Consults- Memorable/Dismal/Ridiculous/Unique

[FlowRate]

Had a dude sent to me for dysphagia. Admittedly, the issue here is the patient, not the referral, but it’s classic. He was diagnosed with eosinophilic esophagitis about three months ago by GI. They made recommendations which he promptly ignored. He went to another ENT where they told him his dysphagia is probably due to his known diagnosis of EE. He didn’t like that, so he came to see me. He said he wanted a second opinion, so I requested his notes from the other ENT, and the patient got riled up about that, so that’s already a major red flag.

Dude is 40’s, mildly overweight. Looks like anxiety and ADHD with a bronze tan. Chief complaint is “things stick sometimes when I swallow.” The exam otherwise normal. Swallow study shows slow esophageal transit and reflux.

So I tell him I think his EE has something to do with it. He angrily tells me he can’t believe that because he never had that problem before (my favorite denial statement). I explain that most people aren’t born with all of the medical problems they’ll eventually get.

He asks what to do about it. I tell him dietary restrictions. He tells me he’d “rather die” than cut anything from his diet.

I offered steroids. He said he tried that already and it helped but he doesn’t want to “depend on medication.”

I offer reflux treatment. Obviously he won’t take medicine and he won’t make dietary changes. I tell him he could sleep with his head elevated and he says he can’t sleep that way and he won’t even try. I tell him he could split up his meals and he says “I have a friend that did that and it worked, but I can’t. I eat one big meal a day, at night when I get home. It’s usually pretty late and that’s when it’s convenient. I can’t eat breakfast. I just can’t do it.” I explain that’s one of the worst things you can do for reflux. He says we’ll have to find another treatment because he can’t change that.

I tell him to could cut back on alcohol. He says he can’t do that either.

This goes on.

So I tell him we’re kind of at an impasse. He tells me he doesn’t think I’m listening to him, and he wants another opinion.

…cool…bon voyage.

It’s like he was reading from a book of things not to do when you have reflux and EE, and specifically doing those things out of spite.

You might have already done this, but did you ask him what he thought he needed/thought was causing his issue? Can be a great place to start with patients like this who clearly have some sort of preconceived notion and to get buy in that you "hear" them. Obviously some people are SO fixed on whatever specific outcome that even the gentlest explanation why it's inappropriate will fail but some patients are just relatively concrete and feel frustrated if the question they want answered (but aren't actually asking directly) is "ignored." (in their mind)

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[HighPriest]

You might have already done this, but did you ask him what he thought he needed/thought was causing his issue? Can be a great place to start with patients like this who clearly have some sort of preconceived notion and to get buy in that you "hear" them. Obviously some people are SO fixed on whatever specific outcome that even the gentlest explanation why it's inappropriate will fail but some patients are just relatively concrete and feel frustrated if the question they want answered (but aren't actually asking directly) is "ignored." (in their mind)

Yeah, I do usually insert a “what is your goal here?” Question and in his case he wanted a medication that would fix this permanently, like an antibiotic. Something he could take once and then be done. I think in his mind he was a healthy guy and shouldn’t have any long haul medical problems.

I find that a lot of these patients feel like the medical system has failed them because we don’t have a treatment like that for their issue.

 

[HighPriest]

There’s still a decent portion of the population who truly believes that the medical system doesn’t want to fix people because chronic illness makes more money. If that conspiracy is true, I’m not a part of it. I would love if I didn’t have to see anyone a second time. And I’m definitely not making enough money to want to listen to people b@$ch all of the time.

 

[TypeADissection]

Had a dude sent to me for dysphagia. Admittedly, the issue here is the patient, not the referral, but it’s classic. He was diagnosed with eosinophilic esophagitis about three months ago by GI. They made recommendations which he promptly ignored. He went to another ENT where they told him his dysphagia is probably due to his known diagnosis of EE. He didn’t like that, so he came to see me. He said he wanted a second opinion, so I requested his notes from the other ENT, and the patient got riled up about that, so that’s already a major red flag.

Dude is 40’s, mildly overweight. Looks like anxiety and ADHD with a bronze tan. Chief complaint is “things stick sometimes when I swallow.” The exam otherwise normal. Swallow study shows slow esophageal transit and reflux.

So I tell him I think his EE has something to do with it. He angrily tells me he can’t believe that because he never had that problem before (my favorite denial statement). I explain that most people aren’t born with all of the medical problems they’ll eventually get.

He asks what to do about it. I tell him dietary restrictions. He tells me he’d “rather die” than cut anything from his diet.

I offered steroids. He said he tried that already and it helped but he doesn’t want to “depend on medication.”

I offer reflux treatment. Obviously he won’t take medicine and he won’t make dietary changes. I tell him he could sleep with his head elevated and he says he can’t sleep that way and he won’t even try. I tell him he could split up his meals and he says “I have a friend that did that and it worked, but I can’t. I eat one big meal a day, at night when I get home. It’s usually pretty late and that’s when it’s convenient. I can’t eat breakfast. I just can’t do it.” I explain that’s one of the worst things you can do for reflux. He says we’ll have to find another treatment because he can’t change that.

