Consults- Memorable/Dismal/Ridiculous/Unique

[SLUser11]

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No one is blameless in this whole thing. Usually the consult is coming because the other team just doesn't know what to do. I can't count how many times medicine's been consulted for BS by surgery (or by psych) but we tend to be happy to see them because you guys need the help. Honestly, surgery should probably consult us more than they already do for normal inpatient management. You say you can deal with medical issues but in my experience it often isnt the case. Surgeons know the surgical stuff, medicine knows the medicine stuff, psych knows the psych stuff.

You say "surgery" is consulting you, but do you really mean orthopedics? If you mean general surgery, it would be nice to know where you are training, as that's not the national experience.

As far as "medicine knows the medicine stuff, psych knows the psych stuff," that's true to some degree, but this mentality can waste a lot of people's time. In the end, doctors should know the doctor stuff, and a lot of these things are basic medical care.

 

[SouthSideSteve]

This one a standard "breast mass" consult.

Only memorable because it came from "Dr. X, hospitalist".

Only significant because "Dr. X" is a nurse practitioner. Apparently the DNP has infiltrated even the backwoods of Arizona (this was a small town about an hour outside of PHX).

I would like to think this was addressed with the NP or administration. I'm an RN in PA school and that makes me sick.

 

[Instatewaiter]

You say "surgery" is consulting you, but do you really mean orthopedics? If you mean general surgery, it would be nice to know where you are training, as that's not the national experience.

As far as "medicine knows the medicine stuff, psych knows the psych stuff," that's true to some degree, but this mentality can waste a lot of people's time. In the end, doctors should know the doctor stuff, and a lot of these things are basic medical care.

I tend to lump you guys together. We tend to get more BS consults from ortho but general surgery is not immune. The gen surg consults tend to be for more reasonable things but there are always a handful of BS ones thrown in there.

Overall, where I am there tend to be fewer BS consults all around because the hospital tends to be one where the residents in every field like to deal with stuff themselves. We don't expect you all to to know how to deal with complex medical problems- advanced cardiomyopathy, brittle diabetes, anything with an EKG- just like you shouldn't expect us to to know how to deal with complex surgical ones. Now if I had an intern consult you guys for a line placement like someone said earlier in the thread, he wouldn't be walking right for a month. I'm sure it's very hospital dependent. We have some medicine residents rotate through Hopkins from other hospitals and the mentality is very different.

That said if a private attending asks us to consult for a ridiculous reason, I don't have a choice if I can't talk him out of it.

 

[SocialistMD]

I can't count how many times medicine's been consulted for BS by surgery (or by psych) but we tend to be happy to see them because you guys need the help. Honestly, surgery should probably consult us more than they already do for normal inpatient management. You say you can deal with medical issues but in my experience it often isnt the case.

Overall, where I am there tend to be fewer BS consults all around because the hospital tends to be one where the residents in every field like to deal with stuff themselves.

Which is it, captain?

 

[SLUser11]

I tend to lump you guys together. We tend to get more BS consults from ortho but general surgery is not immune. The gen surg consults tend to be for more reasonable things but there are always a handful of BS ones thrown in there.

Please don't lump us together for obvious reasons. If you are really gettin BS consults from the Johns Hopkins general surgery residency, I would love to hear some examples.

I am glad to hear that you guys do your own lines. I am sad to hear that you expect so little from your surgical colleagues, though.

My biggest problem with the practice of consulting everyone on everything is that it is a huge waste of time and resources. Instead, we should all take our collective heads out of our collective @#ses, and spend time learning basic triage skills for other areas of medicine. And, I don't care if it's Baltimore, Houston, or whatever...I think we need to work on our inter-specialty communication, which is just horrible.

This could easily degenerate into an IM vs surgery argument, which is used out. But, you have to admit that Tired's comment was funny.

 

[45408]

Got a dismal consult today. Patient was septic and had a large amount of free air in the abdomen. That wasn't noticed on the other plain films this morning though, because they were all supine. Turned the pt on her side for a lateral decubitus film and saw the most free air I've seen in a while. She was already in multi-system organ failure (with some pretty bad underlying problems), and after discussion with the family, her next consult was going to be with palliative care. We're not doing anything for her. Family was crying pretty hard...

The most dismal part was that she came in last night, and it's the one time they didn't call us...

 

[Instatewaiter]

Which is it, captain?

It's both- better than where I came from but much more than I would hope for.

Please don't lump us together for obvious reasons. If you are really gettin BS consults from the Johns Hopkins general surgery residency, I would love to hear some examples.

I'll post some next time I'm on a consult service.

This could easily degenerate into an IM vs surgery argument, which is used out. But, you have to admit that Tired's comment was funny.

It was funny. I chuckled a bit.

I doubt he'd have the balls to say it to my face. And if he did, I doubt he'd have balls for much longer.

 

[smq123]

This one a standard "breast mass" consult.

Only memorable because it came from "Dr. X, hospitalist".

Only significant because "Dr. X" is a nurse practitioner. Apparently the DNP has infiltrated even the backwoods of Arizona (this was a small town about an hour outside of PHX).

