I don’t disagree with you. I’m not a Nephrologist or other consultant specialist other than being an EP. I therefore usually don’t dictate definitive care for patients where the consultant is the one performing the intervention. I’m annoyed when a primary physician or mid level sends a patient to the ED with the expectation that a specific procedure will be performed where I question the indication and there are relative or absolute contraindications (not saying that is the same exact scenario as your example). I understand certain emergent procedures better than some other non emergency physicians, and I know there are procedures, and especially surgeries, that other physicians understand much better than I do.
If you are dealing with residents or fellows in primarily academic settings then that might change the approach and conversation. Much, but not all, of my experience has been dealing with out of house attendings at night who are more reluctant to come in to the hospital and intervene outside of convenience hours. I’ve found this true for many specialists at several hospitals. This isn’t universal as some specialists are rock stars and will come in at night frequently when on call, work a full day before and after, never complain, and thank you for the referral. I’ve never been thanked by Nephrology though for requesting emergent dialysis. Not knocking on them, but just my experience.
I try not to get into confrontational battles with attending consultants. At a community hospital your relationships with other specialists are very important in helping to maintain interdepartmental respect, and more importantly for keeping a hospital contract by laying down roots throughout a hospital. I state my case once to a specialist with the request that they perform the intervention that I believe is indicated whether it is dialysis for hyperkalemia, a cath for a borderline STEMI, a stent for an infected obstructed stone, or an ex lap for a perforation, etc. If the specialist gives me push back disagreeing and saying no, then I carefully and objectively document our conversation moving on the next most appropriate care such as medical management of hyperkalemia with admission to the ICU. Infrequently I’ve surprisingly had a specialist call me back changing their mind, which I think is more related to the fact that after they hang up the phone they can’t go back to bed because they know they probably do need to intervene. Occasionally if I receive push back when I call a specialist, I will request they personally evaluate the patient in the ED if I think it will change the specialist’s decision. Typically more so when examining a patient clinically or pushing on a belly might make a difference. Hyperkalemia and EKG changes are fairly objective findings. If they won’t dialyze, yelling at them doesn’t often help. Sending the case along with your documentation to a peer review committee if the patient codes will have a much greater impact. I do think that sometimes you need to fight hard for an individual patients’ best interest, but you also can’t fight every battle or you will wear yourself thin, wear any good standing out in your hospital, and burn out without the ability to fight future battles.