I tell him to could cut back on alcohol. He says he can’t do that either.

This goes on.

So I tell him we’re kind of at an impasse. He tells me he doesn’t think I’m listening to him, and he wants another opinion.

…cool…bon voyage.

It’s like he was reading from a book of things not to do when you have reflux and EE, and specifically doing those things out of spite.

I just can't even. There is no world where I have enough patience to see this kind of bull**** in clinic on a weekly basis. This is my varicose vein practice down to the tee.

Wear compression? No.
Will you wear compression? No.
How can I help you then? Make my legs look a 20-year old model.
OK cool, well you can F/U PRN and see my PA the next time because there has to be a better way for me to spend my day than dealing with this ****.

 

[HighPriest]

I just can't even. There is no world where I have enough patience to see this kind of bull**** in clinic on a weekly basis. This is my varicose vein practice down to the tee.

Wear compression? No.
Will you wear compression? No.
How can I help you then? Make my legs look a 20-year old model.
OK cool, well you can F/U PRN and see my PA the next time because there has to be a better way for me to spend my day than dealing with this ****.

Yeah. I do ultimately tell some patients (if I think their ego can handle it) that I don’t know why they expect me to take their health seriously when they won’t. I’ve had a few patients actually respond to that kind of bluntness. Usually VA patients, or at least older businessmen or professionals. But as I said, you have to make sure they can handle that. Many of them really just want to be pampered like a newborn.

 

[HighPriest]

Had a guy come in today, 8 minutes late. I reschedule them if they’re 5 minutes late because if I don’t it makes me behind the rest of the day.

I’m listening to the front desk talk to him about it. Keep in mind that, I’m sure like any other practice, we expect people to show up 15 minutes early and always tell them that, even though they never do it.

They tell him he’s late. He asks how late he can be before he has to be rescheduled. They tell him 5 minutes. He says, angrily, “well, I’m only 3 minutes past 5 minutes!”

Yeah, bro, that’s 8 minutes. I’m not sure how that seems better in your mind.
You don’t get a grace period for your grace period.

 

[ThoracicGuy]

I just can't even. There is no world where I have enough patience to see this kind of bull**** in clinic on a weekly basis. This is my varicose vein practice down to the tee.

Wear compression? No.
Will you wear compression? No.
How can I help you then? Make my legs look a 20-year old model.
OK cool, well you can F/U PRN and see my PA the next time because there has to be a better way for me to spend my day than dealing with this ****.

Do you get a fair number of no shows for the actual procedures once they are scheduled too?

 

[TypeADissection]

Do you get a fair number of no shows for the actual procedures once they are scheduled too?

Actually no. Insurance requires 90-days minimum w/ compliant compression hose therapy and documented reflux on a vein competency study. If they've committed to the compression life and jumped through all the hoops, they show up and do quite well afterwards.

I do zero cosmetic vein stuff bc I don't have the mental strength or desire to deal with that horses.h.i.t. It's just hard for me to switch gears during a busy clinic day talking to patients about carotid/aneurysm surgery, or why their legs need revasc, and then have this person complain about their spider veins and why they want sclero. Hard pass. I started punting that to our Cosmetic Center about 6 months into my practice because I just couldn't listen to the whining anymore. Same patients also are the ones that jam my inbox in the patient portal with how they don't like the look of their legs in a miniskirt or bathing suit when at the club pool. So once I completely dropped these referrals from my practice, the detritus in my inbox went down, and my happiness somehow went up - weird how that worked, I'm sure there's no relation.

 

[ThoracicGuy]

Actually no. Insurance requires 90-days minimum w/ compliant compression hose therapy and documented reflux on a vein competency study. If they've committed to the compression life and jumped through all the hoops, they show up and do quite well afterwards.

I do zero cosmetic vein stuff bc I don't have the mental strength or desire to deal with that horses.h.i.t. It's just hard for me to switch gears during a busy clinic day talking to patients about carotid/aneurysm surgery, or why their legs need revasc, and then have this person complain about their spider veins and why they want sclero. Hard pass. I started punting that to our Cosmetic Center about 6 months into my practice because I just couldn't listen to the whining anymore. Same patients also are the ones that jam my inbox in the patient portal with how they don't like the look of their legs in a miniskirt or bathing suit when at the club pool. So once I completely dropped these referrals from my practice, the detritus in my inbox went down, and my happiness somehow went up - weird how that worked, I'm sure there's no relation.

We have people go through the hoops of the ultrasound study and compression use and STILL will no call no show their scheduled procedures. Doesn't happen as much now, but it isn't rare either.

 

[ThoracicGuy]

And I know those ridiculous July consults are happening too! Inquiring minds want to know!

 

[dpmd]

And I know those ridiculous July consults are happening too! Inquiring minds want to know!

