The consultologists

[scoopdaboop]

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Hospitalists who consult for every tiny little problem (some of my attendings). You are an embarrassment. As a pgy3 I manage patients better than some of my attendings, how do I know? Because when I work with another attending who is actually a judicious physician good things happen.
Sad what this field has become.

 

[glorifiedresident]

Hospitalists who consult for every tiny little problem (some of my attendings). You are an embarrassment. As a pgy3 I manage patients better than some of my attendings, how do I know? Because when I work with another attending who is actually a judicious physician good things happen.
Sad what this field has become.

There's definitely another side to that coin. In some systems, hospitalists are pushed to manage a wider range of issues on their own, often taking on "specialty" care that might otherwise be handled by a consultant. Most of the time, this approach works out just fine.

However, there's a risk to that kind of independence. When you choose not to consult, you're going out on a limb. It's not necessarily because you don't know what to do; often, you have a solid plan. The problem comes when a patient's condition takes a bad turn. In that situation, you can be asked why you didn't consult, even if the consultant would have made the exact same recommendation you did. You may not have the formal training to make that final, binding call.

So, while it can be frustrating to see what you perceive as over-consulting, there's also a real danger in playing the consultant yourself. It's a thorny issue, and while things usually go well, when they don't, it can go very wrong.

 

[DrMetal]

Hospitalists who consult for every tiny little problem (some of my attendings). You are an embarrassment. As a pgy3 I manage patients better than some of my attendings, how do I know? Because when I work with another attending who is actually a judicious physician good things happen.
Sad what this field has become.

And in some hospitals, you're almost required to consult.

I get hate inquiries when I don't consult the Diabetic NP , as if I can't titrate insulin myself.

What's even worse, is some consults are placed automatically (tele-neuro, sepsis NP, etc) as per nurse-driven protocols.

@scoopdaboop Stay Gold Ponyboy . . . the real world awaits.

 

[chessknt]

Hospitalists who consult for every tiny little problem (some of my attendings). You are an embarrassment. As a pgy3 I manage patients better than some of my attendings, how do I know? Because when I work with another attending who is actually a judicious physician good things happen.
Sad what this field has become.

 

[dozitgetchahi]

And in some hospitals, you're almost required to consult.

I get hate inquiries when I don't consult the Diabetic NP , as if I can't titrate insulin myself.

What's even worse, is some consults are placed automatically (tele-neuro, sepsis NP, etc) as per nurse-driven protocols.

@scoopdaboop Stay Gold Ponyboy . . . the real world awaits.

Exactly.

Some hospitals have built their entire ecosystem out of hospitalists slinging BS consults, ie calling nephrology for every creatinine over 1.2, etc.

 

[whoknows2012]

Exactly.

Some hospitals have built their entire ecosystem out of hospitalists slinging BS consults, ie calling nephrology for every creatinine over 1.2, etc.

I don’t think I could work in that environment. How do y’all do it.

I’m inpatient only and have total control over consulting and take very seriously the idea that to consult a specialty outside of my own (mal heme) I should have questions, (ie need help with work up or diff dx) or need procedure (ie egd bronch etc). I work closely with transplant ID which is closest thing I have to policy that we need to consult a specific service ( abx stewardship which I wholeheartedly support). Is this just academic vs community?

I do my best to get a full handle of a given clinical scenario (barring urgency ie micu consult 🙄 ) before consulting to avoid the appearance of asking another service to do my work for me. Additionally it helps to have a good back and forth once the consult is called and recs start coming through. Many of the consulting teams don’t know the first thing about the toxicities or complications of the diseases I treat or the drugs I use. Which is crazy but not expected

Edit; for reference my census is 20-25. And this is not meant to suggest this is the only way to do it, just that I understand OPs concerns and there are multiple sides to this issue

 

[VA Hopeful Dr]

Exactly.

Some hospitals have built their entire ecosystem out of hospitalists slinging BS consults, ie calling nephrology for every creatinine over 1.2, etc.

Let's not forget that some hospitals work their hospitalists way too hard. If you have 20+ patients on your service, you're likely to consult more just for lack of time to do a proper job.

 

[dozitgetchahi]

Let's not forget that some hospitals work their hospitalists way too hard. If you have 20+ patients on your service, you're likely to consult more just for lack of time to do a proper job.

Yes, I’ve definitely heard of that happening too. When I was a resident, I had an attending who used to work at a busy community hospital that was like this. Each hospitalist was covering way too many patients, and he said he didn’t have time to think through anything. Just consult for every issue.

 

[DrMetal]

It gets even shadier. My border-town hospital has an emergency fund that pays for the un-insured and indigenous population.

Everyone asks to be consulted, so they can dip into this emergency fund, which often reimburses better than some private insurances.

