Why is admitting a patient so hard?

[ICmyFuture]

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Rant


I'm an IM intern on my ED rotation. I really like it thus far, all the attendings and uppers are awesome(except one) and I am learning a lot. The only bad part of my day is admitting patients to medicine. They give me sooo much crap about every freaking patient. I feel like I have to "sell" each and every patient before they even come look at them. I'm so sick of it. I promise everyone I won't be a dnozzle next year when people have to admit patients to my team.

/rant

 

[deleted547339]

HAHAHAHAHAHAHA. This is awesome and it made my day.

 

[gman33]

Nobody likes doing extra work. Especially when they don't get paid for it.

 

[secants]

How does it work if the ED has admitting privileges vs you have to ask the senior resident every time if the patient has admission criteria?

 

[goodoldalky]

How does it work if the ED has admitting privileges vs you have to ask the senior resident every time if the patient has admission criteria?

Never understood this. I still don't understand your question. No ED has "admitting privileges". That means the ability to admit a patient to yourself as attending into the hospital. Hospitalists and the like do this and have "admitting privileges". There is also no such thing as admission criteria. That is a made up foo-foo term that means "I don't want to admit the patient, so can you please send them home?" In which case, the correct response is generally no.

 

[southerndoc]

Never understood this. I still don't understand your question. No ED has "admitting privileges". That means the ability to admit a patient to yourself as attending into the hospital. Hospitalists and the like do this and have "admitting privileges". There is also no such thing as admission criteria. That is a made up foo-foo term that means "I don't want to admit the patient, so can you please send them home?" In which case, the correct response is generally no.

It's amazing how much easier one of our hospitalist groups became when we formed a subsidiary, hired a few hospitalists, and started running an observation unit.

 

[secants]

Never understood this. I still don't understand your question. No ED has "admitting privileges". That means the ability to admit a patient to yourself as attending into the hospital. Hospitalists and the like do this and have "admitting privileges". There is also no such thing as admission criteria. That is a made up foo-foo term that means "I don't want to admit the patient, so can you please send them home?" In which case, the correct response is generally no.

One of the pseudo-academic hospitals I rotated at for IM made me rotate in the ED where the EP said the group had "admitting privileges". My take was that they could admit whoever they wanted to which IM would come and do the H&P whereas normally you consult IM first and they decide if admission is needed?

 

[Perrin]

Rant


I'm an IM intern on my ED rotation. I really like it thus far, all the attendings and uppers are awesome(except one) and I am learning a lot. The only bad part of my day is admitting patients to medicine. They give me sooo much crap about every freaking patient. I feel like I have to "sell" each and every patient before they even come look at them. I'm so sick of it. I promise everyone I won't be a dnozzle next year when people have to admit patients to my team.

/rant

One of our ED attendings gave a lecture that I wish I had gotten the powerpoint presentation for. The essential point was that, "I", the ED physician am consulting you to evaluate and admit the patient to the hospital. If, after your evaluation, you feel the patient does not need to be admitted, it is your obligation to discharge the patient. If you decline to be consulted on the patient, I will document our conversation and your explanation in my chart. This chart will be reviewed by the hospital.

As a resident, especially an intern, it can be hard to stand up to the 5th year ortho resident or senior medicine resident. If they just won't budge, tell them to hold on a second and let them speak to your attending. Listen to the conversation and you'll learn the 'med-speak' to use to let the consulting resident know that you know they cannot refuse to consult on a patient.

As a second year, I happened to be working with one of our senior residents who was known for being blunt. His intern was trying to consult ortho on a patient and was getting nowhere. He picked up the phone and said, "Is this the ortho intern? Guess what, you've been a surgeon for what, 6 weeks now? I've been doing EM for over 2 years. If I think the patient needs an ortho consult, you have two options. 1. You come see the patient in the ED or, 2. you wake your attending up, explain to him/her why they have to come to the ED at 3am, evaluate a patient, and then discharge them." The ortho intern arrived shortly and admitted the patient.

You can offer a carrot on a stick to the consulting service by offering to write some basic admission orders so they can meet the patient after they arrive on the floor in an hour or so. This depends on the service as some, esp medicine residents, have to eval, write an H&P, and write admit orders before the pt leaves the ED. If they agree to let your write the orders, it serves as a good learning opportunity for you as to what to anticipate when admitting to various services in actual practice. The out of house docs appreciate it because they don't have to rush to get to the ED. It's good for you b/c you move the pt and open up a bed much quicker. If it's a soft admit that I'm just not comfortable sending home, I just transition from the patient presentation directly into offering to write some skeleton orders to get the patient to the floor. The other doc is usually taken aback and lets down the wall enough to agree.

