends to put in a foley. And I do, you can be sure that I've tried a coude, urojet, small silicone, etc. etc. Basically, if they come in and do anything but scope them to get the catheter in, I'd be embarrassed.

As for the comment about nurses, I'd echo the sentiments that "If the nurses can't do it, I can't." I think that's a gross over estimate of many nurses' initiative. Basically, if something is going to take time, or be moderately difficult, there's a good chance they will just say "I couldn't do it". Unless I know the nurse, I don't take those comments at face value.

 

[Bostonredsox]

I honestly hate having to call one of my urology friends to put in a foley. And I do, you can be sure that I've tried a coude, urojet, small silicone, etc. etc. Basically, if they come in and do anything but scope them to get the catheter in, I'd be embarrassed.

As for the comment about nurses, I'd echo the sentiments that "If the nurses can't do it, I can't." I think that's a gross over estimate of many nurses' initiative. Basically, if something is going to take time, or be moderately difficult, there's a good chance they will just say "I couldn't do it". Unless I know the nurse, I don't take those comments at face value.

Agreed, but that's why I included 'the MICU nurse also tried. I trust my MICU nurses here the vast majority of them are excellent. A floor nurse, different story

 

[Thanatos]

Well this has been illuminating.

I have several wtf moments with medicine residents a week, and the "i don't do foleys" comments have actually cleared up something I've been wondering for a few years.

I get several GI bleed consults a week from medicine. I tell them to keep good IV access, put some blood on hold, call GI (I usually get called before GI, which is awesome), the usual.

The main thing I recommend, and I would think this is fairly accepted/standard, is to monitor the hemoglobin. I will tell them to trend it like q6 for example.....and 8, 10, 12, 24 hours later they won't have checked one. I will go to follow up on it and it will be ordered, but no results. Hmmm....as an attentive intern I would page the medicine guys and say "hey, we recommended you check this, its probably a good idea and all, just wanted to make sure you knew."

They would assure me they were on it, just waiting/paging/begging/pleading with phlebotomy to come do it......and then no results until the next morning or even later. This is even in people who were getting transfusions....and I used to think to myself, are these guys just stupid? You have someone bleeding, GI is saying they won't scope them tomorrow afternoon, you were concerned enough to consult surgery but you won't check serial hemoglobins? Why is this so hard? But I always get the same excuses.....

1. the nurses couldn't get the stick
2. we are waiting on phlebotomy
3. i paged phlebotomy, they will be here any second I promise
4. I called the administrator on call, talked to the phlebotomy manager, heads will roll, they're coming
5. we're going to the icu to get the charge nurse who they call the vein whisperer to help us
6. we are lazy, unmotivated cowards too afraid to take matters into our own hands so we demand that people whose time is less important than ours come do this. instead of thanking you of course we will continue to look down on you somehow and be completely unaware of how ridiculous that is. because i don't do blood draws.

Kind of explains almost every wtf moment I've ever had with medicine....patients on the floor with raging pancreatitis that have one 24 gauge iv (if you don't do iv's) and no foley, people screaming in pain with a distended abd for 6 hours and no imaging (we don't transport people down to xray), people vomiting blood with no labs in 3 days (we don't do blood draws).

My advice to other specialties is that if doing tasks my medical students can do is beneath you, I wish you find using the paging system to call me beneath you as well.

 

[filter07]

An instant classic

 

[Bostonredsox]

Well this has been illuminating.

I have several wtf moments with medicine residents a week, and the "i don't do foleys" comments have actually cleared up something I've been wondering for a few years.

I get several GI bleed consults a week from medicine. I tell them to keep good IV access, put some blood on hold, call GI (I usually get called before GI, which is awesome), the usual.

The main thing I recommend, and I would think this is fairly accepted/standard, is to monitor the hemoglobin. I will tell them to trend it like q6 for example.....and 8, 10, 12, 24 hours later they won't have checked one. I will go to follow up on it and it will be ordered, but no results. Hmmm....as an attentive intern I would page the medicine guys and say "hey, we recommended you check this, its probably a good idea and all, just wanted to make sure you knew."

They would assure me they were on it, just waiting/paging/begging/pleading with phlebotomy to come do it......and then no results until the next morning or even later. This is even in people who were getting transfusions....and I used to think to myself, are these guys just stupid? You have someone bleeding, GI is saying they won't scope them tomorrow afternoon, you were concerned enough to consult surgery but you won't check serial hemoglobins? Why is this so hard? But I always get the same excuses.....

1. the nurses couldn't get the stick
2. we are waiting on phlebotomy
3. i paged phlebotomy, they will be here any second I promise
4. I called the administrator on call, talked to the phlebotomy manager, heads will roll, they're coming
5. we're going to the icu to get the charge nurse who they call the vein whisperer to help us
6. we are lazy, unmotivated cowards too afraid to take matters into our own hands so we demand that people whose time is less important than ours come do this. instead of thanking you of course we will continue to look down on you somehow and be completely unaware of how ridiculous that is. because i don't do blood draws.

Kind of explains almost every wtf moment I've ever had with medicine....patients on the floor with raging pancreatitis that have one 24 gauge iv (if you don't do iv's) and no foley, people screaming in pain with a distended abd for 6 hours and no imaging (we don't transport people down to xray), people vomiting blood with no labs in 3 days (we don't do blood draws).

My advice to other specialties is that if doing tasks my medical students can do is beneath you, I wish you find using the paging system to call me beneath you as well.

I read like half of this ******ed post then stopped. No medicine resident with half a brain calls a surgeon for a gi bleed. You call GI. After the scope, if what they find needs surgery, they call surgery.

Do nurses put in 24 ga ivs? They call me when 2-3 of them can't get in a 22 and I either put in an EJ or a TLC, see above post. We have nothing smaller than a 22 that I have ever seen.

If I get called phlebotomy can't stick a patient that needs blood, I go an fem stick them. Takes me about 20 seconds. And if they are a really hard stick getting q6 h and hs, I put in a line and they just draw off it as often as needed.

