Consults- Memorable/Dismal/Ridiculous/Unique

[HighPriest]

Is it because no one uses insufflation on the TM?

I mean, there are a variety of reasons. I think the way they (med school and residency) teach ear exams is bad. I think otoscopes are suboptimal. I think the way they teach the pathophysiology is bad. I think the anatomy is poorly understood. I think to get good at ear exams you have to start by looking in everyone’s ear even if they’re normal, and that takes time and effort and planning. I think people come out of primary care training with a very poor differential diagnosis for the causes of plugged ear or ear pain, so they don’t really ask any pertinent questions. But mostly I think it’s just way easier to call everything eustachian tube dysfunction and place a referral. The patient feels like you’ve figured it out and put them on the right path and you don’t have to see them again. Hands washed.

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[OtoHNS]

I mean, there are a variety of reasons. I think the way they (med school and residency) teach ear exams is bad. I think otoscopes are suboptimal. I think the way they teach the pathophysiology is bad. I think the anatomy is poorly understood. I think to get good at ear exams you have to start by looking in everyone’s ear even if they’re normal, and that takes time and effort and planning. I think people come out of primary care training with a very poor differential diagnosis for the causes of plugged ear or ear pain, so they don’t really ask any pertinent questions. But mostly I think it’s just way easier to call everything eustachian tube dysfunction and place a referral. The patient feels like you’ve figured it out and put them on the right path and you don’t have to see them again. Hands washed.

In 4 years of med school, I think we spent a total of 1 hour learning how to do the "eye, ear, nose, and throat" exam during M2 physical exam class. Other than ENT rotation, I can't remember ever being taught how to look in an ear again. Any doctor who is not ENT probably has this level of training in the otoscopic exam.

That's problem #1. Problem #2 is that an otoscopic exam is not a reliable way to determine if there is a middle ear effusion. Sometimes it's visually obvious, and many times it is not. Sometimes, the eardrum looks very abnormal but there is no effusion and the pressure is normal.

I've never tried to insufflate an ear, but I use a tympanometer multiple times a day in clinic which reliably measures the middle ear pressure and tells me if there is actually fluid or not and whether the patient has ETD or not.

But yeah, ear pain/pathology is a total black box for most referring providers, especially doc-in-a-box types.

 

[TypeADissection]

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

I'm gonna be real honest. I don't know jack **** about the ears. My wife will tell me about her day or some cool ear case she did and I just smile and nod. One of my favorite interactions:

Her: I mean seriously, any med student could diagnose this as ear wax and not a cholesteatoma.
Me: Well, 'aight, check this out, dawg. First of all, you throwin' too many big words at me, and because I don't understand 'em, I'm gonna take 'em as disrespeck.

 

[DoctwoB]

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.

The good news is that we're probably not far off from NP/PAs just plugging the digital otoscope into their phone, snapping a picture, and then GPT bot tells them if there is an ear infection or not.

Artificial Intelligence Model Outperforms Clinicians in Diagnosing Pediatric Ear Infections

A machine-learning model developed at Mass Eye and Ear accurately diagnosed pediatric ear infections at a rate 30 percent higher than doctors surveyed in head-to-head testing.

masseyeandear.org

I'm inherently skeptical about AI in medicine, but when comparing to a very low bar as in this case it's probably an appropriate use case.

 

[HighPriest]

The good news is that we're probably not far off from NP/PAs just plugging the digital otoscope into their phone, snapping a picture, and then GPT bot tells them if there is an ear infection or not.

Artificial Intelligence Model Outperforms Clinicians in Diagnosing Pediatric Ear Infections

A machine-learning model developed at Mass Eye and Ear accurately diagnosed pediatric ear infections at a rate 30 percent higher than doctors surveyed in head-to-head testing.

masseyeandear.org

I'm inherently skeptical about AI in medicine, but when comparing to a very low bar as in this case it's probably an appropriate use case.

22 test images isn’t necessarily a revelation, and I can say that there’s some significant bias in diagnosing an ear infection based upon a still image versus a program that’s designed specifically to look for predetermined findings on said images, but it can’t possibly be worse than what we’re doing now. 600 images with 80% accuracy is pretty good.

 

[DoctwoB]

22 test images isn’t necessarily a revelation, and I can say that there’s some significant bias in diagnosing an ear infection based upon a still image versus a program that’s designed specifically to look for predetermined findings on said images, but it can’t possibly be worse than what we’re doing now. 600 images with 80% accuracy is pretty good.

Yeah it's interesting that MEEI couldn't pull together a larger training set. There are millions of infected ears a year but acquiring the data is 99% of the battle.

The training data and what is the gold standard to compare to are always issues. Of course the context of the pictures and metadata are also problems. The classic example is the model that could identify melanoma was trained to identify rulers. You could omagine a similar situation where a model recognizes from metadata that the picture is of a 2 year old at an urgent care center in winter and assigns an auto AOM dx.

 

[HighPriest]

You could omagine a similar situation where a model recognizes from metadata that the picture is of a 2 year old at an urgent care center in winter and assigns an auto AOM dx.

Basically what we’re doing now. Except it’s any patient with an ear in any season.

 

[eyeeye_captain]

I feel for you ENT folks. If you want at least as big a black box as ears, try eyes. My favorite from training:

Call at 3 AM:
ER resident: “Hey, I’ve got this non-verbal, combative patient sent in from his facility because he’s pointing at his eye and yelling. I checked his pressure and it’s sky high, I think he’s got angle closure glaucoma.”

See patient.

