how do you handle the bs?

[McLovin]

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As I have grown up I have learned from those above me. A consult for an inguinal hernia that has been present for 20 yrs, reducible and not causing any problems, in a guy admitted for some exacerbation of one of his 20 medical problems gets a brief exam (unless I am able to talk the person out of the consult) and a very short note detailing how this is a problem which can be worked up as an outpatient when the patient is medically optimized for surgery. For the hepatic hydrothorax patient if I can't convince them over the phone, My consult consists of a few lines on how chest tubes aren't appropriate, and depending on if I have it handy, an article describing why.

As an intern I would do a full H+P on these folks, but I quickly learned that if I bumped it up to my senior it would save me a lot of work and allow me to get other stuff done faster. I now teach my interns to run things by me first.

"Ugh" to people who love to hand out articles and quote studies in their notes.

 

[McLovin]

The things that frustrate/irritate me most are the calls in which someone tells me there is no surgical issue but they "just want to spread the risk". I also get frustrated with delayed consults. Not because of the late hour or weekend, rather because I now have a patient often down the road of badness unnecessarily. I much prefer a few extra premature/garbage calls to having people delay and hurt the patient.

This last aspect (delay) is what I have found when people are afraid or adverse to interacting with certain consultants. I always saw the nasty/rude/mean surgeons getting the last minute delayed diagnosis perforated tics/etc.... The requesting physician team would almost universally apologize to the surgical team. They would then go on to explain the delay was cause they didn't want to unnecessarily bother surgeon, "The last time we called surgeon "x" he/she was so angry we had not done the full work up... yelled... made such a big fuss....".

It is 2010. Anyone that actually believes interacting with anger and displaying your temper is effective or efficient is naive... or making an excuse for or rationalizing their lack of self control. The minute you do that, you loose the "high ground". You may not know it yet, but, the power has just been transferred to the source of your irritation. You can communicate/educate and keep track and report failures. This will ultimately improve things. Building an umbrella of fear and track record of outbursts hurts you in the long run.Absolutely

+1. I remember as a resident getting an old lady with a Type A dissection who clearly wasnt surgical (late 80's and pleaseantly demented), but thought surgery should at least opine on the matter. I talked to the CT surgeon on the phone and got the response "SHE'S DEAD! DO YOU HEAR ME DEAAADDDD!!!" and then hung up on.

I realize the consult was annoying, but still........

 

[maxheadroom]

+1. I remember as a resident getting an old lady with a Type A dissection who clearly wasnt surgical (late 80's and pleaseantly demented), but thought surgery should at least opine on the matter. I talked to the CT surgeon on the phone and got the response "SHE'S DEAD! DO YOU HEAR ME DEAAADDDD!!!" and then hung up on.

I realize the consult was annoying, but still........

While the CT Surgeon could have been nicer, that kind of consult is not the type that many surgeons will respond well to.

 

[JackADeli]

+1. I remember as a resident getting an old lady with a Type A dissection who clearly wasnt surgical (late 80's and pleaseantly demented), but thought surgery should at least opine on the matter...
I realize the consult was annoying, but still....

Really? Are you serious?
I am not agreeing or supporting abusive conduct.... but, exactly why should surgery be called to "opine"? This is akin to the consults I get, "she's not a surgical candidate/doesn't have a surgical issue, but we would like to share the liability or just cover ourselves...". Be a physician, make a decision... don't start calling consultants to "opine".... In general, if a patient "clearly wasn't surgical", it is unprofessional to call a surgical consultant....Period.

 

[dpmd]

"Ugh" to people who love to hand out articles and quote studies in their notes.

Not a common practice of mine, but one particular attending would keep harassing us when we refused to put chest tubes in their hepatic hydrothorax folks on 20 of lasix and 100 a day of aldactone (or some equally silly regimen). The thoracic surgeon was the one who started giving it out. I just got tired of having to write the same thing every time.