Your medicine residents are bad. Don't generalize.

 

[SLUser11]

Well this has been illuminating.

I have several wtf moments with medicine residents a week, and the "i don't do foleys" comments have actually cleared up something I've been wondering for a few years.

I get several GI bleed consults a week from medicine. I tell them to keep good IV access, put some blood on hold, call GI (I usually get called before GI, which is awesome), the usual.

In a thread where we are chastising people for deflecting work to other services, I'm not sure I agree that a GI bleed is non-surgical.

What is stopping you from performing your own endoscopy?

 

[Bostonredsox]

In a thread where we are chastising people for deflecting work to other services, I'm not sure I agree that a GI bleed is non-surgical.

What is stopping you from performing your own endoscopy?

I am sure this is aimed at the prior poster the GS pgy3 and not me. But what % of GI bleeds would you say require surgical intervention as opposed to endoscopic therapy?

In academia where there are tons of surgeons who scope and tons of GI fellows too, I am sure its a bit of a turf war. In smaller community shops like mine, our few surgeons are already overwhelmed with gallbladders, hernias, biopsies, port placements, etc. etc. They do not, although they can, place PEG tubes, do colonoscopies, etc. They have enough on their plate without the GI crap.

And I can count on one hand in 2 years the number of distal gastrectomies and diverting colostomies with resections for non-remitting bleeds that my patients have had in 2 years on one hand. Whereas the number with clipped varices, cauterized ulcers and Bicap'd colonic bleeds are in the hundreds. To me, unless at your shop the surgeons are routinely doing lots of endoscopy, which I am sure hospitals with GS residencies are, the GI bleed goes to the GI guy first.

Ex. its 3am on a sunday and a 67y/o male comes in vomiting blood and is hypotensive. after intubating, throwing in lines and attempting to stabilize in MICU, I call surg and give them the scoop, I get, "has GI scoped them and tried to stop the bleed already?" That was the first any only time I ever called surgery first. Save one other time, but in that instance there was free air on film so I knew there was perforation and thus urgent surgery was needed.

 

[dpmd]

I read like half of this ******ed post then stopped. No medicine resident with half a brain calls a surgeon for a gi bleed. You call GI. After the scope, if what they find needs surgery, they call surgery.

Do nurses put in 24 ga ivs? They call me when 2-3 of them can't get in a 22 and I either put in an EJ or a TLC, see above post. We have nothing smaller than a 22 that I have ever seen.

If I get called phlebotomy can't stick a patient that needs blood, I go an fem stick them. Takes me about 20 seconds. And if they are a really hard stick getting q6 h and hs, I put in a line and they just draw off it as often as needed.

Your medicine residents are bad. Don't generalize.

It isn't just his medicine residents. At my institution they made it mandatory to consult surgery on any GI bleeder since we got tired of getting involved at the last second after proper care wasn't given (we will probably start getting all the pancreatitis consults for the same reason instead of just the gallstone ones or the ones who need a necrosectomy). It is not infrequent that we see inadequate lines, no foley and no repeat hgb ordered. It might just be that they haven't gotten to it yet since they work at a slower pace than surgery (or maybe it is just that they are busy seeing consults and don't check to make sure the stuff they ordered has actually been done, whereas we have a way of making sure stuff happens for our potential disasters even if we are busy).

 

[Dr.LeoSpaceman]

It isn't just his medicine residents. At my institution they made it mandatory to consult surgery on any GI bleeder since we got tired of getting involved at the last second after proper care wasn't given (we will probably start getting all the pancreatitis consults for the same reason instead of just the gallstone ones or the ones who need a necrosectomy). It is not infrequent that we see inadequate lines, no foley and no repeat hgb ordered. It might just be that they haven't gotten to it yet since they work at a slower pace than surgery (or maybe it is just that they are busy seeing consults and don't check to make sure the stuff they ordered has actually been done, whereas we have a way of making sure stuff happens for our potential disasters even if we are busy).

I agree, I think the GI bleed (along with pancreatitis) are two of the situations that should get you a routine surgical consult. They're annoying because they're so often non-surgical, but on the chance they do require intervention, it's unpleasant to get the "Oh, hey, this guy's been here for 72 hours and needs to go to the OR right now."

And it's not that medical services (including GI) are ignorant of the appropriate decision making--it's that they often do not pursue it with the requisite zeal. This includes how to adequately resuscitate someone. If I walk into a room with a GI bleeder who has neo running and I ask "How much blood have they received?", it's disheartening when the answer is "None." That's where I believe having surgery involved is generally helpful.

Perhaps it is different in the community, but we rotate at a community hospital and still have similar problems. And part of that problem is a GI group that is notoriously bad about scoping someone outside of the hours 9-5 and 9a-12p on weekends. The difference is when the family practice residents get the "We'll scope them in the morning," they drop it. If I see someone that needs to be scoped immediately, I'm more likely to lean on GI (and have my attending staff do so, if necessary).

I'll add that our University system has internal data that showing significantly better outcomes in moderate-severe pancreatitis compared to reported data, and it's our belief that this comes from approaching it in a multidisciplinary fashion (Pancreaticobiliary GI, HPB Surgery, and surgical critical care). I strongly believe that if all of these services share a common strategy to managing these patients it absolutely stremlines their care and results in improved outcomes.

 

[45408]

In a thread where we are chastising people for deflecting work to other services, I'm not sure I agree that a GI bleed is non-surgical.

What is stopping you from performing your own endoscopy?

Location, location, location.

We've certainly oversewn bleeding ulcers, removed colons, and so on, but it's the exceedingly rare situation where you would head to the OR without endoscopy, or even plan to go to the OR to do the endoscopy.

We don't do our own endoscopy because most of our staff don't do them regularly at all, and certainly not the ones taking acute care call. I could do a diagnostic scope on most of these patients, but I wouldn't want to start injecting/clipping/cauterizing.