ER resident: “So it’s angle closure, right?”
Me: “Technically his angle is closed, but I’m more worried that it’s closed because half of his iris is coming out of his cornea.”

At least the resident looked I guess, but that’s not exactly a subtle finding. Also not usually a good idea to poke on an open eyeball.

 

[HighPriest]

I feel for you ENT folks. If you want at least as big a black box as ears, try eyes. My favorite from training:

Call at 3 AM:
ER resident: “Hey, I’ve got this non-verbal, combative patient sent in from his facility because he’s pointing at his eye and yelling. I checked his pressure and it’s sky high, I think he’s got angle closure glaucoma.”

See patient.

ER resident: “So it’s angle closure, right?”
Me: “Technically his angle is closed, but I’m more worried that it’s closed because half of his iris is coming out of his cornea.”

At least the resident looked I guess, but that’s not exactly a subtle finding. Also not usually a good idea to poke on an open eyeball.

I have no doubt that the globe is in league with the ear when it comes to misdiagnosis. Did they try to just poke the iris back in there? Pop a contact lens over it for a bandage?

 

[eyeeye_captain]

I have no doubt that the globe is in league with the ear when it comes to misdiagnosis. Did they try to just poke the iris back in there? Pop a contact lens over it for a bandage?

Nah, emergent surgery with iris repositioning and a ton of 10-0 nylon sutures. Not a fun case. Patient had an old corneal transplant that he managed to dehisce.

More along the lines of poorly diagnosed common ear stuff:

ER NP: “Hey, I’ve got a patient here for something completely unrelated, but she has a red painful eye and I’m not discharging her until you come in. *chuckle* Called your co-resident in for 5 patients last night. *chuckle*”

See patient, NP is now off shift.

Me to ER doc who came on: “Hey, that lady you’re waiting for dispo on has a stye. Nothing to do.”
ER doc: *heavy sigh* “Sorry.”

 

[HighPriest]

Nah, emergent surgery with iris repositioning and a ton of 10-0 nylon sutures. Not a fun case. Patient had an old corneal transplant that he managed to dehisce.

More along the lines of poorly diagnosed common ear stuff:

ER NP: “Hey, I’ve got a patient here for something completely unrelated, but she has a red painful eye and I’m not discharging her until you come in. *chuckle* Called your co-resident in for 5 patients last night. *chuckle*”

See patient, NP is now off shift.

Me to ER doc who came on: “Hey, that lady you’re waiting for dispo on has a stye. Nothing to do.”
ER doc: *heavy sigh* “Sorry.”

At least he didn’t drop the “hey I got an interesting one for you” line. He knew he was just dumping his work on you so he could get out. In a way I almost prefer the self insight.

So did the provider taking care of the dehised cornea at least ask and then mention to you that the patient had a history of a corneal transplant? I’m betting “no,” because why would you ask someone with a suspected eye problem if they’d ever had eye surgery
Although sometimes that backfires. Like: any patient who has ever had sinus surgery, even if it was 30 years ago, if they get a sinus infection they get sent to ENT without treatment because no one is “sure” how to treat a patient with a sinus infection if they’ve had surgery before.

Hint: you can treat them exactly the same way and it’ll probably work.

Had a guy yesterday who say his NP for a swimmers ear. She looked in his ear, diagnosed a swimmers ear, then referred him to me with no treatment because in 2019 I put an ear tube in his ear after a post-flight effusion. Tube had been out for a few years. She was the one who noted that it fell out and that his ear looked normal after. He had had no other ear issues since 2019. Not to mention you don’t treat swimmers ear with tubes. So he had a draining ear for a month so that I could order drops for him.

 

[eyeeye_captain]

At least he didn’t drop the “hey I got an interesting one for you” line. He knew he was just dumping his work on you so he could get out. In a way I almost prefer the self insight.

So did the provider taking care of the dehised cornea at least ask and then mention to you that the patient had a history of a corneal transplant? I’m betting “no,” because why would you ask someone with a suspected eye problem if they’d ever had eye surgery
Although sometimes that backfires. Like: any patient who has ever had sinus surgery, even if it was 30 years ago, if they get a sinus infection they get sent to ENT without treatment because no one is “sure” how to treat a patient with a sinus infection if they’ve had surgery before.

Hint: you can treat them exactly the same way and it’ll probably work.

Had a guy yesterday who say his NP for a swimmers ear. She looked in his ear, diagnosed a swimmers ear, then referred him to me with no treatment because in 2019 I put an ear tube in his ear after a post-flight effusion. Tube had been out for a few years. She was the one who noted that it fell out and that his ear looked normal after. He had had no other ear issues since 2019. Not to mention you don’t treat swimmers ear with tubes. So he had a draining ear for a month so that I could order drops for him.

Unfortunately the only self insight was from the ER MD who relieved her. I dream that she got written up for that garbage, but I know it would never happen.

To be fair to the resident on the cornea issue, the patient was non-verbal and I don’t think I’ve ever seen a long term care facility actually bring useful records anywhere. My gripe is that it’s not tough to see half of the inside of an eyeball coming out. Hell, I used to get calls on head trauma with brain plainly visible - maybe we can work on priorities, folks?

Totally feel you on the “someone operated on it years ago so now I can’t touch it“ ridiculousness. There’s a big time hot potato mentality in a lot of settings. Hopefully your referral sources don’t know buzzwords to force emergent/urgent referrals. I’m pretty sick of people calling everything a retinal detachment so it’s my problem immediately and they can wash their hands of whatever is going on.