Not quite sure how we live with ourselves . . . but it sure gets easier with time.

 

[whoknows2012]

It gets even shadier. My border-town hospital has an emergency fund that pays for the un-insured and indigenous population.

Everyone asks to be consulted, so they can dip into this emergency fund, which often reimburses better than some private insurances.

Not quite sure how we live with ourselves . . . but it sure gets easier with time.

Yikes! Shady is right

 

[MD46]

It gets even shadier. My border-town hospital has an emergency fund that pays for the un-insured and indigenous population.

Everyone asks to be consulted, so they can dip into this emergency fund, which often reimburses better than some private insurances.

Not quite sure how we live with ourselves . . . but it sure gets easier with time.

where I previously worked, we were on collection model, so hospital got paid from the fund but the consulting physicians didnt. So you saw the patient, gave recommendations, took liability, did all the work and didnt get paid. So when questioned, they said others do it as well and its part of the culture. Mind you, there were at least 60 plus patients I saw within a 9 month period that were uninsured.

 

[scoopdaboop]

What's even worse, is some consults are placed automatically (tele-neuro, sepsis NP, etc) as per nurse-driven protocols.

that's fine. and some consults are forced. GI needs to be involved in a bleeder obviously. But these are not what I am speaking of. What I really mean is silly things, CAP necessitating a pulm consult, obvious prerenal aki necessitating nephro.

and let's be honest. Half a hospitalist's list are rocks pending dc. let's not pretend 10 patients is hard to manage out of 20 you skim review, or don't even have daily labs on etc.

 

[DrMetal]

and let's be honest. Half a hospitalist's list are rocks pending dc. let's not pretend 10 patients is hard to manage out of 20 you skim review, or don't even have daily labs on etc.

True. Make's the general hospitalist role look like a scam.

In due time---with the advent of AI to write your note, nurses to do your physical exams for you (as if the physical exam matters anymore)---the hospitalist will soon have to cover 50 patients by herself. The typical hospitalist group of 20 will dwindle down to 5.

And the Sun will become a Red Giant one day engulfing the Earth . . . so why does it matter anyway? I'm going drinking.

 

[rockstar88]

Hospitalists who consult for every tiny little problem (some of my attendings). You are an embarrassment. As a pgy3 I manage patients better than some of my attendings, how do I know? Because when I work with another attending who is actually a judicious physician good things happen.
Sad what this field has become.

As a resident, you have ACGME caps on the number of patients you manage. Hospitalists do not. They manage 20-24 patients themselves per day. They might probably not consult as much if they managed fewer patients.

 

[HemeOncHopeful19]

It gets even shadier. My border-town hospital has an emergency fund that pays for the un-insured and indigenous population.

Everyone asks to be consulted, so they can dip into this emergency fund, which often reimburses better than some private insurances.

Not quite sure how we live with ourselves . . . but it sure gets easier with time.

Government "emergency fund" paying better than private insurers (and thus dramatically more the Medicare/Medicaid for its own citizens) is peak government

 

[Euxox]

and let's be honest. Half a hospitalist's list are rocks pending dc. let's not pretend 10 patients is hard to manage out of 20 you skim review, or don't even have daily labs on etc.

Very dependent on location and practice. A profitable hospital doesn't have a huge population of rocks. In my group we generally carry 18 to 20 patients (with a PA to help) and usually only one or two are rocks. There are generally three to four fresh admits and three to four discharges each day, and the remaining patients have multiple active medical issues, even if not extremely sick. I wish I had 10 rocks on service every day - reminds me of being a senior resident at the VA.

 

[CatFactorial]

In residency was firmly against consulting unnecessarily, as a point of pride. Carried that ethos to attending on the inpatient transplant service (in the community) and eventually the ID docs mildly complained that they were not seeing enough consults. So now, gram negative bacteremia, doing great on cefepime? Consult ID, no skin off my back

 

[shouldigomd]

I thought this way as a resident too but you will see that in the real world of medicine there are many political pressures at play. Providing care for our patients is a minority of what we do nowadays.

 

[dozitgetchahi]

It gets even shadier. My border-town hospital has an emergency fund that pays for the un-insured and indigenous population.

Everyone asks to be consulted, so they can dip into this emergency fund, which often reimburses better than some private insurances.

Not quite sure how we live with ourselves . . . but it sure gets easier with time.

That’s pretty bad…but sadly not surprising given some of the really unscrupulous stuff I’ve seen in medicine.

 

[Meerkatology]

As a nocturnist who doesn’t need to deal with needing every consultants blessing to discharge, half of my consults are probably for cya purposes.

ID in particular is the one that i feel comfortable not consulting most of the time.