I was driving through some podunk town in either Arizona or Utah....saw a sign for someone who is an "optometric physician." Which I suppose is a fancy way of saying "Optometrist." 🙄

 

[skiz knot]

I think my biggest beef is the BS dumps. Patient comes in with a femur fracture after a fall and their normal, stable medical issues- how does that come to medicine? I'm pretty sure giving insulin and antibiotics isn't going to fix the leg. I really would love to meet the first person to do the first successful dump. They must have been a genius.

People that "(come) in with a femur fracture after a fall" aren't healthy individuals, period. That is why they, one, fell, and two, broke their femur (you probably are referring to a hip fracture). They have a multitude of comorbid medical conditions and a low physiolgic reserve. 25% percent will be dead in a year, and 1/3 of those within 30 days. They will undergo a major orthopaedic surgery associated with a fair amount of blood loss and will be (relatively) immobile for some time afterwards. "giving insulin and antibiotics" isn't going to fix the leg, but it will keep the patient healthy. Frankly, in orthopaedics, we are not trained to necessarily recognize or appropriately treat medical conditions. We focus our training on disorders of the peripheral nervous and musculoskeletal systems. That keeps us plenty busy. We can not be efficient if we have to manage issues outside of our specialty. Would you want your parent managed medically by an orthopod?

J Bone Joint Surg Am. 2010 Apr;92(4):807-13.
Use of medical comorbidities to predict complications after hip fracture surgery in the elderly.
Donegan DJ, Gay AN, Baldwin K, Morales EE, Esterhai JL Jr, Mehta S.
Source
Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 2 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA.
Abstract
BACKGROUND:
Comorbidities before and complications following hip fracture surgery can impact the return of function. We hypothesized that the American Society of Anesthesiologists (ASA) classification of medical comorbidities is a useful surrogate variable for the patient's general medical condition and would be a strong predictor of perioperative medical complications following hip fracture surgery.

METHODS:
A retrospective review of the cases of 197 elderly patients who had undergone operative management of a hip fracture was performed. The ASA class, data regarding perioperative medical and surgical complications, and demographic data were obtained. Medical complications were defined as those requiring intervention by an internist or medical specialist. Differences in complication rates among the ASA classes were determined.

RESULTS:
Medical complications were more common in patients in ASA class 3 (p < 0.001) and those in class 4 (p = 0.001) than in those in class 2. Patients in ASA class 3 had a 3.78 times greater chance of having a medical complication than did those in class 2 (p < 0.001). Patients in ASA class 4 had a 7.39 times greater chance of having medical complications than did those in class 2 (p = 0.001). No significant relationship was identified between the ASA class and surgical complications.

CONCLUSIONS:
The ASA class is strongly associated with medical problems in the perioperative period following hip fracture surgery in the elderly. Patients identified as being at higher risk (in ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion.

 

[skiz knot]

Why? Because shut up and admit the patient, that's why.

😀

Stupid medicine residents don't realize that the only way they make money when they get out is by managing the "stable" ortho patient post op.

 

[chael]

not the worst ever, but kind of annoying

Got consulted at the VA (where I'm the only resident and not in-house) by medicine to come see an "elbow wound" on a patient that "fell on their elbow a week ago"

Me: so, what is it, just an abrasion? if its a simple abrasion, you can probably just put some baci and xeroform on it and it'll be fine. is there something concerning about the wound? what about the wound necessitates a consult from plastic surgery?

Medicine resident: we can't get ahold of the wound nurse because she's on vacation. Its a wound, and I'm not comfortable with wounds, and since no one has looked at it, we need you to come see it.

the guy had an abrasion that was 95% healed, with an ~ 1x1cm scab. literally, a f---ing scab. my mother could have treated it.

 

[maxheadroom]

the guy had an abrasion that was 95% healed, with an ~ 1x1cm scab. literally, a f---ing scab. my mother could have treated it.

Received lots of these at one point. Annoying.

 

[Dr.LeoSpaceman]

Frankly, in orthopaedics, we are not trained to necessarily recognize or appropriately treat medical conditions.

That's a defect in training, then.

 

[45408]

Honestly, surgery should probably consult us more than they already do for normal inpatient management. You say you can deal with medical issues but in my experience it often isnt the case. Surgeons know the surgical stuff, medicine knows the medicine stuff, psych knows the psych stuff.

Managing the medical issues in a surgical patient is not the same as managing the medical problems in a medical patient.

 

[skiz knot]

That's a defect in training, then.

I disagree. Do you know what to do for a young patient with an irreparable rotator cuff tear? It is a surprisingly common condition. Since you don't know what to do, it must be a defect in your training.

 

[DHT]

That's a defect in training, then.

I agree. I think to eliminate all the defects in training that we combine all specialties into one. We'll call it MedicoSurgical Radiopathology. Its a 30 year residency, but at least at the end you will be a complete doctor without any defects in your training.