I read like half of this ******ed post then stopped. No medicine resident with half a brain calls a surgeon for a gi bleed. You call GI. After the scope, if what they find needs surgery, they call surgery.

Do nurses put in 24 ga ivs? They call me when 2-3 of them can't get in a 22 and I either put in an EJ or a TLC, see above post. We have nothing smaller than a 22 that I have ever seen.

If I get called phlebotomy can't stick a patient that needs blood, I go an fem stick them. Takes me about 20 seconds. And if they are a really hard stick getting q6 h and hs, I put in a line and they just draw off it as often as needed.

Your medicine residents are bad. Don't generalize.

I guess my IM program is in need of numerous half brains then. I've gotten numerous consults for GI bleeds for MICU patients and floor patients before GI has even seen the patient, let alone scoped them.

I agree, I think the GI bleed (along with pancreatitis) are two of the situations that should get you a routine surgical consult. They're annoying because they're so often non-surgical, but on the chance they do require intervention, it's unpleasant to get the "Oh, hey, this guy's been here for 72 hours and needs to go to the OR right now."

And it's not that medical services (including GI) are ignorant of the appropriate decision making--it's that they often do not pursue it with the requisite zeal. This includes how to adequately resuscitate someone. If I walk into a room with a GI bleeder who has neo running and I ask "How much blood have they received?", it's disheartening when the answer is "None." That's where I believe having surgery involved is generally helpful.

Perhaps it is different in the community, but we rotate at a community hospital and still have similar problems. And part of that problem is a GI group that is notoriously bad about scoping someone outside of the hours 9-5 and 9a-12p on weekends. The difference is when the family practice residents get the "We'll scope them in the morning," they drop it. If I see someone that needs to be scoped immediately, I'm more likely to lean on GI (and have my attending staff do so, if necessary).

I'll add that our University system has internal data that showing significantly better outcomes in moderate-severe pancreatitis compared to reported data, and it's our belief that this comes from approaching it in a multidisciplinary fashion (Pancreaticobiliary GI, HPB Surgery, and surgical critical care). I strongly believe that if all of these services share a common strategy to managing these patients it absolutely stremlines their care and results in improved outcomes.

Man, it's not that I disagree that things would probably be better if we were on board early, but it's awfully painful to see so many non-operative consults. It just takes away from other things you could be doing (e.g., double-scrubbing a good case or doing a teaching case).

Our painful setup is that we see virtually every trauma imaginable that comes through the door, from same-level falls to low-speed restrained MVCs.

 

[Dr.LeoSpaceman]

Man, it's not that I disagree that things would probably be better if we were on board early, but it's awfully painful to see so many non-operative consults. It just takes away from other things you could be doing (e.g., double-scrubbing a good case or doing a teaching case).

Yeah, perhaps. But I also think it's important to see these patients as a junior resident so that you have an appreciation for when something isn't just another NTD consult as a chief. Plus, it's easy to bang out one of these in 15 minutes, and it takes little effort to follow as a consult for a day or two. You can also generally get an idea from the consultant whether this is a "You need to see this now" or "I can see this in between cases". So I don't necessarily agree that these are 1) without educational value or 2) come at the expense of other educational opportunities.

 

[dpmd]

We don't do our own endoscopy because most of our staff don't do them regularly at all, and certainly not the ones taking acute care call. I could do a diagnostic scope on most of these patients, but I wouldn't want to start injecting/clipping/cauterizing.

Agree. As a resident I did zero management of bleeding, so now despite the fact that I maintain my scoping privileges and seek out patients to keep up my skills with, I would be much less useful than our GI guy in scoping a bleeder (I would do it if our GI guy died on the way to the hospital or something and give it the old college try-is the banding of varices similar to banding hemorrhoids?)

 

[Thanatos]

I read like half of this ******ed post

Your medicine residents are bad. Don't generalize.

So says the guy who can't put in a foley. We agree that my medicine residents are bad though.

In a thread where we are chastising people for deflecting work to other services, I'm not sure I agree that a GI bleed is non-surgical.

What is stopping you from performing your own endoscopy?

I know you're playing devils advocate here, we are taught diagnostic scoping but I can't really do anything therapeutic. GI has cornered the market on scoping where I am, whether that is a good or bad thing who knows.

I am sure this is aimed at the prior poster the GS pgy3 and not me. But what % of GI bleeds would you say require surgical intervention as opposed to endoscopic therapy?

In academia where there are tons of surgeons who scope and tons of GI fellows too, I am sure its a bit of a turf war. In smaller community shops like mine, our few surgeons are already overwhelmed with gallbladders, hernias, biopsies, port placements, etc. etc. They do not, although they can, place PEG tubes, do colonoscopies, etc. They have enough on their plate without the GI crap.

And I can count on one hand in 2 years the number of distal gastrectomies and diverting colostomies with resections for non-remitting bleeds that my patients have had in 2 years on one hand. Whereas the number with clipped varices, cauterized ulcers and Bicap'd colonic bleeds are in the hundreds. To me, unless at your shop the surgeons are routinely doing lots of endoscopy, which I am sure hospitals with GS residencies are, the GI bleed goes to the GI guy first.

Ex. its 3am on a sunday and a 67y/o male comes in vomiting blood and is hypotensive. after intubating, throwing in lines and attempting to stabilize in MICU, I call surg and give them the scoop, I get, "has GI scoped them and tried to stop the bleed already?" That was the first any only time I ever called surgery first. Save one other time, but in that instance there was free air on film so I knew there was perforation and thus urgent surgery was needed.

A lot of this I actually do agree with, I feel like I get a ton of these consults yet very very few of them ever actually go to the OR. And if they do its usually after a couple days of scoping, angio-embolizing, rescoping, transfusing, etc..

I get called on every GI bleeder that hits the door on their way from the ED to the MICU while GI is sleeping comfortably, and that is getting old.

Location, location, location.

