The occasional pissy consultant

[Bioengineer]

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Most of the time when I consult a service eg. Medicine, Surgery, Psychiatry, etc. I am able to give a brief, pertinent story to them and my reasoning behind the admission and I am equally entreated by the consult with any further pertinent tests they would like prior to seeing/admitting/scheduling outpatient services for the patient; however, especially lately, I have been met with some just plain rude behavior from my consultants. Whether acting gruff, pissed off by the fact that I am even talking to them, rolling their eyes, etc. Just pure unprofessionalism. I am getting sick of trying to be the nice guy to them and an advocate for the patient. I realize these residents are not getting paid extra to see these patients, or do anything for them, but this is part of what they signed up for in residency, right? ER residency is rough too, and after several 12 hour shifts in a row with very sick/demanding/crazy patients I would like to act in like manner, but I choose not to. It's just getting ridiculous and I am getting tired of it. Does it really get better with these consultants once I am in private practice? Anyone out there have advice on dealing with rude consultants?

 

[Tiger26]

I've noticed this as well and I think it has to do with getting halfway through the year and people are starting to get burnt out. In addition, not only is the novelty of residency gone (for the interns and yes, I know it only lasts a few weeks), but people have also started to figure out the ins and outs of the system.

The way I've dealt with this is to have done some introspection about what I say when I call for consults and admits. I'm much more direct now than when I started and try to sift out the less pertinent information. In addition, I've become better at ordering some of the things other services want in advance even though it's completely meaningless to me (i.e. AST or Mg on neuro pts . . . )

Aside from that, careful use of buzzwords and phrases can help (just don't overuse)

Example:
--"given this, this, and this, I'm very concerned for _________"
--"given this and this, I'm worried about the pts safety if they go home"
--"having evaluated the pt down in the ED, I think ________"
--"given multiple comorbidities and these vitals ______, we'd like you to see/admit them for ______"


--If all else fails, you can use the nuclear option "My attending really believes that you should evaluate/admit this pt" and if necessary "if you have any more questions, I'd be more than happy to put my attending on the phone"

 

[Apollyon]

At one of my hospitals, the hospitalists have a GREAT gig - they aren't there 24 hours (seriously - if one of their patients expires overnight, they don't find out until they get there the next time, and, if the floor needs orders, the nurse calls the hospitalist in-house at the other hospital, who knows NOTHING of the patient - NOTHING), and they can admit over the phone without seeing the patient (which is crazy, but it's on them). There are two of them that are fresh out of training, and they try to block admissions all the time, without laying eyes on the patients. This is crazy talk, especially because they don't have experience on which they can fall back. The more experienced don't give me stress. Ortho has given me confidence to do stuff - "If that doesn't work, call me back", and it has worked.

To summarize, it doesn't end outside of training. However, don't tolerate unprofessional behavior. Tell your attending, and it should go through the chain to your PD, to THEIR PD, and down to them.

 

[Gastrapathy]

Example:
--"given this, this, and this, I'm very concerned for _________"
--"given this and this, I'm worried about the pts safety if they go home"
--"having evaluated the pt down in the ED, I think ________"
--"given multiple comorbidities and these vitals ______, we'd like you to see/admit them for ______"


--If all else fails, you can use the nuclear option "My attending really believes that you should evaluate/admit this pt" and if necessary "if you have any more questions, I'd be more than happy to put my attending on the phone"

First of all, by the time I was an R2, all I wanted was a bed number. I really didn't listen to anything else except for clues that the patient had already been turfed by another service and was a classic IM dump.

If the IM residents aren't playing nice, the reality is that you hold all the cards. You've consulted them, now get off the phone. All you have to say is "we need you to evaluate Mr Jones in bed 4 for admission to your service."

I don't think any of the phrases listed above hold any real power. Particularly the "multiple comorbidities" comment inevitably translates into "pt looks like a gomer to me so lets call medicine". "I'm worried about the patients safety" = we know he could go home but that would be risky to us, so we'd rather you admit. "very concerned" = "not comfortable" = every other meaningless phrase that reflects the uncertainty of medicine and nothing about this particular patient.