 

[dgdg]

One large issue with consulting, inpatient or outpatient, is when there is (eventually) a negative outcome.
Did you practice to the level of a board certified specialist? That can be very subjective in front of a jury with all the what ifs and seeing things retrospectively.
Call it "CYA" or general prudence for patient care. That is the thing you have to decide each time you make a diagnosis, write an order.

Fortunately, there are a lot of published standard of care guidelines developed by these expert consultants. If you follow one of them, your decision making was solid technically, but it is still up to the jury's emotional sentiment.

 

[DrMetal]

One large issue with consulting, inpatient or outpatient, is when there is (eventually) a negative outcome.
Did you practice to the level of a board certified specialist? That can be very subjective in front of a jury with all the what ifs and seeing things retrospectively.
Call it "CYA" or general prudence for patient care. That is the thing you have to decide each time you make a diagnosis, write an order.

Fortunately, there are a lot of published standard of care guidelines developed by these expert consultants. If you follow one of them, your decision making was solid technically, but it is still up to the jury's emotional sentiment.

None of this matters. If there's a bad outcome, and if cause/effect can be established, the jury will always side with the patient. If you were flying solo, you get named. If you consulted every service known to man, you all get named.

Where it might matter more, is if your hospital decides to challenge your credentials, and/or report you to the NPDB (if you made a mistake and did not consult).

For instance, I just DC'd PO AC in a patient (who was on it for pAF), because of recurrent GI bleeds and an Hgb of 4 (multiple admissions for bleeding). I did this without consulting cardiology. What a cowboy I am for using common sense. Now, in 6 months, if she throws a clot and strokes out, can I be sued? Absolutely, and the patient will be awarded. Will my hospital admonish me for not consulting cardiology (to decide whether PO AC should've been dc'd)? I dunno. I hope not. I guess we'll find out in 6 months.

 

[chessknt]

None of this matters. If there's a bad outcome, and if cause/effect can be established, the jury will always side with the patient. If you were flying solo, you get named. If you consulted every service known to man, you all get named.

Where it might matter more, is if your hospital decides to challenge your credentials, and/or report you to the NPDB (if you made a mistake and did not consult).

For instance, I just DC'd PO AC in a patient (who was on it for pAF), because of recurrent GI bleeds and an Hgb of 4 (multiple admissions for bleeding). I did this without consulting cardiology. What a cowboy I am for using common sense. Now, in 6 months, if she throws a clot and strokes out, can I be sued? Absolutely, and the patient will be awarded. Will my hospital admonish me for not consulting cardiology (to decide whether PO AC should've been dc'd)? I dunno. I hope not. I guess we'll find out in 6 months.

See this is an issue when you don't see people get hurt/die often enough--your perspective is ****ed. Nobody is going to sue you if the patient has a stroke and you documented the risk/benefit of stopping AC. There is no lawyer on the planet that would take that case and it would never make it to court--total waste of their time. People die all the ****ing time in the ICU from malpractice as well as unavoidable scenarios and lawsuits arent falling out of the sky. The anestheisa people are the same--they are terrified of lip lacs when nobody gives a **** about that.

 

[DrMetal]

e and you documented the risk/benefit of stopping AC. There is no lawyer on the planet that would take that case and it would never make it to court--total waste of their time.

I don't know about that. If damages occurred, and if there's enough evidence of a cause-effect relationship, despite your documentation of counseling (which the patient can deny happened) . . . this is often enough to make a case. Some lawyer might take it. All you really need is damages and cause-effect. With that, you can convince a judge (mediator) or jury for a payout.

Whether or not the physician is held accountable (loss of credentialling, privileges, licensure, report to National databank etc) is a different story. There could be a legal case that pays out, but the physician is not labelled as truly at fault.

That's why we document. To ensure we're not ascribed with fault.

 

[VA Hopeful Dr]

I don't know about that. If damages occurred, and if there's enough evidence of a cause-effect relationship, despite your documentation of counseling (which the patient can deny happened) . . . this is often enough to make a case. Some lawyer might take it. All you really need is damages and cause-effect. With that, you can convince a judge (mediator) or jury for a payout.

Whether or not the physician is held accountable (loss of credentialling, privileges, licensure, report to National databank etc) is a different story. There could be a legal case that pays out, but the physician is not labelled as truly at fault.

That's why we document. To ensure we're not ascribed with fault.

I mean, that's clearly not all you need as the vast majority of lawsuits come out in our favor.

 

[chessknt]

I don't know about that. If damages occurred, and if there's enough evidence of a cause-effect relationship, despite your documentation of counseling (which the patient can deny happened) . . . this is often enough to make a case. Some lawyer might take it. All you really need is damages and cause-effect. With that, you can convince a judge (mediator) or jury for a payout.