We've certainly oversewn bleeding ulcers, removed colons, and so on, but it's the exceedingly rare situation where you would head to the OR without endoscopy, or even plan to go to the OR to do the endoscopy.

We don't do our own endoscopy because most of our staff don't do them regularly at all, and certainly not the ones taking acute care call. I could do a diagnostic scope on most of these patients, but I wouldn't want to start injecting/clipping/cauterizing.


I guess my IM program is in need of numerous half brains then. I've gotten numerous consults for GI bleeds for MICU patients and floor patients before GI has even seen the patient, let alone scoped them.


Man, it's not that I disagree that things would probably be better if we were on board early, but it's awfully painful to see so many non-operative consults. It just takes away from other things you could be doing (e.g., double-scrubbing a good case or doing a teaching case).

Our painful setup is that we see virtually every trauma imaginable that comes through the door, from same-level falls to low-speed restrained MVCs.

I get a ton of nonoperative consults for "mild"pancreatitis, "stable" GI bleeds.....these are knee jerk reaction consults. I don't consult medicine for every patient with hypertension.....can you imagine if every hernia, thyroid, or total mastectomy with well controlled hypertension got a medicine consult for hypertension management?

 

[cpants]

Yeah, perhaps. But I also think it's important to see these patients as a junior resident so that you have an appreciation for when something isn't just another NTD consult as a chief. Plus, it's easy to bang out one of these in 15 minutes, and it takes little effort to follow as a consult for a day or two. You can also generally get an idea from the consultant whether this is a "You need to see this now" or "I can see this in between cases". So I don't necessarily agree that these are 1) without educational value or 2) come at the expense of other educational opportunities.

Uh, no. I disagree with this. After about 2 GI bleed consults this is no longer educational for your junior residents, and it can and does take away from learning if surgery is on board for every GI bleed. Who cares if it is a quick consult? Consults for routine pressure ulcers take 15 minutes too. You want to see all of those? GI bleed is common as hell. At a busy hospital your intern could easily see 4-6 of these consults a night, an hour or two much better spent double scrubbed in the OR or sleeping.

It makes a lot more sense for surgery to get involved when conservative measures have failed or the patient is going downhill fast. I think a good way to handle it might be a rule like "Only GI can consult surgery for GI bleed".

 

[45408]

I can see a consult in 15 minutes if I need to, but to write it up, staff it, sign it out to the next crew, and discuss the plan with the patient and the primary team is the real time sink. Plus, what is there to learn on a trickle GI bleed that turns out to be a smoldering ulcer that I couldn't gather from a good review article?

Now, the last time I put in a Minnesota tube? Yes, that was highly memorable and useful.

 

[Apollyon]

Our faculty pretty much only have privileges for outpatient colonoscopies and uppers and its only a few who maintain those...

In my hospital (which is rural, but not critical access, as the next closest hospital is "only" 25 miles away), I have two general surgeons, no GI, and a cardiologist who is invasive but not interventional.

Both surgeons routinely scope upper and lower, but I don't know if they do any interventions. One of the two also routinely puts in permanent pacemakers (yes, cardiac, not GI). That's what happens in the community, when push comes to shove. Oh, and, for 3 out of 4 weekends a month, I don't have any GSx on call. By the numbers, they cover 2/3 of the days of the year - just during the week.

 

[thunder hawk]

Ex. its 3am on a sunday and a 67y/o male comes in vomiting blood and is hypotensive. after intubating, throwing in lines and attempting to stabilize in MICU, I call surg and give them the scoop, I get, "has GI scoped them and tried to stop the bleed already?" That was the first any only time I ever called surgery first. Save one other time, but in that instance there was free air on film so I knew there was perforation and thus urgent surgery was needed.

Dont forget to put NGT ( yes I have seen that)

 

[Bostonredsox]

So says the guy who can't put in a foley. We agree that my medicine residents are bad though.



I know you're playing devils advocate here, we are taught diagnostic scoping but I can't really do anything therapeutic. GI has cornered the market on scoping where I am, whether that is a good or bad thing who knows.



A lot of this I actually do agree with, I feel like I get a ton of these consults yet very very few of them ever actually go to the OR. And if they do its usually after a couple days of scoping, angio-embolizing, rescoping, transfusing, etc..

I get called on every GI bleeder that hits the door on their way from the ED to the MICU while GI is sleeping comfortably, and that is getting old.





I get a ton of nonoperative consults for "mild"pancreatitis, "stable" GI bleeds.....these are knee jerk reaction consults. I don't consult medicine for every patient with hypertension.....can you imagine if every hernia, thyroid, or total mastectomy with well controlled hypertension got a medicine consult for hypertension management?

This is absolutely what happens. The number of post-op elective GBs and total hips that I have been consulted to manage HTN with a post op BP of 145/80 is incredible. They have DM2...consult. The have Dylipidemia, on a statin already, consult. Happens everyday, usually 2-3 times daily. While it seems you feel internists are bad, the reverse is shared. I have come to the conclusion, from direct observation, any surgeon over the age of 45 cannot for lack of knowledge, or chooses not to for lazyness, manage anything on any patient except their wound. It is as if anything taught along the way from medical school to being an attending not related to operating was wontonly ignored/forgotten/disregarded. As I stated in my original post, the consults we get from surgery are just as horrible as the ones you get from the ****ty internists you have encountered Accept it that those consults came from bad doctors, not that their specialty is bereft of any intelligence at all.

 

[balaguru]

This is an observation I've heard from other community practitioners. I think there are several issues:

1. Medications used today are in some cases very different than the medications older surgeons learned about in med school and they may feel uncomfortable adjusting them in the perioperative period. Even I'm starting to see meds that I don't recognize pop up on med lists. The examples that comes to mind right now are Januvia and Byetta. I keep saying I'll sit down one of these days and review these "new" classes of drugs but I never seem to get to it.

