Medicine consultants

[ORS]

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What do you think. The medicine consultants (loose term) in our hospital refuse to write orders. Even if we say we would like you to actively manage the pts AFIB, HTN, etc.

This does not happen at private hospitals, why should it happen at an academic institution.

Imagine if I was consulted for a hip Fx and my note stated.

Recs: Hemi- arthroplasty, careful when broaching. Get XR, Close with interrupted vicryl sutures and staples. If XR OK then WBAT. Have pt F/U in 2 weeks. Will sign off. Call with questions.

My point is that we all work hard and are specialized in certain areas. They are much (and I emphasize MUCH) better than me at treating medical conditions and should do this actively.

In fact I think that more medical errors happen when we transcribe another physicians orders.

The point that they will cap if they care for these conditions is ridiculous. When do I cap?

Next point:

Who should admit the old sick pt with 10 med problems and a Fx hip. I think the medicine service. This is not how it works at my hospital. If it was my Mother I would want her on the medicine service so someone could see her anytime, not btw cases.

Young and healthy pts should be on the trauma or ortho service. I have no problem with that.

OK, I vented, sorry ....

 

[dynx]

What do you think. The medicine consultants (loose term) in our hospital refuse to write orders. Even if we say we would like you to actively manage the pts AFIB, HTN, etc.

This does not happen at private hospitals, why should it happen at an academic institution.

Imagine if I was consulted for a hip Fx and my note stated.

Recs: Hemi- arthroplasty, careful when broaching. Get XR, Close with interrupted vicryl sutures and staples. If XR OK then WBAT. Have pt F/U in 2 weeks. Will sign off. Call with questions.

My point is that we all work hard and are specialized in certain areas. They are much (and I emphasize MUCH) better than me at treating medical conditions and should do this actively.

In fact I think that more medical errors happen when we transcribe another physicians orders.

The point that they will cap if they care for these conditions is ridiculous. When do I cap?

Next point:

Who should admit the old sick pt with 10 med problems and a Fx hip. I think the medicine service. This is not how it works at my hospital. If it was my Mother I would want her on the medicine service so someone could see her anytime, not btw cases.

Young and healthy pts should be on the trauma or ortho service. I have no problem with that.

OK, I vented, sorry ....

Holy ****! did I? Wait...did that really just happen? Did an Orthopod bitch about having to take care of a patient that should be on another service? Really? REALLY? How about this...Next time some drunk ******* trips and breaks his wrist and gets a little scrape on his hand if I can find an orthopod that will take him onto the ortho service before his hand lac (in the orthopods mind his "other trauma issues")scabs over, I'll join your personal crusade to completely void your service of all people that might actually require care beyond the skeletal region. Till then, and I say this with all possible respect, STFU.

Thank you.

 

[Entei]

Pts should be on the trauma service. I have no problem with that.

Fixed that for you. 🙄

 

[SocialistMD]

I understand you were just venting, but let me "vent" in return.

I, a general surgery resident, am kind of upset by the fact that some of the smartest physicians graduating every year from medical school claim not to know how to take care of diabetes or hypertension. I mean, come on. Who are you trying to kid? It is a rare patient whose hypertension or diabetes are so out of control that a specialist is needed for management. Home meds are a great thing in patients tolerating PO.

Secondly, from a pure accredidation standpoint, surgical services need to admit traumas. The ACS mandates that x% of traumas (I don't know the exact percentage) be admitted to a surgical service. This means that the 85 year old who fell from standing that was triaged a level 4 trauma needs to be admitted to a surgical service for her isolated femur fracture.

Thirdly, why will ortho refuse to admit a young trauma patient with a complex leg fracture that is going to need the OR when they also have a non-operative facial fracture? ENT has said there is nothing to do except clindamycin, yet ortho still dumps it to the general surgery trauma service because it is "polytrauma."

As for the order thing, I understand your argument and agreed with you all intern year. The thing that I realized, though, was that their recs come based on patients without surgical problems. Their fear is that they might make a rec for a drug/treatment that would be bad in a post-op patient, so they leave the decision as to whether or not to start it up to us, the primary physicians taking care of the patient. Having seen where things could go wrong if they simply wrote the orders without getting our approval, I like the system as it is.

