When patients say "I only want an attending to do my..."

[Colba55o]

Just curious how other folks handle these situations.

As a resident at a large academic hospital, I rarely run into this, but I've had it come up a few times lately.

You know the patient who is about to get an epidural, nerve block, etc and says "I only want an attending to do my procedure".
These instances are when you find out which attendings are really committed to education and which are are just in it for the paycheck.
Some of them will quickly drop what they are doing and say "Sure" and do the procedure themselves, but I heart the ones that respectfully say "So and so here is a senior resident, and this is a teaching institution and I will be supervising"

This seems to happen moreso on OB, with nervous primips.
And no, I'm NOT talking about when an attending takes over for a resident who is flailing or for a dangerous situation/difficult case. I'm talking about when the request is purely based on patient request.

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[bigdan]

I ALWAYS say "I would be happy to ask my attending to come in". .Having a complication with a pt asking for an attending is only slightly better than having one after you've talked a pt into a procedure that they initially refused. Some of the more savvy attendings will point out to the patient that I'm a senior resident and am competent; the best one we have (a very experienced attending at our OB hospital) will send us back in the room to say "He's busy right now, but thinks he can get here in an hour or so"...I like that. If the patient wants an attending, I have no issue with that. I've done enough of any of the elective procedures (that a patient can be awake to request an attending for) that it really is no issue - pride, experience, or otherwise - for me. Especially the 350 lb+ epidurals that say "I want the boss - they had trouble last time"

As an aside, you'll surely get more answers posting this in the general forums, as opposed to the Anesthesiology Positions spot.

 

[yappy]

It seems most the expecting mothers I've seen at teaching hospitals tend to be people who are uninsured or can not afford services at a regular hospital. Their care will most likely be written off. Ever tempted to reply "Beggars cannot be choosers"

 

[aneftp]

It seems most the expecting mothers I've seen at teaching hospitals tend to be people who are uninsured or can not afford services at a regular hospital. Their care will most likely be written off. Ever tempted to reply "Beggars cannot be choosers"

Usually the private insurance patients asking for attending to do epidurals at academic/teaching hospitals.

The medicaid/uninsured know they are lucky to get any care at all.

 

[neutropeniaboy]

These instances are when you find out which attendings are really committed to education and which are are just in it for the paycheck.
Some of them will quickly drop what they are doing and say "Sure" and do the procedure themselves, but I heart the ones that respectfully say "So and so here is a senior resident, and this is a teaching institution and I will be supervising"

As an attending at a university hospital, I take issue with this statement. In fact, I see more and more people like yourself who walk through our busy halls and expect everyone to alter his or her day for the pleasure of teaching you.

My primary job is to treat the patient, not coddle your ego and Millennial mentality. My secondary job is research. Given that 1/10th of my salary comes from the university, I'd say 1/10th of my job is teaching.

As much as I like teaching, if a patient says no resident, so be it. They have the right. Just because they are at a teaching hospital doesn't mean they give up their basic rights. There's no clause that states they must allow residents and students to be involved in their care. (they're being ignorant or foolish if they expect it in all cases, but nevertheless....)

So, if I teach you 1/10th of the time, I guess you can say I'm in it for the paycheck.

 

[bedrock]

As an attending at a university hospital, I take issue with this statement. In fact, I see more and more people like yourself who walk through our busy halls and expect everyone to alter his or her day for the pleasure of teaching you.

My primary job is to treat the patient, not coddle your ego and Millennial mentality. My secondary job is research. Given that 1/10th of my salary comes from the university, I'd say 1/10th of my job is teaching.

As much as I like teaching, if a patient says no resident, so be it. They have the right. Just because they are at a teaching hospital doesn't mean they give up their basic rights. There's no clause that states they must allow residents and students to be involved in their care. (they're being ignorant or foolish if they expect it in all cases, but nevertheless....)

So, if I teach you 1/10th of the time, I guess you can say I'm in it for the paycheck.

And that is why it takes 15years to become a doctor. A lot of inefficient time "in training" but not learning anything.

I had a few attendings like you who I wish had never accepted "teaching positions", but thank god, most understood that the priorities of a teaching institutions (university-based) are 1/3 patient care, 1/3 teaching, and 1/3 research.