 

[WinslowPringle]

Bumping the thread…

Return ED page. All lines busy. Wait for a few minutes, tech picks up. Introduce myself. “Yeah, let me get the midlevel for you….” Wait longer. Tech comes on the line. “I can’t find the NP, what do you want me to do?” “Have them page me again when they’re available”.
I keep working, page comes again a few minutes later. Return the phone call to the general ED number, again a wait, again a tech answers but finally the ED NP is found. This is about 20minutes in….
ED NP: “So, I’ve got this 70yo guy who came in with….(beings life long medical history)”
Me: “Ma’am, ma’am…Ma’am. Please, I’m a surgeon, can you tell me what surgical question you have? Why are you calling?”
ED NP: “The CT says that he as a …hold on let me pull it up…” and proceeds to read off description of body part nowhere near where I operate.
Me: “I’m sorry, that call will need to go to another specialty. Thanks.”


Another call:
ED midlevel: “Hello, yes, I have a 90+ yo pt being admitted to the medical team for failure to thrive. He also has this (insert surgical finding that is asymptomatic but could potentially cause problems but the only way of dealing with it is major surgery that no 90yo is likely to withstand…). So, we just needed to know your recommendations for how to manage this.”
Me: “…..I recommend we stop the madness that is the American health system and let this guy live his days out in whatever peace he can.”
ED midlevel: “….”
Me: “……”
Me: *Sigh* Of course, I’ll see him tomorrow and discuss it with him. I recommend ongoing GOC discussion. Patient is not a surgical candidate. “
ED midlevel. “Great! I’ll let them know you’re not recommending surgery right now.”
Me:”Thanks.”

 

[DOVinciRobot]

Bumping the thread…

Return ED page. All lines busy. Wait for a few minutes, tech picks up. Introduce myself. “Yeah, let me get the midlevel for you….” Wait longer. Tech comes on the line. “I can’t find the NP, what do you want me to do?” “Have them page me again when they’re available”.
I keep working, page comes again a few minutes later. Return the phone call to the general ED number, again a wait, again a tech answers but finally the ED NP is found. This is about 20minutes in….
ED NP: “So, I’ve got this 70yo guy who came in with….(beings life long medical history)”
Me: “Ma’am, ma’am…Ma’am. Please, I’m a surgeon, can you tell me what surgical question you have? Why are you calling?”
ED NP: “The CT says that he as a …hold on let me pull it up…” and proceeds to read off description of body part nowhere near where I operate.
Me: “I’m sorry, that call will need to go to another specialty. Thanks.”


Another call:
ED midlevel: “Hello, yes, I have a 90+ yo pt being admitted to the medical team for failure to thrive. He also has this (insert surgical finding that is asymptomatic but could potentially cause problems but the only way of dealing with it is major surgery that no 90yo is likely to withstand…). So, we just needed to know your recommendations for how to manage this.”
Me: “…..I recommend we stop the madness that is the American health system and let this guy live his days out in whatever peace he can.”
ED midlevel: “….”
Me: “……”
Me: *Sigh* Of course, I’ll see him tomorrow and discuss it with him. I recommend ongoing GOC discussion. Patient is not a surgical candidate. “
ED midlevel. “Great! I’ll let them know you’re not recommending surgery right now.”
Me:”Thanks.”

Those system CYA consults probably irk me the most. “Hey this poor grandma is 100 years old but we found a new pancreatic head mass and need your recs.”

 

[Pir8DeacDoc]

Ok. So the above stuff made me think of this.

Do you all think it's appropriate or annoying to get called directly from an np/ pa in the ED?
I am happy to help anyone. But I get agitated when a relatively simple problem gets turfed to me and there's been no discussion with the supervising ER physician. I'm not your phone a friend. Ask the person at the computer next to you. But I sometimes feel like a jerk for having those thoughts. Please advise

 

[LucidSplash]

Ok. So the above stuff made me think of this.

Do you all think it's appropriate or annoying to get called directly from an np/ pa in the ED?
I am happy to help anyone. But I get agitated when a relatively simple problem gets turfed to me and there's been no discussion with the supervising ER physician. I'm not your phone a friend. Ask the person at the computer next to you. But I sometimes feel like a jerk for having those thoughts. Please advise

Most of these midlevels are essentially acting independently. I’ve given up trying to redirect the flow in the ED. It’s easier just to answer the question. Many times there is one ED doc and a bunch of midlevels and they are expected, institutionally, to operate nearly independently.

 

[Smurfette]

Ok. So the above stuff made me think of this.

Do you all think it's appropriate or annoying to get called directly from an np/ pa in the ED?
I am happy to help anyone. But I get agitated when a relatively simple problem gets turfed to me and there's been no discussion with the supervising ER physician. I'm not your phone a friend. Ask the person at the computer next to you. But I sometimes feel like a jerk for having those thoughts. Please advise

I agree with you, and the ERs I cover tend to vary. Some of the docs will call me instead of having the midlevel do it, but haven't actually looked at the patient themselves and it quickly becomes obvious since I ask a lot of questions. Sometimes the docs just let the midlevels call but did at least discuss it with them first. The newer ER docs seem to be the ones letting the midlevels run completely independently. Sometimes when the midlevel is really off-base or lost, I ask if they've talked to their staff. They universally get really offended if I ask that...

All midlevel ER notes here have to be cosigned by the attending. Always interesting to read the attestations and wonder how much truth is in the "patient discussed" or "patient also seen and examined by me" canned statements they can choose from.

 

[HighPriest]

Ok. So the above stuff made me think of this.

