Dealing with EM bashing

[Dirae]

Long time lurker, and have followed the forums for a long time, but never registered. Figured I would register to vent some.

I know similar threads have been posted but looking for how individuals deal with it, and hopefully some reassurance that it improves at least some once an attending or in a smaller community rather than a lvl 1 trauma academic center.

I'm a PGYII. I used to get along great with the IM folk, and went to school with several of the IM residents at my hospital. More recently however, I'm getting more and more flak and bashing. Ran into an IM friend who asked what was up. I said something about having resuscitated a patient, intubated, started a line, started Abx on a septic pneumonia. His response was, so.... you intubated them then actually called ICU to do the work? Are they another 90 year old that is just going to die anyways? As I left he said go intubate more people that dont need it! Thing is maybe he was having a bad day but all the other IM people chimed in too. (Of course I did walk into the lounge, which is normally only occupied by IM residents)

I didn't say anything and walked away but my thoughts in my head were: what do you want me to do? Sorry Mr. X, I didnt intubate your mother because I figure she'll die anyways, so I just left. Or, Let me keep this patient in my ED for a week so I can check their XRs daily, cultures etc. My job is to stabilize, start treatment, and dispo them to the appropriate caregiver if they need admitted, or treat and d/c with followup if I can, of course I gave it to ICU!

How would you guys respond? I try to never bash other specialties and always say thanks, feel free to call or come by if you have any more questions before I hang up with a consultant. It seems to be spiralling out of control at my institution and its driving me crazy.

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[southerndoc]

Things are quite different in the community. If you're an EM doc that just shows up and does his shifts, you probably won't get a great deal of respect. Get on a few hospital committees, show up at medical staff meetings, etc. and get to know your surgeons and physicians and you won't get this kind of teasing.

The residents where I trained were pretty good at not doing this. We all can point out things (the ICU team will just consult out all the other specialties), but in the end you have to know where to draw the line about teasing. Some people get offended. (Personally, I could care less. I make enough money that you can say anything you want and it won't bother me. Constructive criticism is always welcome.)

 

[The White Coat Investor]

Get your lovin' at home. Thick skin is a job requirement.

I'm not sure what "all the work" is. It always seemed to me we did nothing but talk when I was rotating in the ICU. All the work had already been done in the ED.

 

[gro2001]

Different specialties have different ways of doing things and different objectives. We all know this. Yet we still bash/make fun of other specialties. Have you never made fun of ortho? Or IM? Or the PMD? Or derm? It's easier to bash EM because of the retrospectoscope, but really everyone is guilty of this. Maybe you are the one EM physician who is never condescending about any one else's way of doing things, but most likely you are guilty of the same thing.

Having said that, other people just don't get acute resus. The other day a hospitalist told me straight up that I was 'practicing bad medicine' because I didn't wait till a UA and urine culture were sent off on a patient before starting antibiotics. Well, the pt was hypotensive, tachycardic and febrile. I tried to explain the whole 'golden hour' and 'early goal directed therapy' concept but he just didn't seem to get it. Which is understandable, his priorities and treatment goals are different. He never sees the florid septic shock patients. He does see the tainted culture UTI all the time though. To him, what I did was 'bad medicine'. To me, it would have been nonsense to delay abx for a ua/uc.

 

[EctopicFetus]

Agreed on all accounts on this thread.

1) Thick skin is a requirement. I will say not admitting complete bs or telling the IM service it is garbage went a long way for me. I didnt try to sell a BS admission as anything other than that. I keep to this practice. If I have a "social" admit I dont make up some bs, I just tell em like it is and they get it.

2) Ill fight tooth and nail if someone is being ridiculous. When I was a chief I was gonna admit some drunk guy with seizures (dont remember the details anymore), but the senior IM resident said she wouldnt accept my admit until neuro saw the patient. I pushed so hard on her that she accepted the patient nonetheless.

3) Community medicine is 100% different. They love my admits no matter what since it PAYS their bills. crappy bs admit, they say thanks Dr Ectopic. Of course I have the fortune of being around for a little while so I know all of the guys I admit to. lastly, the thing about getting on committees etc is dead on!

 

[Cerberus]

You got dogged out by the fleas, so you just took it and walked away feeling sad?

I wouldn't tell anyone about this, because I'm pretty sure that's grounds for the AAEP to refuse you board certification.