Probably not what you had in mind but i have an outpatient referral which i am very curious about. Patient is being sent to me a general surgeon for pleural effusion. Now technically i did learn to deal with this issue in residency and while on my thoracic/foregut rotation in med school but in the 10 yrs i have been in private practice this is only the second time i have been consulted for this (the other was an effusion in a patient a month out from thyroidectomy by another surgeon who had an esophageal injury at time of surgery and refused to see the patient as he was convinced it was unrelated so they asked me as the on call surgeon to see the patient because they thought it was related, turns out it wasnt but i figured it was a reasonable ask). In residency it was mostly hepatic hydrothorax patients so that was an easy but unsatisfying consult. No cirrhosis mentioned in the consult, but they have chf. Will see what they end up having as an etiology. Maybe they will have forgotten to mention metastatic cancer or something.

 

[ThoracicGuy]

Probably not what you had in mind but i have an outpatient referral which i am very curious about. Patient is being sent to me a general surgeon for pleural effusion. Now technically i did learn to deal with this issue in residency and while on my thoracic/foregut rotation in med school but in the 10 yrs i have been in private practice this is only the second time i have been consulted for this (the other was an effusion in a patient a month out from thyroidectomy by another surgeon who had an esophageal injury at time of surgery and refused to see the patient as he was convinced it was unrelated so they asked me as the on call surgeon to see the patient because they thought it was related, turns out it wasnt but i figured it was a reasonable ask). In residency it was mostly hepatic hydrothorax patients so that was an easy but unsatisfying consult. No cirrhosis mentioned in the consult, but they have chf. Will see what they end up having as an etiology. Maybe they will have forgotten to mention metastatic cancer or something.

Sometimes they have translocation from the abdomen to the pleural space. You can do a nuclear test to check for this if you have suspicions. CHF definitely can cause it and treating that is the answer rather than chest tube. Certainly no chest tubes in a hepatic hydrothorax... you'll never get it out. You can always get really weird stuff like a catamenial hemothorax. It'd be easy to just start with a thoracentesis and fluid analysis. I'm not sure why a general surgeon would send this to another general surgeon instead of a thoracic surgeon, though. That's just odd.

 

[dpmd]

Sometimes they have translocation from the abdomen to the pleural space. You can do a nuclear test to check for this if you have suspicions. CHF definitely can cause it and treating that is the answer rather than chest tube. Certainly no chest tubes in a hepatic hydrothorax... you'll never get it out. You can always get really weird stuff like a catamenial hemothorax. It'd be easy to just start with a thoracentesis and fluid analysis. I'm not sure why a general surgeon would send this to another general surgeon instead of a thoracic surgeon, though. That's just odd.

It is being sent by some primary care type i believe. I decided to just see the patient rather than say no and have the poor referring doc try to figure out who to send it to instead. We dont exactly have thoracic surgeons in town anyway. The cardiac guys dont like to do any non heart chest stuff. Patient has had it tapped before so i just need to figure out where the results are because they werent sent with the referral.

 

[ThoracicGuy]

It is being sent by some primary care type i believe. I decided to just see the patient rather than say no and have the poor referring doc try to figure out who to send it to instead. We dont exactly have thoracic surgeons in town anyway. The cardiac guys dont like to do any non heart chest stuff. Patient has had it tapped before so i just need to figure out where the results are because they werent sent with the referral.

Ahh, I had misread your post about another general surgeon sending it... So who does the lung cancers, empyemas, malignant effusions, and the like there? Everyone just gets shipped out somewhere else?

Feel free to shoot me a message if you want to ask any questions in more detail when you get the info going.

 

[dpmd]

Ahh, I had misread your post about another general surgeon sending it... So who does the lung cancers, empyemas, malignant effusions, and the like there? Everyone just gets shipped out somewhere else?

Feel free to shoot me a message if you want to ask any questions in more detail when you get the info going.

Not sure if it all gets shipped or what. Have asked for help on a few things with mixed results. Had a patient who after a toupet fundoplication who somehow had the stomach go through the intact repair into the chest resulting in a tight obstruction that perfed the stomach into the chest and even after opening the repair i could not for the life of me budge the stomach so i asked for help and the came in the room but did not scrub. Just gave some advice from the corner and i ended up making the perf bigger to decompress the stomach to get it down and then irrigated the crap out of her chest and left a chest tube. They did end up having me ship her when her chest unsurprisingly got infected. I got a hard no when i asked for help with an unstable esophageal perf who i ended up draining by chest tube and through the diaphragm before she stabilized enough to ship. But they did agree that if the patient i was working up for tracheoinnominate fistula began to exsanguinate they would take it to the or (thankfully ruled out for this).

 

[WheezyBaby]

Pretty sure the only times I've consulted a surgeon for a pleural effusion is when my question is "VATS?", "pleurodesis?", or "oh my god, that's so much blood". Do thoracics actually frequently get "hey they have an effusion" referrals?