 

[Castro Viejo]

Did an Orthopod bitch about having to take care of a patient that should be on another service? Really? REALLY?

Well, let's be honest. It's probably just easier for a physician with clinical experience beyond the third year of medical school to manage complex medical issues like HTN and DM.

I mean, would you really want to stand there and listen to an Orthpod struggle through giving a verbal order to the nurse to treat the patient's hypertension?

Orthpod: "Nurse, uh..." (looks at his pocket pharmacopeia) "Give the patient 25 milligrams of Hicktuhzee."

Nurse: (thinking... WTF?) "No problem, Doctor."

(Nurse pages General Surgery resident...)

Gen Surg: "What's up?"

Nurse: "The bone doc just asked to give 25 milligrams of Hicktuhzee to treat Mr. Smith's hypertension. What's that?"

Gen Surg: "He means Hydrochlorothiazide."

I kid, I kid... We're all surgeons, but we're not all physicians. I think Orthopods actually have a somewhat legitimate claim that the patient's medical problems would ideally be managed by a medical consultant or by a General Surgery resident. Some of my better friends in the world are Orthopods and, as much as I enjoy their company, I would never want them to medically treat my mom or anyone else's mom. They're just not born like that.

I was there too. Getting the stupid Ortho dumps pre and postop. As much as I hated it then, now I realize it was the right thing to do.

 

[hammena1]

When a ...fill in the blank specialist/generalist... can interpret radiographs to determine existing implant, position the patient, set up the back table and know the sets for a revision THA in a dislocator, let alone make the approach, I'll get out my med school text and take care of diabetes. It's just not what orthopadic surgeons do.

 

[dynx]

Next consult I get from General Surgery for a hip fracture, I'm going to respond "You're a surgeon, so go ****ing operate on it."

Or better yet, I'll wait til your mama gets a nice intertroch fracture, then I will manage all her medical issues myself, just so I can hear you whine about how maybe a physician who actually received Medicine training should be handling it.

I can see my point flew way over the meat in your head. I think the medicine folks should take the medicine patients/consults. I think the general surgeons should take the general surgery patients and true multiple injury folks. But orthopods are the MOST notorious group in any hospital for not wanting to take pure ortho injuries for ANY reason. And a medicine team thinking Ortho should be managing a patient with DM and a hip fracture is far more reasonable than a Pod thinking general surgery should be handling a broken femur because the patient also has a black eye. My amazment was that the king of the dumping services was still bitching about getting dumped on.

wait...let me help you out with this:
Its like, you know, that dude...at the gym. When you're like benching and stuff and you got like hella weight on the bar, right? And you need a spot right, its his obligation to spot you right? but like he doesn't because he's a jerk and like whatever. But then when he's benching and you don't spot him he's like "DUDE!" and you're like "DUDE! WHAT?"

Get it?

 

[SocialistMD]

Its like, you know, that dude...at the gym. When you're like benching and stuff and you got like hella weight on the bar, right? And you need a spot right, its his obligation to spot you right? but like he doesn't because he's a jerk and like whatever. But then when he's benching and you don't spot him he's like "DUDE!" and you're like "DUDE! WHAT?"

It is a rare post that makes me actually laugh out loud. Bravo, my friend. Bravo.

 

[mosfet]

wait...let me help you out with this:
Its like, you know, that dude...at the gym. When you're like benching and stuff and you got like hella weight on the bar, right? And you need a spot right, its his obligation to spot you right? but like he doesn't because he's a jerk and like whatever. But then when he's benching and you don't spot him he's like "DUDE!" and you're like "DUDE! WHAT?"

Get it?

That was BEAUTIFUL!!!

 

[njbmd]

In vascular surgery, I get loads of consults and actually consult medicine very rarely. My rule is that I write orders if I take the patient on my service. If not, I write recommendations. It is up to the service that consulted me to take my recommendations or not. I am not obligated to take the recommendations of the services that I consult.

If the patient needs vascular surgery, they come on my service for management and then return to the service of that consulted me. I really don't want medicine managing the post (or preop) issues in the patients that I am taking to surgery.