While a resident, I can't say that I've done this, but I know some of my folks have done the following. The EM resident consults a resident service and that service gives reasons X,Y,Z as to why the pt doesn't need to be admitted. The EM resident says, "You have a good point. Let's admit this pt tonight and I'll have my chief email your chief to have y'all put together a lecture presentation so you can update the ED residents on this condition and your specialty's current treatment guidelines. That way next time, we can better disposition patient's with presentation X." It is a bit of a dick move, but it reinforces the fact that ED physicians are not nephrologists, cardiologist, or neurologists.

 

[NYEMMED]

One of the pseudo-academic hospitals I rotated at for IM made me rotate in the ED where the EP said the group had "admitting privileges". My take was that they could admit whoever they wanted to which IM would come and do the H&P whereas normally you consult IM first and they decide if admission is needed?

Many hospitals actually use this model. The ED/ EP has all the authority to admit. They click admit, and transfer the patient onto the IM doctors service. From that point forward it is all on IM to see the patient for orders, or D/C the patient. If they do nothing there will be a bunch of angry nurses and administrators to answer to, so they always come.

 

[deleted109597]

There is also no such thing as admission criteria. That is a made up foo-foo term that means "I don't want to admit the patient, so can you please send them home?" In which case, the correct response is generally no.

Not true. Lots of places use Interqual or Milliman (or something else). Remember, the hospital needs to get paid as well, and if they don't have a reason to admit, they're left with an unpaid visit, as well as loss of a bed for someone who might pay. That's why case workers are always trying to get you to buff the charts.
You can't just say "I don't think they should go home." There has to be a specific "why" as well.

 

[Daiphon]

Not true. Lots of places use Interqual or Milliman (or something else). Remember, the hospital needs to get paid as well, and if they don't have a reason to admit, they're left with an unpaid visit, as well as loss of a bed for someone who might pay. That's why case workers are always trying to get you to buff the charts.
You can't just say "I don't think they should go home." There has to be a specific "why" as well.

Yep.

My personal "why" when all else fails is a combination of "it's not safe for them to go home" and/or "they can't perform their ADLs."

Tends to get UR off my back... for now at least.

-d

Sent from my DROID BIONIC using Tapatalk

 

[Happy3nding]

Rant


I'm an IM intern on my ED rotation. I really like it thus far, all the attendings and uppers are awesome(except one) and I am learning a lot. The only bad part of my day is admitting patients to medicine. They give me sooo much crap about every freaking patient. I feel like I have to "sell" each and every patient before they even come look at them. I'm so sick of it. I promise everyone I won't be a dnozzle next year when people have to admit patients to my team.

/rant

Report them to EMTALA. That ought to teach 'em.

 

[survivordo]

Generally when an ED resident/attending calls and TELLS me they are admitting a patient to the service is when things get aggravating, even if it is a slam dunk. You're much better off to offer it as a suggestion/request (because that really is what it is) and then let the service come to the conclusion that you are correct (everyone likes to think that they came up with the answer themselves!)

Survivor DO

 

[deleted109597]

Generally when an ED resident/attending calls and TELLS me they are admitting a patient to the service is when things get aggravating, even if it is a slam dunk. You're much better off to offer it as a suggestion/request (because that really is what it is) and then let the service come to the conclusion that you are correct (everyone likes to think that they came up with the answer themselves!)

Survivor DO

That's because you guys like to argue. This switches in the real world where interactions go like this.

Hello, Dr. Hospitalist. I have a pneumonia that needs admitted.
Thank you Dr. Emergency, can you give the phone to a nurse for orders?

They get paid per admission. They don't want to waste their (and your) time on the phone. They don't want to hear the story about how many kittens the guy has at home. They just want to get done with it. I absolutely hate it when people spend more time arguing about an admission than it takes to actually do the admission.

 

[deleted547339]

That's because you guys like to argue. This switches in the real world where interactions go like this.

Hello, Dr. Hospitalist. I have a pneumonia that needs admitted.
Thank you Dr. Emergency, can you give the phone to a nurse for orders?

They get paid per admission. They don't want to waste their (and your) time on the phone. They don't want to hear the story about how many kittens the guy has at home. They just want to get done with it. I absolutely hate it when people spend more time arguing about an admission than it takes to actually do the admission.

I actually had a cards fellow ask me if I had considered a diagnosis other than ACS in my CP patient I was trying to get admitted. lol.

 

[gman33]

I understand that people like to complain.
I usually just don't have time to play along.
Too many other patients to be seen.

I really do try not to admit BS, but sometimes you don't have much of a choice.
With certain CCs, along with age and PMH, it's impossible to send someone home.

I had a CP admission, someone who just needed a rule out.
Did I think they had ACS, no, but they had a medical history that made sending them home seem crazy.

The IM resident just kept arguing about the admission.
It actually really surprised me that this was the case they wanted to fight.

I just told them the patient was admitted to their service.
If they wanted to come down and d/c the patient, that was their right.

Overnight, of course this means, their attending would have to come in and see the patient.

Case closed.

