Disruptive Physicians

[Noyac]

Anyone dealing with disruptive physicians at your facility. If so what's your approach.

I ask b/c we have one that has a long history of poor behavior long b/4 our anesthesia group arrived. However, my partners and I are not the type to tolerate it like the past groups did. So we have petitioned administration and they have agreed to this point that something needs to be done. THe problem is that this physician makes some of my partners very leary of working with him b/c of malpractice issues. This physician points fingers at everyone but himself when things don't go well. For example, he did an AV fistula on a very sick pt that we cancelled 2 days earlier b/c she wasn't ready for surgery (it wasn't emergent). He stated that he needed a GA or very deep sedation on a pt with well documented gastroparesis due to DM. The anesthesiologist said that that meant a tube and that he needed to do it under local like the rest of the country. He got very upset as you can imagine and demanded a GA. Now I wasn't there but the case went well and the pt was extubated and was brought to PACU doing well after 2 hours of GA with 300 cc IVF. Shortly after arriving in PACu she had resp difficulties and hypotension. She was re-intubated and put on pressors eventually and admitted to the ICU. He blamed the anesthesia. Fine, maybe but maybe it was the AV fistula as well that put the pt in CHF. When this was brought up he stormed out and made a deragatory comment about the anesthesia. Well, we decided that enough is enough and have made a move to "fire" this surgeon from our services.

I tell this story b/c many of you residents and early PP guys may never have seen this or much less had to deal with this. You have resources. Every facility must have a disruptive physician policy. If you document events and submit written complaints, the administrators must deal with the issue. It is JACHO mandated as of this year.

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[sevoflurane]

Exactly the kind of person I dislike working with (and not for). There is a reason why the case was originaly put in the back burner. Right?

At my institution we have some colorectal surgons who resemble their job description. Disruptive, loud, and entirely sold on their perception that the OR is their territory to control. They see themselves as the silverback of the collective medical society.

My approach is different since I'm a resident.... Ignore the hell out of them and keep on doing the best I can do for my patient. If they yell... just chuckle under your mask and pretend you didn't hear them.

This does two things for me...


1) let them know that there are people in the OR that are not dominated by their infantile outbursts.

2) annoy them to the point that they won't want to talk to you.

I agree wity Noy... documentation can be your life saver if you ever make it to court or if you want some trouble maker to go somewhere else and practice.

 

[jwk]

Federal and state labor laws include sections about "hostile work environments". I'm sure your hospital and/or medical staff have policies about this. Abusive behavior (including sexual harassment) cannot and should not be tolerated by the hospital or your department. In particular, the hospital leaves itself open to civil action for knowingly tolerating abusive behavior in it's work environment, whether by it's employees or the medical staff. In this day and time, surgeons who throw instruments can quickly find themselves being charged with assault and battery.

We had a surgeon a couple years ago who resorted to some really nasty name calling. Big mistake - as a condition of his continued appointment to the medical staff, he was required to undergo anger management counseling.

As far as this surgeon and his comments, document it all, including documenting in the medical record if necessary. We have surgeons who want to do "emergency" cases for various reasons, some legit, some not. If we have an issue with it, we'll require them to write a note in the chart that this case is truly an emergency and the patient will be harmed if surgery is not undertaken immediately. Otherwise, we don't leave the holding area.

 

[johankriek]

Anyone dealing with disruptive physicians at your facility. If so what's your approach.

I ask b/c we have one that has a long history of poor behavior long b/4 our anesthesia group arrived. However, my partners and I are not the type to tolerate it like the past groups did. So we have petitioned administration and they have agreed to this point that something needs to be done. THe problem is that this physician makes some of my partners very leary of working with him b/c of malpractice issues. This physician points fingers at everyone but himself when things don't go well. For example, he did an AV fistula on a very sick pt that we cancelled 2 days earlier b/c she wasn't ready for surgery (it wasn't emergent). He stated that he needed a GA or very deep sedation on a pt with well documented gastroparesis due to DM. The anesthesiologist said that that meant a tube and that he needed to do it under local like the rest of the country. He got very upset as you can imagine and demanded a GA. Now I wasn't there but the case went well and the pt was extubated and was brought to PACU doing well after 2 hours of GA with 300 cc IVF. Shortly after arriving in PACu she had resp difficulties and hypotension. She was re-intubated and put on pressors eventually and admitted to the ICU. He blamed the anesthesia. Fine, maybe but maybe it was the AV fistula as well that put the pt in CHF. When this was brought up he stormed out and made a deragatory comment about the anesthesia. Well, we decided that enough is enough and have made a move to "fire" this surgeon from our services.