Teaching 1/10 of your priority.........ridiculous.

You need a different job and your residents need a new attending.

 

[IlDestriero]

We just remind them that it's a teaching hospital, and we can't personally provide their care without several days of advanced notice. It's also covered in their surgical consent form. If I'm working with a CRNA, I tell them I'll be the one placing the lines, blocks, etc and that the CRNAs all have years of peds experience. If I'm with a fellow, I explain that fellows have already completed a residency in anesthesia and are here for specialty training. If I'm with a resident, I explain how I'll be closely supervising them during the case.
Very very rarely, they still insist on the "attending only" silliness. The surgeon may or may not fib, saying they will do everything themselves, knowing that the Resident or fellow will be scrubbed in and helping. I insist that it's not possible to do the anesthetic myself and that they will have to cancel and reschedule. None have canceled yet. This only comes up ~ 1 time a year. Our Ambulatory Surgery Centers are all attending only, so some of these patients may be funneled out there by the surgeons that I don't know about. It wouldn't come up again out there during my pre op interview. Everyone that goes out there has several years of experience.

 

[yappy]

POS hippie.

My primary job is to treat the patient, not coddle your ego and Millennial mentality. My secondary job is research. Given that 1/10th of my salary comes from the university, I'd say 1/10th of my job is teaching.

 

[IlDestriero]

POS hippie.

Ugh, his logic is flawed.
The goal of essentially all academic departments is three fold. Clinical excellence, research, and education. The goal is to excel in all three areas.
You go 100% or get out.
If my teaching evals said "fantastic 5 out of 5 teaching score 1/2 the time, but poor teaching effort the other 1/2 time" I'd be told to find another job, and quick.
In this case, you can elect to do the case yourself if the patient insists, it's that or cancel, but to suggest you only owe your residents 10% of your total effort is ridiculous.

 

[WholeLottaGame7]

I ALWAYS say "I would be happy to ask my attending to come in". .Having a complication with a pt asking for an attending is only slightly better than having one after you've talked a pt into a procedure that they initially refused. Some of the more savvy attendings will point out to the patient that I'm a senior resident and am competent; the best one we have (a very experienced attending at our OB hospital) will send us back in the room to say "He's busy right now, but thinks he can get here in an hour or so"...I like that. If the patient wants an attending, I have no issue with that. I've done enough of any of the elective procedures (that a patient can be awake to request an attending for) that it really is no issue - pride, experience, or otherwise - for me. Especially the 350 lb+ epidurals that say "I want the boss - they had trouble last time"

As an aside, you'll surely get more answers posting this in the general forums, as opposed to the Anesthesiology Positions spot.

Agreed. Pass it on to the attending. It's like trying to talk someone into regional who's hesitant about it and you have other options available. The risk:reward ratio is just too low. You're not going to win. And worst-case scenario, you have a bad outcome plus the patient being able to say "I told you so."

I had a narcissistic patient who had an extensive inguinal lymph node dissection with one of the chief surgeons who was his country club buddy. Talked about different anesthetic options; he basically waved me off and said to ask Dr. Surgeon what he would do. Told my attending, who said, "fine, let's ask the surgeon." Surgeon was like, "I don't care, just do a general." Was OK in PACU but on the post-op check saw that they had trouble getting his pain under control with the PCA. But, the patient got what he wanted.

 

[anonperson]

As an attending at a university hospital, I take issue with this statement. In fact, I see more and more people like yourself who walk through our busy halls and expect everyone to alter his or her day for the pleasure of teaching you.

My primary job is to treat the patient, not coddle your ego and Millennial mentality. My secondary job is research. Given that 1/10th of my salary comes from the university, I'd say 1/10th of my job is teaching.

As much as I like teaching, if a patient says no resident, so be it. They have the right. Just because they are at a teaching hospital doesn't mean they give up their basic rights. There's no clause that states they must allow residents and students to be involved in their care. (they're being ignorant or foolish if they expect it in all cases, but nevertheless....)

So, if I teach you 1/10th of the time, I guess you can say I'm in it for the paycheck.

