Warning: Plastic surgery resident rant! Read at your own risk.

[igap]

The current rotation I am has me covering a few different hospitals for inpatient consults, and for ED consults. As such, I find myself shuttling between EDs, and hospital floors in different hospitals pretty much non-stop during busy weekends.

One thing I have noticed is that many primary teams get irritated when I don't show up 5 minutes after they call me for a consult. ED attendings can be pretty pushy sometimes as well. I have spent considerable time and effort to try to spread the word that I am just one person covering a large geographic area, but this does not seem to help.

Medicine teams, general surgery teams, and EDs are very busy as well, I know. However those teams typically have several layers of resident help to get the work done. In my program, usually there is just one resident to handle the on-call work load per rotation.

I get irritated when medicine attendings call me and are upset that I haven't written a note on their sacral decub patient by 8am when I am in an ED somewhere else sewing someone's face lac up. Or when an ED attending power pages me when I don't show up to her ED within 10 minutes of getting her first call. I wonder what goes through their heads.

I have even heard residents in different specialties remarking how it is hard to get plastics to see a consult at 2am on a Saturday night. They don't take the mental effort to think that maybe the reason that I am not at the bedside of their patient in 10 minutes is because I am busy taking care of another patient on someone else's service, or in another ED.

Grrrr!

Well... I guess this is my first SDN rant!

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[skiz knot]

Grrrr!

Well... I guess this is my first SDN rant!

The same problems exist with any surgical service, although having only one layer makes it tough. Medicine/ER services and nursing staff don't seem to understand that you will see the patient when you get done operating/seeing other consults etc...
At my institution, weekends can get irritating at the trauma hospital because we are operating all day (ortho). Therefore consults in the ED or the floor usually don't get seen until after cases finish or if there is time between cases. It is the same as it has been for years, but they still don't seem to get it through their skulls that we won't be there within 5 minutes of their call.

 

[JaggerPlate]

The current rotation I am has me covering a few different hospitals for inpatient consults, and for ED consults. As such, I find myself shuttling between EDs, and hospital floors in different hospitals pretty much non-stop during busy weekends.

One thing I have noticed is that many primary teams get irritated when I don't show up 5 minutes after they call me for a consult. ED attendings can be pretty pushy sometimes as well. I have spent considerable time and effort to try to spread the word that I am just one person covering a large geographic area, but this does not seem to help.

Medicine teams, general surgery teams, and EDs are very busy as well, I know. However those teams typically have several layers of resident help to get the work done. In my program, usually there is just one resident to handle the on-call work load per rotation.

I get irritated when medicine attendings call me and are upset that I haven't written a note on their sacral decub patient by 8am when I am in an ED somewhere else sewing someone's face lac up. Or when an ED attending power pages me when I don't show up to her ED within 10 minutes of getting her first call. I wonder what goes through their heads.

I have even heard residents in different specialties remarking how it is hard to get plastics to see a consult at 2am on a Saturday night. They don't take the mental effort to think that maybe the reason that I am not at the bedside of their patient in 10 minutes is because I am busy taking care of another patient on someone else's service, or in another ED.

Grrrr!

Well... I guess this is my first SDN rant!

You're still a badass. It's better to have people wait for you, compared to the other way around.

 

[maxheadroom]

I used to give them a time estimate. On summer nights it could easily get to three or four hours. Occasionally, that would inspire the EM doc to just sew something up themselves. The funny thing was, patients almost always understood, especially if I was nice and cheerful with them. The docs, though, could be a real pain. Go figure.

 

[smq123]

I get irritated when medicine attendings call me and are upset that I haven't written a note on their sacral decub patient by 8am when I am in an ED somewhere else sewing someone's face lac up. Or when an ED attending power pages me when I don't show up to her ED within 10 minutes of getting her first call. I wonder what goes through their heads.

I have even heard residents in different specialties remarking how it is hard to get plastics to see a consult at 2am on a Saturday night.

A couple of things that I have noticed:

- In some community hospitals, an ED physician's reimbursement can be tied to how long it takes before a patient is seen by a consultant and by how many patients that particular ED can see in a day. It therefore makes sense that the ED will want to move patients through ASAP. (It has something to do patient satisfaction surveys, etc.)

