Who has final call on procedure?

[Redpancreas]

At academic hospitals, who typically has the ultimate say on whether a cath or scope is warranted? When I was in the ED, when we had abscesses and wanted things drained or wanted patients admitted, ED physician had the final say.

What about for IM? Does the primary team have the final say or the procedural team? Obviously the proceduralists have the right to give a give their recommendation and refuse if it’s clearlt contraindicated, but if there’s a grey zone, who does it come down to?

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[IMreshopeful]

At academic hospitals, who typically has the ultimate say on whether a cath or scope is warranted? When I was in the ED, when we had abscesses and wanted things drained or wanted patients admitted, ED physician had the final say.

What about for IM? Does the primary team have the final say or the procedural team? Obviously the proceduralists have the right to give a give their recommendation and refuse if it’s clearlt contraindicated, but if there’s a grey zone, who does it come down to?

The procedural team ALWAYS has the right to refuse. If it’s felt that a cath or TEE is inappropriate I will usually discuss with my attending and tell the primary team why I don’t think is a great idea. We can have a discussion about it but nobody can force you to do it. Surgeons can always say “no, I’m not taking this person to the OR” because it’s ultimately their prerogative- they are the ones taking on the most risk.

 

[Redpancreas]

What if it’s a push enteroscopy after a upper/lower GI scope because the patient traveled from so far to get the work up and primary wants it because of more or less social issues, the patient is willing to pay, and there are minimal risks involved?

What about an instance of bronch+BAL in an individual you have zero suspicion for PJ Pneumonia given his vitals and imaging but you want to be sure before discharge, especially at these well reputed hospitals?

 

[IMGASMD]

If you’re an intern, this is not the right time to ask these questions. You should learn to manage your patients first. A lot of “it” have political, cultural and yes sometimes even financial implications for all the parties involved. You will have to learn how to navigate all that within your own hospital system, and later your own practice.

So that’s the long answer, the short answer. It depends....

Good luck.

 

[Crayola227]

um, since bronch and BAL have risk of introducing all sorts of nasty, I don't know that it's the most benign "just to be sure" sort of test to use in the example case

 

[Crayola227]

also welcome to one of the classic headaches in IM, where you think as the primary team that you know better than the specialist what needs to be done for the patient, and ARE correct because you are accounting for things they are not outside their scope, and where you think this as well, and are WRONG, because the specialist is accounting for things you are not

nevermind the times where everyone agrees on all the facts but still holds a different opinion for other reasons

sometimes knowing what you know, you know best, and sometimes you don't

beyond being sure that you really speak your piece about why you think the consultant should do as you ask, and really eliciting why the consultant does not agree, there's really not much else to do, but I find that being really clear on communication is key

also, rather than focusing on what you think needs to be done to address the concern, say, "this is the problem I want to solve for the patient, what ideas do YOU have to accomplish that?" "I just want to be sure we're clear on X, Y, Z, about the patient that I'm factoring into my thought process. What are you basing yours on to come to a different conclusion? For my own education."

this sort of changes the power dynamic from push-pull to collaborative

by being sure you're on the same page, you ensure each party is working towards the best solution without misunderstanding

usually, if you invite someone to help you understand when their decision is different than yours, they will share their thought process

 

[2010houston]

What if it’s a push enteroscopy after a upper/lower GI scope because the patient traveled from so far to get the work up and primary wants it because of more or less social issues, the patient is willing to pay, and there are minimal risks involved?

What about an instance of bronch+BAL in an individual you have zero suspicion for PJ Pneumonia given his vitals and imaging but you want to be sure before discharge, especially at these well reputed hospitals?

It’s really important to remember that NONE of those things you mentioned are risk-free. They have serious complications- which your proceduralists have likely seen, even if such complications are relatively rare and you haven’t seen such an example. This is why the team doing the procedure- whether it be surgery, cath, scope, LP (unless you’re doing it), etc - is always the one who makes the final call. Of course it should be a discussion with primary team, procedure team, and patient / family as to what would be done, and ideally you can all come to a consensus. But they always have the right to say no.

