Comments on: Jerk Consultants and Telephone Etiquette http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html Ramblings of an Emergency Physician in Texas Fri, 10 Feb 2012 00:40:33 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Greg P http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4457 Greg P Tue, 05 Sep 2006 16:17:17 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4457 It's hard to keep a level head sometimes, but I try not to "shoot the messenger." As a subspecialist, there are times I'm called to "see today" a patient who's been in the ED all day long, yet I get called just after I get home, or just after I go to bed. I'm not sure the ED docs consider that, and it's in many cases not of their creation. So many primary guys want every last test done, every answer answered before they'll agree that the patient needs admitting, THEN they ask for the consultant. And many of the hospitalists are the same way. The newest wrinkle is that there is a self-labelled "hospitalist neurologist" at our hospital (translation: I only see patients in the hospital, you'll have to find someone else after you go home. I have no office, no office overhead.) Since our office is right next to the hospital, we have no need for this guy. So I may get called at 3am for advice to the ED doc about a patient (usually don't need to come in), then when I get in the next day, the admitting hospitalist has asked the "hospitalist neurologist" to see the patient. Great, now I'm taking calls in the middle of the night so the hospitalist neurologist can sleep. Whose "fault" is it? The ED doc? The hospitalist? Not much sense in getting angry at either. But I have made the hospital's Medical Director VP aware -- no results yet. It’s hard to keep a level head sometimes, but I try not to “shoot the messenger.”
As a subspecialist, there are times I’m called to “see today” a patient who’s been in the ED all day long, yet I get called just after I get home, or just after I go to bed. I’m not sure the ED docs consider that, and it’s in many cases not of their creation. So many primary guys want every last test done, every answer answered before they’ll agree that the patient needs admitting, THEN they ask for the consultant. And many of the hospitalists are the same way.

The newest wrinkle is that there is a self-labelled “hospitalist neurologist” at our hospital (translation: I only see patients in the hospital, you’ll have to find someone else after you go home. I have no office, no office overhead.) Since our office is right next to the hospital, we have no need for this guy.

So I may get called at 3am for advice to the ED doc about a patient (usually don’t need to come in), then when I get in the next day, the admitting hospitalist has asked the “hospitalist neurologist” to see the patient. Great, now I’m taking calls in the middle of the night so the hospitalist neurologist can sleep.

Whose “fault” is it? The ED doc? The hospitalist? Not much sense in getting angry at either. But I have made the hospital’s Medical Director VP aware — no results yet.

]]> By: Sid Schwab http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4456 Sid Schwab Mon, 04 Sep 2006 00:09:39 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4456 I can't find the center of all these comments. Probably there are diffences among various communities. I may not have made clear enough: where I live, if an ER doc sends a pt to a consultant out of his referral pattern, hell might break loose. There were very strong and acrimonious political divides. In addition, in my practice, I was generally on call every third nite, every third weekend -- and weekends meant Friday am to Monday am, inclusive; except when someone was away, when it was every other. So yeah: I considered my own needs when being called in error. I needed sleep. I had a full schedule the next day, and the next. Is that a concern to an ER doc? Ought it to be? Maybe not. But it's one part of the gestalt. I NEVER refused to see an appropriately referred patient, or to provide whatever help was indicated. But I did, when the referral was mis-directed, point it out. Not always to the understanding of the ER doc. I can’t find the center of all these comments. Probably there are diffences among various communities. I may not have made clear enough: where I live, if an ER doc sends a pt to a consultant out of his referral pattern, hell might break loose. There were very strong and acrimonious political divides. In addition, in my practice, I was generally on call every third nite, every third weekend — and weekends meant Friday am to Monday am, inclusive; except when someone was away, when it was every other. So yeah: I considered my own needs when being called in error. I needed sleep. I had a full schedule the next day, and the next. Is that a concern to an ER doc? Ought it to be? Maybe not. But it’s one part of the gestalt. I NEVER refused to see an appropriately referred patient, or to provide whatever help was indicated. But I did, when the referral was mis-directed, point it out. Not always to the understanding of the ER doc.