Do you all think it's appropriate or annoying to get called directly from an np/ pa in the ED?
I am happy to help anyone. But I get agitated when a relatively simple problem gets turfed to me and there's been no discussion with the supervising ER physician. I'm not your phone a friend. Ask the person at the computer next to you. But I sometimes feel like a jerk for having those thoughts. Please advise

It’s irritating AF. But as mentioned, they are all “independent providers” in my state.

What I find -really- hilarious, and this is a a hospital policy not a state policy, is that the ER PA can see a patient, dispo them, consult specialists at 3 am to ask what kind of antibiotic they prefer for an ear infection in a healthy kid. But my PA is not allowed to take call after hours even with an MD back up readily available because he’s a PA.

So the hospital realizes that PAs don’t have the education or experience to function independently when it matters, but apparently also realize that the ER is just a place where people go to get shunted to other services.

 

[eyeeye_captain]

the ER is just a place where people go to get shunted to other services.

Bingo. My experience is that it’s even worse at academic centers. The midlevel wants the easiest dispo, what can they do? Oh, page the resident who can’t give me any pushback or my supervisor complains to your department chair. Zero need to think.

 

[Arcan57]

Bingo. My experience is that it’s even worse at academic centers. The midlevel wants the easiest dispo, what can they do? Oh, page the resident who can’t give me any pushback or my supervisor complains to your department chair. Zero need to think.

It doesn't have to be laziness. The ED is a really tough environment in which to become competent if you don't have 1 )a very broad knowledge base and 2) someone that cares enough to walk you through what does and doesn't need a phone call. Most MLPs have neither of those. Add in that your department chair wants you getting called on everything and that docs in academic medical centers are the most risk averse people ever and its going to be a miserable time carrying the consult pager.

Now if i could only get medicine to admit patients that have no chance of ever seeing the inside of an OR without requiring at least two notes from surgical specialties and an evaluation by the ICU team, I could go weeks without bothering you guys. Except of course for the stable post-op patients directed by medical assistants to go to the ED for nausea/pain/wound checks.

 

[HighPriest]

It doesn't have to be laziness. The ED is a really tough environment in which to become competent if you don't have 1 )a very broad knowledge base and 2) someone that cares enough to walk you through what does and doesn't need a phone call. Most MLPs have neither of those. Add in that your department chair wants you getting called on everything and that docs in academic medical centers are the most risk averse people ever and its going to be a miserable time carrying the consult pager.

Now if i could only get medicine to admit patients that have no chance of ever seeing the inside of an OR without requiring at least two notes from surgical specialties and an evaluation by the ICU team, I could go weeks without bothering you guys. Except of course for the stable post-op patients directed by medical assistants to go to the ED for nausea/pain/wound checks.

I don’t think most are lazy. Obviously, some are but that’s true anywhere.

I also don’t think it’s just lack of education as I have given lectures (usually with minimal attendance) and discussed treatment rationale and in many cases this is disregarded in future calls. Again, not always.

It’s a mixed bag. And I don’t work in academia. And our hospitalists admit anything. I sometimes have to call them off a patient who has a simple medical issue that I think I can take care of myself.

 

[HighPriest]

ER: “hey, how are you?”

Me: (it’s 3am and I have a full OR that starts in 2.5 hours and this is my third call since midnight) “I’m great.”

ER: I have this pleasant 68 year old female who….(I think I learned the name of her dog and what elementary school she went to)
Me: hey man, sorry to cut you off, but what can I do for you?

ER: well she had an ear infection and she’s allergic to everything, and I even called ID and they said the only thing they can put her on is iv gentamicin.

Me: …uh, ok… that sounds fine to me. You don’t need my permission.

ER: well, yeah I’m going to ask medicine to admit her, but I wanted you in the loop.

Me: why?

ER: so medicine knows you’re in the loop.

Me: well, if they need me in the loop, couldn’t they call me, you know…like…tomorrow? I’m definitely not coming in now for an uncomplicated ear infection. (Or, like, ever, man).

ER: well, sometimes they get nervous because they don’t know if it’s even something you manage.

Me: just to make sure I’m understanding you: this is a 68 year old, not septic patient with ear pain for two days?

ER: correct

Me: it is definitely within my purlieu. Although 70% of these will get better with no treatment at all.

ER: ok, I’ll let medicine know.

 

[dpmd]

ER: “hey, how are you?”

Me: (it’s 3am and I have a full OR that starts in 2.5 hours and this is my third call since midnight) “I’m great.”

ER: I have this pleasant 68 year old female who….(I think I learned the name of her dog and what elementary school she went to)
Me: hey man, sorry to cut you off, but what can I do for you?

ER: well she had an ear infection and she’s allergic to everything, and I even called ID and they said the only thing they can put her on is iv gentamicin.

Me: …uh, ok… that sounds fine to me. You don’t need my permission.

ER: well, yeah I’m going to ask medicine to admit her, but I wanted you in the loop.

Me: why?

ER: so medicine knows you’re in the loop.

Me: well, if they need me in the loop, couldn’t they call me, you know…like…tomorrow? I’m definitely not coming in now for an uncomplicated ear infection. (Or, like, ever, man).

ER: well, sometimes they get nervous because they don’t know if it’s even something you manage.

Me: just to make sure I’m understanding you: this is a 68 year old, not septic patient with ear pain for two days?

ER: correct

Me: it is definitely within my purlieu. Although 70% of these will get better with no treatment at all.

ER: ok, I’ll let medicine know.