 

[dpmd]

Really? Are you serious?
I am not agreeing or supporting abusive conduct.... but, exactly why should surgery be called to "opine"? This is akin to the consults I get, "she's not a surgical candidate/doesn't have a surgical issue, but we would like to share the liability or just cover ourselves...". Be a physician, make a decision... don't start calling consultants to "opine".... In general, if a patient "clearly wasn't surgical", it is unprofessional to call a surgical consultant....Period.

Well said.

 

[dynx]

Really? Are you serious?
I am not agreeing or supporting abusive conduct.... but, exactly why should surgery be called to "opine"? This is akin to the consults I get, "she's not a surgical candidate/doesn't have a surgical issue, but we would like to share the liability or just cover ourselves...". Be a physician, make a decision... don't start calling consultants to "opine".... In general, if a patient "clearly wasn't surgical", it is unprofessional to call a surgical consultant....Period.

simply brilliant!
This is the dude that's been talking about whistling-while-you-work for the last 3 pages?
Way to politely divine someone elses motives Mr. "but we would like to share the liability or just cover ourselves...". I'm sure that's what they say to you. Or maybe thats just how you treat them...how rude you are sir! And telling someone to "be a physician", classy move all the way. I always like to end a conversation with "period" as well, did it just last night on call. Capital P by the way? Polite emphasis? It was when I said it.

I think I'm done here. I'm glad this thread confirmed all my suspicions. From now on I'm going to talk loudly about being polite while remaining exactly how I am in order to more fully fit the stereotype-douch-bag surgeon persona everyone thinks glade and I are trying to fill. Clearly we were allmost there...all that was missing was the hypocrisy.

Seriously, best post of the year.

 

[dynx]

Well said.

Well typed. He would *gasp* never say such a thing. Why would you speak the truth and risk offending someone and being a "disruptive physician". That stuff aint tolerated yo. Just ask jackad...oh, wait.

 

[glade]

Yeah, the proper response for the well-adjusted surgeon is to take the consult, see the patient at any time of day or night, leave a detailed note that mentions a few times the gigantic size of the primary physician's genitals (so that it can be permanently entered into legal documents if necessary), and close with "thank you for the opportunity to see this interesting patient! Please call me at any time for any further questions." Then leave Winged Scapula's cell phone number at the end.

 

[dynx]

Remember: these are our colleagues, every consult is a call for help!

 

[glade]

Apparently some physicians place consults because they're lonely and want to talk to someone at night. It's like "you consulted me for abdominal pain, but this patient doesn't have any abdominal pain." "Oh, uh ....sorry ...hey, did you watch the series finale of 'Lost'? What did you think about it?" "What?"

 

[McLovin]

Really? Are you serious?
I am not agreeing or supporting abusive conduct.... but, exactly why should surgery be called to "opine"? This is akin to the consults I get, "she's not a surgical candidate/doesn't have a surgical issue, but we would like to share the liability or just cover ourselves...". Be a physician, make a decision... don't start calling consultants to "opine".... In general, if a patient "clearly wasn't surgical", it is unprofessional to call a surgical consultant....Period.

Whoa, relax chief. Let me rephrase and add context. If I'm still "wrong", well then shame on me.

Surgery was not contraindicated in any way, but in my opinion surgery should not have been done on that patient. But, since this is someone's life we're talking about here, I wanted someone else to opine. Not to cover my a**, or to share the liability, but to get another opinion on wether or not that was the right decesion that the lady was better off dying than going through the surgery. Hence, I decided to "consult" someone else for their opinon on the matter. I didn't ask him to come in and evaluate the patient, just talk to me on the phone. He did confirm my initial impression...I just wish they were more civil on the phone.

 

[JackADeli]

...I remember as a resident getting an old lady with a Type A dissection who clearly wasnt surgical ...but thought surgery should at least opine on the matter...

...Way to politely divine someone elses motives Mr. "but we would like to share the liability or just cover ourselves...". I'm sure that's what they say to you. Or maybe thats just how you treat them...how rude you are sir! And telling someone to "be a physician", classy move all the way...