2. Older surgeons may not know how to do the E&M to get reimbursed for managing these periop problems.

3. Maybe I just have a poor memory, but I can't seem to remember a single question on the ABSITE about the management of common comorbidities during the perioperative period. I imagine the same will be true on the boards and maintenance of certification exams. Pharmacology and the managagement of common perioperative problems is on the ABS curriculum but does this just refer to meds and problems with a surgical focus?

This is absolutely what happens. The number of post-op elective GBs and total hips that I have been consulted to manage HTN with a post op BP of 145/80 is incredible. They have DM2...consult. The have Dylipidemia, on a statin already, consult. Happens everyday, usually 2-3 times daily. While it seems you feel internists are bad, the reverse is shared. I have come to the conclusion, from direct observation, any surgeon over the age of 45 cannot for lack of knowledge, or chooses not to for lazyness, manage anything on any patient except their wound. It is as if anything taught along the way from medical school to being an attending not related to operating was wontonly ignored/forgotten/disregarded. As I stated in my original post, the consults we get from surgery are just as horrible as the ones you get from the ****ty internists you have encountered Accept it that those consults came from bad doctors, not that their specialty is bereft of any intelligence at all.

 

[45408]

2. Older surgeons may not know how to do the E&M to get reimbursed for managing these periop problems.

What does/doesn't fall into the global period?

 

[balaguru]

What does/doesn't fall into the global period?

You'd probably want to confirm this with your billing people but my understanding is that you can bill for anything a hospitalist can bill for under the CPT 9923[1-3] for each postop visit depending on the complexity of the problem you are treating. Your documentation will need to support it of course. This can add 0.76 to 2 RVU per day to your billing. Obviously, you will need to be managing a medical problem that is not inherent to your surgical procedure. Trying to bill for calcium management after a (para)thyroidectomy or HTN after an adrenalectomy or diabetes while a pt is NPO probably won't fly. You can also bill for critical care CPT 99291 if you are spending at least 30 minutes managing organ failure even if the patient is not in the ICU. Shock, respiratory failure and renal failure are probably the most common periop problems that we might treat. The 30 minutes might include not only the bedside care (e.g. putting in IV's and foleys 😉) but also communicating with other members of the care team and family if the pt is incapacitated.

 

[Bostonredsox]

You'd probably want to confirm this with your billing people but my understanding is that you can bill for anything a hospitalist can bill for under the CPT 9923[1-3] for each postop visit depending on the complexity of the problem you are treating. Your documentation will need to support it of course. This can add 0.76 to 2 RVU per day to your billing. Obviously, you will need to be managing a medical problem that is not inherent to your surgical procedure. Trying to bill for calcium management after a (para)thyroidectomy or HTN after an adrenalectomy or diabetes while a pt is NPO probably won't fly. You can also bill for critical care CPT 99291 if you are spending at least 30 minutes managing organ failure even if the patient is not in the ICU. Shock, respiratory failure and renal failure are probably the most common periop problems that we might treat. The 30 minutes might include not only the bedside care (e.g. putting in IV's and foleys 😉) but also communicating with other members of the care team and family if the pt is incapacitated.

You can not include procedure time in your billing for a critical care 291. When I bill a 291 in the MICU it is rate x for 0-74 minutes plus another fraction for every 30 minutes after that (and subsequent visits as 292's for each 30 if in the same day as the original 291).
However, my note is as an example, total critical care time spent EXCLUDING procedures is 110 minutes. The procedures are billed for separately and have their own dictations and billing codes and the time cannot be counted twice.
This may be different for surgeons I do not know. But if I see a MICU patient and then tube them and throw in a line and that takes an extra 30 minutes on top of the 60 I spent seeing them evaluating them and reviewing images/labs and writing orders, I do not bill for 90. I bill for 60, and then bill separately for the airway and for the line. Apparently from the administrators that generates higher revenue than lumping the minutes together. We apparenltly bill almost $200 for an US guided IJ. You dont get an extra $200 for thise 30 minutes in pure time.

 

[balaguru]

My assumption was that you would not bill seperately for IV's and foley's and this time would be included in bedside care. 99291 rvu is 4.5 and 51703 (complicated foley) is 1.47 so it depends on whether you need the procedure time or not. Not sure if you can even bill for an IV placement.

You can not include procedure time in your billing for a critical care 291. When I bill a 291 in the MICU it is rate x for 0-74 minutes plus another fraction for every 30 minutes after that (and subsequent visits as 292's for each 30 if in the same day as the original 291).
However, my note is as an example, total critical care time spent EXCLUDING procedures is 110 minutes. The procedures are billed for separately and have their own dictations and billing codes and the time cannot be counted twice.

 

[dpmd]

What does/doesn't fall into the global period?

Only that which is related to the surgery. So on all my trauma patients that I ex lap but have other injuries I am addressing, I bill for that. For my diabetics and hypertensives that I am making adjustments for, I bill. For the guy that has those things but is stable preop and post op and I am not actually managing those issues (making no change to meds and not doing any further testing for) I don't bill.

As for the 99291, there is a list of things that it includes and you can't bill separately for those. I don't have it on me but I think it is for things like PIV's and such. So that time (if you did it or I think if you even just supervised it) counts. For other things (like central lines) you don't double count the time since you bill for the procedure. And if you spend less than 30 minutes providing critical care you can't bill a 99291 (although magically some people always spend 30 minutes total even on people they just look at from the door while the resident manages everything since they are stable on the vent or something-can't include the time the resident works or they time you spend teaching the resident in your time for billing)

 

[Dr.LeoSpaceman]

Maybe I just have a poor memory, but I can't seem to remember a single question on the ABSITE about the management of common comorbidities during the perioperative period. I imagine the same will be true on the boards and maintenance of certification exams. Pharmacology and the managagement of common perioperative problems is on the ABS curriculum but does this just refer to meds and problems with a surgical focus?

I haven't seen one, but it doesn't take much to figure out "restart home meds".