This sounds like a place that has been burned before by the specialist refusing to consult on a patient when called by the hospitalist honestly. Are you sure your colleagues aren't being obstructive in those situations (we had one who was and despite him no longer being on the call schedule for years the hospitalists are still scared to admit and then consult)

 

[HighPriest]

This sounds like a place that has been burned before by the specialist refusing to consult on a patient when called by the hospitalist honestly. Are you sure your colleagues aren't being obstructive in those situations (we had one who was and despite him no longer being on the call schedule for years the hospitalists are still scared to admit and then consult)

I’m aware of two scenarios in 7 years where this occurred, and in both situations they admitted complex trauma (like, needed a neurosurgeon which we don’t have) and advanced head and neck cancer without calling. And in both of those cases we still consulted on the patient, we just told them the patients condition is beyond our capability and they needed transfer. Mind you, a pre-admission call would have been totally reasonable on either one of those patients.

that being said, this is an acute uncomplicated ear infection. It doesn’t need an ENT consult to begin with. It’s like them admitting someone with constipation x 2 days because they don’t like miralax and calling gen surg just to make sure they’re available. Call when you need something, not when needing something is one of the remotely possible outcomes. If it’s a weird zebra of a problem and you don’t know, that’s ok. Call. This was an ear infection. I mean, if you want to get technical in my experience 95% of ER diagnosed ear infections aren’t ear infections at all. Just pain referred to the ear, but let’s assume he was right.

If this patient had a neck abscess due to mastoiditis, then sure. Call. If they had been on antibiotics, or were septic, or even had a history of needed some kind of surgical intervention, sure.

So while I get what you’re saying, there’s absolutely no reason to call for every complaint above the collar bone that gets admitted. If it’s complex, no complaints.

Along the reasoning that they should call “just to make sure,” ear infections are pretty common. Sinus infections too. What if the patient gets admitted for intubation? Maybe they’ll get a sinus infection from prolonged NG and then that becomes complicated and they get orbital cellulitis? Should ENT be consulted regardless of the admitting diagnosis? Nah. They shouldn’t. Because that’s a ridiculous waste of resources. This call was -marginally- better. The patient would have gone home if not for her insane number of allergies.

This is like my wife refusing to drive my car because when she first tried she couldn’t figure out how to put it in gear. I get that you had a bad experience once, but no one is asking you to rebuild the transmission. Just figure out where “drive” is. You can do it.

 

[dpmd]

I’m aware of two scenarios in 7 years where this occurred, and in both situations they admitted complex trauma (like, needed a neurosurgeon which we don’t have) and advanced head and neck cancer without calling. And in both of those cases we still consulted on the patient, we just told them the patients condition is beyond our capability and they needed transfer. Mind you, a pre-admission call would have been totally reasonable on either one of those patients.

that being said, this is an acute uncomplicated ear infection. It doesn’t need an ENT consult to begin with. It’s like them admitting someone with constipation x 2 days because they don’t like miralax and calling gen surg just to make sure they’re available. Call when you need something, not when needing something is one of the remotely possible outcomes. If it’s a weird zebra of a problem and you don’t know, that’s ok. Call. This was an ear infection. I mean, if you want to get technical in my experience 95% of ER diagnosed ear infections aren’t ear infections at all. Just pain referred to the ear, but let’s assume he was right.

If this patient had a neck abscess due to mastoiditis, then sure. Call. If they had been on antibiotics, or were septic, or even had a history of needed some kind of surgical intervention, sure.

So while I get what you’re saying, there’s absolutely no reason to call for every complaint above the collar bone that gets admitted. If it’s complex, no complaints.

Along the reasoning that they should call “just to make sure,” ear infections are pretty common. Sinus infections too. What if the patient gets admitted for intubation? Maybe they’ll get a sinus infection from prolonged NG and then that becomes complicated and they get orbital cellulitis? Should ENT be consulted regardless of the admitting diagnosis? Nah. They shouldn’t. Because that’s a ridiculous waste of resources. This call was -marginally- better. The patient would have gone home if not for her insane number of allergies.

This is like my wife refusing to drive my car because when she first tried she couldn’t figure out how to put it in gear. I get that you had a bad experience once, but no one is asking you to rebuild the transmission. Just figure out where “drive” is. You can do it.

Oh it is definitely an overreaction and not appropriate. Just saying it usually doesn't come from nowhere. Pretty the sure the ER would rather not be calling consults the hospitalist could easily call their damn selves.

 

[HighPriest]

Oh it is definitely an overreaction and not appropriate. Just saying it usually doesn't come from nowhere. Pretty the sure the ER would rather not be calling consults the hospitalist could easily call their damn selves.

That is a fair point.

 

[Pir8DeacDoc]

Let's be serious here. There's no way in hell this lady had a real acute otitis media. I think in 12 years of practice I could count on two hands the number of times I've been told an adult "has fluid" or "the ear is red" or "the ear is bulging" and they are seen shortly thereafter and have an actual ear problem. And then I'm left trying to explain how it's sometimes hard to examine the ear. It's really not all that hard but they never practice. If you only look when someone has a complaint then you have no sense on the difference between normal and abnormal. It's mind numbing to be on the receiving end of these things. / end rant

 

[operaman]

Let's be serious here. There's no way in hell this lady had a real acute otitis media. I think in 12 years of practice I could count on two hands the number of times I've been told an adult "has fluid" or "the ear is red" or "the ear is bulging" and they are seen shortly thereafter and have an actual ear problem. And then I'm left trying to explain how it's sometimes hard to examine the ear. It's really not all that hard but they never practice. If you only look when someone has a complaint then you have no sense on the difference between normal and abnormal. It's mind numbing to be on the receiving end of these things. / end rant

Oh yeah no doubt. Odds of actual AOM here is about 0.001%.