I think I'm done here. I'm glad this thread confirmed all my suspicions. From now on I'm going to talk loudly about being polite while remaining exactly how I am in order to more fully fit the stereotype-douch-bag surgeon persona everyone thinks glade and I are trying to fill. Clearly we were allmost there...all that was missing was the hypocrisy...

Remember: these are our colleagues, every consult is a call for help!

Interesting. You do not have to believe what I have typed. But, Yes, I have gotten consults in which the requesting physician specifically states...."no surgical issue.... wanted to share the liability". It is apparently not uncommon... from what colleagues around the country mention in discussions, my experiences with this are not unique.

Yes, we are on a bulletin board to discuss matters. I am not receiving a consult. However, even here, the poster states there is no surgical issue but calls a surgical consult to "opine".... exactly what are they opining? As physicians "we" are called to make decisive decisions. That is our job. If you know there is no issue for a surgical consult but call the consultant to make the decision for you, you are not being a physician. This act is akin to being a midlevel. Again, the poster told the story and said this was an example of his/her calling a surgical consult when it was unnecessary.

Hypocrisy? Point out to someone on an anonymous bulletin board that calling a consultant when there is no need is unprofessional is somehow similar or consistant to yelling at nurses, being rude to colleagues in the hospital, etc... Sure, if you say so...

 

[JackADeli]

...But, since this is someone's life we're talking about here, I wanted someone else to opine...

I understand that sentiment... especially if you are a trainee/resident. But in general, that other person should be your supervising attending in the ED/etc... We as physicians are called to make life/death/end of life advise and/or decisions all the time. As a resident, I have and probably every other resident before/after me calls for the attending back-up in important decisions. As an attending, you need to make these decisions. That is not to say you can not or should not seek advise and consult on specific occasions/cases. But, there are numerous attendings (not saying you necessarily) that never take responsibility and or make the final decision. They often act as residents or midlevels forever. They call someone else to "confirm" their feelings/opinions/etc.... then write a note in the chart to the effect that the consultant made determination/decision that patient was not appropriate for x, y, z.

...I just wish they were more civil on the phone.

I agree with you on that. we get tired and/or exhausted and can be short fused. But, ideally, we would behave professionally.

 

[glade]

You should be thrilled at the chance to use your abilities to assist a colleague and do so in a professional manner.

 

[blue2000]

I guess one question that this raises is who is responsible for determining whether someone is or is not a surgical candidate? I think if someone has said "I do not want an operation at any cost" than sure, don't call surgery. But I've had issues where medicine has assumed someone is not a surgical candidate or something is not a surgical issue, where depending on the situation, we would take them to OR. I don't think it's inappropriate to consult surgery when someone who has multiple comorbidities has a life-threatening condition that is surgically correctable. On the other hand, it totally frosts me when I get consulted on patients who definitely do not want an operation.

 

[McLovin]

I guess one question that this raises is who is responsible for determining whether someone is or is not a surgical candidate? I think if someone has said "I do not want an operation at any cost" than sure, don't call surgery. But I've had issues where medicine has assumed someone is not a surgical candidate or something is not a surgical issue, where depending on the situation, we would take them to OR. I don't think it's inappropriate to consult surgery when someone who has multiple comorbidities has a life-threatening condition that is surgically correctable. On the other hand, it totally frosts me when I get consulted on patients who definitely do not want an operation.

Right -- which is why I wanted a surgical opinion on the issue rather than my attendings.

In any case, I don't think "the time fit the crime" imo. Was I more wrong than right? probably. But heck, I was a resident and I learnded from it.

I will say that now, as a specialist, I don't give anyone grief for a "stupid consult". I may try to do it on a curbside capacity, but I certainly don't berate them.

And I do get and did get some that made you take a deep breath -- even from almighty surgeons ("we're discharging the patient tommarrow, but could you see him and figure out why he had the PEA arrest 12 days ago?").