There is also another side to that garbage IM consult at a community hospital, at least the one where we work. We are essentially obligated to consult the PCP on any of their patients, regardless of whether we need them or not (which, were it my preference, would be infrequently). If we don't, the PCPs ge their panties in a bunch, which jeopardizes the all-important referral base (or so our attendings tell us). I'm perfectly capable of handling any stable chronic medical condition--titrate some BP meds or a sliding scale if necessary.

The time I'll get someone else involved is if there is a new diagnosis that will require followup/management by a PCP or specialist as an outpatient. At that point, I think it's reasonable to see how that specialist wants to manage it since they're the ones that are going to ultimately be responsible for it.

 

[45408]

The time I'll get someone else involved is if there is a new diagnosis that will require followup/management by a PCP or specialist as an outpatient. At that point, I think it's reasonable to see how that specialist wants to manage it since they're the ones that are going to ultimately be responsible for it.

This. I can and do manage someone's new onset a-fib, but they're not going to be coming to my attending for refills on diltiazem or metoprolol, and they certainly won't be dosing their warfarin, so we often get a cardiologist on board. I just don't call them at 2am when it first happens, unless there's something else concerning.

 

[Bostonredsox]

I haven't seen one, but it doesn't take much to figure out "restart home meds".

There is also another side to that garbage IM consult at a community hospital, at least the one where we work. We are essentially obligated to consult the PCP on any of their patients, regardless of whether we need them or not (which, were it my preference, would be infrequently). If we don't, the PCPs ge their panties in a bunch, which jeopardizes the all-important referral base (or so our attendings tell us). I'm perfectly capable of handling any stable chronic medical condition--titrate some BP meds or a sliding scale if necessary.

The time I'll get someone else involved is if there is a new diagnosis that will require followup/management by a PCP or specialist as an outpatient. At that point, I think it's reasonable to see how that specialist wants to manage it since they're the ones that are going to ultimately be responsible for it.

The majority of community hospitals, such as mine, have very few PCPs seeing patients in them. The PCPs have relinquished control of their inpatients to the hospitalists and it is they who get the consults. And I assure you, they/we, do not want the consult for glycemic control post TKA nor would not consulting us jeopardize any referrals. If you can manage it on your own, you should. To the same degree we manage pancreatitis in patients who can be treated with simple analgesics and IVF with close observation, 95% of them, without calling surgery. It is not just a surgeon problem, it is IM, FM, ortho, ENT, no one wants to manage anything themselves anymore. Consult rates are out of control. My GI block I did >20 consults one saturday and 9 of them were for anemia. Just plain anemia. No rectal done. No iron panel. Just, HB is 10 it should be >13, consult GI. Now that came from a very weak PCP who is the only one still seeing his patients in the hospital instead of the younger, EBM based hospitalists and should be forced to retire, but still. Had a STEMI where the cardioligist consulted Hosp team for diabetes management. Your a ****ing cardiologist and you cant manage DM??? In my shop it comes from the orthos relentlessly. They want to come see pt, fix knee, go home. leave everything else to medicine. and I mean everything. The gen surgeons are a bit better and most will manage the stable home problmes fine. But if they develop post op infections not related to their wound (PNA, Cdiff etc.) they consult. New onset AFib forget it. they consult me and cardio at the same time. I guess I just have a different philosophy on consulting. In my mind, you consult for two things. A, a procedure you cannot perform or have tried and failed and need someone else with more experience to try, (a cath, a colonoscoy, a trach, a Lap C)and B, when you cannot solve a problem you have already worked up and cannot figure out the answer/treatment. this is unversal across all specialties.

 

[Pir8DeacDoc]

Lot of consults are CYA. If something goes wrong while your orthopod is managing DM you can bet the sharks would be all over him. Medicine in general has become so specialized. It makes sense to have someone managing things who does it everyday, not just once in awhile. It's better for the pt and better at keeping the lawyers away. A win win situation really.

While another ball of wax, it also pays your salary. You think if your consults cut in half and you sat in the lounge all day you'd get paid the same? No way.

 

[Bostonredsox]

Lot of consults are CYA. If something goes wrong while your orthopod is managing DM you can bet the sharks would be all over him. Medicine in general has become so specialized. It makes sense to have someone managing things who does it everyday, not just once in awhile. It's better for the pt and better at keeping the lawyers away. A win win situation really.

While another ball of wax, it also pays your salary. You think if your consults cut in half and you sat in the lounge all day you'd get paid the same? No way.

The CYA makes sense to me, I just hate the medical-legal state of the US.

Amd as for consults. we admit so many patients on the hospitalist service the additional consults just make our day overwhelmingly long. Same salary regardless of the consults.

 

[Winged Scapula]

Lot of consults are CYA. If something goes wrong while your orthopod is managing DM you can bet the sharks would be all over him. Medicine in general has become so specialized. It makes sense to have someone managing things who does it everyday, not just once in awhile. It's better for the pt and better at keeping the lawyers away. A win win situation really.

This.

Malpractice insurance providers and attorneys tell us that these things NEED to be consulted out.

Hit a major blood vessel while doing an ex-lap? Call a Vascular Surgeon to repair it. Patient has a slight bump in enzymes post OP without symptoms? Call Cards.

My partner was reviewing a case for an attorney and one of the plaintiffs complaints was that the General Surgeon should have consulted a "wound care specialist" for post OP care of her wounds. I was sued for chronic pain after a MRM and it was claimed that I should have sent her to a pain management specialist despite the fact that by her own deposition, she was only taking a couple of Tylenol per week for her pain.

That is what it has come to.

While another ball of wax, it also pays your salary. You think if your consults cut in half and you sat in the lounge all day you'd get paid the same? No way.

Yep. Consults are annoying for residents but your attendings get paid to see them and they'll make more seeing 4 easy ones than 1 complicated one despite taking the same amount of time.

 

[Bostonredsox]

This.

Malpractice insurance providers and attorneys tell us that these things NEED. o be consulted out.