We’ve been working on this as a dept and making clear what we will and won’t see on call. This would fall squarely in the do not see and doesn’t even need ENT follow up category.

 

[HighPriest]

It’s almost never actually an ear infection.

 

[operaman]

It’s a small consolation but I just figured out how to bill for these ED telephone consults. Apparently there are actual codes for having these conversations. I was looking for a second read for radiology codes but the only one that exists doesn’t have an RVU value which is useless to me the way I’m bonused. But these pay 0.7 to 1.4 depending on how much of a time suck they are.

They don’t pay much obviously but ill bet it adds up. I probably get 20 of these calls a week when I’m on call. 20 RVUs is like doing an extra tracheal resection per week for work I’m already doing.

 

[ThoracicGuy]

It’s a small consolation but I just figured out how to bill for these ED telephone consults. Apparently there are actual codes for having these conversations. I was looking for a second read for radiology codes but the only one that exists doesn’t have an RVU value which is useless to me the way I’m bonused. But these pay 0.7 to 1.4 depending on how much of a time suck they are.

They don’t pay much obviously but ill bet it adds up. I probably get 20 of these calls a week when I’m on call. 20 RVUs is like doing an extra tracheal resection per week for work I’m already doing.

So how do you document it for billing?

 

[operaman]

So how do you document it for billing?

I use the 99447-9 codes if I talk to someone, and 99451 if I just review a chart and scans and drop a note.

Mainly I just document which physician called me, what we talked about. I summarize my chart review and imaging interpretation as indicated. And then I have a phrase about time spent on each part. I also make it clear they don’t need to follow up with me.

Not much guidance out there on these codes so what I’ve surmised so far from my digging that I try to include:
- you were asked for consultation by another MD
- for the verbal codes, at least 50% of the time billed must be the conversation(s)
- must document what you did
- cannot bill these codes if you see the patient or intend to see the patient within 14 days.

I’m still learning but that’s my approach so far! I’m just surprised nobody ever told me about these before - seems like I was leaving a lot of money on the table before.

 

[HighPriest]

I use the 99447-9 codes if I talk to someone, and 99451 if I just review a chart and scans and drop a note.

Mainly I just document which physician called me, what we talked about. I summarize my chart review and imaging interpretation as indicated. And then I have a phrase about time spent on each part. I also make it clear they don’t need to follow up with me.

Not much guidance out there on these codes so what I’ve surmised so far from my digging that I try to include:
- you were asked for consultation by another MD
- for the verbal codes, at least 50% of the time billed must be the conversation(s)
- must document what you did
- cannot bill these codes if you see the patient or intend to see the patient within 14 days.

I’m still learning but that’s my approach so far! I’m just surprised nobody ever told me about these before - seems like I was leaving a lot of money on the table before.

Very interesting, indeed. How long have you been doing this? Any pushback?

 

[operaman]

Very interesting, indeed. How long have you been doing this? Any pushback?

About 48 hours! So a little too soon for that.

They’re definitely legit codes and the descriptions and all the clarifying info in prior CPT Assistant issues support what I’m doing, so in theory should be paid.

Only issues I can foresee might be that I’ll need to get the ED to formally order a consult or something logistical like that, or some quibble with my documentation.

Not sure why nobody ever pointed these codes out to me so maybe there’s some hidden issue.

 

[ThoracicGuy]

About 48 hours! So a little too soon for that.

They’re definitely legit codes and the descriptions and all the clarifying info in prior CPT Assistant issues support what I’m doing, so in theory should be paid.

Only issues I can foresee might be that I’ll need to get the ED to formally order a consult or something logistical like that, or some quibble with my documentation.

Not sure why nobody ever pointed these codes out to me so maybe there’s some hidden issue.

One article I just read about these codes stated that the patient needed to give consent to consultative services or something along those lines since this would generate a separate copay.

How to report interprofessional telephone/internet/electronic health record consultations

Psychologists now have a mechanism to provide and report interprofessional telephone/Internet/electronic health record consultations.

www.apaservices.org

 

[operaman]

One article I just read about these codes stated that the patient needed to give consent to consultative services or something along those lines since this would generate a separate copay.

How to report interprofessional telephone/internet/electronic health record consultations

Psychologists now have a mechanism to provide and report interprofessional telephone/Internet/electronic health record consultations.

www.apaservices.org

Yeah I saw that article in my digging. I think the consent rule is a Medicare thing and also applies to any sort of consultation.

Im not sure how closely they will scrutinize documentation on the ED side. If this becomes the sticking point I’ve got two possible solutions:

1) make sure the ED places formal consults whenever they call me

2) ask them if they have the patients consent to call me and then document that in my note and remind them to document it in theirs too.

I fully expect someone to complain eventually which I hope leads to some discussion about using on call surgeons as free backup radiologists.

 

[ThoracicGuy]

Yeah I saw that article in my digging. I think the consent rule is a Medicare thing and also applies to any sort of consultation.

Im not sure how closely they will scrutinize documentation on the ED side. If this becomes the sticking point I’ve got two possible solutions:

1) make sure the ED places formal consults whenever they call me

2) ask them if they have the patients consent to call me and then document that in my note and remind them to document it in theirs too.

I fully expect someone to complain eventually which I hope leads to some discussion about using on call surgeons as free backup radiologists.

Our radiology department is in a bit flux to say the least... I've been called on more than once to do quick reads on scans... Would be nice to get some RVU for it.

 

[Apollyon]

I’m still learning but that’s my approach so far! I’m just surprised nobody ever told me about these before - seems like I was leaving a lot of money on the table before.