Most of the medicine folk are quite happy to take their patients back once the immediate post op period is done. I also have the option of writing in the chart that management of X, Y or Z will be done by service X, Y or Z if the patient stays on my service. That way, we can share the experiences.😎

As far as my ortho colleagues are concerned, I am happy to have them do the ortho and leave the rest of the patient management to me. I have no desire to fix fractures and they are not crazy about anything else on the patient. It doesn't matter much to me and it's not that much trouble and much better for the patient in the long run.

 

[ESU_MD]

Specialty surgeons(ortho, vasc, ent, etc..) belong in the OR, leave the babysitting to medicine... and the trauma guys (the "er" docs of surgery)

 

[ddmo]

Next consult I get from General Surgery for a hip fracture, I'm going to respond "You're a surgeon, so go ****ing operate on it."

Don't put the idea in their heads. I can't tell you how many GS's have told me that they could operate on hip fxs, despite never having even seen one repaired.

I love you GS's for doing what you do, but the "We are general surgery, we can do anything as well as the specialists" shtick gets old after awhile. 🙄

 

[ddmo]

Because we don't care where the patient goes to, we just want them to go away. And that's the God's honest truth.

Preach on brother Tired, preach on.

 

[maxheadroom]

I agree (and practice like) njbmd. I only write orders on consult patients when it's an emergency. "To OR stat for debridement of Necrotizing Fasciitis." Anything beyond that is a recommendation. When I consult another service, I'll leave in my consult request if I want them to "manage" something or "make recommendations." Most services at my place are pretty reliable to understand when they should write orders and when not.

I also agree that ortho shouldn't be taking care of DM, HTN and the like. Our hospitals now have a hospitalist service that admits and manages pts with those issues so that the surgical specialists can focus on the surgical care and not all of the other stuff. The hospitalist gets to bill for doing something that's usually pretty straightforward. The surgeon gets to focus on surgery. When it works, it's great. Occasionally things get a small snag, but that's pretty rare. I love the hospitalists. It's sooooooo much better that the PCP who has a busy practice across town and wants to admit the patient but then never really sees the patient.

 

[maxheadroom]

And yes, surgical specialists (Ortho, PRS, ENT) do come from the more competitive part of the medschool class, but they spend lots of time learning detailed anatomy and complex operations. We don't talk about management of HTN, DM, COPD, CHF and all that other stuff in journal club or in our core conferences. While I do have a basic idea of how to take care of those things, it's been a long time and I might miss some of the more subtle details. If home meds will keep the DM or HTN well-regulated (i.e. nursing isn't calling me for abnormal values on a regular basis), I'll take care of it. When the home regimen doesn't work, it's time for Medicine. And if you have COPD, CHF, CRI, or any other chronic problem that likes to flare into an acute-on-chronic problem while in the hospital, you definitely need someone besides me.

 

[SocialistMD]

If home meds will keep the DM or HTN well-regulated (i.e. nursing isn't calling me for abnormal values on a regular basis), I'll take care of it. When the home regimen doesn't work, it's time for Medicine.

Exactly. This is how it should be. The thing is, the orthopods like to pretend every patient has problems that are beyond their home meds, so they put the patient on medicine upfront to prevent from having to potentially consult them later.

I don't claim to know how to manage HTN and DM as well as the medicine residents do, but I do know how to dose hydralazine, clonidine and metoprolol and I know how to write a sliding scale for insulin. That is something that I mastered within the first six months of my intern year, which, coincidently, is exactly how long the orthopods do as a general surgery intern. Seems to me they know how to do it, they just don't want to, and I think that attitude is unfortunate.

I get that you cry a lot for getting dumped on, but we can just keep doing it because you lack to the cojones to stop it.

I think it is more that we are concerned for doing what is right for a patient and right for the situation and it isn't worth the headache to keep trying to remind you guys that you are physicians and that, somewhere in the lost reaches of your head known as your brain, you actually do know how to take care of these simple problems.

 

[dynx]

I get that you cry a lot for getting dumped on, but we can just keep doing it because you lack to the cojones to stop it.

Maybe you and Medicine can share a box of tissues and talk about feelings?

lighten up son, this aint fifth grade where the "You gonna cry" line trumps the conversation. You can ussually come up with a more witty response, don't let me ruin your sense of humor.