If you hate teaching that much and 'coddling egos' get out of your teaching institution. This is a ridiculous attitude and I resent attendings who CHOOSE jobs at places where teaching residents/fellows is part of the job and act as though it's a huge inconvenience.

Patient's do have a basic right to refuse care from residents but how an attending responds is huge. They can either throw you under the bus or back you up and involve you in patient care.

Where'd this millenial mentality BS come from anyways? Most residents want an opportunity to learn and get taught and are willing to put in the time.

 

[sevoflurane]

Residents need to learn, but this is a perfect example of a attending getting alone time...

Which is 100% reasonable... unless they've become used to a second hand.

Attendings need to do alone cases as well. They enjoy it and it mixes their week up a bit it.

It's not always about the resident... in academics. I'm sure you all see that @ least weekly.

 

[saratoga733]

for most folks out there this is a real none issue. when i was training i can count on ONE hand the number of times a patient insisted on an attending. depending on attending the situation would be handled differently. for the patients that persist and insist i was happy to be hands off as that way you will NOT be blamed for anything that goes wrong. to be sure, these are the type of folks who complain about everything! go grab a coffee, your training will not be affected by doing a couple less epidurals...

 

[Yangkower]

This happened to me once. I say "sure will be happy to have the attending do it". Of course I don't tell them that the attending has probably only done a half dozen epidurals in the past 6 months and is more likely to struggle than the senior resident. But hey patients should get exactly what they ask for.

As an anesthesia provider the percentage of residents I wouldn't want to do my anesthesia is almost the same as the percent of attendings. The savy patients ask for the person with the best skill or reputation not just for an "attending"

 

[ssmallz]

Before feeling offended, residents should take the type of procedure into account. For a general labor epidural or a strait forward case, do you really care if you get 1 more? By the middleof 2nd year, I could care less if one of my OB patients requested an attending for their epidural b/c I had done tons, same w/a basic OR cases. I think it's perfectly reasonable for your attending to just do it b/c in the end it's his licence and insurance on the line. If there is significant learning value like a continuous nerve block or non standard case like an aneurysm clipping then your attending should certainly put up more of a fight for you to do the procedure or case.

 

[pillowhead]

As an attending at a university hospital, I take issue with this statement. In fact, I see more and more people like yourself who walk through our busy halls and expect everyone to alter his or her day for the pleasure of teaching you.

My primary job is to treat the patient, not coddle your ego and Millennial mentality. My secondary job is research. Given that 1/10th of my salary comes from the university, I'd say 1/10th of my job is teaching.

As much as I like teaching, if a patient says no resident, so be it. They have the right. Just because they are at a teaching hospital doesn't mean they give up their basic rights. There's no clause that states they must allow residents and students to be involved in their care. (they're being ignorant or foolish if they expect it in all cases, but nevertheless....)

So, if I teach you 1/10th of the time, I guess you can say I'm in it for the paycheck.

Wow. As an academic attending at a large county trauma hospital (maybe that's the key difference here, not stuck in an ivory tower), I'm more than a bit disappointed in this response. Basic rights? Since when does someone have an absolute basic right to an attending physician only for every aspect of their healthcare? If they feel so strongly about that, they are more than welcome to choose private hospital down the street rather than XYZ University hospital.

 

[DrN2O]

As an attending at a university hospital, I take issue with this statement. In fact, I see more and more people like yourself who walk through our busy halls and expect everyone to alter his or her day for the pleasure of teaching you.

My primary job is to treat the patient, not coddle your ego and Millennial mentality. My secondary job is research. Given that 1/10th of my salary comes from the university, I'd say 1/10th of my job is teaching.

As much as I like teaching, if a patient says no resident, so be it. They have the right. Just because they are at a teaching hospital doesn't mean they give up their basic rights. There's no clause that states they must allow residents and students to be involved in their care. (they're being ignorant or foolish if they expect it in all cases, but nevertheless....)

So, if I teach you 1/10th of the time, I guess you can say I'm in it for the paycheck.

Does that mean you or any other academic attending is only 50% as good a surgeon/anesthesiologist as your private practice buddies, and 40% as good a researcher as your full time PhD? Of course not. You didn't stay in academia because of the pay check, and doing teaching and research make it more challenging but interesting.