]]> By: student http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4455 student Sun, 03 Sep 2006 14:30:55 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4455 Re: "Hey, Student: Although I understand the sympathy for the ER doc, what you don't seem to realize is that there are patient populations to whom exhortations to call first are truly in vain. Flea's Medicaid population, for example; I don't think they'd call Dr. Welby before going to an ER even if he lived next door and paid for their cell phones, so it really isn't fair to assume their reticence is just because "the doctor doesn't care enough." But not all patients are of the "medicaid population". I'm simply givng my own observations. I'd rather deal with a doctor who knows my history. And as a self paying patient, I'd also rather stay away from an expensive ED if I can. However, when I explain my symptoms to a doctor who cuts me off in the middle of it(and I do have some medical training and know what symptoms are important to note) and begans speaking to my chart with their back to me, then does a quick physical exam, writes me a script then hurries me out the door...no, I don't feel that doctor is the one I should call in the middle of the night. Aside from one doctor (whom I never did call outside of office hours), I have never been told that I could call them with any concerns. It's simply an observation and one I hope all doctors will tuck away in their pockets and remember. And again, I praise Flea for making things right. Re: “Hey, Student: Although I understand the sympathy for the ER doc, what you don’t seem to realize is that there are patient populations to whom exhortations to call first are truly in vain. Flea’s Medicaid population, for example; I don’t think they’d call Dr. Welby before going to an ER even if he lived next door and paid for their cell phones, so it really isn’t fair to assume their reticence is just because “the doctor doesn’t care enough.”

But not all patients are of the “medicaid population”.
I’m simply givng my own observations. I’d rather deal with a doctor who knows my history. And as a self paying patient, I’d also rather stay away from an expensive ED if I can.
However, when I explain my symptoms to a doctor who cuts me off in the middle of it(and I do have some medical training and know what symptoms are important to note) and begans speaking to my chart with their back to me, then does a quick physical exam, writes me a script then hurries me out the door…no, I don’t feel that doctor is the one I should call in the middle of the night. Aside from one doctor (whom I never did call outside of office hours), I have never been told that I could call them with any concerns.
It’s simply an observation and one I hope all doctors will tuck away in their pockets and remember.

And again, I praise Flea for making things right.

]]> By: scalpel http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4454 scalpel Sun, 03 Sep 2006 08:44:29 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4454 <a href="http://www.emtala.com/faq.htm" rel="nofollow">http://www.emtala.com/faq.htm</a> http://www.emtala.com/faq.htm

]]> By: scalpel http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4453 scalpel Sun, 03 Sep 2006 08:38:31 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4453 I think there is some misunderstanding about what EMTALA requires. As an example, let's just say that at midnight, I get a verbally abusive homeless uninsured patient who is brought into the ER after cutting his hand in a knife fight with another homeless guy 4 hours ago. He has multiple flexor tendon lacerations, and the wound was not cleaned or dressed prior to arrival. Yes, it's dirty. As soon as I evaluate the patient, I order a tetanus booster and antibiotic and then I ask my nurse to start irrigating the wound, I go write my note, and look to see who is on call for hand surgery. Well, lookie here, Plastics is taking hand call tonight. Now you might make whatever recommendations over the phone you think might keep you from having to come in and evaluate this patient, but none of them are quite up to the standard of care. This patient by definition has an emergency medical condition that requires urgent attention. I can't fix it. You are on the staff of this hospital (for now), and you do have the expertise to fix it. Once I have called you and asked for your consultation, the responsibility is yours. No other facility is going to take this transfer, and you know it. He isn't going to go to your office in the morning, but even if he did, that's too long to wait. If I am working at the "urgent care" facility, and you refuse to see him there, then I will transfer him to our main ER where you will be obligated to see him. Do your job. If you don't want to work for a hospital, then don't. But as long as you *are* on staff, then you have to take the bad consults too. Sorry to bother you. I think there is some misunderstanding about what EMTALA requires. As an example, let’s just say that at midnight, I get a verbally abusive homeless uninsured patient who is brought into the ER after cutting his hand in a knife fight with another homeless guy 4 hours ago. He has multiple flexor tendon lacerations, and the wound was not cleaned or dressed prior to arrival. Yes, it’s dirty.

As soon as I evaluate the patient, I order a tetanus booster and antibiotic and then I ask my nurse to start irrigating the wound, I go write my note, and look to see who is on call for hand surgery. Well, lookie here, Plastics is taking hand call tonight.

Now you might make whatever recommendations over the phone you think might keep you from having to come in and evaluate this patient, but none of them are quite up to the standard of care.