At our ED, the PAs get a monetary bonus if they see X number of patients in a month. This has led to PAs becoming very aggressive when it comes to patient turnover - some of the PAs have taken to starting their H&Ps while the patient is still in the ambulance bay. One PA harassed a surgery resident to come down ASAP and see a patient with cholecystitis that was otherwise stable....he tried to explain that he was busy seeing a patient who had free air on X-ray, but got nowhere.

So they might harass you because they're trying to turn over as many patients as they can.

- When it comes to medicine, I have found that most medicine residents/attendings have never spent significant time rotating through a surgical subspecialty, and don't understand how busy things are or how thinly spread many attendings are. For instance, before I rotated through general surgery at a community hospital while as an FP intern, I had always assumed that there was SOMEONE from plastics/vascular/CT in house, available most of the time...because that was what I was used to, as a med student who did surgery at a big university hospital. It wasn't until I was the intern on gen surg that I realized that oh.....Dr. X, the vascular attending, spends 3 days a week at a local affiliate, or that Dr. Y, the CT attending, only comes to our hospital on Thursdays. It's hard to explain that concept to IM hospitalists who, like I said, don't really understand how surgical subspecialties work in the "real" world.

 

[maxheadroom]

In some community hospitals, an ED physician's reimbursement can be tied to how long it takes before a patient is seen by a consultant and by how many patients that particular ED can see in a day. It therefore makes sense that the ED will want to move patients through ASAP. (It has something to do patient satisfaction surveys, etc.)

One hospital where I trained had a nightmare ED. The EM docs (only about a third of the docs there were EM trained) were paid based upon the number of patients that they saw. They chronically would understaff the ED and then beat the hell out of the surgical specialty residents for just about anything. It came to a head one night when (unknown to the EM doc) they consulted Plastics/Hand for a teenager with a "hand fracture". Problem was, the patient's x-ray didn't demonstrate a fracture (epiphyseal plates were closed, too). Certain that there must be a fracture, the EM doc had called for a consult before the x-ray was obtained. And didn't ever look at it. And didn't notice that the teenager's last name was the same as the hospital CEO (which my junior resident DID notice). That EM group ended up getting the most painful audit. The Director of Emergency Medicine was fired. Several EM docs left the group. Suddenly the crap consults slowed down and the EM docs were a LOT more helpful.

 

[Apollyon]

One hospital where I trained had a nightmare ED. The EM docs (only about a third of the docs there were EM trained) were paid based upon the number of patients that they saw. They chronically would understaff the ED and then beat the hell out of the surgical specialty residents for just about anything. It came to a head one night when (unknown to the EM doc) they consulted Plastics/Hand for a teenager with a "hand fracture". Problem was, the patient's x-ray didn't demonstrate a fracture (epiphyseal plates were closed, too). Certain that there must be a fracture, the EM doc had called for a consult before the x-ray was obtained. And didn't ever look at it. And didn't notice that the teenager's last name was the same as the hospital CEO (which my junior resident DID notice). That EM group ended up getting the most painful audit. The Director of Emergency Medicine was fired. Several EM docs left the group. Suddenly the crap consults slowed down and the EM docs were a LOT more helpful.

This is unclear. Unknown to the EM doc, the surgical residents consulted Hand? Or who consulted hand? But, then, you state the EM doc called for a consult before seeing the Xray. Who called the consult? And was this teen with the same name of the CEO related to the CEO, or just coincidental? And why did the EM group get the audit - for OVERconsulting? If it was a resident, that should have gone through the residency program.

 

[maxheadroom]

Sorry, it's a non-academic ED -- no residents of any sort. Staffed by attendings and physician-extenders. The ED attending called for a consult without looking at the x-ray. The teenager was the hospital CEO's son. The audit was essentially for inappropriate consults. This particular ED had a culture of calling consultants for piddly stuff that they should have been able to handle. When the hospital CEO asked why his son was seen by the Hand surgery consultants when he didn't have a surgical problem, the whole story came out. Pretty quickly other stories of similar scenarios (along with documentation) came to his attention. He decided that if the EM group couldn't practice EM at a level that was similar to his hospital's competition, he would have to recruit a new group to run the ED, which eventually happened.