 

[ThoracicGuy]

Pretty sure the only times I've consulted a surgeon for a pleural effusion is when my question is "VATS?", "pleurodesis?", or "oh my god, that's so much blood". Do thoracics actually frequently get "hey they have an effusion" referrals?

Most of mine are already diagnosed or they've run out of diagnosis options. They ER and hospitalists still sometimes give us the plain has an effusion without any workup consult...

 

[deleted50541]

Most of mine are already diagnosed or they've run out of diagnosis options. They ER and hospitalists still sometimes give us the plain has an effusion without any workup consult...

My experience is similar. Obvious medical causes have been ruled out and the referring provider isn't sure what to do next. I typically offer a VATS, pleural biopsies, decortication as needed, and pleurodesis with the understanding to the patient they we may not know what caused this.

For me, these cases are usually post-op CABGs, retained hemothorax after trauma, or chronic inflammation that I can often narrow down to a possible cause. Maybe 1-2x per year do I see a truly "idiopathic" effusion.

As for the old hepatic hydrothorax, I operated on one last year. Somebody already put a drain in and the output was obviously not going to stop. Sure enough, there was a hole in the diaphragm that I closed and then pleurodesed. Worked well and no recurrent pleural effusion. Managing her abdominal ascites was another issue, but not my problem. She was a semi-homeless, alcoholic. I'm sure she's doing fine.

 

[ThoracicGuy]

We need some updates here too... Bump!

 

[DOVinciRobot]

Time to bump this thread, currently on night float and had some prime consult requests

To start, a delightful interaction with the ED last week
*page*
Me: Hey this is surgery, I got a page?
ED: Hi this is EM senior resident calling for a consult
Me: Ok sounds good, whats the MRN and can you tell me whats going on?
ED: Ya, ###. Well this guy came in with abdominal pain. Labs are normal. Vitals are normal. Physical exam is normal. Only symptom he has is some abdominal pain, says his belly hurts and is uncomfortable. And we got a CT and it's normal too.
Me: *sits quietly waiting for the shoe to drop
ED: hello? you still there? Can you see him?
Me: wait, that's it? You just said everything is normal
ED: Yeah crazy right? Everything is normal.
Me: ......so...... what is the consult for?
ED: abdominal pain. We want you guys to see him and make sure it's ok if we DC him, give him your stamp of approval
Me: ('_')

When I saw him he was feeling much better. Said he had "ripped a big one" and now he felt like he was back to his normal self. Pretty sure my attending had a stroke when I told him we were consulted for a fart. That week we got 3 consults on patients with negative imaging.

The most recent memorable consult was on a Crohn's patient with some terminal ileitis who medicine wanted to consult us to "make sure it's ok if we give an enema."

Cherry on top is these calls are coming at 1AM.

I'm sure more will come to me.

 

[TypeADissection]

Time to bump this thread, currently on night float and had some prime consult requests

To start, a delightful interaction with the ED last week
*page*
Me: Hey this is surgery, I got a page?
ED: Hi this is EM senior resident calling for a consult
Me: Ok sounds good, whats the MRN and can you tell me whats going on?
ED: Ya, ###. Well this guy came in with abdominal pain. Labs are normal. Vitals are normal. Physical exam is normal. Only symptom he has is some abdominal pain, says his belly hurts and is uncomfortable. And we got a CT and it's normal too.
Me: *sits quietly waiting for the shoe to drop
ED: hello? you still there? Can you see him?
Me: wait, that's it? You just said everything is normal
ED: Yeah crazy right? Everything is normal.
Me: ......so...... what is the consult for?
ED: abdominal pain. We want you guys to see him and make sure it's ok if we DC him, give him your stamp of approval
Me: ('_')

When I saw him he was feeling much better. Said he had "ripped a big one" and now he felt like he was back to his normal self. Pretty sure my attending had a stroke when I told him we were consulted for a fart. That week we got 3 consults on patients with negative imaging.

The most recent memorable consult was on a Crohn's patient with some terminal ileitis who medicine wanted to consult us to "make sure it's ok if we give an enema."

Cherry on top is these calls are coming at 1AM.

I'm sure more will come to me.

I seriously went to some very snarky and dark places during my PGY-2 & 3 years because of consults just like this.

ED: I just need you guys to see him and give your blessing. I know there's nothing wrong but just wanted to loop you guys in.
Me: I'm not a priest and last I checked you could also man up and be a doctor too.

A day later, sitting in my PD's office.
PD: Listen TAD, you can't go around calling people stupid.
Me: I didn't say they were stupid, I said that their decision making was.

 

[HighPriest]

This was just an office visit but still, I think, worthy.

Had a patient come in with a two page laundry list of symptoms. Everything you would expect from fatigue to vague pain, a diagnosis list that you couldn’t scroll through in 60 seconds, prior sleeve gastrectomy, a few auto-immune issues, and the fibro.