 

[Dr.LeoSpaceman]

I disagree. Do you know what to do for a young patient with an irreparable rotator cuff tear? It is a surprisingly common condition. Since you don't know what to do, it must be a defect in your training.

It's a suprisingly common condition that I never saw nor treated in medical school, then. On the other hand, I saw inumerable patients with diabetes and hypertension. Enough that I'm perfectly capable of restarting their home meds, monitoring their pressures and sugars, and titrating as necessary while they're an inpatient. Managment of stable, chronic medical conditions shouldn't be impossible for a surgeon. It just takes a bit of thought.

Now for people that have exacerbations of their chronic problems that require more than tweaking or the long term mangement of a newly diagnosed medical condition, asking for help from the people that will be managing that condition once they're an outpatient does seem appropriate. But it also doesn't require a transfer to their service. Calling the internal medicine team on the way out of the PACU is the same as the "just wanted to get you on board" consults I'm sure everyone else hates. Either the person has pathology that you need help managing or they don't--making them show up on a consult list "just in case" is a waste of someone's time (excpetions to be made in community/private systems where PCP consults are routine as a matter of reciprocity).

Recently I admitted a trauma that ended up having isolated facial fractures and a history of etoh use. ENT is going to take him to the OR, but balked at taking him on their service because "he might withdraw". That's absolute nonsense. I have become more jaded about this since neurosurgery, ortho, ENT, etc. treat the trauma service as something of the surgeon "internists".

 

[Pir8DeacDoc]

Recently I admitted a trauma that ended up having isolated facial fractures and a history of etoh use. ENT is going to take him to the OR, but balked at taking him on their service because "he might withdraw". That's absolute nonsense. I have become more jaded about this since neurosurgery, ortho, ENT, etc. treat the trauma service as something of the surgeon "internists".

That's complete non-sense. I could be wrong but I think at my institution we (ENT) treat more people with EtOH withdrawal than any other service. Basically every big wack we do goes through DT's, it just comes with the territory.

 

[ZagDoc]

That's complete non-sense. I could be wrong but I think at my institution we (ENT) treat more people with EtOH withdrawal than any other service. Basically every big wack we do goes through DT's, it just comes with the territory.

Second this. You can't treat head & neck cancer without being comfortable treating EtOH withdrawal... I'd say about half our head & neck patients go through some post-operative withdrawal whether its tremulousness, HTN, or a day or so of tachycardia (and a higher percentage of the advanced cancer/bigger whacks). We have 3 patients on service right now on CIWA. Don't know what that resident was smoking that night... but seems like alot of anecdotes in this thread are being broadened to characterize entire fields (though thats half the fun 😀)

 

[dpmd]

That's complete non-sense. I could be wrong but I think at my institution we (ENT) treat more people with EtOH withdrawal than any other service. Basically every big wack we do goes through DT's, it just comes with the territory.

Not every ENT does big wacks though. One of our guys does everything and would be comfortable admitting patients to the floor (no step down or ICU admitting privileges). The other does mainly T+A's, face pus, and fractures and doesn't admit anyone to his service if he can help it (not defending the practice)

 

[Pir8DeacDoc]

Not every ENT does big wacks though. One of our guys does everything and would be comfortable admitting patients to the floor (no step down or ICU admitting privileges). The other does mainly T+A's, face pus, and fractures and doesn't admit anyone to his service if he can help it (not defending the practice)

I assume in an academic center with ENT residents, there should be someone on the ENT service who can manage detox. I know not all ENT's do big wacks, but someone can manage that pt if they really wanted to. Dumping on another service like that is lame. We as surgical sub-specialists should do our part to unload the trauma service for the folks that need them. Just my .02 🙂

 

[dpmd]

I assume in an academic center with ENT residents, there should be someone on the ENT service who can manage detox. I know not all ENT's do big wacks, but someone can manage that pt if they really wanted to. Dumping on another service like that is lame. We as surgical sub-specialists should do our part to unload the trauma service for the folks that need them. Just my .02 🙂

Like I said I wasn't defending the practice. Even though he doesn't have ENT residents, he does have a PA to help him out. As interns we were the ones receiving the consult and having to tell the ED to call medicine to admit was not fun.

 

[jdh71]

Aw, you went and cited one of the studies. What are you doing? If they know that 'pods are smart, and have evidence to back up pretty much everything they do (unlike, for example, Medicine), the whole "We're too dumb to manage the patient ourself" line stops working.

Besides, didn't you read the other thread in this forum? Orthopaedists are the least "cerebral" of all the specialties.

Stick to the script: Orthopods aren't smart enough to manage medical comorbidities. Plus it cuts into gym time, and I think the game just started on ESPN. Did you just fart? Seriously bro, you gotta help us out with this, because Medicine residents are just so much smarter than us. Didn't you hear that our residency interview process is just like the NFL combine? All we do is bench, and whoever pushes the most weight gets a slot.

If you don't stick to the script, we're going to have to start explaining that the "medical" versus "surgical" distinction is really bunk, that many patients actually require attention to both areas, and that when we work together patients actually do better. I know it's obvious to people like us (which is why, for example, we don't expect Medicine teams to do an ORIF on "their" medical patients that fall out of bed in the hospital). But that level of logic and common sense will completely destroy the reputation of the specialty.