I tell this story b/c many of you residents and early PP guys may never have seen this or much less had to deal with this. You have resources. Every facility must have a disruptive physician policy. If you document events and submit written complaints, the administrators must deal with the issue. It is JACHO mandated as of this year.

dude

suck it up.. Maybe it was anesthesia's fault. 300cc of Iv fluid? Or maybe it was just the patient's co-morbidities.. You cant fire everysurgeon you dont like. Yeah he has a difficult personality, learn to deal with it. You have an exclusive contract with the hospital.. learn how to deal with him or they will fire you and Ill come in and do the cases my friend. I hate to say this but he has a right to comment on the care his patients get. You are just mad because your feelings are hurt. I cancel cases once in a g reat while (Potassium of 6.2) on a av fistula. the surgeons are pissed and call me names.. but you know what... thats still not going to get me to take the risk.. I am not going to lose my license because the surgeon is mad at me.. I will when the guy goes into a malignant arrhythmia.. and i tactfully explain that to them Its nothing personal, dont get too upset over it. take it in stride

 

[mille125]

why not do the case with a peripheral nerve block (supraclavicular, infraclavicular) and light sedation?????

 

[VolatileAgent]

For example, he did an AV fistula on a very sick pt that we cancelled 2 days earlier b/c she wasn't ready for surgery (it wasn't emergent).

you cancelled a case? don't tell mil that...

 

[Planktonmd]

The best answer for disruptive behavior is passive aggressive behavior

 

[Noyac]

Well, I expected a few responses like Johan's and VA's. I'm not surprised that it comes from you two since you were on my short list of people to think this way.
First, I didn't cancel the case, VA. I was actually not there that week. Read your quote of mine. I said "we" meaning the anesthesia group, but I'm sure that is hard for you to understand and with your eagerness to cause waves on this forum and split hairs you will probably make something of this as well.

Secondly, Johan. If you ever find yourself in a bad outcome with a surgeon that likes to point fingers at others, you can be assured that your time on the stand will be as miserable as possible. Now, when that surgeon goes to family members making blanket complaints, your f*cked. People like this don't go down alone. They grab on to everyone around and bring them down with them. If you read my post (as seems to be a problem with the two of you) I said "maybe" it was the fluid and maybe it was the AV fistula. I find it hard to believe that 300 cc over 2 hrs with the additional blood loss, he losses 25 -50 cc in these cases, is the sole cause of the CHF/Resp difficulty. I'm more inclined to believe it is from the fistula, but I'm an anesthesiologist, so what do I know? Now the next thing is that the hospital is trying to limit its liability. It will be named in any case involving any pt as well as doublely named in cases that involve anesthesia. This surgeon routinely brings pts to the OR without cardiac workups for CEA's. He calls carotids minor surgery and claims that they don't need any cardiac w/u. We have been dealing with this for 3 years that I know of. Would you call this learning to "deal with it"? He critisizes every aspect of the hospital, ER docs, ICU docs, Radiiology, and Path. A pathologist recently came to us asking what could be done about this guy. We said the wheels are in motion and he said "just tell me what I need to do". Administration is fed up with him and has asked us to help document behavior 6 months ago. Do I need to go on? Do you get the picture?

And Yes, he does have the right to question the care of his pts. And No, I am not mad and I didn't get my feelings hurt because it wasn't my case. All of this happened while I was away. For your information, I get along great with this surgeon and he has called me his "favorite anesthesiologist". With me its not personal but I need to go with my group and the rest of the hospital on this. Although, I have managed to stay fairly out of it to this point.

 

[Noyac]

PS: VA, I just looked at your post again and I think you were being funny or sarcastic. Thats fine I can take sarcasm. If so disregard my previous post.

 

[VolatileAgent]

PS: VA, I just looked at your post again and I think you were being funny or sarcastic. Thats fine I can take sarcasm. If so disregard my previous post.

my point was that "other" posters on this forum wouldn't have even remotely considered the possible negative outcome that this patient suffered. you did. kudos to you. i have the inkling that, post-residency, many clinicians forget that they are actually physicians, and at some point start to believe that they are merely service providers too afraid to say "no" when something is clearly out of bounds and, even probably more commonly, borderline.

it doesn't sound like 300cc of any fluid would have done this. we're talking less than a can of coca-cola here. this was a high-risk patient and you were right to be concerned, that it was appropriate.

i've taken plenty of trainwrecks to the OR against my personal better judgment. as you can probably imagine, at this point in my training i'm pretty much left alone to run cases. it doesn't always mean that i know 100% what to do in every instance. and, most still make it through. however, learning how to successfully navigate "difficult" surgeons and sell them your concern in a constructive way, despite my boisterousness on this forum, is a true skill that i've been fortunate to either have learned along the way and/or been taught. it's all about how and when you document your concern, and the conversation you have with the patient's family before the surgery. that's what's going to keep your ass out of hot water. always oversell how risky the surgery is to the family, even if you're doing a bunionectomy on an asa1. you have nowhere to go but up if you make them understand that every surgery is a life-or-death matter.

and, then again, some people are just going to sue no matter what. i've yet to be involved in litigation. i know it will happen. i'm sure there's a chance i'll get subpoenaed sooner or later for a case i participated in during residency. but, i'm equally certain (and i'm not boasting) that my careful documentation is going to make it hard for someone to pin my balls to the wall. you cannot be lazy in your documentation - ever. (i hope this is stressed where people train.)