So she had an incidental <2cm mildly suspicious thyroid nodule with Norma TSH. But of course she had “done her research” and had a stack of print offs of explaining how her thyroid is probably the lynchpin cause of everything. But she reassured me that she knows how crazy that sounds but that I shouldn’t worry because she has a PhD and she’s not just some crazy person.

PhD was in communications.

I would also like to point out that she had a lot of trouble describing her symptoms and would stop and look at the ceiling for 10-20 seconds before answering tough questions like “is symptom x worse in the morning of evening?”

 

[TypeADissection]

PhD was in communications.

Don't think it helped. You should add ICD-10 code F80.82 - Social pragmatic communication disorder.

 

[HighPriest]

Don't think it helped. You should add ICD-10 code F80.82 - Social pragmatic communication disorder.

Maybe it’s like the ‘ol schtick about psychiatrists? Sane people don’t go in to that field?

 

[OtoHNS]

This was just an office visit but still, I think, worthy.

Had a patient come in with a two page laundry list of symptoms. Everything you would expect from fatigue to vague pain, a diagnosis list that you couldn’t scroll through in 60 seconds, prior sleeve gastrectomy, a few auto-immune issues, and the fibro.

So she had an incidental <2cm mildly suspicious thyroid nodule with Norma TSH. But of course she had “done her research” and had a stack of print offs of explaining how her thyroid is probably the lynchpin cause of everything. But she reassured me that she knows how crazy that sounds but that I shouldn’t worry because she has a PhD and she’s not just some crazy person.

PhD was in communications.

I would also like to point out that she had a lot of trouble describing her symptoms and would stop and look at the ceiling for 10-20 seconds before answering tough questions like “is symptom x worse in the morning of evening?”

Sounds like she needs a balloon sinuplasty asap.

 

[HighPriest]

Sounds like she needs a balloon sinuplasty asap.

What’s if I told you, Sir, that you could have clear sinuses with no pain, no risks, and no recovery right here in this very office for the very low price of $5,000? Well, you’d tell me I’m crazy, and I would tell you you’d be crazy not to do it!

 

[TypeADissection]

What’s if I told you, Sir, that you could have clear sinuses with no pain, no risks, and no recovery right here in this very office for the very low price of $5,000? Well, you’d tell me I’m crazy, and I would tell you you’d be crazy not to do it!

My wife explained to me how much money could be made doing balloon sinuplasties after we drove by a sinuplasty clinic w/ a Ferrari parked outside. But noooooooooooooo, instead of relaxing her ethics she'd rather do CIs and work in the middle ear. Which by the way is completely fictitious, last I checked there's only a left and a right ear.

 

[HighPriest]

My wife explained to me how much money could be made doing balloon sinuplasties after we drove by a sinuplasty clinic w/ a Ferrari parked outside. But noooooooooooooo, instead of relaxing her ethics she'd rather do CIs and work in the middle ear. Which by the way is completely fictitious, last I checked there's only a left and a right ear.

And for what? So some kids and old people can hear again? She could be doing questionably sham surgery, then offering a real surgery to wash it down. It’s a solution to a problem and that problem is the rising costs of a good sportscar.

 

[TypeADissection]

And for what? So some kids and old people can hear again? She could be doing questionably sham surgery, then offering a real surgery to wash it down. It’s a solution to a problem and that problem is the rising costs of a good sportscar.

Dayum. I like the way you think. I'm gonna re-pitch this idea to her later tonight. Stay tuned homies. Maserati ain't gonna pay itself.

 

[Pir8DeacDoc]

We've hit on my favorite topic. The surgeon in town doing totally unnecessary things to people to line his own pockets.

I left my last practice (along with other questionable behavior) because the guy did 4-5 balloon cases a week on totally normal scan patients. Wild that everyone needed pan sinus dilation and also needed a turbinate reduction and "septoplasty" at the same time. Also strange that volume of surgery went crazy when we got an in office scanner and read our own scans. Sure way to make 2 million bucks a year. Unreal. I ran as fast as I could away. Unfortunately the feds still haven't showed up there

 

[HighPriest]

We've hit on my favorite topic. The surgeon in town doing totally unnecessary things to people to line his own pockets.

I left my last practice (along with other questionable behavior) because the guy did 4-5 balloon cases a week on totally normal scan patients. Wild that everyone needed pan sinus dilation and also needed a turbinate reduction and "septoplasty" at the same time. Also strange that volume of surgery went crazy when we got an in office scanner and read our own scans. Sure way to make 2 million bucks a year. Unreal. I ran as fast as I could away. Unfortunately the feds still haven't showed up there

It’s pretty disgusting, honestly. You made a good call, feds or not.

 

[Pir8DeacDoc]

It’s pretty disgusting, honestly. You made a good call, feds or not.

I had a lot of internal ethical and moral discussions with myself. I recognize we all tackle things in different ways. And I'm humble enough to know my way isn't the only way. But blatantly intentionally misreading scans to get people approved for surgery is just hard to watch. Ultimately I decided to just leave. But I still think about it and wonder if I should have done more. Patients are real people. Not ATMs.