My first guess would be "things not looked for are rarely found". If there's no light cast on it, and you haven't seen it before, you wouldn't know.

 

[operaman]

Our radiology department is in a bit flux to say the least... I've been called on more than once to do quick reads on scans... Would be nice to get some RVU for it.

Yeah we lost most of our good radiologists when admin wouldn’t budge on a stupid technicality in our comp plan that kinda screwed the DR guys. Basically our per rvu rate is pegged to national medians for our specialties, but this meant that IR guys reading scans were getting more per scan than the fellowship trained DR people reading those same scans. Sigh.

So we lost most of the good fellowship trained ones so between that and the nighthawk stat rads folks, you get some haphazard H&N scan reading!

I originally thought of billing the actual scan CPT code but with a -62 modifier, but then found these consult codes that are similar RVU but less likely to get shot down.

 

[Wordead]

Our radiology department is in a bit flux to say the least... I've been called on more than once to do quick reads on scans... Would be nice to get some RVU for it.

Dude why on earth would you take on the liability for this with no payment? That's bananas.

 

[ThoracicGuy]

Dude why on earth would you take on the liability for this with no payment? That's bananas.

It's only happened a couple of times, but it should be fixed shortly. A new group that is very capable is in the process of taking over. Right now we have a telerad group that is absolutely awful. So many wrong reads.

 

[HighPriest]

I think between myself and my partners, we’re calling our radiologists 1-2 times per week asking for corrections. If it’s not “hey, that thyroid isthmus: you means 5mm not 5cm, right? Because the patient is losing their mind and they have a totally normal exam” then it’s “could you take a look at image 146 on series 2 of the scan we did specifically to rule out vestibular schwannoma? That filling defect in the IAC? Do you think it’s possible that’s an acoustic neuroma? The read says “normal.” Or at one point: hey man, this normal facial CT that we got for facial trauma specifically:. I can’t be sure but I think there’s a comminuted, fully displaced fracture of the left mandibular ramus with cross bite and reduction in facial height. Could you double check that?”

And this isn’t a nighthawk service. I wish I got paid for re-reading.

 

[operaman]

I think between myself and my partners, we’re calling our radiologists 1-2 times per week asking for corrections. If it’s not “hey, that thyroid isthmus: you means 5mm not 5cm, right? Because the patient is losing their mind and they have a totally normal exam” then it’s “could you take a look at image 146 on series 2 of the scan we did specifically to rule out vestibular schwannoma? That filling defect in the IAC? Do you think it’s possible that’s an acoustic neuroma? The read says “normal.” Or at one point: hey man, this normal facial CT that we got for facial trauma specifically:. I can’t be sure but I think there’s a comminuted, fully displaced fracture of the left mandibular ramus with cross bite and reduction in facial height. Could you double check that?”

And this isn’t a nighthawk service. I wish I got paid for re-reading.

I feel like we must have the same folks working here.

“Hey this CT neck for right vocal fold paralysis that you read as normal, maybe it’s just contrast artifact but seems like there’s a large partly calcified mass in the right thyroid and adjacent level 3/4 nodes also with little calcifications - might that be something?” Our old radiologists used to appreciate those calls so they could amend the read, but now nobody even responds half the time.

I take some minor consolation in that under the new E&M rules, reading a scan usually gets you to at least a level 4 visit.

 

[maxxor]

I feel like we must have the same folks working here.

“Hey this CT neck for right vocal fold paralysis that you read as normal, maybe it’s just contrast artifact but seems like there’s a large partly calcified mass in the right thyroid and adjacent level 3/4 nodes also with little calcifications - might that be something?” Our old radiologists used to appreciate those calls so they could amend the read, but now nobody even responds half the time.

I take some minor consolation in that under the new E&M rules, reading a scan usually gets you to at least a level 4 visit.

I wish I could be as bad at my job as the reads you describe…wowowowowow

 

[ThoracicGuy]

I wish I could be as bad at my job as the reads you describe…wowowowowow

Many of our ultrasound reads just regurgitate numbers from the tech worksheet and give absolutely zero analysis on what those numbers mean. It's absolutely worthless.

 

[TeddyBoomBoom]

ugh. As an ER doc… this pains me. I’ve been following this thread for YEARS.

regarding ophtho:

I’m fairly worthless with a slit lamp, but would be willing to at least look for herpetic lesions, gross papilledema, etc, but not one of the multiple hospitals that I currently work at even has a working slip lamp. One of these is a site with 80-100k yr census. So fairly busy. feels bad man.

I realized a while back that the ophthalmologists really did not care about my bedside ultrasound of the potential retinal detachment. lol.


It’s important to me to have a collegial relationship between the ED and admitting and consulting teams.


My personal practice which has served me well:

- ANY patient I’m admitting or for whom I’m consulting surgery or an ancillary subspecialty gets at least a focused exam by me personally. That may sound obvious, but the signed out patient, the PA patients, resident patients if you have them, need to be seen 100% in the ED by the person making the phone call to the consult. Ideally a physician.

- Be truthful in the conversation. I have really tried to cultivate, over last few years, a culture of honesty between the emergency department, the hospitalist, subspecialist, etc. As an ER doctor, I found that when the other physicians trust that I’m giving them my actual, forthright opinion, instead of just trying to “dispo” the patient things go much smoother.