I guess my take is that its fun to tell stories of the bogus consults we get, but chances are you've placed 1 or 2 bad ones yourself, so it would be a bit hypocritical to get all worked up when you in turn get one. My issue now is that if you are going to place a bogus consult, at least have the courtesy to do it in the morning rather than 5 pm.

 

[JackADeli]

I guess one question that this raises is who is responsible for determining whether someone is or is not a surgical candidate?...

My practice and general practice of most I work with or have worked with is, if you do not know, then call. That is different then saying, "I know, but I just want you to back up what I know...". This goes for all consulting in all specialties.

I don't find it hypocritical to point out an error that you may have made yourself. Most if not all of us have made mistakes at all levels.... If an error occurs, under that reasoning we should all remain quiet and say nothing. My reply was in reference to the continued statement/belief in the consult as described.

...I remember as a resident getting an old lady with a Type A dissection who clearly wasnt surgical ...but thought surgery should at least opine on the matter. ...CT surgeon on the phone and got the response "SHE'S DEAD! DO YOU HEAR ME DEAAADDDD!!!" and then hung up...

....Was I more wrong than right? probably. But heck, I was a resident and I learnded from it...

I also do not see what someone learned by said described consult. I still think the discussion should have been with an attending that was supervising to guide your learning as opposed to an innappropriate consult that result in rude interaction and hang up. Really, what was learned by that consultant at the other end of the line as you have described it. i just see the continued justification of the consult as described as some sort of attempt to hold onto a shred of justifiability...
"clearly wasnt surgical",
"got the response "SHE'S DEAD! DO YOU HEAR ME DEAAADDDD!!!" and then hung up on,
"More wrong then right",
"But ...I was a resident and I learned from it"....
what did you learn? she was dead? maybe more to learn if you spoke with your supervising attending? Yes, we all make mistakes... so admit it, accept it, move on.... don't rationalize or look for threads of excuses. Just don't know why a consulting surgeon should be opining your ~"dead" patient he/she will not be providing care for... Physicians in general opine to much death as it is.... we don't need to opine just to opine.

The caveat being, it is a different story if you just didn't know. The problem is when someone wants it both ways.... i.e. they say they know/knew but then try to justify the contradicition.

 

[SocialistMD]

My practice and general practice of most I work with or have worked with is, if you do not know, then call. That is different then saying, "I know, but I just want you to back up what I know...". This goes for all consulting in all specialties.

I don't find it hypocritical to point out an error that you may have made yourself. Most if not all of us have made mistakes at all levels.... If an error occurs, under that reasoning we should all remain quiet and say nothing. My reply was in reference to the continued statement/belief in the consult as described. I also do not see what someone learned by said described consult. I still think the discussion should have been with an attending that was supervising to guide your learning as opposed to an innappropriate consult that result in rude interaction and hang up. Really, what was learned by that consultant at the other end of the line as you have described it. i just see the continued justification of the consult as described as some sort of attempt to hold onto a shred of justifiability..."More wrong then right", "But ...I was a resident and I learned from it",

I do think it is difficult for non-surgeons to tell which patients are operative candidates and I don't think it is a bad consult to call if there is uncertainty. We know the risks of operating on the frail and elderly, yet we continue to push the envelope. I have no doubt this consult occurred around the same time this article was published and absolute contraindications became relative. How is an internist to know what is right and what is wrong when we as surgeons don't?

Did McLovin dig himself a hole in his initial description? Yes, but I don't think there is anything in what he said that makes his consult unreasonable other than the way he described it. I know it rubbed a nerve with you because of your experience, but I don't think this consult would be unreasonable if phrased in a better way.

 

[JackADeli]

I do think it is difficult for non-surgeons to tell which patients are operative candidates and I don't think it is a bad consult to call if there is uncertainty...

...dig himself a hole in his initial description? Yes, ...I know it rubbed a nerve ...I don't think this consult would be unreasonable if phrased in a better way.

