Do you consult less when you don't have a resident to make the call for you?

[december07]

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As an attending, do you consult less when you work without a resident?

 

[Arcan57]

The idea being that the attending wouldn't call for a consult if they actually had to speak to the consultant? Most of the attendings I knew in residency that were consult happy had zero problems calling weak consults personally. Usually something along the lines of "I'm an attending and you're a resident, get down here". In my current job I work with IM residents, and it's far easier to call a consult myself than deal with an inappropriate plan from a consultant secondary to a poor presentation from the resident. That being said if a patient needs a consult, they get a consult. If they don't, they don't.

 

[december07]

I can see how and EM Attending making a consult to a IM resident is much easier.

At my current place, for each consult, the EM resident has to make the call to the IM Attending. So, you can see where the balance of power is shifted. 🙂

Sometimes, us residents get ripped up by the IM attendings for pushing a "weak" consult or un-billable consult. And yes, it's a tougher when they have no insurance. As an intern, it's hard to put up an argument against an IM attending that has been with the hospital for 20+ years.

 

[BADMD]

And yes, it's a tougher when they have no insurance.

If that became a clear pattern, the chief of staff and the hospital CEO would start hearing about it. Wallet biopsies and potential EMTALA violations don't fly.

 

[Flopotomist]

If that became a clear pattern, the chief of staff and the hospital CEO would start hearing about it. Wallet biopsies and potential EMTALA violations don't fly.

EMTALA does not require that the facility provide treatment beyond stabilization of emergency conditions. The consultant might well be within his or her legal rights to argue that an Emergency trained physician is qualified to stabilize emergency conditions and thus be clear from any emtala obligations - no?

 

[december07]

EMTALA does not require that the facility provide treatment beyond stabilization of emergency conditions. The consultant might well be within his or her legal rights to argue that an Emergency trained physician is qualified to stabilize emergency conditions and thus be clear from any emtala obligations - no?

plus when they refuse an admission, they will not out right say it's because of no insurance. They'll find another reason to refuse it. Or if they have to take the admission, they'll be sure to let you know about their frustration.

 

[WilcoWorld]

plus when they refuse an admission, they will not out right say it's because of no insurance. They'll find another reason to refuse it. Or if they have to take the admission, they'll be sure to let you know about their frustration.

How are they learning that the patient is uninsured during your call for the consult/admission?

 

[BADMD]

EMTALA does not require that the facility provide treatment beyond stabilization of emergency conditions. The consultant might well be within his or her legal rights to argue that an Emergency trained physician is qualified to stabilize emergency conditions and thus be clear from any emtala obligations - no?

They can try that. That would be a very difficult to position to argue without having seen the patient. EMTALA requires a screening exam. If that screening exam reveals that the patient has an emergency condition, the hospital must provide for transfer or a list of specialists that are available for further evaluation and stabilization.

When there is a dispute, CMS has provided this guidance:

Disagreement Between Emergency Physician and On-Call Specialist. While the emergency physician and the on-call specialist may need to discuss the best way to meet the individual’s medical needs, any disagreement regarding the need for an on-call physician to come to the hospital and examine the individual must be resolved by deferring to the medical judgment of the emergency physician or other practitioner who has personally examined the individual.

Keep in mind that EMTALA was created specifically to prevent dumping of uninsured patients. So allowing the patient's insurance status to influence whether or not a specialist does a consult basically falls right into the reason EMTALA exists.

The penalties to the hospital for an EMTALA violation can include loss of participation in Medicare/Medicaid, so the hospital CEO will be very interested in patterns of potential EMTALA violations.

Now, EMTALA technically no longer covers the patient, once the patient is admitted. However admission may create its own obligations.

 

[deleted65604]

The heart of the issue is..."Do residents get treated different than attendings?"

The answer is yes. As a resident, I saw what I thought was a young borderline faking facial paralysis. My attending agreed, but thought that we couldn't call her bluff short of getting an MRI. She had a private doctor who uses private private neurology services. I called the PCP to admit, who asked me to call the neurologist to consult. He said he'd see her in the morning. My attending insisted that I get the neurologist at the bedside. I tried to ask the private neurologist to come see the patient and got the verbal middle finger and asked to talk to my attending. My attending did some major back-peddling to the neurologist on the phone and then laid into me after his conversation with the neurologist had ended. He asked me why I didn't tell him that the consultant was a private physician, not a resident. I had no clue that it would matter.

The truth is that residents get dumped on more easily than full-fledged attendings. Why? 2 reasons:

1. Sometimes we consult for weak reasons and it is easier to inconvenience a resident, whose job it is to be learning the answers to the questions we ask.