As for the "talk to the staff" threat: if I ever wanted to dispo a consult out of the ED, the staff was where I started. Its up to them anyway.

Your problem may be that you actually give *too much* info in the presentation. Its easy to argue once you have data. If you know you are dealing with an antagonistic resident, give them the bare bones and excuse yourself. If they want more info, politely decline and state "We have requested an IM consultation for consideration of admission on Mr Jones."

If things are really ugly between your services, its probably a two way street. If you complain and it reaches a PD to PD level, expect to receive counterfire in the form of numerous examples of incorrectly managed patients, delayed diagnoses, etc (its easy from our end).

 

[Birdstrike]

Consultants giving you trouble never goes away totally, but he longer you've been somewhere, the more people will respect you and the less hassle they'll give you, but it never goes away. The bottom line is that you need them to take a patient to make less work for you, and they need you to go away, to make less work for them. Its an eternal struggle. Don't take it personally. Just remember that they're powerless against you and they know it. The longer you peck away at them, its gets to a point that just doing the admission, or doing the consult becomes less painful than having you call them over and over and over again droning on about how worried you are about the patient. Hearing you call them is just like hearing the ambulance radio rattle off 10 ambulance reports in 5 minutes when you're on single coverage at 3 am by yourself. Stay strong bro.

 

[deleted65604]

Consultants often act like sphincters wherever you go. No really... they make a lot of noise and stink but what they actually produce (what they claim they have to hurt you with) is just a bunch of huey.

I have a hard time dealing with the guff. You've got to focus on keeping professional and trying hard not to take it personally.

I think there are a lot of angry and or disfunctional doctors. Of course there are you would say, because there are a lot of angry/dysfunctional people. I would have thought that physicians would act more professional and courteous than the public, but that isn't the case.

There are various stressors in all of our lives that often heavily impact our dealings with other people and might come into play with an individual physician:

1- Relationships- in my group of 6 physicians I work with here, three out of six have committed adultery in the past year. A fourth got a divorce for reasons I'm not privy to. The stresses of undergraduate, med school, residency, and first years of practice are really hard on loved ones and a TON of relationships break apart. Who cares much about how polite they are when their home-life is a wreck?

2- Clinical depression- We have idealized the lifestyle and wealth of a being a physician for years (some for decades), and when we finally get there, thinking oh so naively, "Life will be perfect then." Becoming a physician doesn't magically make mood better. I'd say that it often does the opposite.

3- Sleep deprivation- You've seen the angry drunks. Some of you ARE angry drunks. Sleep deprivation is equivalent of intoxication, and often, inhibitions are lowered.

4- Personality disorders- Many people's natural narcissism is matured and honed in the fire of med school and residency, turning what used to be decent people into arrogant turds.

5- Simple anger- I'd say about a third of people have anger problems, myself being one of them. Some people live on edge of boiling over, constantly viewing the world as working against them. This is usually a self-fulfilling prophecy leading to more anger.

6- Alcoholism and drug addiction- I'd say doctors are even more prone to addiction than the average person. The constant glamorization of alcohol in the media, and academic settings isn't a healthy environment for those who have an addictive personality.

7- Job stressors- I have the most problems with patient interaction and with anger with staff when the excrement is really hitting the fan. The times that they are really ornery with you is probably the time when they are the busiest. Modern hospitalist/residency programs run to maximize the efficiency and time off of fellow physicians so that every three or four days, you are incredibly busy and then you have more pleasant schedules. You are calling when they are most stressed out.

I'm sure you could all add many things to the above list. What percentage of physicians are affected at any given time by one of the above stressors? What percentage are affected by all seven, and just got sued last year and are worrying about whether or not they can actually continue to be a physician.

To simplify, walk in their shoes, and imagine what their job/personal life might be like at the moment.

Some jerk consultants have no excuse. They are intentionally rude as a rule. Their goal is to get you to call them less, and admit less. It is generally an effective tool as an attending. As a resident, while not effective, it is popular behavior. The heroes of the internal medicine residencies are the residents that actually have spines and chew out the ER, and occasionally, block admissions.