I totally saw what you did there, and it's kind of funny . . . stereotypes do exist for some kind of reason, do they not?

The bottom line for me and the ortho service, especially ortho residents, is that some of the smartest freaking people in medical school go into ortho by simple virtue of the gardes and boards scores necessary to secure a match these days, then to turn around with a straight face and try and tell me, medicine needs to admit YOUR "needs to go to the OR sometime during this admission" fracture because they are on two blood pressure medications . . . Dude come on. You can piss on my back, just don't insult my intelligence by trying to tell me it's raining. I never balked at admitting a real gomer with an ortho issue, usually a hip fracture. You guys are smart enough to know the difference - all the protein shakes can't be going to your head, can they?

 

[jdh71]

(2) Regardless of how the residents feel about it, these types of specialty relationships are set by the staff. If Medicine *really* didn't think it should go their service, there would be a sit-down between department heads and the issue would be settled. The residents can get worked up all they want on both sides, but as long as the Medicine staff is comfortable taking these patients, that's how it will continue to be.

(3) At some institutions, basically all the Ortho patients go to Medicine. That's just how it is. I have never understood why, in facilities like that, the Medicine R2s continue to bitch and moan and fight. Just like with consults, if you know that you're going to take the patient, just shut up and take the patient. The perpetual whining just makes them look stupid. Hence the frequent "tool belt" jokes when the surgical teams see Medicine rounding...

I think you would be wrong about medicine staff being able to block ortho admits, even if they wanted to (some do, and others just don't care enough anymore - no one is happy about it). Politics man, directly related to money. Ortho, and any other service that actually makes money for a hospital, usually CT-surg and cardiology, get to do whatever they hell they want, and everyone else simply has to put up with it. We bitch and moan because it's garbage and the attitude of "shut-up and take it" doesn't really help much - if you're gunna get raped, lay back and try and enjoy it? ENT and urology are starting to do this stuff too. It seems like a lot of it is that you'd like us to do all of the heavy lifting, while you simply do your fun little thing and then bail. This is one of the reasons I've always appreciated GS, they at least attempt to take care of their patients and consults to medicine at all the places I've been have been few and far between. I've never had to admit a surgery patient for them, even if the patient was a gomer. I do think it's a deficiency in your training, but one you may argue doesn't matter, because, at least as long as you're allowed your bad behavior, and always will, what's the point?

At least call a spade a spade.

 

[VA Hopeful Dr]

You never saw a rotator cuff tear as a student? Or anywhere else? There is zero chance that is true. More likely you just don't know how to evaluate shoulder complaints, and consulted it off to Ortho or Sports Med.

Deficiencies in training...very amusing.

Never saw one either. It is (or should be by now) well known that MSK pathology is the most neglected area of medicine during med school.

 

[Rollo]

Just wanted to comment that on my Peds rotation couple months back, we saw a 18 year old with anterior labral tear who was being managed by orthopedics. Credit to my attending, she went ahead and evaluated him clinically with range of motion testing.

At the end though, there wasn't much that the pediatrician did or could do except told the patient to keep following it with the orthopedic surgeon.

 

[McGillGrad]

Just wanted to comment that on my Peds rotation couple months back, we saw a 18 year old with anterior labral tear who was being managed by orthopedics. Credit to my attending, she went ahead and evaluated him clinically with range of motion testing.

At the end though, there wasn't much that the pediatrician did or could do except told the patient to keep following it with the orthopedic surgeon.

Not much ortho can do that PM&R couldn't do better...at least for conservative treatment.

 

[michaelrack]

Not much ortho can do that PM&R couldn't do better...at least for conservative treatment.

A good physical therapist is also helpful

 

[SLUser11]

The fact that the curriculum neglects it doesn't mean you never saw a case. You probably just didn't know what it was. Based on my experiences as an MS3, it likely went something like this:


Patient: I'm here for my blood pressure check. Also I've noticed that I have this pain in my shoulder when I lift my arm.

Attending: Okay, well you BP looks good today, I don't think we need to adjust your medicine.

Patient: Great. But what about my shoulder? It's making it hard to hang up my clothes when I do laundry.

Attending: I'm sure you just sprained it or something. Try taking some Tylenol. See you in 3 months.

That may be true in some places, but it's not a universal truth. The FPs in St. Louis and Wichita did a pretty good job with sports medicine.

Otherwise, I think you and JDH both make good arguments, and neither of you are clearly right or wrong. Of course, in general surgery we're pretty busy, and we work very long hours, but we still find time to learn medical management of surgical patients.

It has less to do with the complexity of orthopedics, and more to do with the culture of orthopedics.

My guess would be that if you treated the fleas a little better, and acted more thankful for their contribution, they wouldn't be as butt-hurt over the relationship.