In general I think I try to help the admitting services in every way possible.
Sometimes you just have to dig in and be kind of a dick.

 

[Birdstrike]

Rant


I'm an IM intern on my ED rotation. I really like it thus far, all the attendings and uppers are awesome(except one) and I am learning a lot. The only bad part of my day is admitting patients to medicine. They give me sooo much crap about every freaking patient. I feel like I have to "sell" each and every patient before they even come look at them. I'm so sick of it. I promise everyone I won't be a dnozzle next year when people have to admit patients to my team.

/rant

There's two things to think about here. One is the obvious, already mentioned, that is simple laziness and work avoidance. If an IM resident can deflect an admission, then it's less work for him. Less effort, same paycheck. The flip side is an ER resident over consulting so he can wash his hands of patients and decrease his effective workload. It's a game. Don't take it personally. Play it better.

The other issue can make you step up your game. You need to know the indications for admission of each diagnosis, backwards and forward, especially if you are IM. If you find yourself on your heels, against the ropes and unable to explain why a cellulitis patient needs to be admitted, and can't be treated outpatient, then you are losing the game. The opposing resident has your Achilles heel. Yes, the admitting resident might be lazy, but by the same right, wouldn't you be irritated if you got knee deep into a tome-like IM H&P to realize the patient could have been sent out with oral antibiotics and clinic follow up?

Before you call and involve someone in a potential admission, always ask yourself, "Why can't this patient be sent home and treated outpatient?" You should know this in the first place, and if you do, you'll be ready when they test you. Your answer should never be, "Because my attending wants him admitted." You need to know why your patient has to be admitted.

In academic settings, the admission card is WAY, WAY overused. In the "real world" this luxury is much more scarce. Have your next 2 moves planned, before you make that call.

 

[Bostonredsox]

I think of the ED-hospitalist relationship to be one that needs mutual respect. You want me to admit a pt to the hospital for reason X, great. Call me, tell me the patient presented with X, my work up yielded Y, i have started therapy Z and I think they need to come in. Done. You treated me like a fellow doctor, told me what you need, presented it succinctly, and wasted no time. My response is great, bridge him to tele and ill see him when he gets there, hope your shift goes well the rest of the day.

That is how an admit should go. Mutual respect, effective and efficient transition of care.

I do not like to hear "Pt has PNA, I admitted them to your service, see them on the floor." I am not a nurse or a unit secretary. I am a fellow physician. It takes all of 30 seconds to give me a quick line of " 67 y/o presented with cough and fevers. Xry shows RUL PNA. Hes community acquired. History of chf but not in flare on my exam. Satting well on 2L, vitals stable, lactate normal. I gave a liter of fluid, ceftriaxone and azithromycin"........"thanks man admit inpatient to general med floor ill be up to see him Ina bit." done.

And to answer some other response, most hospitalist are paid by shift, nothing extra for an admit. And we're just as busy as you. If the Ed docs are good where we practice, the phone call proceeds as above, wasting none of your time or more importantly to me, any of my time. But if the Ed docs are routinely calling for garbage admits, 31 y/o with chest pain, negative markers, normal EKG and xry...sure I'm gonna ask why you think that pt has to come in. This is not something I encounter frequently though unless I'm getting called by the mid levels who always seem to be too overly cautious and want to admit everything. What I have a major problem with at my hospital is not refusing soft admits, it's not trusting that the PNA admit to GMF is not really severe sepsis with impending respiratory failure and arrest. I come to see the pts in ed most every time to lay eyes on them before they go up. Part of that is security. It's my license once they leave through your doors. And if the stable chf you called me for GMF admission crashes 20 minutes later the jury will chew me up for "we'll the Ed doc told me stable chf to GMF", it will be my head.

I rarely ever try and refuse an admission. At my place if you call, I have to see them. The time it takes to see them and dictate a consult and discharge them is equivalent to admitting them so I gain nothing by doing that. I am more concerned that I'm getting the real story and not being handed a ticking time bomb.

 

[WilcoWorld]

There's two things to think about here. One is the obvious, already mentioned, that is simple laziness and work avoidance. If an IM resident can deflect an admission, then it's less work for him. Less effort, same paycheck. The flip side is an ER resident over consulting so he can wash his hands of patients and decrease his effective workload. It's a game. Don't take it personally. Play it better.

The other issue can make you step up your game. You need to know the indications for admission of each diagnosis, backwards and forward, especially if you are IM. If you find yourself on your heels, against the ropes and unable to explain why a cellulitis patient needs to be admitted, and can't be treated outpatient, then you are losing the game. The opposing resident has your Achilles heel. Yes, the admitting resident might be lazy, but by the same right, wouldn't you be irritated if you got knee deep into a tome-like IM H&P to realize the patient could have been sent out with oral antibiotics and clinic follow up?