2. Residents will not think about a medical problem unless you force them to come down and see the patient. Most residents don't take ownership for their patients as consultants in the middle of the night. You say, "Mrs Johnson is a 56 year old female with a history of CAD, who had a normal stress test about 9 months ago, last cath with stent 16 months ago. She is having vague chest pain that has resolved and is rather adamant that she doesn't want to be in the hospital. I think that it would be reasonable to go home as long as you guys could arrange to see her in clinic and maybe order an out-patient stress test in the near future."

The resident hears, " blah blah blah, go home, blah blah blah." And sleepily says, "Ya, great plan." You can tell that they haven't taken down her name, looked at her records, that they don't care who Mrs Johnson is, or why you are calling. This problem is solved when their body is in the room, they are doing a history and the disposition has been discussed with their attending.

 

[deleted65604]

If the ER attending could talk to an actual attending and get their advice over the phone, a lot of official consults probably wouldn't have to happen, but in academia, that would piss people off when the whole purpose and benefit of having residents is to field these kinds of crap calls. An attending is happy to get consulted when they are going to be able to bill a full history and physical when they co-sign the resident's note.

 

[december07]

The heart of the issue is..."Do residents get treated different than attendings?"

The answer is yes. As a resident, I saw what I thought was a young borderline faking facial paralysis. My attending agreed, but thought that we couldn't call her bluff short of getting an MRI. She had a private doctor who uses private private neurology services. I called the PCP to admit, who asked me to call the neurologist to consult. He said he'd see her in the morning. My attending insisted that I get the neurologist at the bedside. I tried to ask the private neurologist to come see the patient and got the verbal middle finger and asked to talk to my attending. My attending did some major back-peddling to the neurologist on the phone and then laid into me after his conversation with the neurologist had ended. He asked me why I didn't tell him that the consultant was a private physician, not a resident. I had no clue that it would matter.

The truth is that residents get dumped on more easily than full-fledged attendings. Why? 2 reasons:

1. Sometimes we consult for weak reasons and it is easier to inconvenience a resident, whose job it is to be learning the answers to the questions we ask.

2. Residents will not think about a medical problem unless you force them to come down and see the patient. Most residents don't take ownership for their patients as consultants in the middle of the night. You say, "Mrs Johnson is a 56 year old female with a history of CAD, who had a normal stress test about 9 months ago, last cath with stent 16 months ago. She is having vague chest pain that has resolved and is rather adamant that she doesn't want to be in the hospital. I think that it would be reasonable to go home as long as you guys could arrange to see her in clinic and maybe order an out-patient stress test in the near future."

The resident hears, " blah blah blah, go home, blah blah blah." And sleepily says, "Ya, great plan." You can tell that they haven't taken down her name, looked at her records, that they don't care who Mrs Johnson is, or why you are calling. This problem is solved when their body is in the room, they are doing a history and the disposition has been discussed with their attending.

Thank you! That is the heart of the issue.

 

[december07]

How are they learning that the patient is uninsured during your call for the consult/admission?

delete- 🙂

 

[MadHat]

How are they learning that the patient is uninsured during your call for the consult/admission?

They ask. They nonchalantly ask the patient how they are planning to pay for the treatment. And most clueless patients or their relative respond. And depending on the doctor, might admit them the first time to specialty floor, but not often the second time. Then it is general inpatient.

 

[fergustsi]

A bit off topic, but a few months ago, my attending asked me to consult the hospitalist IM service (I'm an MS IV), with a pretty weak consult. It was my first consult to an attending and needless to say when he found out I was an MS IV i got my hat handed to me over the phone. The EM attending got a real good chuckle out of it when I told her. I think it was her plan all along since she later DCed the patient from the ED. good times.

 

[Tiger26]

When I was a med student trying to admit somebody (or get a test or whatever) I quickly found that I was way more successful calling and saying "hey, this is tiger26 from the ED--I've got this 85 yo F who has . . . ). Introducing yourself as a med student is the cue for them tuning out and then pushing back against the admit.

Still, I feel kinda bad about the soft call admits (then I remind myself that those services picked that field for the most part voluntarily, so I don't feel as bad)

 

[xaelia]

Over half our medicine admissions at our hospital go to a private hospitalist service, so we get our fair share of pushback every time we call, and even moreso for the weak admits. Usually, if it's legitimate, I'll start out with "I have someone I'd like to bring in for X". If it's a soft/social/borderline admit, I'll start out with "I have someone I'd like your help with" and try to steer the conversation such that we're on the same team and need to find a way to keep the patient safe.

Can't say I'm typically successful in avoiding the confrontation....

Not uncommon for admissions here to involve multiple phone calls to various services and specialists trying to punt to one another.