Back to the point: the most pathetic thing I've seen of an attending was a Pod that had a "young healthy" patient with a blood transfusion reaction, short of breath, back pain the whole nine yards. He wanted a medicine consult for it and the on-call med team wasn't returning the page. Had no idea what to do. this is what happens when you depend upon others for even basic things for years on end, when they suddenly arent available you sit there with a dumb look on your face as the "I can deal with it, but I prefer to just do the surgery" facade fades and your patient suffers. But I know, its "cooler" to think that dumping your patients means you have cojones.

 

[SLUser11]

lighten up son, this aint fifth grade where the "You gonna cry" line trumps the conversation. You can ussually come up with a more witty response, don't let me ruin your sense of humor.

Back to the point: the most pathetic thing I've seen of an attending was a Pod that had a "young healthy" patient with a blood transfusion reaction, short of breath, back pain the whole nine yards. He wanted a medicine consult for it and the on-call med team wasn't returning the page. Had no idea what to do. this is what happens when you depend upon others for even basic things for years on end, when they suddenly arent available you sit there with a dumb look on your face as the "I can deal with it, but I prefer to just do the surgery" facade fades and your patient suffers. But I know, its "cooler" to think that dumping your patients means you have cojones.

This is awesome. You guys keep fighting. I'll be silently watching from the sideline.....


.....try to work in a "yo mamma" burn if you can.

 

[SocialistMD]

Then why so bitter every time you have to take a patient? Funny how General Surgery and Medicine will readily admit that it is more appropriate for them to take these patients on their service, but then continue to whine about how they have to take these patients on their service.

Honestly, at least be consistent.

It's better to admit the patient than to bicker where the patient goes while the patient sits and waits in the ED. It is better to admit a surgical patient to a surgical service than a medicine service. I don't think it is more appropriate for us (or medicine) to take the isolated fracture with medical problems or the trauma patient with another injury that does not require management. It is only better for the patient because we actually care about the patient, not because we know how to care for the patient. That is a sad reality.

 

[ORS]

There are three issues being discussed here and each deserves its own thread:

1. What is the role of a hospitalist, medicine consult team? I believe they should treat the pt for the consulted condition and manage all chronic medical conditions (i.e. DM, HTN, CHF, etc). This is the model at Harvard (i have heard?) and is what happens in private practice. Why not in academics.

2. Who should admit the pt. I have often admitted a pt I think would be better served on the medicine service, but do not feel like bickering at 3 am. E.g. the pt had a syncopal fall and elevated troponins. Oh yeah, this pt really belongs on an ortho service. More on this at a later date.....

3. Respect for other specialties. I know that medicine residents and attendings are far more qualified to take care of medical problems than surgeons are. Yes, we are all doctors, but they can read the latest articles on CHF, HTN, DM, Electrolyte imbalances, endocrine problems, etc and treat the pt better for these. We chose to read up on the latest surgical tx of a pt.

They are just as smart as surgeons, but chose their specialty because they like treating these conditions. We (as surgeons prefer surgery). Keep in mind that the medicine residents did not chose medicine b/c they did not get a surgical residency. They just chose a different path. I am sick of my partners talking down the medcine team. Likewise, the medicine team needs to appreciate that we chose surgery b/c we want to be in the OR. Not on the floor taking care of medical problems. Help us with these and will have more time to perform surgery (possibly on your mother, etc).

 

[MD2b06]

There are three issues being discussed here and each deserves its own thread:

1. What is the role of a hospitalist, medicine consult team? I believe they should treat the pt for the consulted condition and manage all chronic medical conditions (i.e. DM, HTN, CHF, etc). This is the model at Harvard (i have heard?) and is what happens in private practice. Why not in academics.

2. Who should admit the pt. I have often admitted a pt I think would be better served on the medicine service, but do not feel like bickering at 3 am. E.g. the pt had a syncopal fall and elevated troponins. Oh yeah, this pt really belongs on an ortho service. More on this at a later date.....

3. Respect for other specialties. I know that medicine residents and attendings are far more qualified to take care of medical problems than surgeons are. Yes, we are all doctors, but they can read the latest articles on CHF, HTN, DM, Electrolyte imbalances, endocrine problems, etc and treat the pt better for these. We chose to read up on the latest surgical tx of a pt.