Before you call and involve someone in a potential admission, always ask yourself, "Why can't this patient be sent home and treated outpatient?" You should know this in the first place, and if you do, you'll be ready when they test you. Your answer should never be, "Because my attending wants him admitted." You need to know why your patient has to be admitted.

In academic settings, the admission card is WAY, WAY overused. In the "real world" this luxury is much more scarce. Have your next 2 moves planned, before you make that call.

👍

 

[WilcoWorld]

I think of the ED-hospitalist relationship to be one that needs mutual respect. You want me to admit a pt to the hospital for reason X, great. Call me, tell me the patient presented with X, my work up yielded Y, i have started therapy Z and I think they need to come in. Done. You treated me like a fellow doctor, told me what you need, presented it succinctly, and wasted no time. My response is great, bridge him to tele and ill see him when he gets there, hope your shift goes well the rest of the day.

That is how an admit should go. Mutual respect, effective and efficient transition of care.

I do not like to hear "Pt has PNA, I admitted them to your service, see them on the floor." I am not a nurse or a unit secretary. I am a fellow physician. It takes all of 30 seconds to give me a quick line of " 67 y/o presented with cough and fevers. Xry shows RUL PNA. Hes community acquired. History of chf but not in flare on my exam. Satting well on 2L, vitals stable, lactate normal. I gave a liter of fluid, ceftriaxone and azithromycin"........"thanks man admit inpatient to general med floor ill be up to see him Ina bit." done.

And to answer some other response, most hospitalist are paid by shift, nothing extra for an admit. And we're just as busy as you. If the Ed docs are good where we practice, the phone call proceeds as above, wasting none of your time or more importantly to me, any of my time. But if the Ed docs are routinely calling for garbage admits, 31 y/o with chest pain, negative markers, normal EKG and xry...sure I'm gonna ask why you think that pt has to come in. This is not something I encounter frequently though unless I'm getting called by the mid levels who always seem to be too overly cautious and want to admit everything. What I have a major problem with at my hospital is not refusing soft admits, it's not trusting that the PNA admit to GMF is not really severe sepsis with impending respiratory failure and arrest. I come to see the pts in ed most every time to lay eyes on them before they go up. Part of that is security. It's my license once they leave through your doors. And if the stable chf you called me for GMF admission crashes 20 minutes later the jury will chew me up for "we'll the Ed doc told me stable chf to GMF", it will be my head.

I rarely ever try and refuse an admission. At my place if you call, I have to see them. The time it takes to see them and dictate a consult and discharge them is equivalent to admitting them so I gain nothing by doing that. I am more concerned that I'm getting the real story and not being handed a ticking time bomb.

No ED doc should ever give you hassle for saying "gee this gal sounds kinda sick, mind if I come to the ED to check her out?" But please understand that "what's this patient's PSI score?" is sort of a silly question when I call to admit a 62 year old homeless alcoholic COPD'er for pneumonia.

 

[Bostonredsox]

No ED doc should ever give you hassle for saying "gee this gal sounds kinda sick, mind if I come to the ED to check her out?" But please understand that "what's this patient's PSI score?" is sort of a silly question when I call to admit a 62 year old homeless alcoholic COPD'er for pneumonia.

agreed. i always ask for a lactate and the hemodynamics/respiratory status. but here, they do give us crap if us coming down to look at the pt holds them up in any way from being transferred to the floor. even if that eval results in a change in their destination. they just want em out of the ed fast to cutdown wait times, outcomes are irrelevant.

 

[deleted547339]

I do not like to hear "Pt has PNA, I admitted them to your service, see them on the floor." I am not a nurse or a unit secretary. I am a fellow physician. It takes all of 30 seconds to give me a quick line of " 67 y/o presented with cough and fevers. Xry shows RUL PNA. Hes community acquired. History of chf but not in flare on my exam. Satting well on 2L, vitals stable, lactate normal. I gave a liter of fluid, ceftriaxone and azithromycin"........"thanks man admit inpatient to general med floor ill be up to see him Ina bit." done.

What about somewhere in the middle? When giving report to IM, the upper levels have all told me to lead with the punchline, either diagnosis or whatever I want them to do.

I.e. I've got a 65 y/o here I'd like to admit to you for a CP rule out. Negative EKG, neg trop, but concerning hx and pmh of HTN, CAD and DM. Vitals have beens table in the dept and he looks good. --- I generally don't give them much more than that unless they ask (which they normally do not). That's not exactly what you're asking for, but I don't want to waste their time either.

 

[Bostonredsox]

What about somewhere in the middle? When giving report to IM, the upper levels have all told me to lead with the punchline, either diagnosis or whatever I want them to do.

I.e. I've got a 65 y/o here I'd like to admit to you for a CP rule out. Negative EKG, neg trop, but concerning hx and pmh of HTN, CAD and DM. Vitals have beens table in the dept and he looks good. --- I generally don't give them much more than that unless they ask (which they normally do not). That's not exactly what you're asking for, but I don't want to waste their time either.