This patient by definition has an emergency medical condition that requires urgent attention. I can’t fix it. You are on the staff of this hospital (for now), and you do have the expertise to fix it. Once I have called you and asked for your consultation, the responsibility is yours. No other facility is going to take this transfer, and you know it. He isn’t going to go to your office in the morning, but even if he did, that’s too long to wait. If I am working at the “urgent care” facility, and you refuse to see him there, then I will transfer him to our main ER where you will be obligated to see him.

Do your job. If you don’t want to work for a hospital, then don’t. But as long as you *are* on staff, then you have to take the bad consults too. Sorry to bother you.

]]> By: familydoc http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4452 familydoc Sun, 03 Sep 2006 06:47:32 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4452 Sorry - Canadian , eh- what is EMTALA and does it need a safety catch ? Sorry – Canadian , eh- what is EMTALA and does it need a safety catch ?

]]> By: Anon http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4451 Anon Sun, 03 Sep 2006 03:27:15 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4451 As a used to be regular reader of flea's ...read back through his blog. If a parent doesn't do as he says ...he gets mad at them. The ED docs MUST call him, but when they do, he proudly treats them like second class citizens. They should know better than to decide what to do, how DARE they act like doctors. He make jokes about short yellow busses (special education busses for schools) then tells the mothers of children with special needs to get a grip and not be so sensitive and if they can't handle the jokes, don't read his blog. He gets up in arms when someone criticisizes him, yet, he is very quick to make short insulting remarks to anyone who does not take his side. He is definitely proud of the fact that kids must be very very sick before they get antibiotics, regardless of how worried the mom is and no mom will ever bully him into antibiotics whether she understands the need to not give them or not. Go back ...read his blog entries for the year ... this interaction with this ED doc wasn't out of the ordinary. He supposedly runs a small private practice, all by himself, and if he treats his patients as strongly and as rudely as he claims to, he'd have no practice. No wonder mom's are taking their kids in his practice to the ED. They don't know if they're getting good medical care or not because he's so busy pushing his weight around instead of educating them. As a used to be regular reader of flea’s …read back through his blog.

If a parent doesn’t do as he says …he gets mad at them.
The ED docs MUST call him, but when they do, he proudly treats them like second class citizens. They should know better than to decide what to do, how DARE they act like doctors.

He make jokes about short yellow busses (special education busses for schools) then tells the mothers of children with special needs to get a grip and not be so sensitive and if they can’t handle the jokes, don’t read his blog.

He gets up in arms when someone criticisizes him, yet, he is very quick to make short insulting remarks to anyone who does not take his side.

He is definitely proud of the fact that kids must be very very sick before they get antibiotics, regardless of how worried the mom is and no mom will ever bully him into antibiotics whether she understands the need to not give them or not.

Go back …read his blog entries for the year … this interaction with this ED doc wasn’t out of the ordinary.

He supposedly runs a small private practice, all by himself, and if he treats his patients as strongly and as rudely as he claims to, he’d have no practice.

No wonder mom’s are taking their kids in his practice to the ED. They don’t know if they’re getting good medical care or not because he’s so busy pushing his weight around instead of educating them.

]]> By: CHenry http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4450 CHenry Sun, 03 Sep 2006 02:22:39 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4450 Scalpel, the problem is with your assumption is that I must remain on the hospital staff. I really don't need them, or the EDs referral business, or really their OR. In my specialty, I really do not have to have a hospital, which is a good thing in my view. So as long as I stay on staff, and don't bail as my plastic surgeon colleagues in my community have, I have a great deal of leverage against ER over-consulting. My local hospital has gone into the business of opening walk-in urgent care clinics, staffed by the ER docs. It is a separate corporate entity. I don't technically have to answer any after-hours calls from them and they know that. If I choose to, that is my privilege. Those doctors know better than to abuse me. Sorry to disappoint you, but EMTALA does not obligate me to appear like a trunk monkey at the ER's bidding. I can tell them that the hospital is not equipped to handle their problem and they should transfer the patient to the university medical center. I can provide them instructions over the phone if I think the patient does not need to be seen by me immediately. You seem like someone who likes to quote EMTALA and maybe bully other staff with that. The law requires reasonable efforts to assess and stabilize. Sorry to say, but you are not the sole arbiter of what is reasonable. I don't know how long you have been doing ER practice, but in most hospitals, if you tried that threatening tack, you probably would get a frfiendly and informal reminder to stop and play nice. If you didn't, you would sooner or later be looking for another job. Scalpel, the problem is with your assumption is that I must remain on the hospital staff. I really don’t need them, or the EDs referral business, or really their OR. In my specialty, I really do not have to have a hospital, which is a good thing in my view. So as long as I stay on staff, and don’t bail as my plastic surgeon colleagues in my community have, I have a great deal of leverage against ER over-consulting. My local hospital has gone into the business of opening walk-in urgent care clinics, staffed by the ER docs. It is a separate corporate entity. I don’t technically have to answer any after-hours calls from them and they know that. If I choose to, that is my privilege. Those doctors know better than to abuse me.