I am fortunate to work primarily at a site where we all play super well in the sandbox, and can’t hardly imagine some of these rediculous consults. I’m also a big fan of ordering a consult for the hospitalist but adding “pls call at 7am” for technically emergent but not actual emergent cases (well appearing appy/chole/etc that should maybe review the OR schedule but not at 4am.) I have no trouble waking ppl up for on call emergencies, but i also try to respect ppls sleep if I can. On the flip side, if I call a stat consult, the docs know I’m concerned, bc I rarely do so.

^^ Just one perspective of an ER doc

 

[eyeeye_captain]

From the ophtho perspective, EM folks are set up to fail on eye complaints. My residency had/has a well regarded EM program, but ophtho was a one week elective that had devolved into hang out with a first year resident and leave at lunch kind of vacation rotation. The mid-levels poaching all the eye stuff (which is already low volume) lead to them seeing basically nothing but trauma, and most of those were multi-system to some degree that minimized their chance to manage things. It’s tough to learn without any real world experiences.

Don’t get me started on crappy/nonexistent equipment at hospitals. Again kneecapping you guys, I’ve been there too.

I have more bones to pick with my optometry colleagues who have none of those barriers. I once had a referring “doctor” who exclusively used a camera they can’t interpret for “dilated” examinations. I can’t count the number of normal young patients checking their glasses who have been told they probably have cancer and came in freaking out.

 

[HighPriest]

ugh. As an ER doc… this pains me. I’ve been following this thread for YEARS.

regarding ophtho:

I’m fairly worthless with a slit lamp, but would be willing to at least look for herpetic lesions, gross papilledema, etc, but not one of the multiple hospitals that I currently work at even has a working slip lamp. One of these is a site with 80-100k yr census. So fairly busy. feels bad man.

I realized a while back that the ophthalmologists really did not care about my bedside ultrasound of the potential retinal detachment. lol.


It’s important to me to have a collegial relationship between the ED and admitting and consulting teams.


My personal practice which has served me well:

- ANY patient I’m admitting or for whom I’m consulting surgery or an ancillary subspecialty gets at least a focused exam by me personally. That may sound obvious, but the signed out patient, the PA patients, resident patients if you have them, need to be seen 100% in the ED by the person making the phone call to the consult. Ideally a physician.

- Be truthful in the conversation. I have really tried to cultivate, over last few years, a culture of honesty between the emergency department, the hospitalist, subspecialist, etc. As an ER doctor, I found that when the other physicians trust that I’m giving them my actual, forthright opinion, instead of just trying to “dispo” the patient things go much smoother.

I am fortunate to work primarily at a site where we all play super well in the sandbox, and can’t hardly imagine some of these rediculous consults. I’m also a big fan of ordering a consult for the hospitalist but adding “pls call at 7am” for technically emergent but not actual emergent cases (well appearing appy/chole/etc that should maybe review the OR schedule but not at 4am.) I have no trouble waking ppl up for on call emergencies, but i also try to respect ppls sleep if I can. On the flip side, if I call a stat consult, the docs know I’m concerned, bc I rarely do so.

^^ Just one perspective of an ER doc

We have ER docs like you. I know them by name. When they call me, I’m never irritated by it. Even at 3am. Sure, I don’t WANT to be called at 3am but I legitimately feel a little relief when I hear their name announced as the caller because I know either they have it figured out already but need me input or it’s an actual emergency.

Then there are the guys where I hear their name and automatically roll my eyes. It’s not even voluntary anymore.

 

[gensurgry]

2am
ED PA: "Hey I have a consult for trauma. This 30 yo F fell down a flight of stairs."

Me: "Ok, what injuries do they have? Looks like their scans show no injuries or fractures."

ED PA: "No injuries, just a lot of bruising, wondering if you could admit her to trauma?"

Me: "You want me to admit a patient to our service for bruising? Can she walk?"

ED PA: "Yeah, there's a lot of bruising all over her legs and arms etc. She can walk."

Me: Laughing at this point "Yep, no indication for admission to trauma, and I don't need to see her. Thanks."



New ED NP: "Hey can you see this patient for a vascular consult for acute limb ischemia? 75 yo lady with CHF, I cannot find distal pulses or doppler signals"

Me: "Is she complaining of leg pain, numbness, etc?"

ED NP: "No, she is walking around just fine."

Me: "Doesn't sound like acute limb ischemia then, but sure, I'll take a look later after I see some other consults." Walk by this lady in the ED. Her legs look like water balloons. Doppler signals intact. "No need for vascular consult, rec workup for CHF exacerbation."


-Burnt out PGY-3

 

[HighPriest]

2am
ED PA: "Hey I have a consult for trauma. This 30 yo F fell down a flight of stairs."

Me: "Ok, what injuries do they have? Looks like their scans show no injuries or fractures."

ED PA: "No injuries, just a lot of bruising, wondering if you could admit her to trauma?"

Me: "You want me to admit a patient to our service for bruising? Can she walk?"

ED PA: "Yeah, there's a lot of bruising all over her legs and arms etc. She can walk."

Me: Laughing at this point "Yep, no indication for admission to trauma, and I don't need to see her. Thanks."



New ED NP: "Hey can you see this patient for a vascular consult for acute limb ischemia? 75 yo lady with CHF, I cannot find distal pulses or doppler signals"

Me: "Is she complaining of leg pain, numbness, etc?"

ED NP: "No, she is walking around just fine."

Me: "Doesn't sound like acute limb ischemia then, but sure, I'll take a look later after I see some other consults." Walk by this lady in the ED. Her legs look like water balloons. Doppler signals intact. "No need for vascular consult, rec workup for CHF exacerbation."


-Burnt out PGY-3

How dare you! They’re equivalent providers!!!!