Don't let fleas diss you (or surgeons, or anyone else). It's easy for them to talk ****, but it's just as easy to throw it back on them.

 

[EctopicFetus]

One more point. Call your friend on all your days off and ask them how their day is going.

Just kidding passive aggresiveness is for the weak but this could be fun.

 

[Dirae]

Yea thanks. I felt foolish right after posting but think I just needed to vent. There were some other things said about how we always paralyze bla bla bla. I just dont understand how some people can fly into this assault on you/your specialty just because you walked by and they are having a bad day.

Anyways, I thought I would let everyone know, I uninvited them from my Chuck-E-Cheese birthday party and took back my kite. Next order of business is sooooo unfriending them all on facebook.

 

[gro2001]

Yea thanks. I felt foolish right after posting but think I just needed to vent. There were some other things said about how we always paralyze bla bla bla. I just dont understand how some people can fly into this assault on you/your specialty just because you walked by and they are having a bad day.

Anyways, I thought I would let everyone know, I uninvited them from my Chuck-E-Cheese birthday party and took back my kite. Next order of business is sooooo unfriending them all on facebook.

Also nonsense from people who don't understand RSI. IMP is a solid plan in the OR on an empty stomach and an elective case, but the worst thing you can do in the ED. You know why there is no good data comparing the two? All the studies were stopped because of much higher death rate in the IMP group.

Also, an IM resident is lecturing about intubation? Really? I don't know about your institution, but at my place IM aren't exactly the airway experts.

 

[EctopicFetus]

In residency when I was rotating off service, they always looked to me for the floor codes, airways etc. Anyways, a thick skin is needed. People are miserable with their choices. Simply put you will be criticized your whole career.

 

[alreadylernd]

As told to me by a surgeon when I was a medical student - when people look to criticize other specialties, it says more about them then the specialty they are criticizing.

In the ER, we interface with ALL specialties, and you need a thick skin. Out in the community there is a degree of professionalism as everyone is the "same level" while an academic medical center breeds contempt for one another as a strict hierarchy of medical student < intern < resident < fellow < attending I think contributes to a lot of unprofessional behavior as people think they can "get away with" unprofessionalism in front of a "lower" ranking person. Still, there are some consultants who don't like to be called in the middle of the night, some primary care doctors who treat you like their admitting resident, but in the end that says more about them then about our work in the ER.

 

[TysonCook]

....also, it helps when you can know more about the medical/surgical workup than they do. You can't argue with fact.... or at least thats what they say.

...I'm a huge fan (and user) of the phrase "get your lovin at home"...

So very true.

Lastly, it doesn't hurt from time to time to be confrontational, question their comments, question their though process, ask for their evidence etc. Its one thing to criticize, but when it becomes belittling etc its a problem that needs to be addressed.

 

[pinipig523]

IM and surgery can bash all they want - let them come down to the ER and see how they flail.

 

[porthcurno]

Most other residents seem to have respect for what EM doctors are able to do.

gro2001, regarding the antibiotics, I think that the hospitalist should have said that the fluids and pressors are things that help your septic patient IMMEDIATELY, but that the antibiotics do take some time to work, and therefore that it would be prudent to have someone place a foley and get some pee before you start the IV antibiotics.

 

[Groove]

What everybody has already said... gotta let some stuff roll off your back as an EP, especially if you're a resident working in an academic center. Talk about whipping boy of the hospital.

That being said, you have to find your own way and it largely depends on your personality. If you're charismatic, take the used car salesman approach. I lean towards the darker side of the force and have gotten especially good at recognizing and calling their bluffs. I've gotten into several aggressive confrontational verbal encounters, more when I was a PGY2, much less now probably because they know I won't back down. I chewed out an ENT resident at 2a.m. one time who didn't want to come in and see this 7yo kid with a gigantic neck abscess on CT, 1mm from his carotid with tracheal deviation. I told him to get wake his princess ass up and get it in there within 30 mins (after 10 mins of fighting the consult) or I was going to call his attending..."you've been officially consulted.. *click*". We yelled some more when his grouchy ass came into the ED. He backed down, finished his eval and note and said something about "This is ridiculous.... we treat pt's like this all the time as outpatients, we're not going to do anything about this other than send him home tomorrow with abx."