 

[Gastrapathy]

My hands = my call. Easy.

My trainee’s hands = my call. Easy.

You are wrong that the ED physician had the final say about IR drains. The IR docs just rarely say no and the procedures were indicated. ED in some centers can force admission but they can’t dictate the treatment plan (up to and including immediate discharge).

The push enteroscopy comment really illustrates why it’s up to me. What is the yield of push enteroscopy for overt obscure GIB? For IDA? I’ll give you a hint, it approaches zero. That is the wrong way to evaluate the small bowel in 2018 and that isn’t new data. You can argue about capsule vs DBE/SBE vs CTE vs tagged scan, etc but push is simply a pointless test. It’s my job to know that and not put a patient through an unnecessary procedure.

 

[Gastrapathy]

pro-tip for IM housestaff: calling a surgeon to “order” surgery like it’s a diet order might be entertaining to witness but is a poor plan. Telling a patient he will have a procedure when you don’t do it and haven’t talked with the people who do is also a poor plan.

 

[Gastrapathy]

And if your extra special hospital does procedures despite zero clinical suspicion for a condition, then maybe that’s not something to be proud of.

 

[IMreshopeful]

What if it’s a push enteroscopy after a upper/lower GI scope because the patient traveled from so far to get the work up and primary wants it because of more or less social issues, the patient is willing to pay, and there are minimal risks involved?

What about an instance of bronch+BAL in an individual you have zero suspicion for PJ Pneumonia given his vitals and imaging but you want to be sure before discharge, especially at these well reputed hospitals?

I have seen numerous instances where a patient is transferred for evaluation for some procedure from an OSH and we get here to realize, surprise, the procedure isn’t indicated. Or there’s some contraindication to it. Yes the referring might get mad or upset, but you’ll be in a world of hurt if you do a procedure that’s unindicated and something bad happens to the patient. I can’t even tell you how many times someone is transferred for pacemaker evaluation due to “bradycardia” and we’ve said absolutely not, no reason to do it. Tertiary centers usually will accept patients from these hospitals simply because it’s in the interest of the institution to do so but that is in no way a promise to do anything. (Also, surprise, lots of referring hospitals fudge or leave out details)

Also every procedure has risks. People can end up intubated from hypoxia during a bronch. Push enteroscopy can result in bowel perf. All of the sedation related risks. Etc etc

 

[NITRAS]

Both the primary team and the procedure operator can say no.

As the primary team, you are ultimately responsible for the care of the patient, and your documentation is what insurance companies will look at, not your consultants. You also cannot make your consultants do anything.

While you can technically refuse patient from the ED, doing so without justification will land you in hot water from the hospital administration. Its bad practice.

 

[IMreshopeful]

And if your extra special hospital does procedures despite zero clinical suspicion for a condition, then maybe that’s not something to be proud of.

Yeah, we all know this happens. Doesn’t mean that it’s something good, as you’ve intimated. It’s a good way to get sued and or in jail to do unindicated procedures

 

[PlutoBoy]

In my practice, I rarely tell a patient that a procedure should be done unless I’m the one doing it or it is clearly obvious.

I usually say “I’m not a surgeon so I don’t know what they will do but I do know that this is above my paycheck and we should get them involved.”

 

[RecumbentChair]

Their hands their call.
One caveat, unless i am thoroughly convinced by their explanation on why the patient should not have the procedure done, i want theirs on record.

 

[IM2GI]

It takes a certain level of arrogance to think that you, if not the one doing a procedure, have the "final call" on doing anything to a patient.

Your job as an ER provider is to provide care and procedures within your scope of practice, and to have the training and experience necessary to recognize when a patient may need a test or procedure that you are not capable of providing. In that case, you consult an expert who performs that procedure. If you disagree with that assessment, you can be professional and call them to discuss further.