Also, nobody really thinks that the orthopods are clever foxes tricking us into thinking they are simple and incapable, so they need to be rescued from their incompetent patient care. At the same time, nobody thinks that orthopedics is so detailed and complicated that all other areas of medicine must be abandoned to make room.

 

[jdh71]

I think this is the prevailing opinion among the medical services, but it's also kind of dumb. Do you really think that Orthopaedic Surgery is just some "fun little thing"? Believe it or not, it's pretty involved stuff, both intraop and post-op. Then couple that with the pretty large volume most Ortho services maintain. It's no accident that the 80hr work week was kind of shrugged at by Medicine, but sent Orthopaedics into a spiral of fear and despair. We don't do 100+ per week for fun; we do it because we have that much work, even without managing medical issues.

Here's my question: Medicine is a primary care field; Ortho is a specialty service. You would never expect your Orthopaedic Surgeon to manage your diabetes or hypertension as an outpatient; hell, you'd probably call that irresponsible and borederline malpractice. So what changes the moment you get admitted? One could argue that these "routine" medical problems become high-risk conditions once you're an inpatient, given the stresses imposed on the body by an injury and surgical correction. Once upon a time, primary care doctors also managed their patients when they were admitted. Now everyone wants hospitalist services so they don't get called on weekends. But that doesn't mean that the surgical services are responsible for picking up primary care patients, just so the hospitalists can keep their patient load lower.

I'm not arguing that Ortho (and everyone else) doesn't abuse this system. I know it happens, and as an intern it embarrassed me to no end calling Medicine for a lot of these admits. At the same time though, the attitude of "you should remember how to treat that from medical school" is pretentious and annoying. We take an endless stream of consults for mechanical low back pain, patellofemoral syndrome, rotator cuff tendonitis, and any other number of non-surgical diagnoses that a well-trained nurse could easily diagnose and manage. Our clinics are filled with this, and many private groups employ at least one "fellowship-trained in Sports Medicine" FP to screen out and manage the non-surgical cases. It's a commentary on the inadequacy of the primary care (IM and FP) residency education that musculoskeletal management (50% of primary care visits, according to several studies) requires a one-year fellowship to be competent at it.

So basically yeah, I know Ortho sucks when it comes to this stuff. But don't forget that you guys suck too; we just complain about it less.

I wasn't really trying to put down what it is that you guys do, surgically, and I wasn't actually insisting you guys take care of all the medical issues, though I can see how it did sound a little like that. As much as you guys dislike our weakness is MSK, which is generally true (outliers notwithstanding), we dislike your general medicine weakness, and acknowledge why you need our help. In the end it probably ends up being better for patients, especially gomers. I think it's just kind of hard to stomach knowing you're another service's bitch.

FWIW, I never sent an out-patient shoulder, knee, or carpel-tunnel to you guys without an exam, study finding, and an assessment patient could tolerate surgery, AFTER trying other measures first.

 

[LucidSplash]

Ortho, unlike Gen Surg, does not have dedicated non-operative months learn/practice general medical management.

While I agree with many of the points you make, I have to say that you DO have these months - when you are interns alongside the general surgery interns. This is a large part of the time we spend learning to manage these things. In fact, other than critical care (which ortho interns must do as well), I don't have "dedicated non-operative months" where I learn nothing but medical management. I learn all of this in the course of my day as a general surgery junior resident. In fact, at least where I am, ortho interns have more exposure to "general medicine" than the surgery interns as they rotate on rheumatology and emergency medicine (in addition to their 6 months of surgery and ICU rotations).

I can't speak for programs elsewhere, but there are basics (how to write for AC & HS spot glucose checks with an insulin sliding scale) that we learn/know as surgery interns, that I know the ortho interns learn, that they magically disremember as soon as they become PGY-2s. My ortho colleagues are a hard-working bunch and I am not denigrating their work ethic. I agree with the comments that it is more about culture than anything else.

 

[45408]

Here's my question: Medicine is a primary care field; Ortho is a specialty service. You would never expect your Orthopaedic Surgeon to manage your diabetes or hypertension as an outpatient; hell, you'd probably call that irresponsible and borederline malpractice. So what changes the moment you get admitted? One could argue that these "routine" medical problems become high-risk conditions once you're an inpatient, given the stresses imposed on the body by an injury and surgical correction.

I'd argue that those "routine" medical problems that become high-risk after surgery are best managed by someone that manages medical problems in surgical patients, not someone who manages medical problems in medical patients. When we have hospitalists following our general surgery patients, they often make suggestions that are inappropriate in light of the recent operation. I've found that they often do a terrible job of resuscitation of patients with abdominal catastrophes that go unnoticed. Some of that is institution-dependent (at my hospital), so I can't comment on what it's like everywhere else.

Of course. But that culture is one where training is performed with a high volume of highly-complex cases. Ortho, unlike Gen Surg, does not have dedicated non-operative months learn/practice general medical management. The structure of the surgical subspecialties is (gasp) specialty-focused. Gen Surg is the outlier here, for reasons I still don't fully understand. Dedicate some time in the residency to training Orthopods in medical management.

You had no rotations in your intern year dedicated to things other than just orthopedics or other surgical subspecialty?