 

[fergustsi]

When I was a med student trying to admit somebody (or get a test or whatever) I quickly found that I was way more successful calling and saying "hey, this is tiger26 from the ED--I've got this 85 yo F who has . . . ). Introducing yourself as a med student is the cue for them tuning out and then pushing back against the admit.

Still, I feel kinda bad about the soft call admits (then I remind myself that those services picked that field for the most part voluntarily, so I don't feel as bad)

The thing is, I never have any issues with this when consulting a resident service (particularly medicine). they love the soft admits they can obs and DC in a day or worse two and it still counts the same as a longer admission towards their cap. except with the soft ones, their list stays on the trim side to the point, sometimes you might have 0 on your precall day and get some extra time off. Plus, if medicine Obs them, they can punt to the Obs IM doc who then does all the DC paperwork for them so its even less work for them.

I just took my particular experience as a bit of hazing from the attending, we got along great for the month, so i couldnt help but laugh as well after this hapenned.

 

[The White Coat Investor]

I found I consulted less when I got out of residency and started calling attendings because I didn't have some hyperconservative attending making me call them.

Another thing you'll notice is you do a whole lot more phone consulting than seeing them in the ED. I rarely see a consultant in the ED but probably call 5 a day or so.

 

[december07]

I found I consulted less when I got out of residency and started calling attendings because I didn't have some hyperconservative attending making me call them.

Another thing you'll notice is you do a whole lot more phone consulting than seeing them in the ED. I rarely see a consultant in the ED but probably call 5 a day or so.

here is a quick question about billing.

When you call up a consulting attending and have a 5 minutes phone conversation about a patient, does he get paid for that conversation?

I understand that if him or his resident actually go to the ER to evaluate and do a dictation, that's money in the pocket. But if the consultation is purely a phone call, how can they bill for the consulting service?

I do see one benefit is that we do send patient to their office for follow up. That's about it.

 

[The White Coat Investor]

here is a quick question about billing.

When you call up a consulting attending and have a 5 minutes phone conversation about a patient, does he get paid for that conversation?

I understand that if him or his resident actually go to the ER to evaluate and do a dictation, that's money in the pocket. But if the consultation is purely a phone call, how can they bill for the consulting service?

I do see one benefit is that we do send patient to their office for follow up. That's about it.

The main benefit is they get to keep their hospital privileges and they don't have to get out of bed. The fact that they get another patient or a case is purely secondary I assure you.

 

[deleted109597]

When you call up a consulting attending and have a 5 minutes phone conversation about a patient, does he get paid for that conversation?

If you sent the patient to his clinic for followup, as you mentioned

I understand that if him or his resident actually go to the ER to evaluate and do a dictation, that's money in the pocket. But if the consultation is purely a phone call, how can they bill for the consulting service?

So, the attending has to come and see the patient to bill. If he stayed at home, but his resident came in and called him, then he can't bill. Otherwise it is what they call fraud. Similarly, you can't bill a procedure that the attending wasn't standing there "scrubbed and ready" for. This is why surgical residencies frequently have a surgeon in house. That way they can bill for the lines, intubations, and surgeries that happen overnight.

 

[fergustsi]

If you sent the patient to his clinic for followup, as you mentioned



So, the attending has to come and see the patient to bill. If he stayed at home, but his resident came in and called him, then he can't bill. Otherwise it is what they call fraud. Similarly, you can't bill a procedure that the attending wasn't standing there "scrubbed and ready" for. This is why surgical residencies frequently have a surgeon in house. That way they can bill for the lines, intubations, and surgeries that happen overnight.

Seriously? I was shocked if the attending even stuck their head in the room once during surgeries performed at night. Do they just have to be in house or literally in the room?

 

[BADMD]

here is a quick question about billing.

When you call up a consulting attending and have a 5 minutes phone conversation about a patient, does he get paid for that conversation?

Basically no, and certainly not from CMS. Some payers will pay for CPT codes associated with phone consultations. However, the patient must be an established patient and the patient must initiate the call. If the patient later shows up in the clinic, some payers may allow the phone call to be added in for additional complexity and others state that it is part of the typical previsit care. (At least this is what I was told by the billing company)

Signed--

The guy who consults to the entire state by phone and tried to get paid for it

 

[BADMD]

Seriously? I was shocked if the attending even stuck their head in the room once during surgeries performed at night. Do they just have to be in house or literally in the room?

The teaching physician must be physically present in the room during the key portions of the procedure. The teaching physician gets to define what the key portion is. There are obviously some nuances and other rules, but this is the crux of the rule (for CMS).

 

[deuist]

How are they learning that the patient is uninsured during your call for the consult/admission?

I have had attendings in other specialties ask me insurance status and then refuse to see the patient upon hearing of self-pay status.