Tomorrow..? He was booked first for the OR. Nuff said. I hate getting into situations like that because I really don't enjoy it but sometimes you just have to be willing to be confrontational in order to fight for the patient's best interest. No way in hell was I going to send that kid to the floor with 4 hr nursing checks who was already drooling some on the floor with mild trismus.

I've had multiple episodes with cards like that but they don't give me much trouble anymore. They always come up with the most bizarre reason for why it's not cardiac. Bradycardia 2/2 cocaine use, CP'er with congenital heart disease s/p 5 cardiac surgeries and 2 pacers with an EKG that looks like a lie detector test on a death row inmate, yet def not cardiac and def no indication to interrogate the device. You name it.

For the most part, I get along great with my colleague consultants and try to avoid the confrontations but sometimes they are unavoidable and I've found that the root of it is primarily trying to avoid extra work. Usually you have a very good, or should have a very good reason to consult them, so call their bluff. I've found that many consultants hem and haw, sigh and throw small temper tantrums about virtually everything under the sun about the consult, but very few times have much to back it up.

I borrowed one of the coding charts for our hospital with all the criteria for 23h observation status and inpatient admission and sometimes, depending on who is on, will reference that real quick in anticipation of the age old "well that doesn't meet admssion/obs criteria for us". Oh no? Sure it does, I already checked. See you in exam room 7...

I really do hope it's better in private practice because that's prob the most unenjoyable aspect of academic EM, the push back from residents/fellows who are consulted.

 

[Groove]

So, to the OP, keep that in mind when your IM friend grumbles about non-indicated intubations which is a rubber stamp ICU admission for anyone on the vent. He prob just finished his MICU rotation where all of these tubed patients go on his census list = more work for him. It's different perspectives and don't expect him to see things from your EM point of view because he's not.

Reminds me of a bad COPD'er I put on bipap and the ICU fellow ranted about how he was going to have to take the pt now since I had put him on Bipap. I calmly said "Well... it was either that or a tube buddy...and either way, you didn't see this guy when he came in... he aint gonna fly on the floor tonight". He said "Oh yea? I'll have him off the bipap and on the floor by morning!" I grinned and said "be my guest...". He had the peacock feathers fanned a bit due to his troop of med students and residents following him around. Well, sure enough when I checked a few days later...he actually DID get the pt off bipap onto the floor.....for about an hour... before said pt ended up back in the ICU...emergently intubated....and remained that way for a week.

 

[titanjones]

What everybody has already said... gotta let some stuff roll off your back as an EP, especially if you're a resident working in an academic center. Talk about whipping boy of the hospital.

That being said, you have to find your own way and it largely depends on your personality. If you're charismatic, take the used car salesman approach. I lean towards the darker side of the force and have gotten especially good at recognizing and calling their bluffs. I've gotten into several aggressive confrontational verbal encounters, more when I was a PGY2, much less now probably because they know I won't back down. I chewed out an ENT resident at 2a.m. one time who didn't want to come in and see this 7yo kid with a gigantic neck abscess on CT, 1mm from his carotid with tracheal deviation. I told him to get wake his princess ass up and get it in there within 30 mins (after 10 mins of fighting the consult) or I was going to call his attending..."you've been officially consulted.. *click*". We yelled some more when his grouchy ass came into the ED. He backed down, finished his eval and note and said something about "This is ridiculous.... we treat pt's like this all the time as outpatients, we're not going to do anything about this other than send him home tomorrow with abx."

Tomorrow..? He was booked first for the OR. Nuff said. I hate getting into situations like that because I really don't enjoy it but sometimes you just have to be willing to be confrontational in order to fight for the patient's best interest. No way in hell was I going to send that kid to the floor with 4 hr nursing checks who was already drooling some on the floor with mild trismus.

I've had multiple episodes with cards like that but they don't give me much trouble anymore. They always come up with the most bizarre reason for why it's not cardiac. Bradycardia 2/2 cocaine use, CP'er with congenital heart disease s/p 5 cardiac surgeries and 2 pacers with an EKG that looks like a lie detector test on a death row inmate, yet def not cardiac and def no indication to interrogate the device. You name it.

For the most part, I get along great with my colleague consultants and try to avoid the confrontations but sometimes they are unavoidable and I've found that the root of it is primarily trying to avoid extra work. Usually you have a very good, or should have a very good reason to consult them, so call their bluff. I've found that many consultants hem and haw, sigh and throw small temper tantrums about virtually everything under the sun about the consult, but very few times have much to back it up.