Other than one month of ICU as a PGY-2, I have no dedicated time from PGY2-5 to anything other than a procedures/operations (e.g., I have time dedicated to GI/endoscopy, but that's because we have to do nearly a hundred endoscopies to graduate now).

 

[skiz knot]

For all the medicine people that complain that ortho dumps everything on them, they should realize a few things.

In their own training model, they would never let an intern in their 4th month of residency primarily manage an inpatient without oversight, as they do not have the knowledge base, or skill set to appropriately diagnose or treat medical issues. Not to say that they won't have them take call, but there is always an upper level on backup.

As a 4th year orthopaedic resident, I have had less than 4 months of "general" medical training in residency. 12 minus 3 months ortho, minus 1 month PRS, minus 1 month ER (sewing lacs, seeing trauma and ortho patients in a very busy ER, minus 1 month Ped surg, minus 2 months of trauma floor patients (otherwise healthy young people for the most part). That leaves some GSurg and vascular VA and VA SICU time (which in our institution was SICU in name only). We have attendings that have had the same level of training.

If they think we never manage "general medical problems" then they should look at our trauma census at the county hospital. Believe it or not, a large number of our patients have a multitude of comorbidities. At least in our institution, we admit and manage the MAJORITY of patients, inlcluding those that eventually withdraw, have HTN/DM/Stable or undiagnosed CHF/RA/CRI/PVD/CAD/septic joints/Hip Fractures/Femur or Tibia fractures, etc... When the patients have several of these issues concurrently, is when we get medicine "on board". To them, they are often routine issues, and to be honest, ultimately the majority of the time there is no specific issue that needs medical management. That does not, however, mean they don't benefit from medical management, as we lack the experience and expertise. The ortho service doesn't have "Caps" on their census. Summer months it is routine to have a 40-60 person census for a 4 man team, in addition to our elective surgery schedule. How are we supposed to provide adequate care for those patients if we are managing "sick" people.

We do not see this issue from the GSurg trauma service. They will take isolated ortho high energy trauma onto their service "for a day or two" before transferring to our service. However the equivalent does not exist for elderly people and patients with multiple medical comorbidities. They frankly "go down hill" quickly, and we appreciate appropriate medical management.

I'm sure in some institutions Medicine gets "dumped on" worse than where I am training. What tires me the most is Medicine bitching that we consult them, not necessarily asking them to admit. In fact we have a few recent deaths of elderly patients on the ortho service where the medicine team did the passive-aggressive early sign off on patients that "(did) not have any active general medical problems." Preventable? Who knows? Childish on the medical team's part? IMHO, yes.

I understand that their services are overworked, however, if, as they say, these patients are so easy to manage, they should look at them as a blessing of easy labor, lowering their census of difficult patients.

 

[maxheadroom]

I think most people in the field tend to be acutely aware of their medical shortcomings. My experience has been that Ortho interns are far more capable of performing medical management than most residents/attendings, and everyone up and down the chain knows it. Medical management isn't hard, as long as you keep up on the literature, read the periodic drug warnings, follow national guidelines, and keep abreast of current controversies. How often do you think the surgical subspecialty residents do that? Yes, I did a month with IM 4y ago when I was an intern. Yes, I honored my MS3 IM rotation. Neither of those things make me competent at managing anything other than the most routine medical issues in an inpatient setting.

This sums it up. As you become a surgical specialist, there are a whole bunch of "basic" medicine that you don't keep up on and probably aren't the best guy around to handle. Heck, the first three years of my training were GenSurg heavy and I've forgotten a whole bunch of general medical stuff in the last five years.

 

[jdh71]

There is a persistent undertone to this discussion that "admitting" the patient is some kind of monumental task, requiring a whole lot of work that Ortho just wants to avoid. But the actual mechanics of serving as the "primary team" is pretty basic, especially in most of these patients. Dictate an H&P, spend a few minutes rounding, and as long as their stable dictate a discharge note that says, "See Ortho notes for details of care." It's really not a big time-suck, nor is it much work.

If it's not a "big deal", then you do it. We'll consult. 😉

 

[Quinn1988]

I recently got paged by an pedi ER attending on a patient without a surgical problem because "I saw in the computer that you guys saw her last time"

WTF does that rationale for the consult have to do with anything? By that logic, that pedi ED may as well consult the physcian who delivered her at birth since they too saw her last name. Would not be surprised if that attending would try to consult ENT for a pt with a sore throat that just had their tonsils removed in the last couple days....

 

[skiz knot]

Would not be surprised if that attending would try to consult ENT for a pt with a sore throat that just had their tonsils removed in the last couple days....

I would think that if the pain was enough to bring them to the ER, then a ENT consult post tonsilectomy would be in order.

 

[LucidSplash]

Now that we've beat that horse dead...

New least favorite consult scenario: simultaneously starting Xigris and consulting surgery for "rule out intra-abdominal catastrophe/necrotic bowel."

Thankfully, source of patient's sepsis was not amenable to surgical intervention...