No what you described is exactly what I'm asking for.

65 y/o male, cp rule out, negative trop, nonspecific EKG, chest xry clean. Vitals stable. Good story for acs. Said he had a clean stress about 5 years ago but no other workup since.

That's all I need.

 

[deleted547339]

No what you described is exactly what I'm asking for.

65 y/o male, cp rule out, negative trop, nonspecific EKG, chest xry clean. Vitals stable. Good story for acs. Said he had a clean stress about 5 years ago but no other workup since.

That's all I need.

gotchya. i always try to use the phrase "i'd like to admit to you" or "i have a patient i'd like you to come see" - not "i'm admitting this patient to you" or "there's a guy down here you have to come and see"

 

[e30ftw]

No what you described is exactly what I'm asking for.

65 y/o male, cp rule out, negative trop, nonspecific EKG, chest xry clean. Vitals stable. Good story for acs. Said he had a clean stress about 5 years ago but no other workup since.

9/10 times if I say this exact story to one of our cardiologists (who admit cp obs) the next response is a passive aggressive implication that I am an idiot who can neither obtain a history nor even begin to understand the intricacies of cardiovascular pathology management.

cardiology at my shop will insult us for trying to admit > 60 y/o M w/ nondiagnostic EKGs and elevated trops w/ a positive delta. In 6 months of ED rotation during my intern year I have had to fight for admission for 3 separate patients who cards initially refused to admit but after my and my attending's insistence came down to the ED and each of those three patients were cathed the that night or the next day. This on top of several hundred, obviously, who had negative rule-outs..

it depends on your shop who things are managed. this is pretty average in EM imo, there are hosts of people out there who would rather patients come to harm under your (attending's) malpractice than come in and see the pt.. your job is to win the game. the first step to winning the game is doing whats best for the patient.

most other physicians have no idea the level of patient abandonment witnessed regularly in the ED.

end.

 

[KarlPilkington]

I start all conversations with "I've got a guy here that needs to come in to the hospital."

If I get push back I offer "Yeah that's fine, if you wanna come down here and see them I'm happy to help you print off some discharge paperwork."

In 6 years I've had 2 cases where the admitting service was willing to come down and discharge the pt, both times it was a very pleasant interaction with the "admitting" service.

I'm all for playing nice with the admitting services, those guys have tough jobs as well, but I have little tolerance for other folks who try to tell me how to do my job without ever seeing the patient. Know the science of what we do. Don't admit crap but know your standards of care and admit the folks that need to be admitted.

Other tips I've picked up along the way:

-Never apologize for an admission. You may be calling them at 3am, but that means that you're already awake taking care of their patients.

-Use first names as much as possible. If they introduce themselves as Dr. Smith, ask them their first name and use that for the remainder of the conversation. As trivial as this sounds, it will help even the playing field, if you're John and they are Dr. Smith, they have the upper hand.

 

[dotcb]

I would consider this unprofessional conduct and it sounds unacceptable. It sounds like your dept chief or medical director needs to speak to the other department(s). These kinds of things/cases should be clear cut. Having to argue this type of thing or re-invent this every time is completely draining, and to me it sounds like a sign of poor leadership and a culture of unprofessionalism or disrespect.

The only other caveat I'd add is that surgeons and subspecialists really don't like being told what to do. For that reason I always call surgery for a "consult," even though it's really for probable admission. It's harder to refuse a consult than an admission. If there was any pushback I'd say "please come see the patient and we can talk after you've completed your assessment."

9/10 times if I say this exact story to one of our cardiologists (who admit cp obs) the next response is a passive aggressive implication that I am an idiot who can neither obtain a history nor even begin to understand the intricacies of cardiovascular pathology management.

cardiology at my shop will insult us for trying to admit > 60 y/o M w/ nondiagnostic EKGs and elevated trops w/ a positive delta. In 6 months of ED rotation during my intern year I have had to fight for admission for 3 separate patients who cards initially refused to admit but after my and my attending's insistence came down to the ED and each of those three patients were cathed the that night or the next day. This on top of several hundred, obviously, who had negative rule-outs..

it depends on your shop who things are managed. this is pretty average in EM imo, there are hosts of people out there who would rather patients come to harm under your (attending's) malpractice than come in and see the pt.. your job is to win the game. the first step to winning the game is doing whats best for the patient.

most other physicians have no idea the level of patient abandonment witnessed regularly in the ED.

end.