 

[ThoracicGuy]

We've hit on my favorite topic. The surgeon in town doing totally unnecessary things to people to line his own pockets.

I left my last practice (along with other questionable behavior) because the guy did 4-5 balloon cases a week on totally normal scan patients. Wild that everyone needed pan sinus dilation and also needed a turbinate reduction and "septoplasty" at the same time. Also strange that volume of surgery went crazy when we got an in office scanner and read our own scans. Sure way to make 2 million bucks a year. Unreal. I ran as fast as I could away. Unfortunately the feds still haven't showed up there

Maybe you can get some whistleblower monies!

 

[Pir8DeacDoc]

Maybe you can get some whistleblower monies!

I did have that thought. But this guy was crazy enough I would have feared for my well being. Just best to move along, I suppose

 

[Raryn]

I had a lot of internal ethical and moral discussions with myself. I recognize we all tackle things in different ways. And I'm humble enough to know my way isn't the only way. But blatantly intentionally misreading scans to get people approved for surgery is just hard to watch. Ultimately I decided to just leave. But I still think about it and wonder if I should have done more. Patients are real people. Not ATMs.

I'm surprised the insurance companies aren't simply consistently requiring a trained radiologist read any scans used to make the diagnosis that a patient needs an elective outpatient surgery.

 

[ThoracicGuy]

I'm surprised the insurance companies aren't simply consistently requiring a trained radiologist read any scans used to make the diagnosis that a patient needs an elective outpatient surgery.

Have you seen any of the reads from some of these telerad companies that more and more places use? I could provide better reads than some of them.

 

[HighPriest]

Have you seen any of the reads from some of these telerad companies that more and more places use? I could provide better reads than some of them.

This is the issue for sure. Like most of us, I assume, I review every scan myself and I find I disagree with the read about 40% of the time. We don’t have a head and neck radiologist, so it’s all general, but the rate of undercalling and overcalling (both) is insane. And keep in mind it’s bad in both directions. I’m not advocating that we call everything sinusitis. Sometimes I’m zooming in 5x at my kiosk to find this “moderate sinus inflammation” they’re describing. I spend as much time explaining to patients why the read they got in their MyChart maybe doesn’t explain their symptoms as telling them there’s a problem when there wasn’t one on the report.
I suppose the real answer is the scan is read by someone else, but even then you could have an under the table agreement if you wanted to be a scheisster.

But I suppose that’s the crux of the issue for sinuses - what defines mild sinusitis. Normal is easy. Terrible is easy. If I want to do balloon surgery on everyone, any amount of mucosal thickening is a “problem.” And you wouldn’t necessarily be out of range to say it is on a report. But again, there’s radiographic findings and then there’s clinically relevant disease.

 

[Wordead]

You guys will love THE BREATHING TRIANGLE then. ADVENT: A Pioneer in ENT Medicine - ADVENT Company Information and Patient Services

Basically everyone benefits from an in office CT, septoplasty, sinus balloon, turbs, and probably anything else that's lucrative. What a joke.

 

[HighPriest]

You guys will love THE BREATHING TRIANGLE then. ADVENT: A Pioneer in ENT Medicine - ADVENT Company Information and Patient Services

Basically everyone benefits from an in office CT, septoplasty, sinus balloon, turbs, and probably anything else that's lucrative. What a joke.

Oh yeah, if one of them passages is blocked, you’re @&$cked.

 

[LucidSplash]

But do they have a salt cave as part of their wellness offerings? And on site sinus rinse packages. I’m sure you’ve heard of this person. They were all over the news due to their Covid offerings and Ivermectin. BREATHEmd | Optimal Airway Health

 

[HighPriest]

“Hey, this is Dr. X from the ER.”

“Hey”

“Yeah, hey, I got this guy I’m not sure what to do with, I wanted to get your take.”

“Sure. Whatcha got?”

“XX year old (insert entire medical history since time began, none of it at all relevant). Anyway I don’t think any of that matters. (Thanks, then, I got all the time in the world for you) So he started having ear pain a couple days ago and some hearing trouble. Today his ear drum looks red and there’s pus behind it. He’s also a little tender around the ear. So I got a CT and it shows fluid in the middle ear and some in the mastoid too. What should I do?

…well, I mean, does the CT report describe any sort of erosion?

No.

So this is a guy with an ear infection?

….


Maybe just pop him on an antibiotic and have him follow up if I doesn’t resolve or gets worse?

Yeah, ok, we’ll do that. Should he follow up with his PCP if it gets better?

Yeah I think that’s a reasonable thing to suggest.

 

[dpmd]

“Hey, this is Dr. X from the ER.”

“Hey”

“Yeah, hey, I got this guy I’m not sure what to do with, I wanted to get your take.”

“Sure. Whatcha got?”