For epidurals, I would just make them wait for the attending. It's elective. For nerve blocks, I just say it's requires more than two hands. For OR cases, it means a delay because the attending is covering two rooms, so either come back another day, or when there is a free attending later in the day. Most patients are reasonable. The unreasonable ones are the ones I'm happy to turf. Now I don't know how surgeons get away with requests to have them do the closure.

 

[Gern Blansten]

I had an attending who had a unique way of handling this request. He was on call and did not do much OB. He was in the twilight of his career. When the laboring woman made the "attending only" request, the resident passed along the message. The attending showed up and here is how the conversation went:
Attending: "Hello, I am Dr XX and I am the attending anesthesiologist. I understand that you requested that I do your epidural."
Patient: "Yes, that is correct. Thank you for coming."
Attending: "No, thank YOU! I am glad you did. Working at a teaching hospital, I supervise residents so much that I never get to do the procedures. I haven't gotten to do one of these in about a year. These residents are doing them all and they have probably done several hundred in the last year. So, I am really excited that you asked for me to do it."
Patient: "Well, if the resident has done a lot of them, I guess I would be okay with them doing it"
Attending: "Are you sure?"
Patient: "Yeah, I'm sure."
Attending: "Well, okay then..."
He takes off his gloves and walks back to his call room whistling as he walks down the hall.

 

[BobBarker]

Ha, an attending doing a case on his own. Haven't seen that happen yet.

 

[scudrunner]

My primary job is to treat the patient, not coddle your ego and Millennial mentality. My secondary job is research. Given that 1/10th of my salary comes from the university, I'd say 1/10th of my job is teaching.

Glad I have 0% chance of having you as an attending. That mentality sucks.

I would have no problem letting the patient have the attending do the procedure, but I think the patient should be informed that it is a teaching hospital and they should expect that trainees will be participating in their care.

 

[scudrunner]

I had an attending who had a unique way of handling this request. He was on call and did not do much OB. He was in the twilight of his career. When the laboring woman made the "attending only" request, the resident passed along the message. The attending showed up and here is how the conversation went:
Attending: "Hello, I am Dr XX and I am the attending anesthesiologist. I understand that you requested that I do you epidural."
Patient: "Yes, that is correct. Thank you for coming."
Attending: "No, thank YOU! I am glad you did. Working at a teaching hospital, I supervise residents so much that I never get to do the procedures. I haven't gotten to do one of these in about a year. These residents are doing them all and they have probably done several hundred in the last year. So, I am really excited that you asked for me to do it."
Patient: "Well, if the resident has done a lot of them, I guess I would be okay with them doing it"
Attending: "Are you sure?"
Patient: "Yeah, I'm sure."
Attending: "Well, okay then..."
He takes off his gloves and walks back to his call room whistling as he walks down the hall.

HAHAHAHA!!! Oh, that is brilliant.

 

[fakin' the funk]

Just curious how other folks handle these situations.

I think a lot of the time, when patients ask this, they do so because they are under the impression that residents at teaching hospitals provide care with no supervision and that the care therefore is unsafe or inferior.

Usually when patients are educated about "graded responsibility" and closer-than-usual-supervision if they request it, they're OK with trainees.

I will also add that while the uppity privately-insured patients in our system are the ones who tend to ask for attending-only care...the uninsured dirtbags at our public hospital do so too, maybe not as frequently, but usually with more sense of entitlement and more rudeness about it.

 

[2win]

And that is why it takes 15years to become a doctor. A lot of inefficient time "in training" but not learning anything.

I had a few attendings like you who I wish had never accepted "teaching positions", but thank god, most understood that the priorities of a teaching institutions (university-based) are 1/3 patient care, 1/3 teaching, and 1/3 research.

Teaching 1/10 of your priority.........ridiculous.

You need a different job and your residents need a new attending.

Not really.
The ENT physician is right.
You want more? Ask your muti million dollar ACGME about that.
2win

 

[2win]

Glad I have 0% chance of having you as an attending. That mentality sucks.

I would have no problem letting the patient have the attending do the procedure, but I think the patient should be informed that it is a teaching hospital and they should expect that trainees will be participating in their care.