 

[gro2001]

Whenever I get ANY pushback about an admission (whether someone is fighting an admission or thinks they are too sick for the floor), instead of forcing it down people's throats (though thanks to our hospital's protocols we totally have the ability to do that with all except 2 services) I offer people to come down and continue our conversation at the bedside. This is not a 'consult' but am invitation to eye ball the patient themselves. On the rare occasion when they accept my invitation, they almost always come around to my way of thinking. If they don't want to come down, they realize how ridiculous they sound refusing to look at the patient before making make decisions about their care and so 9 times out of 10 they just accept the admission. This approach is respectful because it assumes that your disagreement is not because of laziness or lack of knowledge on someone's part, but rather the advantage you have of having seen and talked to the patient.

 

[deuist]

I can't believe that you would have to fight IM residents for admissions. If you find yourself regularly "pushing" for admissions, you need to change your approach right now and establish that you are not to be argued with. It's a dick move, but occasionally I use this script:

"I am admitting this patient to your service because he needs admission. You are a resident and have no privileges when it comes to deciding who gets admitted and who doesn't. Furthermore, I don't want an unlicensed physician who has never seen this person to tell me how I should treat him. If this continues to be a problem for you, I can call my chairman, who will call your chairman to ask why you are refusing to see the patient."

Usually takes once and you'll set dominance (kind of like beating the biggest guy in prison on your first day and establishing prison bitches). They won't fight you anymore.

 

[michaelrack]

x

 

[Bostonredsox]

I can't believe that you would have to fight IM residents for admissions. If you find yourself regularly "pushing" for admissions, you need to change your approach right now and establish that you are not to be argued with. It's a dick move, but occasionally I use this script:

"I am admitting this patient to your service because he needs admission. You are a resident and have no privileges when it comes to deciding who gets admitted and who doesn't. Furthermore, I don't want an unlicensed physician who has never seen this person to tell me how I should treat him. If this continues to be a problem for you, I can call my chairman, who will call your chairman to ask why you are refusing to see the patient."

Usually takes once and you'll set dominance (kind of like beating the biggest guy in prison on your first day and establishing prison bitches). They won't fight you anymore.

I think you guys work with lazy residents. I would never refuse a pt over the phone. I get called routinely for ICU admission, come and assess the pt and decide they are safe for stepdown or tele. I have never come and refused an admit even after seeing the pt. there have been plenty I knew didn't need to come in, but once I'm called, I have to come and see them. So to refuse and dictate a consult, is as much work as admitting them but its more hassle. So when I get called for the 38 year old chest pain obs who has chest pain because the cops tazed him for being a belligerent drunk in public and he wants to avoid a night in jail, true story, I don't refuse. I laugh to myself about it and am amazed that this pt could be presented to me by any self respecting Ed physician. But I admit them. Write up the admit and orders in about 9 minutes and go onto the next. Not worth arguing. But my respect for that docs opinion takes a hit.

I have I only ever had an Ed doc get upset with me for de-escalating their admission from ICU to tele once. And my answer was listen I know your an attending (who graduated 2 months ago so really you have about a years more experience in medicine than I do), and I'm just a resident.....but I will be the one caring for this pt whether its in the floor or ICU, not you. Put them on the floor or ill just transfer them to the floor the moment they hit ICU and you'll just have a pissed off nursing supervisor. She called my attending, a very good, seasoned hospitalist. he said put the pt on the floor and be happy, had you called me, i would have questioned why you wanted them admitted at all. 99% of the time the Ed doc just cares that the pt gets admitted and out of the Ed, they're happy to put them wherever I want them.

But we never refuse admissions. Whether the ed doc is right of wrong, It's just not worth the effort.

 

[VA Hopeful Dr]

I think you guys work with lazy residents. I would never refuse a pt over the phone. I get called routinely for ICU admission, come and assess the pt and decide they are safe for stepdown or tele. I have never come and refused an admit even after seeing the pt. there have been plenty I knew didn't need to come in, but once I'm called, I have to come and see them. So to refuse and dictate a consult, is as much work as admitting them but its more hassle. So when I get called for the 38 year old chest pain obs who has chest pain because the cops tazed him for being a belligerent drunk in public and he wants to avoid a night in jail, true story, I don't refuse. I laugh to myself about it and am amazed that this pt could be presented to me by any self respecting Ed physician. But I admit them. Write up the admit and orders in about 9 minutes and go onto the next. Not worth arguing. But my respect for that docs opinion takes a hit.

I have I only ever had an Ed doc get upset with me for de-escalating their admission from ICU to tele once. And my answer was listen I know your an attending (who graduated 2 months ago so really you have about a years more experience in medicine than I do), and I'm just a resident.....but I will be the one caring for this pt whether its in the floor or ICU, not you. Put them on the floor or ill just transfer them to the floor the moment they hit ICU and you'll just have a pissed off nursing supervisor. She called my attending, a very good, seasoned hospitalist. he said put the pt on the floor and be happy, had you called me, i would have questioned why you wanted them admitted at all. 99% of the time the Ed doc just cares that the pt gets admitted and out of the Ed, they're happy to put them wherever I want them.

But we never refuse admissions. Whether the ed doc is right of wrong, It's just not worth the effort.