“XX year old (insert entire medical history since time began, none of it at all relevant). Anyway I don’t think any of that matters. (Thanks, then, I got all the time in the world for you) So he started having ear pain a couple days ago and some hearing trouble. Today his ear drum looks red and there’s pus behind it. He’s also a little tender around the ear. So I got a CT and it shows fluid in the middle ear and some in the mastoid too. What should I do?

…well, I mean, does the CT report describe any sort of erosion?

No.

So this is a guy with an ear infection?

….


Maybe just pop him on an antibiotic and have him follow up if I doesn’t resolve or gets worse?

Yeah, ok, we’ll do that. Should he follow up with his PCP if it gets better?

Yeah I think that’s a reasonable thing to suggest.

Did they mention why they scanned an otitis media?

 

[Pir8DeacDoc]

“Hey, this is Dr. X from the ER.”

“Hey”

“Yeah, hey, I got this guy I’m not sure what to do with, I wanted to get your take.”

“Sure. Whatcha got?”

“XX year old (insert entire medical history since time began, none of it at all relevant). Anyway I don’t think any of that matters. (Thanks, then, I got all the time in the world for you) So he started having ear pain a couple days ago and some hearing trouble. Today his ear drum looks red and there’s pus behind it. He’s also a little tender around the ear. So I got a CT and it shows fluid in the middle ear and some in the mastoid too. What should I do?

…well, I mean, does the CT report describe any sort of erosion?

No.

So this is a guy with an ear infection?

….


Maybe just pop him on an antibiotic and have him follow up if I doesn’t resolve or gets worse?

Yeah, ok, we’ll do that. Should he follow up with his PCP if it gets better?

Yeah I think that’s a reasonable thing to suggest.

At least they got the diagnosis right?!? that's kinda good news. Luckily the patient got a huge bill, a CT scan they didn't need, and now will get the $20 antibiotics they needed. Do you know if their ESR was ok? LOL

I have found that the ability for any person not an ENT to diagnose an ear related problem and its proper treatment is no greater than 20%.
Everyone I see has horrible ear infections with "red" drums. When in reality they all have normal exams. And increasingly I'm seeing the shotgun approach to treatment - oral antibiotics and drops.

Man, I'm not perfect. But it feels like the entire world of healthcare skipped learning about ears.

 

[dpmd]

At least they got the diagnosis right?!? that's kinda good news. Luckily the patient got a huge bill, a CT scan they didn't need, and now will get the $20 antibiotics they needed. Do you know if their ESR was ok? LOL

I have found that the ability for any person not an ENT to diagnose an ear related problem and its proper treatment is no greater than 20%.
Everyone I see has horrible ear infections with "red" drums. When in reality they all have normal exams. And increasingly I'm seeing the shotgun approach to treatment - oral antibiotics and drops.

Man, I'm not perfect. But it feels like the entire world of healthcare skipped learning about ears.

The canals are so bendy and there is all that wax in there though

 

[Apollyon]

“Hey, this is Dr. X from the ER.”

“Hey”

“Yeah, hey, I got this guy I’m not sure what to do with, I wanted to get your take.”

“Sure. Whatcha got?”

“XX year old (insert entire medical history since time began, none of it at all relevant). Anyway I don’t think any of that matters. (Thanks, then, I got all the time in the world for you) So he started having ear pain a couple days ago and some hearing trouble. Today his ear drum looks red and there’s pus behind it. He’s also a little tender around the ear. So I got a CT and it shows fluid in the middle ear and some in the mastoid too. What should I do?

…well, I mean, does the CT report describe any sort of erosion?

No.

So this is a guy with an ear infection?

….


Maybe just pop him on an antibiotic and have him follow up if I doesn’t resolve or gets worse?

Yeah, ok, we’ll do that. Should he follow up with his PCP if it gets better?

Yeah I think that’s a reasonable thing to suggest.

This has academics written all over it. As a dumb ER doc, I can count on one hand the times I called oto for an ear complaint. Earring back embedded in the TM, FB I couldn't get out of the EAC, shot in the ear Sat night, bounced around his face, comes in Sunday. That's it, over 17 years.

That third one was interesting (in the PITA way). Since it went in the ear, I called oto on call. He said he wasn't covering facial trauma, and call them. Ok. Facial that day was a DMD, who may have been OMFS, but he was def a dentist first. I even remember his name - Derek. He told me that he didn't do zygoma or higher. I did ask myself "Then why TF are you on for facial trauma?" Ended up having to give the guy the number for an oto office, to call in the week.

 

[HighPriest]

This has academics written all over it. As a dumb ER doc, I can count on one hand the times I called oto for an ear complaint. Earring back embedded in the TM, FB I couldn't get out of the EAC, shot in the ear Sat night, bounced around his face, comes in Sunday. That's it, over 17 years.