Again - any kind of work has to be paid.
By the contract - our primary job is to treat the patients NOT to teach the residents.
If you have issues with that - ask your program director.
And btw - you don't choose your attending.
Ask before to join the program about that.
2win

 

[2win]

Ha, an attending doing a case on his own. Haven't seen that happen yet.

Really???
I never saw a resident either.
2win

 

[scudrunner]

Again - any kind of work has to be paid.
By the contract - our primary job is to treat the patients NOT to teach the residents.
If you have issues with that - ask your program director.
And btw - you don't choose your attending.
Ask before to join the program about that.
2win

The poster is an ENT attending, not an anesthesiologist.

 

[2win]

The poster is an ENT attending, not an anesthesiologist.

I know.
I teach 100% of my time if I see a resident that cares.
But I will not do that for a resident that has a 40 min turnover between cases and still asks for a 30 min lunch. I get pissed off when during rounds or when I teach something - the resident browse the web or is texting...
I never had a patient to refuse a case when a resident was assigned in a room.
They questions but we answered them politely and everything was ok.
2win

 

[FiremedicMike]

I have requested an attending anesthesiologist (well in advance) for my daughter because she had issues with a past surgery. I was obliged in this request and everyone was absolutely fine with it. I will continue to do so in the future for her.

 

[UTKB]

Any special requests for attending-only must be made in advance at all our hospitals. If people make the request the day of surgery, we tell them it's not possible due to scheduling issues, and reassure them the attending will be in the room during the most demanding parts of the case and frequently checks in. And the whole senior resident has experience thing, if that's the case. If they still want attending-only, the have to come back another day. There's no room in the schedule for last minute requests like that.

 

[dhb]

Just curious how other folks handle these situations.

As a resident at a large academic hospital, I rarely run into this, but I've had it come up a few times lately.

As a CA1 thing likes this will annoy you but as you progress you'll be happy to let the attending do some work for a change.

 

[UTKB]

As a CA1 thing likes this will annoy you but as you progress you'll be happy to let the attending do some work for a change.

This is true.

 

[Dejavu]

.

 

[Dejavu]

As a CA1 thing likes this will annoy you but as you progress you'll be happy to let the attending do some work for a change.

Hey, I resemble that remark!

 

[45408]

I'm in surgery, not anesthesia, but the introductions are pretty similar in pre-op. I always tell them my name, that I'm a resident, and that I'll be working with the attending. In two years, no one has ever asked for details on how much I'll be doing versus the attending. I did have one patient's wife recently make a stink about "Well, I hope he'll just be watching!" but it was on a case I was really just observing anyway, so we said "Sure, don't worry." I've done all kinds of procedures on people while they're awake and watching you do it. As long as you are confident about what you're doing, people tend to go with it.

This does probably vary by region and socioeconomic status of your patient population. My patient population is very polite and easygoing.

 

[Arch Guillotti]

As a CA1 thing likes this will annoy you but as you progress you'll be happy to let the attending do some work for a change.

I think this is true also. Your ego takes a bit of a hit. I doubt towards the end of residency you will give a rip. In fact, you may get some pleasure from dragging your lazy-ass attending out of bed at 3 am for a labor epidural.

 

[WholeLottaGame7]

I'm in surgery, not anesthesia, but the introductions are pretty similar in pre-op. I always tell them my name, that I'm a resident, and that I'll be working with the attending. In two years, no one has ever asked for details on how much I'll be doing versus the attending. I did have one patient's wife recently make a stink about "Well, I hope he'll just be watching!" but it was on a case I was really just observing anyway, so we said "Sure, don't worry." I've done all kinds of procedures on people while they're awake and watching you do it. As long as you are confident about what you're doing, people tend to go with it.

This does probably vary by region and socioeconomic status of your patient population. My patient population is very polite and easygoing.

I've noticed patients make a deal with the surgeons at about the same rate as they do with anesthesia. At our institution the attending surgeon has to sign the H&P and the resident usually gets the surgical consent. On one of our kiddos, the mom had written "Dr. X only to do the surgery" on the surgical consent. She didn't get invited back to the OR...