some people may not like my style here, but it has grown mostly as a reaction to some of the ridiculousness i'm repeatedly subjected to on this forum. if you look way back at some of my original posts, i wasn't always like that. but, controversy seems to be the only way you can get people's attention.

i carry the attitude of a fighter pilot into the OR. but, i know how to use tact in the real world too. and, i'm respected for the care i give. if that makes me seem like an arrogant a**hole on this forum, i don't care. but, i've dealt regularly with multiply co-morbid bmi>40's regularly since day one of residency, i know i'll get the airway, i know i'll get the line, i know i can figure out the problem, and i've never screwed the pooch or caused anyone's untimely death as a result of my care. i've even brought a few asa5's to the PACU as well. yet, i never forget my limits, never fail to realize what's unsafe, and - most important - i know how to effectively document (ie., in a way that doesn't make it look like i'm blaming anyone). every resident should learn that skill. if you are not in a program that affords you that instruction, you are seriously losing out.

so, humor? sarcasm? arrogance? eveyrone's perception? fine. just listen to what i say. it's not hubris. i have a lot of life experience to back-up my bravado. and, i'm a damn good anesthesiologist to boot who's been fortunate to have been trained at a phenomenal program.

 

[militarymd]

It is even more amusing to me that some posters here who don't even have privilleges to practice independently talk about being "physicians" or having "judgement".


"Judgement" comes from experience.....Folks who don't have privilleges to practice independently have no experience.

It is even more amusing that based on NO experience, that one can comment on risks and outcome.

After you take care of 2000 of these patients, then you can come back and talk...before then....work on getting some experience.

 

[militarymd]

we're talking less than a can of coca-cola here. this was a high-risk patient and you were right to be concerned, that it was appropriate.

Wrong........

Coca-cola and crystalloid used in IV fluids are completely different.

If you were a physician with experience in talking care of sick patients ...you would know this, but alas.....you are just a resident.

Dialysis dependent patients are not "water" restricted....

However, they are sodium restricted.

And if you use saline...and that is what the majority of new grads and residents in academic centers use for dialysis dependent patients.....300 cc of that is equal to almost 1.5 gm of sodium.....almost a full days' worth of sodium...given over a few hours....definitely can cause sodium overload syndromes in some patients.

If you had given 300cc of d5w, then I would say that it is same as a can of Coke, ....but then what do I know....I 'm done with training....and don't practice medicine any more...I'm just wasting my experience trying to make money from a pool that is drying up.

 

[Noyac]

I need to check on something. I said this wasn't my case so I'm not sure if she was dialysis dependent yet. I don't think she had ever had dialysis b/4 this. However, yes she did need it.

Also, Mil you can't disagree with VA's other statement that documentation can save your otherwise tarred and feathered ass.

The nice thing about all of this is that I am on Peer Review Committee and I can review this case with other physicians. Objectively of course.

 

[VolatileAgent]

Coca-cola and crystalloid used in IV fluids are completely different.

more hair splitting. so, file under: "duh". i'm talking volume.

If you were a physician with experience in talking care of sick patients ...you would know this, but alas.....you are just a resident.

i always love this amusing ploy by you. you act like i just walked in off the street and started giving anesthesia. that i've never taken care of "sick" patients. i've got news for you, every patient we take care of at our tertiary center is sick. we get the cases your hospital can't handle. so, i don't know which little community hospital program you trained at (nor do i care), but it's a rare day when i take care of a patient who isn't asa 3+.

Dialysis dependent patients are not "water" restricted....

again, file under "duh". so, you want to split hairs more? is this an esrd patient that is dialysis dependent? what was the creatinine clearance? was the patient dialysed the day of surgery? do most of your patients come to the OR after having eaten a big salty breakfast? what was their baseline bmp anyway? oh, i forgot. you wouldn't know because you don't order pre-op labs.

However, they are sodium restricted.

again, "duh". what was their baseline bmp again? how much daily sodium is allowed (typically) in a restricted diet?

And if you use saline...and that is what the majority of new grads and residents in academic centers use for dialysis dependent patients.....300 cc of that is equal to almost 1.5 gm of sodium.....almost a full days' worth of sodium...given over a few hours....definitely can cause sodium overload syndromes in some patients.

give me a friggin' break.

If you had given 300cc of d5w, then I would say that it is same as a can of Coke,

more hair splitting... how much dextrose is in a can of coke? do you even know? and, would you give dextrose to a insulin dependent diabetic? oh, wait i forgot. you don't check labs. so, i guess it's safe to assume that you don't check intra-op glucoses either. heck, no studies have ever shown that tight peri-op glucose control affects outcome. why bother?

....but then what do I know....I 'm done with training....and don't practice medicine any more...I'm just wasting my experience trying to make money from a pool that is drying up.

hey, you said it, not me. and, despite what you may believe, some residents actually are equal in intelligence and clinically savvy as you.