That third one was interesting (in the PITA way). Since it went in the ear, I called oto on call. He said he wasn't covering facial trauma, and call them. Ok. Facial that day was a DMD, who may have been OMFS, but he was def a dentist first. I even remember his name - Derek. He told me that he didn't do zygoma or higher. I did ask myself "Then why TF are you on for facial trauma?" Ended up having to give the guy the number for an oto office, to call in the week.

I’ve been in a case where omfs was on trauma but the ear was involved. We just both came in.

But this guy? Nah, not academic.

 

[HighPriest]

Did they mention why they scanned an otitis media?

They scan everything so I don’t even ask anymore.

 

[Apollyon]

I’ve been in a case where omfs was on trauma but the ear was involved. We just both came in.

But this guy? Nah, not academic.

Ouch. I don't know if I should be disappointed or pi$$ed.

 

[HighPriest]

At least they got the diagnosis right?!? that's kinda good news. Luckily the patient got a huge bill, a CT scan they didn't need, and now will get the $20 antibiotics they needed. Do you know if their ESR was ok? LOL

I have found that the ability for any person not an ENT to diagnose an ear related problem and its proper treatment is no greater than 20%.
Everyone I see has horrible ear infections with "red" drums. When in reality they all have normal exams. And increasingly I'm seeing the shotgun approach to treatment - oral antibiotics and drops.

Man, I'm not perfect. But it feels like the entire world of healthcare skipped learning about ears.

This is true for us too. 95% of ear infections and effusion are misdiagnosed. If you ask someone in urgent care to look in your ear for any reason, you’re going to have an effusion. Guaranteed. All pain on the side of the head (any area) - ear infection. Drum too white? Ear infection. To red? Infection. Can’t see past the wax? Infection. Little sclerosis on there? Infection.

I will point out that the VAST majority of these diagnoses are NPs or PAs.

And yeah, no one knows the difference between a swimmers ear and an otitis media. I love it when the patient has been to urgent care three times and treated with oral antibiotic, then drop, then oral antibiotics and drops. And the diagnosis code is “eustachian tube dysfunction.” Where we are, all ear issues are no longer the purview of primary care. At all. They’re a complete black box. About 10% of the time no ear exam is even documented when antibiotics are prescribed for an ear infection. I’ve gotten into the habit of asking urgent care referrals if someone looked in their ear when they went in for ear pain. The answer would make you angry.

I read a study a long time ago where they took like 200 kids, all of whom got ear tubes for whatever reason. On the morning of surgery they had each ear examined (around 400) by an ENT, a pediatric ENT and a pediatrician and the only question was: is there an effusion? Yes or no?
Then the kids got tubes, so you know for sure.
The peds ENT doc was right about 70% of the time which sounds low, but this was an otoscope exam in an awake kid. So they’re not perfect.
The ENT doc was about 60-something %.
The pediatrician was right 30% of the time.

These were all staff docs.

The point of the article was that we need better methods for evaluating effusion. My take away is the pediatrician is misdiagnosing your kid 2x more often then they get it right when it comes to ear infections.

I’m at a point now where if I ask the patient if the referring doc did an ear exam and they say “yes,” my first thought is “alright, man! Good on you for trying!” And that’s pretty sad.

 

[dpmd]

This is true for us too. 95% of ear infections and effusion are misdiagnosed. If you ask someone in urgent care to look in your ear for any reason, you’re going to have an effusion. Guaranteed. All pain on the side of the head (any area) - ear infection. Drum too white? Ear infection. To red? Infection. Can’t see past the wax? Infection. Little sclerosis on there? Infection.

I will point out that the VAST majority of these diagnoses are NPs or PAs.

And yeah, no one knows the difference between a swimmers ear and an otitis media. I love it when the patient has been to urgent care three times and treated with oral antibiotic, then drop, then oral antibiotics and drops. And the diagnosis code is “eustachian tube dysfunction.” Where we are, all ear issues are no longer the purview of primary care. At all. They’re a complete black box. About 10% of the time no ear exam is even documented when antibiotics are prescribed for an ear infection. I’ve gotten into the habit of asking urgent care referrals if someone looked in their ear when they went in for ear pain. The answer would make you angry.

I read a study a long time ago where they took like 200 kids, all of whom got ear tubes for whatever reason. On the morning of surgery they had each ear examined (around 400) by an ENT, a pediatric ENT and a pediatrician and the only question was: is there an effusion? Yes or no?
Then the kids got tubes, so you know for sure.
The peds ENT doc was right about 70% of the time which sounds low, but this was an otoscope exam in an awake kid. So they’re not perfect.
The ENT doc was about 60-something %.
The pediatrician was right 30% of the time.

These were all staff docs.

The point of the article was that we need better methods for evaluating effusion. My take away is the pediatrician is misdiagnosing your kid 2x more often then they get it right when it comes to ear infections.

I’m at a point now where if I ask the patient if the referring doc did an ear exam and they say “yes,” my first thought is “alright, man! Good on you for trying!” And that’s pretty sad.

Is it because no one uses insufflation on the TM?