I borrowed one of the coding charts for our hospital with all the criteria for 23h observation status and inpatient admission and sometimes, depending on who is on, will reference that real quick in anticipation of the age old "well that doesn't meet admssion/obs criteria for us". Oh no? Sure it does, I already checked. See you in exam room 7...

I really do hope it's better in private practice because that's prob the most unenjoyable aspect of academic EM, the push back from residents/fellows who are consulted.

i love your posts. I want to be like you when i grow up.

 

[docB]

So, to the OP, keep that in mind when your IM friend grumbles about non-indicated intubations which is a rubber stamp ICU admission for anyone on the vent. He prob just finished his MICU rotation where all of these tubed patients go on his census list = more work for him. It's different perspectives and don't expect him to see things from your EM point of view because he's not.

Reminds me of a bad COPD'er I put on bipap and the ICU fellow ranted about how he was going to have to take the pt now since I had put him on Bipap. I calmly said "Well... it was either that or a tube buddy...and either way, you didn't see this guy when he came in... he aint gonna fly on the floor tonight". He said "Oh yea? I'll have him off the bipap and on the floor by morning!" I grinned and said "be my guest...". He had the peacock feathers fanned a bit due to his troop of med students and residents following him around. Well, sure enough when I checked a few days later...he actually DID get the pt off bipap onto the floor.....for about an hour... before said pt ended up back in the ICU...emergently intubated....and remained that way for a week.

When I was in residency we had a horrible system for ICU admits. If the patient was admitted to the ICU from the ED they went to the ICU team and when they left the unit they remained on the ICU team's census. So the ICU team had to manage a full general medical panel in addition to the ICU patients. If the patient was admitted to a gen med team, for even an hour, and then crumped and went to the ICU the ICU team could turf the patient back to their original team when they were downgraded.

This created a huge incentive for the ICU team to block admissions and try to shunt sick patients to the floors. I had seniors try to cajole me when I was an intern and a second year with the "Just give it to the medicine team and I'll go consult on it and if they get worse I'll already know about it." jazz. That was a bad system.

 

[dilated]

If you're charismatic, take the used car salesman approach. I lean towards the darker side of the force and have gotten especially good at recognizing and calling their bluffs. I've gotten into several aggressive confrontational verbal encounters, more when I was a PGY2, much less now probably because they know I won't back down. I chewed out an ENT resident at 2a.m. one time who didn't want to come in and see this 7yo kid with a gigantic neck abscess on CT, 1mm from his carotid with tracheal deviation. I told him to get wake his princess ass up and get it in there within 30 mins (after 10 mins of fighting the consult) or I was going to call his attending..."you've been officially consulted.. *click*".

This works as long as outside people in both specialties would agree that the consults are appropriate. We had a run of tough guy ED residents who mysteriously started consulting for every tiny nick on the face when the ED got busy and "wouldn't back down", requiring surgical residents on q2 home call to be there all the time. The result was that the departments taking face call made up an official list of things that consults cannot be called for. So it's fine to push, but you'd better be sure you're on solid ground.

 

[Groove]

This works as long as outside people in both specialties would agree that the consults are appropriate. We had a run of tough guy ED residents who mysteriously started consulting for every tiny nick on the face when the ED got busy and "wouldn't back down", requiring surgical residents on q2 home call to be there all the time. The result was that the departments taking face call made up an official list of things that consults cannot be called for. So it's fine to push, but you'd better be sure you're on solid ground.

Agreed, but c'mon man... "solid ground" is subjective at best. The primary issue in academics is that there is an unpleasant buffer between the EP and consultant attending...that being the resident/fellow. The resident fellow obviously has tremendous incentive to block a consult, or heavily fight it, especially when he/she is woken up at night at 2a.m. and a) isn't getting paid extra to come into the hospital b) doesn't particularly want to get out from underneath the covers and c) isn't in a particular good mood having been woken up in the first place and d) doesn't particularly appreciate nor particularly care to think about the pt's best interests or medico legal aspects of the consult which is taking place.

I hear you... in that a bad attitude can be fostered by consistently weak consults, but what I just described is an obviously recognized commonality in academia. Consults = extra work which does not = extra pay or foster any strong incentive whatsoever to perform the requested consult.

