You Can't Choose Your Friends

[docB]

I don't want to sound disgruntled but there is another negative that is unique to EM that I don't think has ever been mentioned here.

Non-EM docs can usually choose who they associate with professionally. A PMD can choose who to refer to. A specialist can choose who to take referrals from. We can't choose. We have a call list created by the hospital with limited, if any, input from us.

It is not uncommon to have conflicts with or even be involved in litigation with consultants and you still have to call them if it's their day. How are you supposed to interact professionally with someone who threw you under the bus in a deposition the day before? There's one we were definitely not taught in residency.

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[e30ftw]

agreed.

Some of the most eye-opening experiences are seeing the attitudes of consultants towards ED patients.

this happens all the time;

Pt w/ multiple chronic medical problems p/w nonspecific complaints (malaise, n/v, diffuse abdpain,HA, back pain). VSS, comprehensive ED w/u reveals no acute abnormalities but due to your "feeling" you think the pt should be admitted. Call their specialist who refuses admit, call the hospitalist who refuses admit because they think specialist should admit. Finally find someone to admit pt, pt goes upstairs and 24 hrs later has decompensated due to the randomness of human illness and is sicker than initially appeared. Specialist/hospitalist throw ED doc under bus for mismanaging pt at initial presentation (which was uncommon presentation of uncommon illness).

The fact that they didn't want to admit in the first place is never brought up, ED doc reprimanded by administration for poor management.

funtimes.

 

[WilcoWorld]

Another keen observation by docB.

e30ftw's story is all too common. It makes me wonder if the specialists will ever realize that if they weren't so quick to "throw us under the bus" that we'd call them less often. I know that a significant % of my calls are made, not because I think I need the specialist's help, but because the last time I saw a patient like this and didn't call the specialist, I got a complaint (even though the outcome wouldn't have changed).

To the list of death & taxes, ED docs can add another certainty - you always call too early or too late.

 

[Birdstrike]

I don't want to sound disgruntled but there is another negative that is unique to EM that I don't think has ever been mentioned here.

Non-EM docs can usually choose who they associate with professionally. A PMD can choose who to refer to. A specialist can choose who to take referrals from. We can't choose. We have a call list created by the hospital with limited, if any, input from us.

It is not uncommon to have conflicts with or even be involved in litigation with consultants and you still have to call them if it's their day. How are you supposed to interact professionally with someone who threw you under the bus in a deposition the day before? There's one we were definitely not taught in residency.

Rule 47, Birdstrike's Bible: You Need Them, They Need You To Go Away​

The unfortunately reality, is that as an EP you are always on the receiving end of an unequal and "unenlightened" relationship. The imbalance of power is not fair, equal, or conducive to a mutually beneficial relationship. If "X" consultant never got another call from you, his life would be better. He'd sleep more, his clinic day would be interrupted less, and he'd be less stressed. His practice would still flourish, and in fact flourish more since it wouldn't be inundated with unscheduled, uninsured ED patients.

You, on the other hand, need consultant "X" to answer your pages. If he doesn't, your life is worse. You are stuck with a patient you can't help, can't get out of your ER and that you can't make happy (Press-Ganey belly flop). You end up spinning your wheels frustrated, trying to find someone to stand up and "do the right thing" and help this person you are trying to help. When consultant "X" is a jerk, you suffer and the patient suffers. When consultant "X" is a jerk, he wins. How to keep this "relationship" in balance is a mysterious, and difficult art, similar to solving the riddle of cold fusion, perpetual motion, and low cost pollution-free energy. Consider reading Sun Tszu's tome, "The Art of War." Or just stick to DrWhitecoat.com. Carry on, soldier. This is God's work.

 

[deleted547339]

Rule 47, Birdstrike's Bible: You Need Them, They Need You To Go Away​

The unfortunately reality, is that as an EP you are always on the receiving end of an unequal and "unenlightened" relationship. The imbalance of power is not fair, equal, or conducive to a mutually beneficial relationship. If "X" consultant never got another call from you, his life would be better. He'd sleep more, his clinic day would be interrupted less, and he'd be less stressed. His practice would still flourish, and in fact flourish more since it wouldn't be inundated with unscheduled, uninsured ED patients.

You, on the other hand, need consultant "X" to answer your pages. If he doesn't, your life is worse. You are stuck with a patient you can't help, can't get out of your ER and that you can't make happy (Press-Ganey belly flop). You end up spinning your wheels frustrated, trying to find someone to stand up and "do the right thing" and help this person you are trying to help. When consultant "X" is a jerk, you suffer and the patient suffers. When consultant "X" is a jerk, he wins. How to keep this "relationship" in balance is a mysterious, and difficult art, similar to solving the riddle of cold fusion, perpetual motion, and low cost pollution-free energy. Consider reading Sun Tszu's tome, "The Art of War." Or just stick to DrWhitecoat.com. Carry on, soldier. This is God's work.

So, I have a question about real-world, i.e. post-residency EM. Lets say that you have a patient where you just feel general badness and want to admit them to service X, then Dr. Y says "no, they don't need MICU/CCU/Cards floor/GI/whatever." Is it wrong to document "Felt pt needed MICU/CCU/Cards floor/GI/whatever, spoke with Dr. Y who refused admission/refused to see the patient....since I was unable to admit the pt to service X but my clinical opinion was that the pt needed inpatient care, I contacted the hospitalist. The hospitalist graciously accepted the pt."