Absolutely agree. The nerve that was rubbed is simply the not uncommon presentation of "I know "x" but just want to call you...". It occurs in all specialties and may be an aspect of not wanting to admit one's ignorance on a particular subject. It may happen to us all. I call it out so folks don't get into illogical rationalization.

Again, as noted, if you don't know then call. But, let's not play games of "I know" and "it was educational"..... To suggest a phone call as described, for the surgeon to opine, was educational is silly.... From a residency standpoint, it is in general more educational to go through your instructor/supervising attending.... as opposed to calling a consultant to opine. If "clearly wasn't surgical", don't call. Or be honest on what that call is about.... which is often an act of CYA.

 

[McLovin]

My practice and general practice of most I work with or have worked with is, if you do not know, then call. That is different then saying, "I know, but I just want you to back up what I know...". This goes for all consulting in all specialties.

I don't find it hypocritical to point out an error that you may have made yourself. Most if not all of us have made mistakes at all levels.... If an error occurs, under that reasoning we should all remain quiet and say nothing. My reply was in reference to the continued statement/belief in the consult as described.I also do not see what someone learned by said described consult. I still think the discussion should have been with an attending that was supervising to guide your learning as opposed to an innappropriate consult that result in rude interaction and hang up. Really, what was learned by that consultant at the other end of the line as you have described it. i just see the continued justification of the consult as described as some sort of attempt to hold onto a shred of justifiability...
"clearly wasnt surgical",
"got the response "SHE'S DEAD! DO YOU HEAR ME DEAAADDDD!!!" and then hung up on,
"More wrong then right",
"But ...I was a resident and I learned from it"....
what did you learn? she was dead? maybe more to learn if you spoke with your supervising attending? Yes, we all make mistakes... so admit it, accept it, move on.... don't rationalize or look for threads of excuses. Just don't know why a consulting surgeon should be opining your ~"dead" patient he/she will not be providing care for... Physicians in general opine to much death as it is.... we don't need to opine just to opine.

The caveat being, it is a different story if you just didn't know. The problem is when someone wants it both ways.... i.e. they say they know/knew but then try to justify the contradicition.

1. I think you missed my follow-up post ("whoa relax chief, let me rephrase....") that meant to add more detail to the situation. The patient was not "clearly not surgical". She did not refuse surgery, did not have an advanced directive, and not no medical reason why surgery should be contraindicated. She fell into the category of "surgery probably shouldn't be done on this person"

2. I didn't call my medical attending to help calrify, beacuase for this patient with a surgical problem I wanted the opinion of the surgeon who would be doing the surgery.

3. Perhaps you havent spent a lot of time in an ICU setting or had a lot off end-of-life discussion, but to a family there is often a big difference between "we probably shouldn't do surgery" and "surgery is not an option"

4. Again, you may have missed my post attempting to fully explain the situation, but I don't see how I wanted it both ways.

 

[JackADeli]

...I think you missed my follow-up post...

Yes, I caught the follow-up. Again, if you don't know then call.... Also, as a resident/trainee, I do believe attending guidance back-up is appropriate and necessary with serious end-of-life or major medical decisions. My follow up was more in terms of generalities. Though, the one specific is that I really doubt you learned very much if anything from the hang up phone call.

...Perhaps you havent spent a lot of time in an ICU setting or had a lot off end-of-life discussion...

Unfortunately my practice involves too much of this...🙁

...Again, you may have missed my post attempting to fully explain the situation, but I don't see how I wanted it both ways.

Again, a point intended more for generalities. It may not be you, especially at the resident level. However, plenty of practicing physicians that want it both ways, i.e. claim they know (unwilling to admit they don't) and then call a consultant to make the decisions. Again, it is a generality maybe not applicable to your particular situation but as was noted, your presentation rubbed on a nerve of this type of conduct... in general.