Hit a major blood vessel while doing an ex-lap? Call a Vascular Surgeon to repair it. Patient has a slight bump in enzymes post OP without symptoms? Call Cards.

My partner was reviewing a case for an attorney and one of the plaintiffs complaints was that the General Surgeon should have consulted a "wound care specialist" for post OP care of her wounds. I was sued for chronic pain after a MRM and it was claimed that I should have sent her to a pain management specialist despite the fact that by her own deposition, she was only taking a couple of Tylenol per week for her pain.

That is what it has come to.



Yep. Consults are annoying for residents but your attendings get paid to see them and they'll make more seeing 4 easy ones than 1 complicated one despite taking the same amount of time.

Well the hospitalists here are not paid for those consults. They get X-dollars per shift whatever they signed for. That number does not change if their is 14 pts on their list or 24 nor if there are no ed admits and no consults that day or 5 of each. I'm sure the company gets more, but the inidividual hospitalist doesn't see an extra dime.

 

[Pir8DeacDoc]

You can bet they studied the average number of admits and consults when they formulated your salary. While you don't directly get paid for the consult you can bet it's in the equation somewhere.

 

[dpmd]

You can bet they studied the average number of admits and consults when they formulated your salary. While you don't directly get paid for the consult you can bet it's in the equation somewhere.

It explains why he would want to avoid consults whenever possible, though. That is the whole reason residents hate extra consults, even the good educational ones that result in good cases can piss you off if you are really busy (especially if it isn't you that gets to do the case). The problem is when you don't know if people want the iffy consults or not. We rotate at a small hospital a few months out of our residency and there wasn't a single consult that ruffled the staff's feathers no matter how stupid. He got to bill for it, and with the residents there to see the patient and present to him it was like easy money. He would then let the hospitalists be primary or consult on all kinds of patients because they got paid for it too (at least that was my understanding).

 

[Pir8DeacDoc]

It explains why he would want to avoid consults whenever possible, though. That is the whole reason residents hate extra consults, even the good educational ones that result in good cases can piss you off if you are really busy (especially if it isn't you that gets to do the case). The problem is when you don't know if people want the iffy consults or not. We rotate at a small hospital a few months out of our residency and there wasn't a single consult that ruffled the staff's feathers no matter how stupid. He got to bill for it, and with the residents there to see the patient and present to him it was like easy money. He would then let the hospitalists be primary or consult on all kinds of patients because they got paid for it too (at least that was my understanding).

Great points.
We have a very hospitalist heavy hospital here. I am only primary on a pt I operated on. They admit everything else and I consult. I'm sure that works well for the hospital.

 

[balaguru]

Malpractice insurance providers and attorneys tell us that these things NEED to be consulted out.

Hit a major blood vessel while doing an ex-lap? Call a Vascular Surgeon to repair it. Patient has a slight bump in enzymes post OP without symptoms? Call Cards.

This is wrong and wasteful and if it's the expectation of any group I join I'll find a new job.

My partner was reviewing a case for an attorney and one of the plaintiffs complaints was that the General Surgeon should have consulted a "wound care specialist" for post OP care of her wounds. I was sued for chronic pain after a MRM and it was claimed that I should have sent her to a pain management specialist despite the fact that by her own deposition, she was only taking a couple of Tylenol per week for her pain.

Please tell me these never went to court nor cost you or the other surgeon any money or significant time to defend.

That is what it has come to.

I hope this is just an Arizona thing. Do you guys have tort reform? Texas is rather good about this. Loser pays, cap on noneconomic damages, specialty equivalence of expert witnesses, tightening of the definition of negligence in ER settings all work together to discourage frivolous suits.

 

[balaguru]

There is also another side to that garbage IM consult at a community hospital, at least the one where we work. We are essentially obligated to consult the PCP on any of their patients, regardless of whether we need them or not (which, were it my preference, would be infrequently). If we don't, the PCPs ge their panties in a bunch, which jeopardizes the all-important referral base (or so our attendings tell us). I'm perfectly capable of handling any stable chronic medical condition--titrate some BP meds or a sliding scale if necessary.

I don't know--I think it's kind of nice that your PCP's want to follow their patients while in house. That's some old school primary care there.

 

[Gastrapathy]

This thread is entertaining. Its definitely good insight into a foreign world. Some random thoughts below from an interloper.

As a GI attending, having GS housestaff onboard for GI bleeds is generally unhelpful. Patients get CTs they don't need and there is pressure to scope earlier than the evidence supports. The only exception to this is in the one hospital I cover where there aren't hospitalists. In that setting, the GS residents do a much better job than the primary doc of ensuring that appropriate resuscitation occurs.

In general, as someone who works with both IM and surgical services, it is a simple fact of my life that complex patients get better care on surgical services. Sometimes I feel that a couple of hours in the OR getting managed by an anesthesiologist and then getting post-op care from a surgical service is all a patient needs regardless of the indication for surgery. That said, I really want surgeons to operate when I consult.

For the GS residents who feel good teaching the little people a lesson, the sad truth is that you'll either adapt or die. If you are a pain in my ass, even if I deserve it, I'll consult the other guy who took me to dinner and tells me how smart I am. Then he'll consult me right back and I'll stroke him right back. I can think of several surgeons who have moved on because they couldn't get the volume. All were pricks and couldn't figure out why they couldn't compete. I don't care how arrogant you are as long as you are friendly to me and don't try to play in my sandbox.

I'm sure I've tossed over some ******* consults but no one has ever said it...why? because 80% of my consults lead to surgery and I'm a typical sensitive little child who won't call back if you are mean. OK, thats enough intoxicated posting for one day.

Cheers. G

 

[Winged Scapula]

This is wrong and wasteful and if it's the expectation of any group I join I'll find a new job.

Believe me, I think its ridiculous as well, but its not the expectation of the group(s), its the recommendation of the largest malpractice insurance company in the state as well as the attorneys. This is not just an Arizona thing as this is what I was told in both PA and NJ when I worked there.