 

[LucidSplash]

What a depressing way to put it.

True, that sounds bad.

Amended: "Thankfully, the source of the patient's sepsis was appropriately treated with medical interventions and was not a catastrophe requiring surgical intervention."

 

[ZagDoc]

I would think that if the pain was enough to bring them to the ER, then a ENT consult post tonsilectomy would be in order.

Except you would be surprised how very, very often this happens. We courtesy consult on all of these since it is our attending's patient, but 99% of the time we have nothing else to offer that the ED hasn't already done.

We do have a department policy that we don't consult on post-tonsillectomy issues done by surgeons in the community, unless its active bleeding. Everything else, they are told to follow-up with their surgeon who did the operation.

 

[Pir8DeacDoc]

Except people come back to the ER all the time after tonsillectomy, instead of touching base with us and letting us help them out. Only rarely do they truly need to be there for rehydration, anti-emetics, IV pain meds. We generally do not see these kids unless there is bleeding. We have our nurse touch base with them the next day to reaffirm all the stuff we told them when we did the procedure.

 

[SLUser11]

The thing that drives me the most insane - as either a consult resident or the one consulting another service - is the passive aggressive chart wars that medicine residents seem so eager to get into.

It's like a freaking flame war in a chat room, and it is so unprofessional. Drives me insane. If you have a question or a concern - page me/call me...I will be happy to talk to you and try to figure out what the right thing to do for the patient it...don't leave a note in the chart undermining or questioning my decision making without ever saying a word to me.

If it bothers you, I would recommend routinely contacting them when they write crap like that in the chart. Page them and discuss it. Don't wait around for them to page you.

The only time I shared charts with IM residents in the past was when we operated on one of their patients. After an operation, surgery usually ran the show on the patient. When the IM residents disagreed with our management, it was usually because they didn't understand the surgical side of the patient's care. Sometimes they needed a little help to break their tunnel vision, and then we were on a similar page.

 

[blue2000]

This reminds me of a time when as a junior we'd gotten consulted by cardiology (I think cards transplant) at midnight for a VERY soft reason (belly pain with normal labs, a wound, somethings pretty clearly nonurgent) at midnight. My chief came in from home, dutifully assessed the patient...and then called the cardiology attending at 2 in the morning to reassure them that his patient didn't have a surgical issue. Of course the cardiology attending had been deeply asleep. It was passive aggressive, but I loved it.

One of the things we suffered from in residency was what appeared to us to be a lack of supervision by medicine attendings of the medicine residents overnight. A medicine patient, or a MICU patient, would be going down the tubes, and we'd get involved, mainly because the MICU "senior" (R2) was overwhelmed and trying to load the boat. It felt pretty crappy to wake our attendings up in the middle of the night to staff bogus consults at 3 in the morning, when the medicine attending was asleep in their bed (our chairman's policy was that all consults got staffed with an attending within an hour of being seen). Our department finally said that surgery residents would not see overnight consults until a medicine attending okayed it. Weirdly, the number of crazy unnecessary consults went way, way, down.

 

[elr1983]

If it bothers you, I would recommend routinely contacting them when they write crap like that in the chart. Page them and discuss it. Don't wait around for them to page you.

The only time I shared charts with IM residents in the past was when we operated on one of their patients. After an operation, surgery usually ran the show on the patient. When the IM residents disagreed with our management, it was usually because they didn't understand the surgical side of the patient's care. Sometimes they needed a little help to break their tunnel vision, and then we were on a similar page.

Do you guys not routinely contact the team of the patient you're consulting on to talk about the patient and your recommendations after doing the initial consult? At our hospital, all the medical subspecialty services ( ie cardiology, GI, ID, endocrine, etc) find the resident team after doing the initial consult and talks with them about the patient (not so hard to do, given that we have geographic teams and workrooms) and their recommendations. Surgical services do it more often than not, but not 100% of the time. I see how this would be less feasible 1) outside of academia when you're running from place to place 2) if the primary team was hard to locate, but it actually works out well at our hospital having now seen it as a resident and now as a consultant.....that way the primary team gets to learn a little, the consulting team gets a clear(er) question.

 

[maxheadroom]

This reminds me of a time when as a junior we'd gotten consulted by cardiology (I think cards transplant) at midnight for a VERY soft reason (belly pain with normal labs, a wound, somethings pretty clearly nonurgent) at midnight. My chief came in from home, dutifully assessed the patient...and then called the cardiology attending at 2 in the morning to reassure them that his patient didn't have a surgical issue. Of course the cardiology attending had been deeply asleep. It was passive aggressive, but I loved it.

One of the things we suffered from in residency was what appeared to us to be a lack of supervision by medicine attendings of the medicine residents overnight. A medicine patient, or a MICU patient, would be going down the tubes, and we'd get involved, mainly because the MICU "senior" (R2) was overwhelmed and trying to load the boat. It felt pretty crappy to wake our attendings up in the middle of the night to staff bogus consults at 3 in the morning, when the medicine attending was asleep in their bed (our chairman's policy was that all consults got staffed with an attending within an hour of being seen). Our department finally said that surgery residents would not see overnight consults until a medicine attending okayed it. Weirdly, the number of crazy unnecessary consults went way, way, down.