They are just as smart as surgeons, but chose their specialty because they like treating these conditions. We (as surgeons prefer surgery). Keep in mind that the medicine residents did not chose medicine b/c they did not get a surgical residency. They just chose a different path. I am sick of my partners talking down the medcine team. Likewise, the medicine team needs to appreciate that we chose surgery b/c we want to be in the OR. Not on the floor taking care of medical problems. Help us with these and will have more time to perform surgery (possibly on your mother, etc).

As medicine residents, we are often consulted to manage surgical patients with many co-morbidities. We're happy to see the patient and call you with our recommendations. Whether or not you choose to follow them is really up to you as you are the primary team. As a consultant, I almost never place orders on a patient unless I feel something needs to be done stat, and even then, I will always let the primary team know first. I remember getting annoyed when a surgical intern once ordered labs and a chest x-ray on a patient of mine that was comfort care and on a morphine drip! And for everyone involved, please learn how to call a consult. This applies to medicine housestaff as well. Consulting for "coumadin management" but not having any idea why the patient is on coumadin is not a good idea. Consulting cardiology for tachycardia yet not even having an EKG on the chart just slows everything down.

A pt that comes in with a fx who just happens to have HTN and DM does not belong on a medicine service. I have full faith in my the ability of my surgical colleagues to restart anti-HTN meds as well as oral hypoglycemics. If, on the other hand, you have a patient on 4 different anti-HTN meds and still cannot control their BP, call us. We do not like inappropriate transfers of care to our service anymore than any surgical service would like the same on their service. If it bothers people that much, it can be handled at the attending level. Thankfully, most of my attendings will actually come and evaluate patients if I ask them to. This saves many unnecessary admissions.

I agree that respect for other specialties is paramount. Unfortunately, in an era where everyone is overworked, underpaid, and constantly under stress, it's rare to find. Surgery rips on Medicine. Medicine makes fun of surgery. Everyone hates the ED (at least in my hospital) This will probably not change anytime soon...oh well....only 15 more months till fellowship.

 

[SocialistMD]

Whether or not you choose to follow them is really up to you as you are the primary team. As a consultant, I almost never place orders on a patient unless I feel something needs to be done stat, and even then, I will always let the primary team know first. And for everyone involved, please learn how to call a consult. This applies to medicine housestaff as well. Consulting for "coumadin management" but not having any idea why the patient is on coumadin is not a good idea. Consulting cardiology for tachycardia yet not even having an EKG on the chart just slows everything down.

A pt that comes in with a fx who just happens to have HTN and DM does not belong on a medicine service. I have full faith in my the ability of my surgical colleagues to restart anti-HTN meds as well as oral hypoglycemics. If, on the other hand, you have a patient on 4 different anti-HTN meds and still cannot control their BP, call us. We do not like inappropriate transfers of care to our service anymore than any surgical service would like the same on their service. If it bothers people that much, it can be handled at the attending level. Thankfully, most of my attendings will actually come and evaluate patients if I ask them to. This saves many unnecessary admissions.

I agree that respect for other specialties is paramount. Unfortunately, in an era where everyone is overworked, underpaid, and constantly under stress, it's rare to find. Surgery rips on Medicine. Medicine makes fun of surgery. Everyone hates the ED (at least in my hospital) This will probably not change anytime soon...oh well....only 15 more months till fellowship.

I agree with all of this.

I remember getting annoyed when a surgical intern once ordered labs and a chest x-ray on a patient of mine that was comfort care and on a morphine drip!

Out of curiosity, why did you call the consult? While I agree that consultants shouldn't be writing the orders, it sounds like the x-ray and labs were ordered in planning some sort of procedure. If you didn't want the workup or procedure done, why ask for the consult? 😕

 

[bruinrab]

I am suffering through my medicine sub-i right now (required by my school). I'm not even halfway through and I came thisclose to breaking down in tears of frustration and anger at the hospital today - I have never felt that way on a surgical rotation.

If I ever complain about the "horrors" of my internship, please slap me and remind me of this post.

That's all. Thank you. 🙁

 

[Trifling Jester]

There are three issues being discussed here and each deserves its own thread:

1. What is the role of a hospitalist, medicine consult team? I believe they should treat the pt for the consulted condition and manage all chronic medical conditions (i.e. DM, HTN, CHF, etc). This is the model at Harvard (i have heard?) and is what happens in private practice. Why not in academics.

