New Year's Resolution: Broken.

Discussion in 'Emergency Medicine' started by RustedFox, Jan 2, 2019.

  1. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
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    You already have a bad relationship with your consultants. You can't make it worse. You can, however, make them do their job. Even if they whine. You aren't consulting them for advice. You are consulting them for admission. If they want more labs, they can put them on their admission orders. Or, they can discharge the patient. If they keep the patient down for 3 more hours, then it's on them.
     
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  2. GeneralVeers

    GeneralVeers Globus Hystericus
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    I love working in places where I have an "Admit to Dr. ______" order in Cerner. I can place the order, and the hospitalist at that point can take over care and decide what they want to do. Once I've spoken with them and clicked that order its their responsibility. Only time I don't click it is if they say they are going to come see the patient in a timely fashion.
     
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  3. Groove

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    Sounds like a bad environment. I hope you enjoy the job. I'd have little patience for those shenanigans.

    That being said, you have more tools at your disposal:

    1) Formally consult the hospitalist to the bedside. You're not consulting them for their opinion on labs, etc.. You're consulting them for an admission. Hospital bylaws typically dictate that they are required to see the pt within a certain timeframe. It's not negotiable and if they continue to abuse it you can call the administrator on call and report them.

    2) If you think they're unsafe to discharge and the hospitalist won't admit/won't see them then you can threaten to transfer them to another facility. Tell them that this constitutes an EMTALA violation and that you're obligated to report them on the transfer form as there is a question specifically asking whether a consultant has refused to see/treat the pt. I would inform administration prior to transfer that you are afraid that this will constitute an EMTALA violation but the hospitalist is leaving you no choice. These are big fines. This likely will result in a quick phone call from the administrator to hospitalist director to hospitalist on call and an immediate change in attitude. I'd be very sure of your diagnosis and/or management before going this route as it is sure to draw attention to yourself.

    3) If you live in an environment with consistent push back from medicine, then buff the pt's with subspecialty consultations prior to calling medicine. This is perhaps the easiest way to force an admit. Weird neuro sx and you want to admit for possible TIA or CVA r/o? Consult neuro, obtain buy in, then call hospitalist for admission stating neuro recommended it. They are then stuck and can either take the admission or take it up with neuro. Most will just admit because the later will require them coming down to actually see the pt. ACS r/o? Call cards and obtain buy in for their consultation on a medicine admission. Rinse, repeat.

    If you are having consistent issues with push back among the hospitalists, talk to your director about it. #1 and #2 burn bridges quickly and a lot of times these issues can be worked out quietly behind the scenes between the dept admins without involving c-suite. If not, you guys need to identify which administrator has vested interests over ED metrics and who's bonuses depend on them. I would then start including them on communications involving individualized cases where the hospitalist refused or significantly delayed care and how that is having a deleterious effect on throughput and metrics and phrase it in the context of "concern for pt safety" which tends to always get the most attention. Include nursing ED management in your concerns and have them bump it up from the nursing side which will also help gain traction.
     
    #53 Groove, Jan 5, 2019
    Last edited: Jan 5, 2019
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  4. Groove

    Groove Member
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    Yep. I have all my scribes document a clear transition of care to the admitting doc with a timestamp matching my admit order.
     
  5. thegenius

    thegenius Senior Wharf Rat
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    I hear ya guys. I'd say 95% of the time there is no problem with hospitalists. They admit low risk syncope, low risk chest pain and other stuff. We do many of the things @Groove mentioned. I've yet had the need to call the administration for a particular case.

    What we end up doing is often calling consultants, we say "GI: I have a person who vomited 1 drop of blood. I'm doing x, y, and z. Do you have any other recommendations in the ED?" (I already know the answer...) "I'm going to admit the patient." GI: OK sounds good."

    Consult: GI....Dr. Colonoscope: Agrees with plan for admission.
     
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  6. bravotwozero

    bravotwozero Chronically ambitious
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    It’s incredible really, no matter what part of the country or hospital, sound has become notorious for being a terrible hospitalist group amongst EM physicians. They’ve also lost contracts because of crappy satisfaction scores, including at a hospital that I work at.

    I bet they’re also not doing that great in terms of metrics at your shop, which would also give you some leverage with the c suite against them.


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  7. GeneralVeers

    GeneralVeers Globus Hystericus
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    Sound is the primary admitting group at my new job. I've had no bad experiences with them as far as admissions, and in general less pushback than with our other hospitalist groups (we have 6!!!).
     
  8. bravotwozero

    bravotwozero Chronically ambitious
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    That’s likely why, you have 6 groups. They’re struggling for admissions, and will likely beg you for them. I doubt they’ll last very long.


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  9. Dr.McNinja

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    Yeah, Sound seems to have crashed through the bottom of the barrel when they picked their docs. Their metrics are terrible, as they hold onto patients too long, unless they're actually sick, in which case they punt them out and they bounce back at alarming rates.
    I hate them. They're of course moving in to EM staffing as well. Emergency Medicine | Sound Physicians
     
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  10. filhodeinferno

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    If only it were that easy. I've worked at 4 different hospitals out of residency, and "just admit them to obs" is always a soul-sucking, time draining fight. That's why these cases suck the life out of me so much.
     
  11. filhodeinferno

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    Amen, brotha. It's a fight with the hospitalist or a fight with the family, or both with these cases. Or a 8 hour ED stay while the ED case manager attempts placement. Bleh!
     