I think many physicians are affected heavily by confirmation bias-
http://www.skepdic.com/confirmbias.html
They walk around like Eeyore telling themselves three things.
1. ER doctors are idiots
2. The ER always dumps on me
3. The patient doesn't need to be admitted
It is easy to find evidence for these presumptions, especially in residency settings (especially when your definition of "dump" means the ER wants to admit a patient.

It is fascinating to view the orders on some of the people I was chastised for not sending home. I'll look three days later, and the patient is still in the hospital. I smile, shake my head and realize that it was just a game...it was just a game.

 

[beanbean]

Agree with all of the above.

I find it most annoying when a resident whose service I have consulted tries immediately to argue over the phone after I have presented the patient. "Please come EXAMINE the patient and then we will discuss those issues" usually works well. I don't have all the answers and am perfectly willing to discuss and alternate yet reasonable dispo, but you MUST see and evaluate the patient first!

Another pet peeve is when the consultant asks never ending questions on the phone after I give a quick presentation. I am giving you a quick summary of the situation. Don't ask me about allergies, meds, social hx, etc. that needed to be documented in the H&P but are not relevant to the immediate issue you are consulting about. Take your own H&P! Copying what I say or write is just lazy and dangerous.

I have to say most residents are great and only a few seem to thrive on making things difficult. Lets just be professional and do what is right for the patient.

 

[deleted109597]

The other day I had to prevent myself from getting into a shouting match with the hospitalist at my joint.
I had put in a bed order because the patient needed admission. He had already stalled with previous resident and demanded he perform an LP prior to admission. That resident did the LP, but then the hospitalist got mad because he wanted the results of the LP. During the discussion I made the points that: the LP wouldn't have made a change in where the patient went (home, medicine, or ICU). They needed a monitored bed.
Then the discussion devolved from there, and the hospitalist made the statement that I can't consult him until I have all the results of the tests. It was then that I realized what they really think. It's the same reason that clinics send their patients to the ED instead of direct admitting them. We are victims of our own success, because there is now an expectation that we have the full diagnosis before admission, and when that doesn't happen they act as if it is a failure on our part.
I really don't have an answer how to change it at your shop. Even though the chief of staff at our hospital was one of our ED docs, we couldn't make it less difficult to admit. We had neurosurgery and the chair of medicine come to an agreement about chronic subdurals, only to have the hospitalists argue with written policy. It's sad when the hospitalists who do the right thing are so shockingly refreshing that we think they're going above and beyond, instead of just doing their jobs.

 

[danielmd06]

"Please come EXAMINE the patient and then we will discuss those issues" usually works well. I don't have all the answers and am perfectly willing to discuss and alternate yet reasonable dispo, but you MUST see and evaluate the patient first!

Another pet peeve is when the consultant asks never ending questions on the phone after I give a quick presentation. I am giving you a quick summary of the situation. Don't ask me about allergies, meds, social hx, etc. that needed to be documented in the H&P but are not relevant to the immediate issue you are consulting about. Take your own H&P! Copying what I say or write is just lazy and dangerous.

I have to say most residents are great and only a few seem to thrive on making things difficult. Lets just be professional and do what is right for the patient.

Sigh. I know where you're coming from, but I've gotta defend the consultants a bit here.

I understand it's frustrating when people are giving you a hard time at 2AM and being downright jerks to boot. Try to see it from the other side of the fence. Perhaps your history and physical exam aren't as fully developed as you suspect? It's surely a bit ironic that some ED residents complain about consultants not seeing patients before making judgements when they themselves don't do this at times before consulting. The blade cuts both ways.

"Copying what I say or write is just lazy and dangerous?" Ah. If I had $1 every time an ER doctor did this on one of my own patients...surely you've seen examples of this, too? And for the record, if you write something in a chart, then it is supposed to be something another doctor can rely upon.