Whether or not the physician is held accountable (loss of credentialling, privileges, licensure, report to National databank etc) is a different story. There could be a legal case that pays out, but the physician is not labelled as truly at fault.

That's why we document. To ensure we're not ascribed with fault.

How many times have you been sued? Is this PTSD or just ill-informed paranoia driving your beliefs here? People die under my care routinely and often people are upset and trying to fight it but the medical reality is what wins in the end. The legal system does not routinely hallucinate alternative scenarios for well documented good care.

To your specific scenario I have literally taken care of someone in the past few months who had a stroke after having ac held for 3 days after recurring unfixable gib had hemorrhagic conversion anyways and died. No lawsuit is going to come from this.

 

[DrMetal]

How many times have you been sued?

Twice. Both times the plaintiff was paid out. Both times I was absolved of any wrongdoing (nothing bad happened to me, I was deemed to have used sound and documented medical logic). One time, the patient even asked that I not be specifically named (b/c it was a nursing error), but of course, as the attending, you have to be named. I guess 2 out of ~10,000 patients (in a busy hospital practice, over the last 10 years) is not bad.

To your specific scenario I have literally taken care of someone in the past few months who had a stroke after having ac held for 3 days after recurring unfixable gib had hemorrhagic conversion anyways and died. No lawsuit is going to come from this.

Ehhh, you're probably right, but I don't know why you're so confident about this. Lawsuits have become the norm in our profession, they're really not that uncommon.

 

[dozitgetchahi]

Twice. Both times the plaintiff was paid out. Both times I was absolved of any wrongdoing (nothing bad happened to me, I was deemed to have used sound and documented medical logic). One time, the patient even asked that I not be specifically named (b/c it was a nursing error), but of course, as the attending, you have to be named. I guess 2 out of ~10,000 patients (in a busy hospital practice, over the last 10 years) is not bad.



Ehhh, you're probably right, but I don't know why you're so confident about this. Lawsuits have become the norm in our profession, they're really not that uncommon.

I’m actually with Dr Metal here.

While some big fraction of medical lawsuits are stupid and ultimately get dismissed, so many lawsuits get filed that a lot of nonsensical ones still make it to the courtroom and/or settlements. Not to mention that just being named in a lawsuit is a long, expensive, stressful mess - even if it’s complete garbage and it gets dismissed. And the US legal system itself…is not nearly as fair and reasonable as it is cracked up to be. (Anyone saying otherwise clearly hasn’t experienced the joys of going to court and dealing with “the system”.)

Fortunately, I have yet to be sued in the course of my work as a physician (knock on wood) - but I have been sued in other contexts and have dealt with the US family court system. Each of those situations were extremely unpleasant to deal with, and not nearly as “fair” as you were told they’d be in your high school civics class. Lemme tell you, if medical malpractice law is half as ridiculously ****ed up as the rest of the legal system is in this country, then getting sued as a doctor must be a total ****show. Which means that trying to avoid said suits is the right idea as a doc.

 

[DrMetal]

I’m actually with Dr Metal here.

Thank you, but why "actually" ? I am occasionally in the right!

- but I have been sued in other contexts and have dealt with the US family court system.

I would rather be involved in 1,000 mal-practice cases than 1 instance of a family case (never been, but seen it enough). It looks absolutely vicious.

This discussion reminds me of my favorite lawyer joke:

Q: You walk into a room. You see Osama Bin Laden, Adolph Hitler, and a lawyer. You have a gun loaded with only 2 bullets. Which 2 of the 3 do you decide to shoot?

A: You shoot the lawyer the twice.

 

[chessknt]

I’m actually with Dr Metal here.

While some big fraction of medical lawsuits are stupid and ultimately get dismissed, so many lawsuits get filed that a lot of nonsensical ones still make it to the courtroom and/or settlements. Not to mention that just being named in a lawsuit is a long, expensive, stressful mess - even if it’s complete garbage and it gets dismissed. And the US legal system itself…is not nearly as fair and reasonable as it is cracked up to be. (Anyone saying otherwise clearly hasn’t experienced the joys of going to court and dealing with “the system”.)

Fortunately, I have yet to be sued in the course of my work as a physician (knock on wood) - but I have been sued in other contexts and have dealt with the US family court system. Each of those situations were extremely unpleasant to deal with, and not nearly as “fair” as you were told they’d be in your high school civics class. Lemme tell you, if medical malpractice law is half as ridiculously ****ed up as the rest of the legal system is in this country, then getting sued as a doctor must be a total ****show. Which means that trying to avoid said suits is the right idea as a doc.

Avoid how? He was agonizing over the futility of holding anticoagulation in a unfixable gib as being a source of legal risk... What can you do to minimize risk there? Just continue it anyways so they don't have a stroke and keep bleeding?