  12. GeneralVeers

    GeneralVeers Globus Hystericus
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    You're working in the wrong places. Sometimes they give me token pushback, but once I stand firm they relent. Typically not longer than a 2-3 minute conversation with the hospitalist.
     
  13. Groove

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    I actually enjoy the medicine jousting, chess matches. The reality is that we hold all the cards and once we decide the pt needs to come in, it's really just an exercise in futility to fight against it. We'll make it happen one way or another. It's only the new hospitalists fresh out of residency and still in that "I am the wall!" - mode that don't get it. I can hear my guys just sigh over the telephone when they hear it's me, resigned to their fate.

    If I had to deal with an extremely malignant environment where every admission was a knock down, drag out fight...that would get old really quickly and I'd probably be looking for another gig.
     
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  14. Tipsy McStagger

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    I'd rather sit in a bathtub full of scorpions.

    Honestly I'd just prefer people be reasonable. Whether it's families, or admitting docs or whomever...

    Edit: Hope this didn't sound too glib or abrasive. I just wish that I could explain my position to families and have them understand, or to a hospitalist and have them understand. Not be threatened by hospitalists for "condemning a patient to an obs admission" and having patients (and their families) yell at me for their last obs admission and now they're being asked to pay. I hate being a middleman in these situations.
     
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  15. Groove

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    I hear ya man. I’d probably feel differently if I wasn’t so spoiled at my shop. I don’t think they are officially allowed to refuse our admissions so it’s infrequent for us to get much pushback.

    A+ on the horrifying mental imagery. I couldn’t help but picture myself naked in a bathtub of giant scorpions! Tell us how you really feel! :laugh:
    [​IMG]
     
    #65 Groove, Jan 7, 2019
    Last edited: Jan 7, 2019
  16. Apollyon

    Apollyon Screw the GST
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    Centruroides exilicauda or sculpturatus?
     
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  17. OP
    OP
    RustedFox

    RustedFox We're all stars now. In the GOAT RODEO.
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    You seem to like these things enough to know their genus/species.
    I'm worried about you.
     
  18. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
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    The photo is of neither.
    Now, as for what he wants in his bathtub, that's up to Tipsy
     
  19. Apollyon

    Apollyon Screw the GST
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    Honest question: how can you tell? Too small? I never knew what was the genus/species of the scorpions we had in SC, but they were little, little guys.
     
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  20. Groove

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  21. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner
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    Neither of those species is melanistic.
    General rule is, black scorpions hurt, yellow scorpions kill. And even then, they usually only kill kids, similar to black widows.
     
  22. killerleaf

    killerleaf beware, beyond there be dragons
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    what about 2-3" long reddish ones? are they dangerously hurtful? We have found about 5 in the house so far, at different times..two in the bathroom (one in the tub and one in the light fixture), one in the laundry room (which is right by the back door) and the other two perched above the doggie door. I just went "scorpion, kill!!!" without really thinking about if they were the kind that could kill me or not.
     
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  23. BoardingDoc

    BoardingDoc Don't worry. I've got my towel.
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    This thread really took a left turn.
     
  24. Birdstrike

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    Time to review "scorpion bite protocol." Lol.
     
  25. Apollyon

    Apollyon Screw the GST
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    Watch out for that pancreatitis!
     
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  26. filhodeinferno

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    Nah, you just have a rare hospital that likes taking in social admits. If I quit a job every time it was hard to admit a non-sick old person, I'd go through 30 before I found the place that likes to take em. IIRC, you're the guy who make 500/hr and only works 10 days a month seeing 1 pph at the perfect locums gigs where the consultants kiss your feet and the hospitalists love admitting, the older and more demented, the better, right? Isn't that your thing on here? Or am I thinking of someone else?

    That being said, I can always get them in...it just takes effort and a crappy conversation, which is why I hate those cases the most.
     
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  27. GeneralVeers

    GeneralVeers Globus Hystericus
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    Close. I used to make $500/hr seeing 2 pts/hr. That job has dried up, so I'm still making good money but working close to home and not traveling. Honestly I've never worked in a place where it was difficult to admit these weak old people. It could be the region of the country you are working in.
     
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  28. filhodeinferno

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    I’ve worked in the south, Midwest, and West. Each place it was hard. Who knows? We probably have the same ease of admission, but I just hate it and complain about it more...
     
  29. pencilcase

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    It depends on the hospital. There was a hospital I worked at where I dreaded talking to the hospitalist or admitting doctor (some community docs were still admitting their patients there) because of push back.

    My current job is better as far as getting people admitted with no push back even social admits. The new hospital mostly has one admitting group and the primary docs rarely admit their own patients anymore. The difference it makes in the work environment is huge.

    But I agree you can’t just switch jobs for this reason. A better approach is to speak to existing ER doctors at your hospital of interest during interviews to see their experiences with the admitting service before you even accept the job. Take down numbers when people offer to talk to you by phone when they see you touring on interview day. There was one job where talking to the overnight doctor changed my mind about coming on as a new night doc. They implied multiple times that nights there were usually rough. I felt like I dodged a bullet. This is more of an advise for new grads, talk to other docs at your desired site before accepting the job. You can tells lots by someone’s tone when they answer your questions.
     
  30. Dr.McNinja

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    They don't bite, they sting.
     
  31. Birdstrike

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    Man, that stings.
     

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