Yeah, I've sent people home from the ED after assessing but I can't imagine doing it over the phone like that. I think the frustration a few posts up is appropriate.

 

[gro2001]

I think you guys work with lazy residents. I would never refuse a pt over the phone. I get called routinely for ICU admission, come and assess the pt and decide they are safe for stepdown or tele. I have never come and refused an admit even after seeing the pt. there have been plenty I knew didn't need to come in, but once I'm called, I have to come and see them. So to refuse and dictate a consult, is as much work as admitting them but its more hassle. So when I get called for the 38 year old chest pain obs who has chest pain because the cops tazed him for being a belligerent drunk in public and he wants to avoid a night in jail, true story, I don't refuse. I laugh to myself about it and am amazed that this pt could be presented to me by any self respecting Ed physician. But I admit them. Write up the admit and orders in about 9 minutes and go onto the next. Not worth arguing. But my respect for that docs opinion takes a hit.

I have I only ever had an Ed doc get upset with me for de-escalating their admission from ICU to tele once. And my answer was listen I know your an attending (who graduated 2 months ago so really you have about a years more experience in medicine than I do), and I'm just a resident.....but I will be the one caring for this pt whether its in the floor or ICU, not you. Put them on the floor or ill just transfer them to the floor the moment they hit ICU and you'll just have a pissed off nursing supervisor. She called my attending, a very good, seasoned hospitalist. he said put the pt on the floor and be happy, had you called me, i would have questioned why you wanted them admitted at all. 99% of the time the Ed doc just cares that the pt gets admitted and out of the Ed, they're happy to put them wherever I want them.

But we never refuse admissions. Whether the ed doc is right of wrong, It's just not worth the effort.

Yeah, I've sent people home from the ED after assessing but I can't imagine doing it over the phone like that. I think the frustration a few posts up is appropriate.

That's the mature way to deal with such a problem, for sure.

 

[Bostonredsox]

That's the mature way to deal with such a problem, for sure.

Not sure of that's sarcasm or...

 

[jdh71]

I've never fought an admit. And I'm always surprised it goes on as much as it does.

 

[Rendar5]

Not sure of that's sarcasm or...

truth

 

[michaelrack]

Furthermore, I don't want an unlicensed physician who has never seen this person to tell me how I should treat him.

What is your response when the resident replies that he is a fully licensed physician (as many non-intern residents are)?

 

[Arcan57]

What is your response when the resident replies that he is a fully licensed physician (as many non-intern residents are)?

Residents in a teaching hospital are operating under a training license even if they have an unrestricted license also.

 

[deleted6669]

A lot of it also has to do with the personal relationship you have with your hospitalists. I work at 2 rural facilities that foster close relationships between the er and the hospitalists. we invite them to our dept BBQ's, etc and I know them all on a first name basis. at those places an admit goes like this:
"Hi Brian, it's emedpa. I have a hypoxic 84 yr old lady with a chf exacerbation on bipap who needs to come into the unit"
"OK. say, how are the kids"?
at my urban trauma center job it's more like this:
" hello, Dr. venagali, this is emedpa, I'm one of the em pas here(because they have no idea who anyone is). I have a hypoxic 84 yr old lady with a chf exacerbation on bipap who needs to come into the unit"
Dr. V " why do you think she needs to come in? has she been adequately diuresed? what is her serum porcelain level? did you talk to her pcp? has your attending seen this patient? I'm really busy. call me back in 5 hrs if you want me to see her if you haven't fixed her yet." Click.

 

[deleted109597]

What is your response when the resident replies that he is a fully licensed physician (as many non-intern residents are)?

I hang up and call his attending because he's being a dick.

 

[dotcb]

"Please come down to the ED and we can talk about this case in person. Thanks."

What is your response when the resident replies that he is a fully licensed physician (as many non-intern residents are)?

 

[michaelrack]

Residents in a teaching hospital are operating under a training license even if they have an unrestricted license also.

That wasn't true in the state where I did my training (WV), but I will accept that that is the case in dueist's state (and the majority of states).

edit:

My training was a long time ago, so it could be true everywhere now.

 

[michaelrack]

I hang up and call his attending because he's being a dick.

That would be an appropriate response if a resident gave resistance to an ER attending

edit: I am not saying that an IM resident should be rude to an ER resident. I was just confused by deuist's post (#29), because most of the posters prior to that were residents, and such a speech would only be appropriate coming from an attending (as deuist is), but the post doesn't really answer what an ER resident should say to an IM resident.

I am very against IM residents refusing to see a patient in the ER, whatever the level of the doctor requesting the consult.

 

[Bostonredsox]

That would be an appropriate response if a resident gave resistance to an ER attending

edit: I am not saying that an IM resident should be rude to an ER resident. I was just confused by deuist's post (#29), because most of the posters prior to that were residents, and such a speech would only be appropriate coming from an attending (as deuist is), but the post doesn't really answer what an ER resident should say to an IM resident.