Please tell me these never went to court nor cost you or the other surgeon any money or significant time to defend.

Neither one went to court and both were dropped (mine shortly after the plaintiff gave her deposition in which she admitted that her pain only required occasional Tylenol or "rolling over in bed to the other side"). However, mine did cost me significant money. The malpractice insurer will only provide legal counsel when you are actually sued. That meant that when the plaintiff's attorney sent a settlement letter asking for a large sum of money, they could only tell me I needed to decide whether to settle or not. No advice, no referral to an attorney unless I wished to pay out of pocket (which I did, at $350/hour). I refused to settle.

Then when the plaintiff's attorney's next trick was to report me to the Medical Board and I had to defend myself, I again had to pay my attorney to review my response to the complaint and to present it to the board (the Board's expert found that I followed standard of care).

I am not counting the hours I spent in preparation for deposition, for possible trial, missing work, etc. The process was stretched out for nearly 2 years of psychological and physical agony.

I hope this is just an Arizona thing. Do you guys have tort reform? Texas is rather good about this. Loser pays, cap on noneconomic damages, specialty equivalence of expert witnesses, tightening of the definition of negligence in ER settings all work together to discourage frivolous suits.

Its not just an Arizona thing, but we do not have tort reform.

She was not required to pay any of my costs, despite deciding to drop the suit after her deposition .

They could not find an expert witness in my specialty in the state of AZ to testify against me; they found a CT Surgeon in Colorado whom, by the look of his CV, spends most of his time testifying against other physicians rather than operating.

Apparently lawsuits have dropped significantly in the state because of the high rate of physician triumph; however, as my attorney tells it, that means that those who are still in practice suing doctors, are especially hungry and will take any two-bit case that comes along.

The whole process was *very* enlightening.

 

[Winged Scapula]

For the GS residents who feel good teaching the little people a lesson, the sad truth is that you'll either adapt or die. If you are a pain in my ass, even if I deserve it, I'll consult the other guy who took me to dinner and tells me how smart I am. Then he'll consult me right back and I'll stroke him right back. I can think of several surgeons who have moved on because they couldn't get the volume. All were pricks and couldn't figure out why they couldn't compete. I don't care how arrogant you are as long as you are friendly to me and don't try to play in my sandbox.

I'm sure I've tossed over some ******* consults but no one has ever said it...why? because 80% of my consults lead to surgery and I'm a typical sensitive little child who won't call back if you are mean. OK, thats enough intoxicated posting for one day.

Yep. I once lost a good referring physician, when trying to coordinate a case, I made mention of how his scheduler had screwed up.

I had not realized that he had recently hired a new scheduler. His wife.

Oops.

He told me in no uncertain terms that he did not feel comfortable working with me again because I had insulted his wife. Overly dramatic? Perhaps. But I learned my lesson.

(I think he's warming up to me again, however, as I got a Christmas card from him this year. 😛 )

 

[balaguru]

Your username is misspelled.

This thread is entertaining. Its definitely good insight into a foreign world. Some random thoughts below from an interloper.

As a GI attending, having GS housestaff onboard for GI bleeds is generally unhelpful. Patients get CTs they don't need and there is pressure to scope earlier than the evidence supports. The only exception to this is in the one hospital I cover where there aren't hospitalists. In that setting, the GS residents do a much better job than the primary doc of ensuring that appropriate resuscitation occurs.

In general, as someone who works with both IM and surgical services, it is a simple fact of my life that complex patients get better care on surgical services. Sometimes I feel that a couple of hours in the OR getting managed by an anesthesiologist and then getting post-op care from a surgical service is all a patient needs regardless of the indication for surgery. That said, I really want surgeons to operate when I consult.

For the GS residents who feel good teaching the little people a lesson, the sad truth is that you'll either adapt or die. If you are a pain in my ass, even if I deserve it, I'll consult the other guy who took me to dinner and tells me how smart I am. Then he'll consult me right back and I'll stroke him right back. I can think of several surgeons who have moved on because they couldn't get the volume. All were pricks and couldn't figure out why they couldn't compete. I don't care how arrogant you are as long as you are friendly to me and don't try to play in my sandbox.

I'm sure I've tossed over some ******* consults but no one has ever said it...why? because 80% of my consults lead to surgery and I'm a typical sensitive little child who won't call back if you are mean. OK, thats enough intoxicated posting for one day.

Cheers. G

 

[balaguru]

What an irritating story. I wonder if the attorney's vindictive behavior is something his/her state bar can do something about. I'd have probably filed a complaint.

Neither one went to court and both were dropped (mine shortly after the plaintiff gave her deposition in which she admitted that her pain only required occasional Tylenol or "rolling over in bed to the other side"). However, mine did cost me significant money. The malpractice insurer will only provide legal counsel when you are actually sued. That meant that when the plaintiff's attorney sent a settlement letter asking for a large sum of money, they could only tell me I needed to decide whether to settle or not. No advice, no referral to an attorney unless I wished to pay out of pocket (which I did, at $350/hour). I refused to settle.

Then when the plaintiff's attorney's next trick was to report me to the Medical Board and I had to defend myself, I again had to pay my attorney to review my response to the complaint and to present it to the board (the Board's expert found that I followed standard of care).

I am not counting the hours I spent in preparation for deposition, for possible trial, missing work, etc. The process was stretched out for nearly 2 years of psychological and physical agony.



Its not just an Arizona thing, but we do not have tort reform.

She was not required to pay any of my costs, despite deciding to drop the suit after her deposition .

They could not find an expert witness in my specialty in the state of AZ to testify against me; they found a CT Surgeon in Colorado whom, by the look of his CV, spends most of his time testifying against other physicians rather than operating.

Apparently lawsuits have dropped significantly in the state because of the high rate of physician triumph; however, as my attorney tells it, that means that those who are still in practice suing doctors, are especially hungry and will take any two-bit case that comes along.

The whole process was *very* enlightening.