Where I trained it was perfectly acceptable to expect a list of medications, allergies, social history (like drugs and alcohol use, right?), etc from an ED person. I know this varies from one place to the other. But it's sort of silly to consult neurology about AMS when the guy has cocaine flooding his system (ie drugs are in the social history you mention).

I wouldn't be offended if you call an attending and they gripe if you don't have ALL of your pertinent facts together. Especially in the middle of the night. No one should think they're exempt from a proper H&P. And I really don't mean asking the patient about what their dog's name is when they come in complaining of chest pain...but if someone has a subdural hematoma...wouldn't it be important to know if they are taking something like Coumadin? Of course, it depends on the chief complaint.

I'm not excusing poor behavior on the part of others, but just pointing out that professionalism can cut both ways.

Anyway. Not attacking anyone per se, but just defending the consultants a bit.

 

[danielmd06]

I am getting sick of trying to be the nice guy to them and an advocate for the patient.

I realize these residents are not getting paid extra to see these patients, or do anything for them, but this is part of what they signed up for in residency, right? ER residency is rough too, and after several 12 hour shifts in a row with very sick/demanding/crazy patients I would like to act in like manner, but I choose not to.

1) Don't ever get tired of advocating for the patient! Just be sure that you are truly advocating for the patient and not just calling someone else to come take responsibilty (and work) from your own shoulders. Maybe you are indeed already doing this. If so, keep up the good work.

2) I absolutely HATE hearing how ED practitioners, consultants, internists, or whoever should just suffer because "they knew what they were getting into." Nonsense I say! How many of us really knew what we were getting into? Any of us? This second point is such a crucial one for so many young doctors (ANY doctors) to understand, I think.

FORGET this argument. Try and do your best to help other physicians, patients, nurses...anyone, under any circumstances. Don't ever let yourself think that it's okay to pummel someone indirectly because "they knew what they were getting into and it's their fault" or some such concept.

Oh sure, it's easy to think it's someone else's problem now, but those same consultants can throw this same selfish idea back in your face in the years to come (using this same argument) when they dump people into your ED and expect you to quickee quickee makee makee all better because it's 5PM on a Friday (or holiday) and they want to go home.

Do the best you can with what you've got. Best wishes.

 

[alreadylernd]

I think one of the concerns from the ER perspective is that if the consultant is "asking too many questions" over the phone, there's the implication that he/she is looking to get out of doing the consult or isn't planning on seeing the patient as needed. To deal this with, I try to set expectations up front:

"This is a patient I need you to see down in the ER/Being admitted but you'll need to see tomorrow..."
"This is a patient I just wanted to discuss and arrange follow up for..."

Once that expectation is understood, I'm happy to answer any questions the consultant has because hey, even after residency there's stuff to learn. That said, bear in mind that if I'm in a busy department, I haven't been sitting by the phone reviewing the case, waiting to talk with you on the phone about patient X, I may have just come out of a room from one of half a dozen other patients, and therefore don't remember some of the finer points you may ask and may sound a bit "scatter brained" on the phone! 🙂

 

[WilcoWorld]

I think one of the concerns from the ER perspective is that if the consultant is "asking too many questions" over the phone, there's the implication that he/she is looking to get out of doing the consult or isn't planning on seeing the patient as needed. To deal this with, I try to set expectations up front:

"This is a patient I need you to see down in the ER/Being admitted but you'll need to see tomorrow..."
"This is a patient I just wanted to discuss and arrange follow up for..."

Once that expectation is understood, I'm happy to answer any questions the consultant has because hey, even after residency there's stuff to learn. That said, bear in mind that if I'm in a busy department, I haven't been sitting by the phone reviewing the case, waiting to talk with you on the phone about patient X, I may have just come out of a room from one of half a dozen other patients, and therefore don't remember some of the finer points you may ask and may sound a bit "scatter brained" on the phone! 🙂

Very well put. If I'm trying to arrange follow-up and the consultant wants to know certain details about the case, I should be (and usually am) happy to discuss the case. But if I call and say "We have an unstable angina in bed 15 that I need to admit to your service" and before I can even give a name they're trying to block admission then I'm going to have much less patience giving an H&P over the phone.