Obviously, you're throwing Dr. Y under the bus, but Dr. Y is a total d-bag anyway. And you realize if the badness that you suspect may happen does happen, we would not be surprised if Dr. Y told the lawyer "TimesNewRoman never called me about that pt. It obvious from reviewing the case that he needed MICU/CCU/Cards floor/GI/whatever and I would have gladly come in. Why wouldn't I have?"

I imagine that you probably wouldn't have a great reputation with some of the specialists, but I suspect that when you called the specialists they would be a lot more apt to respond quickly for not getting served up as a lay-up in a med-mal case.

 

[Doctor Bob]

So, I have a question about real-world, i.e. post-residency EM. Lets say that you have a patient where you just feel general badness and want to admit them to service X, then Dr. Y says "no, they don't need MICU/CCU/Cards floor/GI/whatever." Is it wrong to document "Felt pt needed MICU/CCU/Cards floor/GI/whatever, spoke with Dr. Y who refused admission/refused to see the patient....since I was unable to admit the pt to service X but my clinical opinion was that the pt needed inpatient care, I contacted the hospitalist. The hospitalist graciously accepted the pt."

Lawyers love this... getting into fights in the medical record. Makes their job that much easier.
Plus you've now documented that you felt the patient needed level of care X, but you put them in level of care Y... when the patient has a bad outcome you've now documented that you willfully put them into, what you believed was the inappropriate level of care.
In the courtroom you won't get points for doing the best you could with jackwad consultants, you'll only get crucified for not doing what you felt was in the best interest of the patient.

 

[deleted109597]

So, I have a question about real-world, i.e. post-residency EM. Lets say that you have a patient where you just feel general badness and want to admit them to service X, then Dr. Y says "no, they don't need MICU/CCU/Cards floor/GI/whatever." Is it wrong to document "Felt pt needed MICU/CCU/Cards floor/GI/whatever, spoke with Dr. Y who refused admission/refused to see the patient....since I was unable to admit the pt to service X but my clinical opinion was that the pt needed inpatient care, I contacted the hospitalist. The hospitalist graciously accepted the pt."

I'll second the "no".

However, always document every time you call someone. You don't have to put what you talked about, or spin it so negatively.
You can simply state "cards paged, they had no recommendations at this time. hospitalist paged" or something similar.
Chart wars never work out. Even if you're right, you're wrong.

 

[WilcoWorld]

If I call a specialist and he or she doesn't do what I want, I'll write something non-inflammatory like "Case was discussed with Dr. Heart, who was apprised of patient's history, ECG findings and vitals signs. He felt that the patient did not require intervention at present. The patient was then admitted to telemetry for further evaluation."

Keep it factual, and don't put spite in the medical record.

 

[emergentmd]

I am lucky that I work at a place where 99% of the specialists are helpful and 99% of the hospitalists will admit anything with a pulse. Isn't that why they are on call? To see pts, admit, make money. Hospitalists at my hospital is like us. Independent contractor. Eat what you kill. Makes no sense to refuse an admission.

But in the rare instances that they refuse admission and I think the pt really needs to be admitted, I tell them "You are consulted, you can come in see the pt and dispo the pt". This usually ends any argument and the pt get admitted.

Keep it simple

 

[Arcan57]

So, I have a question about real-world, i.e. post-residency EM. Lets say that you have a patient where you just feel general badness and want to admit them to service X, then Dr. Y says "no, they don't need MICU/CCU/Cards floor/GI/whatever." Is it wrong to document "Felt pt needed MICU/CCU/Cards floor/GI/whatever, spoke with Dr. Y who refused admission/refused to see the patient....since I was unable to admit the pt to service X but my clinical opinion was that the pt needed inpatient care, I contacted the hospitalist. The hospitalist graciously accepted the pt."

Obviously, you're throwing Dr. Y under the bus, but Dr. Y is a total d-bag anyway. And you realize if the badness that you suspect may happen does happen, we would not be surprised if Dr. Y told the lawyer "TimesNewRoman never called me about that pt. It obvious from reviewing the case that he needed MICU/CCU/Cards floor/GI/whatever and I would have gladly come in. Why wouldn't I have?"

I imagine that you probably wouldn't have a great reputation with some of the specialists, but I suspect that when you called the specialists they would be a lot more apt to respond quickly for not getting served up as a lay-up in a med-mal case.

More likely you'll find yourself the subject of peer review and if you make a pattern out of it the med staff will ask your group to let you go. On the other hand, I don't tolerate the consultants throwing me under the bus in their notes either. While you don't give them the type of business they necessarily want, few docs are willing to consistently write inflammatory notes if the cost is having to explain face-to-face why they did that. Recorded lines are also useful when the consultant starts spinning this line of complete fiction (that's plausible because the ED always left out some crucial bit of info that if only they'd known they would have rushed right in). It tends to shut them up quickly in front of MEC or peer review.

 

[RustedFox]

If I call a specialist and he or she doesn't do what I want, I'll write something non-inflammatory like "Case was discussed with Dr. Heart, who was apprised of patient's history, ECG findings and vitals signs. He felt that the patient did not require intervention at present. The patient was then admitted to telemetry for further evaluation."

Keep it factual, and don't put spite in the medical record.

Yep; this.

When I was a senior resident, we had some of the local med-mal defense guys come in and lecture us about good charting. They specifically stated NEVER to write things that throw another guy under the bus; all it does is show that SOMEONE (including you) didn't do the right thing.

 

[Tiger26]

Agree with all of the above and I really like Wilco's documentation on it.

The problem DocB brings up is that a lot of the upstairs folk don't seem to have the same level of foresight when documentating about decisions we make in the ED.

 

[deleted547339]

Thanks, y'all. I figured since no one does it that it was poor form, just curious. Thanks again.