We had a similar issue when I was a junior resident that centered around Central Lines. It was the inevitable midnight call for a line from the MICU every couple of nights. Our attendings eventually said that the ICU staff had to start doing their own lines.

 

[SLUser11]

Do you guys not routinely contact the team of the patient you're consulting on to talk about the patient and your recommendations after doing the initial consult? At our hospital, all the medical subspecialty services ( ie cardiology, GI, ID, endocrine, etc) find the resident team after doing the initial consult and talks with them about the patient (not so hard to do, given that we have geographic teams and workrooms) and their recommendations. Surgical services do it more often than not, but not 100% of the time. I see how this would be less feasible 1) outside of academia when you're running from place to place 2) if the primary team was hard to locate, but it actually works out well at our hospital having now seen it as a resident and now as a consultant.....that way the primary team gets to learn a little, the consulting team gets a clear(er) question.

I'm only going to speak about my residency experience, as my current practice in Houston is variable, and the level of communication here leaves something to be desired.

As a surgical resident, I would routinely contact consulting teams to relay information. As I became more experienced, I would discriminate the level of needed feedback based on the content of the consult itself. Any time I wrote important orders, changed the level of care, or planned an operation, I would notify the primary team.

If it was a resident-run team, I would typically contact the resident that called me. Otherwise, I'd call the chief resident when appropriate. If it was an ER consult, I would already be down there, so I'd just talk to the ER doc about our plan briefly, and then let him know the patient's disposition.

There are three main reasons that I did this:

1. It enhances the level of communication, hence limiting misunderstandings and incorrect assumptions, and ultimately leading to better patient care.

2. It helps educate the consultant. Many of them have no idea that their consult is BS (or non-urgent). If they do know it's BS, and they call me at 2am anyway, then I spread the fun around a little.

3. If you treat consulting physicians poorly, it can reflect poorly on your service and your attending physician. Since I trained in a community hospital, those docs have a choice who they consult, and they simply won't use you (or your boss) if you're a jerk. Being nice and giving feedback is ultimately good for business.

 

[maxheadroom]

1. It enhances the level of communication, hence limiting misunderstandings and incorrect assumptions, and ultimately leading to better patient care.

2. It helps educate the consultant. Many of them have no idea that their consult is BS (or non-urgent). If they do know it's BS, and they call me at 2am anyway, then I spread the fun around a little.

3. If you treat consulting physicians poorly, it can reflect poorly on your service and your attending physician. Since I trained in a community hospital, those docs have a choice who they consult, and they simply won't use you (or your boss) if you're a jerk. Being nice and giving feedback is ultimately good for business.

As always, SLUser is a wise man. Listen to him, young Padawans.

 

[Buzz Me]

A medicine patient, or a MICU patient, would be going down the tubes, and we'd get involved, mainly because the MICU "senior" (R2) was overwhelmed and trying to load the boat...Our department finally said that surgery residents would not see overnight consults until a medicine attending okayed it. Weirdly, the number of crazy unnecessary consults went way, way, down.

PGY-2 Medicine residents would be calling consults at midnight without their attending being informed? That's weak.

 

[Guile]

PGY-2 Medicine residents would be calling consults at midnight without their attending being informed? That's weak.

Know how to fix that really fast? See the consult, call the resident, discuss your plan and recommendations. Then say, "okay, now I'm going to give your attending a call, too" which they will of course protest because he's sound asleep. Then call the medicine attending at home and talk about the consult.

 

[Dirt]

Do you guys not routinely contact the team of the patient you're consulting on to talk about the patient and your recommendations after doing the initial consult? At our hospital, all the medical subspecialty services ( ie cardiology, GI, ID, endocrine, etc) find the resident team after doing the initial consult and talks with them about the patient (not so hard to do, given that we have geographic teams and workrooms) and their recommendations. Surgical services do it more often than not, but not 100% of the time. I see how this would be less feasible 1) outside of academia when you're running from place to place 2) if the primary team was hard to locate, but it actually works out well at our hospital having now seen it as a resident and now as a consultant.....that way the primary team gets to learn a little, the consulting team gets a clear(er) question.

I have seen marked differences in the few places I have rotated.

At the academic place, it was rare to interact outside of the chart. In fact, the majority of the information sharing was from the top down to one medical student, who then talked to his buddy on the consulting team, who then relayed information back up the ladder. Horribly inefficient and frankly bad for patient care.

At the nice community place, every resident had a phone (not to mention a wonderful EMR), and conversations happened regularly, just a quick "hey, here's the deal". It honestly helped the patients out, and made for far less work on the part of the residents. It is truly amazing how much time is wasted trying to decipher what is scribbled in charts, or having to get a hold of the resident, who needs to get a hold of the attending and then get back to you, all with pagers and land lines.

The moral of the story for me is that EMR and things such as phones for residents will play a large role in my evaluation of places for residency.