 

[Apollyon]

Roger that. Thank you for the clarification. The story makes much more sense now.

**** or get off the pot. Toe the line or get a toe in the ass out the door. That's what happens.

(I'm going to teach a visiting senior resident from an "ivory tower" east coast EM program how to do a felon this week. He's going to be with the Indian Health Service in 5 months, and I told him I've done more ortho as an attending than I EVER did as a resident.)

 

[maxheadroom]

There were a couple of issues in that particular ED.

1. Understaffing. There was never an appropriate number of ED staff working, so even if they were inclined to take care of something, they didn't have time.

2. Bad staffing. They hired FM and Peds attendings straight from residency to staff the ED. There was a core of EM trained partners, but only about a third of the docs were EM trained (partly because they could pay the non-EM docs less, bill the same, and get more money for the partners).

3. Poor oversight. The ED actually turned a decent profit for the hospital (due to a good payor mix), so the hospital didn't pay much attention to the fact that it was poorly run.

I've worked at several other hospitals with much better EDs. While I can go on a bash-the-ED tirade, I recognize EM as a tough job that often occurs in a fishbowl. I have huge respect for a reliable Emergency Physician who practices a broad scope, but knows their limits. And doesn't call me at night.

 

[Apollyon]

While I can go on a bash-the-ED tirade, I recognize EM as a tough job that often occurs in a fishbowl. I have huge respect for a reliable Emergency Physician who practices a broad scope, but knows their limits.

You've crystallized it so succinctly.

However, in the community that I left in SC (as I've said before), the hand surgeons wanted to be called - anytime day or night - for anyone you wanted to sent to them (next day or two or next week). Just don't send anyone blind.

 

[entresident]

- When it comes to medicine, I have found that most medicine residents/attendings have never spent significant time rotating through a surgical subspecialty, and don't understand how busy things are or how thinly spread many attendings are.

In my ENT program we deal with similar issues all too frequently as we end up covering several hospitals and ED's when on call. One thing I have tried to do is just to explain (ie educate) some of the other residents or attendings about how our call is set up. That way they seem to better understand why it might take some time before one of us can actually get over to hospital X to see a patient. Most people seem to be more appreciative after they know why it takes awhile, but it is always good policy to try to see all consults as quickly as possible.

 

[elwademd]

The current rotation I am has me covering a few different hospitals for inpatient consults, and for ED consults. As such, I find myself shuttling between EDs, and hospital floors in different hospitals pretty much non-stop during busy weekends.

One thing I have noticed is that many primary teams get irritated when I don't show up 5 minutes after they call me for a consult. ED attendings can be pretty pushy sometimes as well. I have spent considerable time and effort to try to spread the word that I am just one person covering a large geographic area, but this does not seem to help.

Medicine teams, general surgery teams, and EDs are very busy as well, I know. However those teams typically have several layers of resident help to get the work done. In my program, usually there is just one resident to handle the on-call work load per rotation.

I get irritated when medicine attendings call me and are upset that I haven't written a note on their sacral decub patient by 8am when I am in an ED somewhere else sewing someone's face lac up. Or when an ED attending power pages me when I don't show up to her ED within 10 minutes of getting her first call. I wonder what goes through their heads.

I have even heard residents in different specialties remarking how it is hard to get plastics to see a consult at 2am on a Saturday night. They don't take the mental effort to think that maybe the reason that I am not at the bedside of their patient in 10 minutes is because I am busy taking care of another patient on someone else's service, or in another ED.

Grrrr!

Well... I guess this is my first SDN rant!

first, try to let anyone who pages you know a reasonable time frame that you'll be there.

second, what's your relationship with your attendings/program director(s)? the reason i ask, is that someone higher up than you (ie more clout) needs to go to bat for you and the other residents and let the other services (and thus hospitals) know what kind of schedule you guys/gals are working with.