That being said, it's important for the credibility of you, your department and the specialty that as an EM Doc one knows the cogent details of a case when calling a consultant. If you don't know them, you should be embarrassed. But if the medicine resident demands to know if GI bleeder's 4th hemoglobin is still trending down before he sees the patient, then it's time to go over his head.

 

[deleted65604]

If the ER resident refused to talk and simply said "We have requested a Rad Onc consult"

i can't lie and say I haven't snapped at the ER before when I got page at 2 AM for a consult I felt was unreasonable. I think it's the nature of the beast that residents are going to get frustrated with ER consults at times.

Wow! I didn't know radiation oncologists actually existed, having never talked to one in real life over the past 6 years. How often do you get consulted from the ER at night?

 

[beanbean]

I have no problem giving relevant info to any consultant I am calling and am happy to get more labs/studies before the pt is seen if they are requested. I've done plenty of off-service rotations as an EM resident and know what is is like to be on the "other side of the fence". A rare few residents however expect to be spoon fed every detail over the phone and that is not appropriate or efficient. These residents usually then pick apart the details to try to get out of evaluating the patient. It is laziness pure and simple with no regard for the patient. It is also thankfully very uncommon and most of our on-service residents are very professional.

I have no problem with people reviewing my chart obviously but if you are consulting on a patient you really need to get your own focused H&P.

Home call is a bit different as and I certainly understand the resident or fellow wanting to have more of a discussion and review of the data before coming in.

Most of the time we have no issues and the few residents who constantly push back or are difficult are certainly in the minority.

 

[ER-ER-Oh]

First and foremost I make sure I don't 'dump' patients that are complicated onto the admitting service simply because I'm scared to send them home. That is rule #1. I have good reasoning, solid evidence and concern for any admitted patient. If a consultant gives me grief I find them, in person, and put them to the wall. One particular surgeon gave me a hard time because I called him at 6 a.m. with a young woman with a perfed bowel. He was actually mad that I had waited for the acute abdominal series, which I viewed myself and made the call of intrabdominal air, and didn't call him the moment I had suspected it. It was all because he was off at 6:30 and now had to come in just before signing off to his partner.

He actually yelled at me and told me I was incompetent. I found him in the hallway and told him I would not tolerate his billigerence and that he was way out of line. I said I had always known his arrogance was legendary and that people seemed to be intimidated by him. I then told him that I was not impressed with him one bit and thought that he was undoubtedly making up for a serious sense of insecurity. I told him, as a former boxer, I preferred to just kick his ass. I said it out of earshot of anyone else, and with a smile. But he got the point and has never given me trouble since. That being said, I'm very careful to do what a surgeon would feel is a proper work up before calling them.

 

[yahoomail]

He actually yelled at me and told me I was incompetent. I found him in the hallway and told him I would not tolerate his billigerence and that he was way out of line. I said I had always known his arrogance was legendary and that people seemed to be intimidated by him. I then told him that I was not impressed with him one bit and thought that he was undoubtedly making up for a serious sense of insecurity. I told him, as a former boxer, I preferred to just kick his ass. I said it out of earshot of anyone else, and with a smile. But he got the point and has never given me trouble since. That being said, I'm very careful to do what a surgeon would feel is a proper work up before calling them.

Dude !!! thats badass !! 👍

 

[nitemagi]

First and foremost I make sure I don't 'dump' patients that are complicated onto the admitting service simply because I'm scared to send them home. That is rule #1. I have good reasoning, solid evidence and concern for any admitted patient. If a consultant gives me grief I find them, in person, and put them to the wall. One particular surgeon gave me a hard time because I called him at 6 a.m. with a young woman with a perfed bowel. He was actually mad that I had waited for the acute abdominal series, which I viewed myself and made the call of intrabdominal air, and didn't call him the moment I had suspected it. It was all because he was off at 6:30 and now had to come in just before signing off to his partner.