I think medicine should consult on those chronic conditions and write orders prefaced by "if OK with primary team."

2. Who should admit the pt. I have often admitted a pt I think would be better served on the medicine service, but do not feel like bickering at 3 am. E.g. the pt had a syncopal fall and elevated troponins. Oh yeah, this pt really belongs on an ortho service. More on this at a later date.....

That depends on the primary reason for admission. In an academic setting an elderly woman with controlled HTN and DM on oral meds who broke her hip should be admitted to ortho IMO. Consult medicine if needed to follow along.

In the private setting the medicine staff can bill for an easy admit, so I see it as a totally different situation.

In the example you cite the primary reason for admission is probably medical. If there was a syncope that triggered the fall then she needs a workup, especially with elevated troponins.

3. Respect for other specialties. I know that medicine residents and attendings are far more qualified to take care of medical problems than surgeons are. Yes, we are all doctors, but they can read the latest articles on CHF, HTN, DM, Electrolyte imbalances, endocrine problems, etc and treat the pt better for these. We chose to read up on the latest surgical tx of a pt.

They are just as smart as surgeons, but chose their specialty because they like treating these conditions. We (as surgeons prefer surgery). Keep in mind that the medicine residents did not chose medicine b/c they did not get a surgical residency. They just chose a different path. I am sick of my partners talking down the medcine team. Likewise, the medicine team needs to appreciate that we chose surgery b/c we want to be in the OR. Not on the floor taking care of medical problems. Help us with these and will have more time to perform surgery (possibly on your mother, etc).

I think we're all bound to butt heads, it's just an unavoidable consequence of sleep deprivation.

-The Trifling Jester

 

[fishmonger69]

quite the heated discussion going on here. let's all remember that outside the sh*tty world of academics there lives a place where consultants would love to come by and manage any part of our patient we see fit to call them on (including writing orders). we hate consults as residents because it means more work without an increase in pay (and there's always the chance we take the patient on our service).

the comment about knowing how to setup for a revision THA, the rep is almost always present with calculations and recs put together by his 'experts' (not dissimilar from an EVAAR). yes, the final decision rests with the ortho, but come on, most private guys i've seen go with what the rep says

to the idea that 'trauma' is the dumping ground, that's probably best. patients are usually complex and even dedicated femur fxs can have minor issues become major if left to squander under the absent eye of an ortho/ent (most of my ortho friends operate all day and barely round on their own post-ops, let alone any consults).

the quicker we compartmentalize medicine and understand the days of the 'general practitioner' and 'general surgeon' are over, the less common these issues of patient ownership will become

 

[MD2b06]

I agree with all of this.


Out of curiosity, why did you call the consult? While I agree that consultants shouldn't be writing the orders, it sounds like the x-ray and labs were ordered in planning some sort of procedure. If you didn't want the workup or procedure done, why ask for the consult? 😕

It's not that we didn't want the procedure done, but rather that her clinical course kept deteriorating deeming her unsuitable for the OR per surgery. Surgery had been following along for almost 2 weeks, but the patient's underlying maligancy and co-morbidities were too much for her to overcome. She eventually decided that she didn't want any additional aggressive measures taken, and just wanted to be made comfortable. I understand surgical interns follow a ridiculous number of patients, but please at least keep the primary team in the loop if you want to enter orders on a non-service patient. Most of the time, we're fine with it. However, it's not good when radiology is paging us asking what we're looking for in a study that we didn't even know was ordered.

 

[hammena1]

Just think of the ortho reps as the best paid consultants we use.

I was merely trying to illustrate that as orthopaedists, we spend our time learing to manage the surgical aspects of the patient from indications, to appraoches to rehabilitation to management of complications. Internists dont know contraindications to our surgical options and we don't know drug interactions in polypharmacy. Who would you want to adjust your meds?

 

[balaguru]

Medicine (and apparently much of Surgery) are very good at using the "Doctors are doctors" when it comes to managing medical issues of inpatients.

They're not so good at it when their patients have ankle sprains, osteoarthritis, tennis elbow, and trochanteric bursitis.

Huh? I've never seen a PCP shy away from any of the above complaints.