I am very against IM residents refusing to see a patient in the ER, whatever the level of the doctor requesting the consult.

The bottom line is the truth. Never refuse to see a pt. you can see them and send them home, but you can't render your opinion on the pt until you've seen them.

The exception for me is "I have a 88 year old male from nursing home X, looks septic from uti. Multiple stage 4 decubs, bedbound for 2 years, lactate is 9, gave 2L of fluid but still hypotensive and in RVR. Family says DNR, no lines or aggressive measures/invasive procedures....do you have an ICU bed?"

My response, "no procedures, no CPR, conservative therapy....how bout we give fluids and some amio in stepdown?".

Usually the response is ok, as after all, they just want the pt out of the Ed. Apart from that scenario I come and see everyone before rendering an answer on where to admit them

 

[deleted109597]

That wasn't true in the state where I did my training (WV)

So, you frequently discharged and admitted people without talking to your attending? Even with a full license (as many people who moonlight have), when you're in a training environment, you work under the training license.

 

[Bostonredsox]

So, you frequently discharged and admitted people without talking to your attending? Even with a full license (as many people who moonlight have), when you're in a training environment, you work under the training license.

We do all of the ICU admissions without speaking to the attending. They see the pt when they come up to the unit, but the initial acceptance, admission and often stabilization is done by the MICU senior resident. This is exclusively how it happens at night. Hospitalist is covering 100+ floor pts, 15-20 admissions and all the floor calls. All of the ICU management is done by the resident in the MICU. I send them a text about who I admitted and what I did so they can come by and see them and do there billing.

 

[deleted547339]

The bottom line is the truth. Never refuse to see a pt. you can see them and send them home, but you can't render your opinion on the pt until you've seen them.

The exception for me is "I have a 88 year old male from nursing home X, looks septic from uti. Multiple stage 4 decubs, bedbound for 2 years, lactate is 9, gave 2L of fluid but still hypotensive and in RVR. Family says DNR, no lines or aggressive measures/invasive procedures....do you have an ICU bed?"

My response, "no procedures, no CPR, conservative therapy....how bout we give fluids and some amio in stepdown?".

Usually the response is ok, as after all, they just want the pt out of the Ed. Apart from that scenario I come and see everyone before rendering an answer on where to admit them

This might make me a bad person, but that's a patient I'd rather either send them to a non-tele floor bed or home. If the patient's (and family's) goal is to die peacefully, I say let em. I wouldn't ever call for an ICU bed on a DNR patient where everyone, including family, was on the same page.

 

[gro2001]

Not sure of that's sarcasm or...

No sarcasm. I was agreeing with you about your point that you can't render an opinion over the phone.


On an unrelated note, some of the confusion could stem from the commonly confused issues of LICENSING vs CREDENTIALING. If I, as a resident, apply for a license in my state, I may very well be a fully licensed physician. However, the hospital clearly delineates what privileges I am credentialed for. A resident and attending can be equally licensed but they are never equally credentialed.

 

[Doctor Bob]

We do all of the ICU admissions without speaking to the attending. They see the pt when they come up to the unit, but the initial acceptance, admission and often stabilization is done by the MICU senior resident. This is exclusively how it happens at night. Hospitalist is covering 100+ floor pts, 15-20 admissions and all the floor calls. All of the ICU management is done by the resident in the MICU. I send them a text about who I admitted and what I did so they can come by and see them and do there billing.

Although your attending doesn't see the patient until later, when you admit (or don't admit a patient), you are speaking with your attending's voice.

I had an IM resident accept a patient for admission, then an hour later (while the patient was in transit from the ED to the floor) the resident called back to say "hey, I've talked with my attending now and they don't want to admit the patient. So when they arrive on the floor we're going to send them back." I had a talk with them about how they should have cleared the admission with their attending an hour ago and that there is no way the patient will be sent back to the ED.

It's good when attendings give senior residents the authority to make admission decisions but then they have to abide by them as if they made the decision themselves. And neither of them should be making patient care decisions that go against the decision made by another resident/attending team when they haven't personally seen the patient.

Bostonredsox, it sounds like the approach you take to admitting/refusing patients is spot on.

 

[Bostonredsox]

This might make me a bad person, but that's a patient I'd rather either send them to a non-tele floor bed or home. If the patient's (and family's) goal is to die peacefully, I say let em. I wouldn't ever call for an ICU bed on a DNR patient where everyone, including family, was on the same page.

totally agree. but a lot of ed docs here seem uncomfortable having end of life discussions in the ed with pts they have just met. I understand that. I would take the above described pt to tele as you have said. A lot of the attending hospitalists see the wacky vitals and get all sqeamish and want stepdown. when I said I dont argue with the ED docs, that extends to my attending hospitalists....I just say ok.