He actually yelled at me and told me I was incompetent. I found him in the hallway and told him I would not tolerate his billigerence and that he was way out of line. I said I had always known his arrogance was legendary and that people seemed to be intimidated by him. I then told him that I was not impressed with him one bit and thought that he was undoubtedly making up for a serious sense of insecurity. I told him, as a former boxer, I preferred to just kick his ass. I said it out of earshot of anyone else, and with a smile. But he got the point and has never given me trouble since. That being said, I'm very careful to do what a surgeon would feel is a proper work up before calling them.

Wow.

As a psychiatrist, it's often an issue of bad consults being placed, meaning an insufficient workup or even baseline evaluation. All too often it falls into the "it's psych" and I remember back to being an intern and getting repeated consults where the resident hadn't even talked to the patient. I was annoyed.

Overall, though, I find this is rare with EM residents or attendings. More often I've encountered it with rotating residents from other specialties that haven't really thought out how/why to consult psych. I'm always thankful for good EM residents, just wish they could pass their wisdom onto others!

 

[rongeur]

He actually yelled at me and told me I was incompetent. I found him in the hallway and told him I would not tolerate his billigerence and that he was way out of line. I said I had always known his arrogance was legendary and that people seemed to be intimidated by him. I then told him that I was not impressed with him one bit and thought that he was undoubtedly making up for a serious sense of insecurity. I told him, as a former boxer, I preferred to just kick his ass. I said it out of earshot of anyone else, and with a smile. But he got the point and has never given me trouble since.

How could anyone ever be intimidated by another doctor threatening to beat them up? Oh snap, Mr. boxer man is going to hit me, get fired, lose his medical license and be homeless. It would be very hard to not laugh.

It is true that if you're going to talk crap you'd better not cave like a wet napkin though.

 

[45408]

Agree with all of the above.

I find it most annoying when a resident whose service I have consulted tries immediately to argue over the phone after I have presented the patient. "Please come EXAMINE the patient and then we will discuss those issues" usually works well. I don't have all the answers and am perfectly willing to discuss and alternate yet reasonable dispo, but you MUST see and evaluate the patient first!

The issue is that I can do a surgery consult and a surgery H&P in pretty much the same amount of time. Writing admission orders doesn't take long. If it's a lame consult that isn't necessary, then it's best to block it up front, rather than wasting the time to do an H&P and staff it with our attending. At 2am.

Our ED treats us well the vast majority of the time, so don't take this the wrong way, but sometimes they call for something stupid. My chief told me about a time he got a call for THREE APPIES AT THE SAME TIME!!! Just based on the history and physical. My chief suggested that they at least get some blood work, and if necessary, some imaging. There was no call back. None of them had appendicitis apparently. Saves us a lot of work to not do three consults!

 

[Khaos]

The issue is that I can do a surgery consult and a surgery H&P in pretty much the same amount of time. Writing admission orders doesn't take long. If it's a lame consult that isn't necessary, then it's best to block it up front, rather than wasting the time to do an H&P and staff it with our attending. At 2am.

Our ED treats us well the vast majority of the time, so don't take this the wrong way, but sometimes they call for something stupid. My chief told me about a time he got a call for THREE APPIES AT THE SAME TIME!!! Just based on the history and physical. My chief suggested that they at least get some blood work, and if necessary, some imaging. There was no call back. None of them had appendicitis apparently. Saves us a lot of work to not do three consults!

Funny you say that...I just did something like that a week ago but all of mine were positive. I called the surgery resident over one of them saying I was certain he was an appy and just to let you know, I have 2 others brewing and getting their CT's but I'm certain are appies also...

 

[sluggo]

As long as you provide a differential diagnosis, no one can give you flack-- even if you are wrong. From an admitting consultant's perspective, I understand the time and resource constraints in the ED, and as long as I know someone has thought about the patient and is out of ideas, or is sure the patient needs to come in, I have no problem stepping up.

 

[jdh71]

I never argue with the ED or try and block (except once, she was 32 weeks preggers with pneumonia - we have MFM, call them, I don't do pregos). I just go and admit. After spending a month down there I know how much bull**** actually gets sent home. Although it is annoying when you get what amounts to, "this patient looks like an admit from the doorway" page.