 

[dynx]

Yes, I caught the follow-up. Again, if you don't know then call.... Also, as a resident/trainee, I do believe attending guidance back-up is appropriate and necessary with serious end-of-life or major medical decisions. My follow up was more in terms of generalities. Though, the one specific is that I really doubt you learned very much if anything from the hang up phone call.Unfortunately my practice involves too much of this...🙁Again, a point intended more for generalities. It may not be you, especially at the resident level. However, plenty of practicing physicians that want it both ways, i.e. claim they know (unwilling to admit they don't) and then call a consultant to make the decisions. Again, it is a generality maybe not applicable to your particular situation but as was noted, your presentation rubbed on a nerve of this type of conduct... in general.

I hope all the 3rd parties learned a lot from this. A disagreement that could be handled in a civil fashion given way to abrupt answers and back and forth. Here in SDN world handled with posts that went no where but in real life each side would retreat to their corners and bitch and write each other up. Anyway, don't trust any of these "treat everyone with respect" folks, you'll see that they're all full of **** just like jackadeli. You see how they act when left to be how they want. I'll let you all decide for yourselves.

 

[MattD]

+1. I remember as a resident getting an old lady with a Type A dissection who clearly wasnt surgical (late 80's and pleaseantly demented), but thought surgery should at least opine on the matter. I talked to the CT surgeon on the phone and got the response "SHE'S DEAD! DO YOU HEAR ME DEAAADDDD!!!" and then hung up on.

I realize the consult was annoying, but still........

Really? Are you serious?
I am not agreeing or supporting abusive conduct.... but, exactly why should surgery be called to "opine"? This is akin to the consults I get, "she's not a surgical candidate/doesn't have a surgical issue, but we would like to share the liability or just cover ourselves...". Be a physician, make a decision... don't start calling consultants to "opine".... In general, if a patient "clearly wasn't surgical", it is unprofessional to call a surgical consultant....Period.

I'M RIGHT and YOU'RE WRONG

NO, I'm right and YOU'RE WRONG!!!!

I understand your sentiment, but still, YOU'RE WRONG.

No, I'M right. You are SO wrong.

NUH UH!!!!

Quit saying I'm wrong. Meanie.

But you ARE wrong! And I'm RIGHT!!!!

You could NEVER be right, you were a MEDICINEY resident calling a SURGEON! This was wrong even if you were right!!!!! Which you weren't!!!!! And I am!!!!!

Fixed it for y'all.

 

[glade]

You know, all the numb-nuts who subscribe to "getting along in the hospital" emphasize that "any consult is a learning opportunity" and any attempt, whether by good nature or foul temper, at dissuading a consult constitutes "acting poorly." So getting those "I 'know' that this isn't a surgical problem, but could you lay hands on this patient ...?" from the ER or "I just want you on board, in case ..." from the primary consults are supposedly completely appropriate. Not to me, of course, but since we're all trying to look good here by pretending we're neutered I'm just letting you all know. 🙂

 

[McLovin]

Yes, I caught the follow-up. Again, if you don't know then call.... Also, as a resident/trainee, I do believe attending guidance back-up is appropriate and necessary with serious end-of-life or major medical decisions. My follow up was more in terms of generalities. Though, the one specific is that I really doubt you learned very much if anything from the hang up phone call.Unfortunately my practice involves too much of this...🙁Again, a point intended more for generalities. It may not be you, especially at the resident level. However, plenty of practicing physicians that want it both ways, i.e. claim they know (unwilling to admit they don't) and then call a consultant to make the decisions. Again, it is a generality maybe not applicable to your particular situation but as was noted, your presentation rubbed on a nerve of this type of conduct... in general.

Not true: I learned Dr.Blake was a d***. I've gotten more than my share of bogus consults, and never once did I come close to being that much as an a**.

And yes, I do agree getting a consult that starts with "this is not a surgical problem, but......" would be annoying, and despite how I described my consult in the original post (which was submitted in an irreverant, rapid-fire sort of way) , was not how it actually went down.