Sure you can bully around a hospitalist or resident to force an admission, but check yourself if you think you can push someone into doing a procedure they don't believe to be indicated. I'm not sure what you mean by your abscess story. Were you not lancing your own abscesses? Were you forcing general surgery to drain collections that they did not think was appropriate?

The only x-factor in this is IR, which seems like they will do almost anything if its reasonable. That model however does not and should not extend to other procedural specialties or surgery.

 

[Redpancreas]

Seriously though guys, I'm not advocating that generalists have a final say in any procedures. Some events I saw in the ED (ED physician calling team and telling them why XYZ was indicated) and then calling different services to have the same thing basically done (IR vs. General Surgery or GI vs General Surgery for ERCP). The answer's of course that the individual provider can refuse to do anything he or she feels is unsafe. I kind of knew this deep down, but just felt like some EM attendings made decisions to admit to IM with the assumption of having surgery come see the patient and IM refused my attending's request (again not an EM resident) so patient was wheeled to IR suite.

 

[IM2GI]

Seriously though guys, I'm not advocating that generalists have a final say in any procedures. Some events I saw in the ED (ED physician calling team and telling them why XYZ was indicated) and then calling different services to have the same thing basically done (IR vs. General Surgery or GI vs General Surgery for ERCP). The answer's of course that the individual provider can refuse to do anything he or she feels is unsafe. I kind of knew this deep down, but just felt like some EM attendings made decisions to admit to IM with the assumption of having surgery come see the patient and IM refused my attending's request (again not an EM resident) so patient was wheeled to IR suite.

You have general surgeons doing ERCP? Terrifying

 

[dpmd]

You have general surgeons doing ERCP? Terrifying

I know one guy that does them but it is in a nearby small town where otherwise patients would have to be transferred to another facility (and the gi guys in this bigger but not that big town don't even really want to take call for the hospitals in town so it isn't like they can just send them here, they would have to be sent several hours away). When I rotated there he did a several so at least it isn't like a once a year thing.

 

[dpmd]

The only way the non proceduralist has the final say on a procedure is by not consulting the specialty in question. That is the only way to ensure the patient doesn't have that procedure. Everything else is a request that said specialist can choose to fulfill or not. This is why when I have a patient who I feel requires a procedure I don't perform I advise the patient that I am going to get someone else involved to evaluate their issue and possibly do xyz intervention if they feel it is appropriate and safe to do.

 

[gutonc]

The only way the non proceduralist has the final say on a procedure is by not consulting the specialty in question. That is the only way to ensure the patient doesn't have that procedure. Everything else is a request that said specialist can choose to fulfill or not. This is why when I have a patient who I feel requires a procedure I don't perform I advise the patient that I am going to get someone else involved to evaluate their issue and possibly do xyz intervention if they feel it is appropriate and safe to do.

^ This is how it's supposed to be done.

I tell my patients that I think that they may potentially benefit from a particular procedure (or type of procedure more generally) and then tell them that Dr. Smith is the one that will ultimately make the decision about whether it's indicated/appropriate/safe/beneficial or not. I don't even answer the most basic questions about surgical procedures/recovery/complications/etc. It's not my place.

 

[rokshana]

The only way the non proceduralist has the final say on a procedure is by not consulting the specialty in question. That is the only way to ensure the patient doesn't have that procedure. Everything else is a request that said specialist can choose to fulfill or not. This is why when I have a patient who I feel requires a procedure I don't perform I advise the patient that I am going to get someone else involved to evaluate their issue and possibly do xyz intervention if they feel it is appropriate and safe to do.

The other way is refer to someone that you know will agree with your decision.

I have pts with fnas of thyroid nodules that are positive for malignancy...they need thyroidectomy, maybe whole maybe lobectomy, but need surgery...I’m going to refer to a thyroid surgeon I know agrees with my clinical decisions not the ent that is hesitant to do neck surgery.
I do tell the pt that the details of the surgery, extent, risk, etc will be for the surgeon to discuss with them.