As for your dept manufacturing an arbitrary list of "veto"able consults, I'm not quite sure how you pulled that one off.... considering EMTALA mandates that if you are consulted by the managing ED physician, his clinical perceived need for the bedside consult trumps your remote opinion every time and it's a federal violation to not come see the pt resulting in a 50K penalty. In fact, if the EP doesn't report it, he's liable to being fined 50K also. Let's just say hospital administration does not particularly like EMTALA fines and would not view you too favorably for being drawn into paying one on your behalf. It's not exactly great for job security. A colleague was trying to facilitate a validated transfer to a remote hospital and the hospitalist refused stating that he "wasn't going to come in at 2a.m. and write orders for something like that...". My colleague informed him about EMTALA violations, politely asked him to repeat what he just said to him and to one of his nurses, and then stated that he would be speaking with the guy's hospital administration in the morning. Long story short, hospital administration called him the next day and apologized, stating that there would be no further issues with transferring pt's as that particular hospitalist was no longer an employee of their hospital.

That being said, any EP wants a good relationship with his consultants, so hopefully "most" of the time, it's validated. Again though, I think academia is a completely different can of worms...as well as inter-departmental and social politics.

 

[Danbo1957]

At our Level 1, all EP consults are answered. But, that resident who "abuses" finds his contract "unrenewed"-- and we have one-hundred and fifty applicants looking for PGY2 and PGY3 spots every year.

 

[Apollyon]

At our Level 1, all EP consults are answered. But, that resident who "abuses" finds his contract "unrenewed"-- and we have one-hundred and fifty applicants looking for PGY2 and PGY3 spots every year.

Vague - EM resident gets fired, or the recipient of the consult?

You could be speaking of EM residents "abusing" consulting services by inappropriate consults, but a resident getting fired for that? What about the attendings? A resident calling consults without discussing it with their attending is not working within the educational model. However, you could also be speaking of residents on services that are consulted being abusive towards whomever called.

In addition, your intent with the quotes is muddled.

 

[Groove]

I "think" he's IM judging from his past posts and is referring to IM residents, but I could be wrong.

I can't think of many incidences where an EM resident would be consulting a service without the attending being aware or at least anticipating the need for the consult. I've certainly never heard of an EM resident being fired over such. We had a <insert specialty> fellow who was particularly difficult to deal with for consults in our ED that was placed on probation with psychiatric counseling for several weeks before being allowed to come down to the ED again.... He seems much more mellowed out now.

I've had bad and good encounters but also received some sage advice one time... Good or bad, whatever you're doing, whatever you're saying, if you're doing it with the pt's best interests in mind and trying to do what is absolutely best for that pt, then usually...usually, mind you... you don't have anything to worry about.

 

[Danbo1957]

IM residents and IM specialty fellows on call to the ER must consult each and every request without comment on the reasonableness of the consult. We consider every patient that comes into the ER an emergent case until proven otherwise. We demand a good relationship between IM and all other services; especially with EPs, considering that they are the "gatewayers" to a good percentage of IM admits. Consulting needs to be taught, and considered as important as any other facet of treatment-- we judge residents' abilities to consult and "grade" accordingly. With that said, IM demands the same respect for our residents in return...

 

[The White Coat Investor]

How would you guys respond? I try to never bash other specialties and always say thanks, feel free to call or come by if you have any more questions before I hang up with a consultant. It seems to be spiralling out of control at my institution and its driving me crazy.

I haven't heard EM bashing since residency. Almost every other doc I meet is jealous of either 1) My fewer hours or 2) my higher pay. Some wish they'd done EM instead, but most say good for you guys because I couldn't deal with what you deal with.

 

[leorl]

On the flip side for attendings: what do you do when you hear or find an outside service attending (ie. surgery) yelling at or bashing one of your residents?

Oftentimes they don't do it when I'm in earshot and I only find out about it later. On occasion, even though I'm a young attending, I have called an outside service's team to yell at them for something that I thought was completely inappropriate. I feel rather protective of my residents (unless there was some sort of major fault) and feel like I should say something.

I think it's funny for younger attendings like myself who don't look "seasoned..." I was the airway attending recently for a trauma and the trauma attending started barking. All I did was give him the stfu death stare (I'm a lot taller than he was) and he backed off. I think if that attending was in the presence of someone older looking, he might not have been so brash.