 

[gasflea]

Like bigdan and Gern Blansten approaches...

As a current IM PGY-3 I think most patients are comfortable enough with my seniority... But it is weird that most patients who make a stink about experience are usually less educated. Private, professional patients usually don't have issues along these lines (at least in my experience).

 

[Idiopathic]

As much as I like teaching, if a patient says no resident, so be it. They have the right. Just because they are at a teaching hospital doesn't mean they give up their basic rights. There's no clause that states they must allow residents and students to be involved in their care. (they're being ignorant or foolish if they expect it in all cases, but nevertheless....)

this is flawed thinking. how is not having residents care for you a "basic right"? if patients come to be taken care of in my facility, they get my team, as i see fit. if i choose to do their epidural or their intubation, etc. that is my choice. if i choose to let a trainee do it, that is my choice, and not the patients choice, just as it isnt their choice to dictate which ventilator i use, what size ETT i put in, which induction agent they get, and which direction the bevel is facing on my Touhy. patients can make requests, physicians can choose to accomodate them, or not, and should explain why or why not, but i disagree that its a right.

 

[Idiopathic]

Like bigdan and Gern Blansten approaches...

As a current IM PGY-3 I think most patients are comfortable enough with my seniority... But it is weird that most patients who make a stink about experience are usually less educated. Private, professional patients usually don't have issues along these lines (at least in my experience).

seriously, the private professional patients are often the worst about this. go visit a plastic surgery clinic some day, and see how cash only patients behave. also, they may think its gauche to behave that way, even though they are thinking it. (how could anyone desire to be taken care of by a resident or SRNA over the attending?)

 

[urge]

As an attending at a university hospital, I take issue with this statement. In fact, I see more and more people like yourself who walk through our busy halls and expect everyone to alter his or her day for the pleasure of teaching you.

My primary job is to treat the patient, not coddle your ego and Millennial mentality. My secondary job is research. Given that 1/10th of my salary comes from the university, I'd say 1/10th of my job is teaching.

As much as I like teaching, if a patient says no resident, so be it. They have the right. Just because they are at a teaching hospital doesn't mean they give up their basic rights. There's no clause that states they must allow residents and students to be involved in their care. (they're being ignorant or foolish if they expect it in all cases, but nevertheless....)

So, if I teach you 1/10th of the time, I guess you can say I'm in it for the paycheck.

Interesting. I have always been pro resident but you bring some good points. I will have to sleep over it.

 

[jwk]

this is flawed thinking. how is not having residents care for you a "basic right"? if patients come to be taken care of in my facility, they get my team, as i see fit. if i choose to do their epidural or their intubation, etc. that is my choice. if i choose to let a trainee do it, that is my choice, and not the patients choice, just as it isnt their choice to dictate which ventilator i use, what size ETT i put in, which induction agent they get, and which direction the bevel is facing on my Touhy. patients can make requests, physicians can choose to accomodate them, or not, and should explain why or why not, but i disagree that its a right.

It's not flawed thinking. Touch any patient without their consent, especially if they have told you not to, and see what happens.

We occasionally get MD-only requests for anesthesia - no CRNA, no AA. We will accomodate those requests, but it will most likely require re-scheduling surgery. We would never force a patient to have an anesthetist do their case if they specifically request that a physician provide their anesthesia, nor would we try to sneak one in after induction. That would be stupid.

 

[Idiopathic]

It's not flawed thinking. Touch any patient without their consent, especially if they have told you not to, and see what happens.

We occasionally get MD-only requests for anesthesia - no CRNA, no AA. We will accomodate those requests, but it will most likely require re-scheduling surgery. We would never force a patient to have an anesthetist do their case if they specifically request that a physician provide their anesthesia, nor would we try to sneak one in after induction. That would be stupid.

oh im not saying you fool them or lie to them. you have to be upfront. if they want to cancel their surgery they can, if they arent happy with the model that is in place, but it is such that i cannot solo a case as an attending. i can promise them as much attention as can be given to a case, but there isnt an alternative here. i can choose to perform a block/line personally if a request is made (and i have) but im not sure i agree that it is a "right" of patients to demand no resident/etc involvement.