 

[dpmd]

The other way is refer to someone that you know will agree with your decision.

I have pts with fnas of thyroid nodules that are positive for malignancy...they need thyroidectomy, maybe whole maybe lobectomy, but need surgery...I’m going to refer to a thyroid surgeon I know agrees with my clinical decisions not the ent that is hesitant to do neck surgery.
I do tell the pt that the details of the surgery, extent, risk, etc will be for the surgeon to discuss with them.

Yeah, with experience you know who is on your same wavelength for things where there may be controversy. But even then it doesn't guarantee the outcome.

 

[dpmd]

^ This is how it's supposed to be done.

I tell my patients that I think that they may potentially benefit from a particular procedure (or type of procedure more generally) and then tell them that Dr. Smith is the one that will ultimately make the decision about whether it's indicated/appropriate/safe/beneficial or not. I don't even answer the most basic questions about surgical procedures/recovery/complications/etc. It's not my place.

Similarly I don't tell my cancer patients if and what chemo they are going to get even if I think I know, nor will I put in a port until onc tells me they want one.

 

[Apollyon]

As an EM, community (not timid, wimpy academic) attending, I ALWAYS make it crystal clear that it is the surgeon's call, absolutely. Last thing I need is a confused patient, on top of a consultant ***** at me.

 

[Acoustic]

To add another level to this, you CAN technically “order” an outpatient endoscopy. This prompts scheduling of said scope, but if the indication isn’t valid or if a procedure that is valid wasn’t ordered then what scope is actually done can and will change. This even transfers to clinic visits, where scheduling can be denied if workup isn’t complete or indication isn’t valid. This happens much less often than procedure changes though.

 

[PlutoBoy]

To add another level to this, you CAN technically “order” an outpatient endoscopy. This prompts scheduling of said scope, but if the indication isn’t valid or if a procedure that is valid wasn’t ordered then what scope is actually done can and will change. This even transfers to clinic visits, where scheduling can be denied if workup isn’t complete or indication isn’t valid. This happens much less often than procedure changes though.

Procedures aside, out of collegiality I would see anyone that you send my way if it is remotely associated to my specialty. A referral is a colleague asking for your help and/or input.

If I refer a patient to you and you decline I’d let it pass once. It won’t happen three times, though. Two strikes and I find someone else that wants the business.

 

[dpmd]

Procedures aside, out of collegiality I would see anyone that you send my way if it is remotely associated to my specialty. A referral is a colleague asking for your help and/or input.

If I refer a patient to you and you decline I’d let it pass once. It won’t happen three times, though. Two strikes and I find someone else that wants the business.

I think he means stuff like sending someone for presumptive gallstones but no ultrasound has been done, or a consult to general surgery that should have actually gone to ortho or vascular. So it would get denied with a note to please get ultrasound first then reconsult if stones found, or please send to ortho/vascular/whoever rather than just a no.

 

[PlutoBoy]

I think he means stuff like sending someone for presumptive gallstones but no ultrasound has been done, or a consult to general surgery that should have actually gone to ortho or vascular. So it would get denied with a note to please get ultrasound first then reconsult if stones found, or please send to ortho/vascular/whoever rather than just a no.

I guess I misunderstood. This is completely appropriate.

 

[Acoustic]

I think he means stuff like sending someone for presumptive gallstones but no ultrasound has been done, or a consult to general surgery that should have actually gone to ortho or vascular. So it would get denied with a note to please get ultrasound first then reconsult if stones found, or please send to ortho/vascular/whoever rather than just a no.

Yes, this is what I mean. Also in county systems where you aren’t really worried about maintaining a referral base you can see referrals outright denied for silly reasons, like abdominal pain with an A1C in the 14s or GERD without trying any acid suppression and no red flags. The message would be to try basic things first and if still having issues then refer. This wouldn’t happen in private practice though. Take that how you will as being proper resource utilization or not. Referring a patient to a specialist is not always asking for help with something you’re not sure of, it can sometimes be just offloading work.