Sorry to disappoint you, but EMTALA does not obligate me to appear like a trunk monkey at the ER’s bidding. I can tell them that the hospital is not equipped to handle their problem and they should transfer the patient to the university medical center. I can provide them instructions over the phone if I think the patient does not need to be seen by me immediately.

You seem like someone who likes to quote EMTALA and maybe bully other staff with that. The law requires reasonable efforts to assess and stabilize. Sorry to say, but you are not the sole arbiter of what is reasonable. I don’t know how long you have been doing ER practice, but in most hospitals, if you tried that threatening tack, you probably would get a frfiendly and informal reminder to stop and play nice. If you didn’t, you would sooner or later be looking for another job.

]]> By: TheNewGuy http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4449 TheNewGuy Sun, 03 Sep 2006 02:22:33 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4449 Well... quite a backlash for simply pointing out that ER physicians are not helpless in the face of abusive consultants, and that an aggrieved ER doc can return the favor. I tapped a real vein of hostility and resentment, it seems. I'm well aware that being a jerk to your colleageus cuts both ways... so why do it at all? Most ER docs I know <i>never</i> start fights with consultants on the phone, yet they're expected to endure abuse at the hands of disgruntled physicians? I don't think so. The ER doc is just trying to do his job, so why do some of you feel like you have to defecate in his cornflakes? What ever happened to pulling with the team and taking care of the patient right alongside your colleagues? Working the ER and being on ER call are a big stool sandwich, and we've <b>all</b> got to take a bite. I find as I get older that I have a lower and lower tolerance for those who feel they're entitled to show their ass, or take out their angst on their fellow professionals, whether they be nurses, techs, or other docs. We've all got a job to do...let's be adults, and professionals. <i>Believe me, the last thing you want to be is the ED guy who becomes known for making trouble on the medical staff. Hurt goes both ways.</i> There's no need to threaten me, CHenry. I'm simply the guy holding up the mirror. Well… quite a backlash for simply pointing out that ER physicians are not helpless in the face of abusive consultants, and that an aggrieved ER doc can return the favor. I tapped a real vein of hostility and resentment, it seems.

I’m well aware that being a jerk to your colleageus cuts both ways… so why do it at all? Most ER docs I know never start fights with consultants on the phone, yet they’re expected to endure abuse at the hands of disgruntled physicians? I don’t think so.

The ER doc is just trying to do his job, so why do some of you feel like you have to defecate in his cornflakes? What ever happened to pulling with the team and taking care of the patient right alongside your colleagues? Working the ER and being on ER call are a big stool sandwich, and we’ve all got to take a bite.

I find as I get older that I have a lower and lower tolerance for those who feel they’re entitled to show their ass, or take out their angst on their fellow professionals, whether they be nurses, techs, or other docs.

We’ve all got a job to do…let’s be adults, and professionals.

Believe me, the last thing you want to be is the ED guy who becomes known for making trouble on the medical staff. Hurt goes both ways.

There’s no need to threaten me, CHenry. I’m simply the guy holding up the mirror.

]]> By: scalpel http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html/comment-page-1#comment-4448 scalpel Sat, 02 Sep 2006 20:46:14 +0000 http://gruntdoc.com/2006/08/jerk-consultants-and-telephone-etiquette.html#comment-4448 EMTALA <b>does</b> apply to you and every other consultant who takes unassigned call for a hospital. If a physician of any specialty is on call for the hospital, they may be called by an ER physician if that physician believes the services of the on call physician are necessary in order to stabilize the condition of the patient presenting for treatment. If a patient needs to be admitted, than an admission must be performed. A consultant who is on call and who is requested by an emergency physician to evaluate a patient is required by EMTALA to evaluate the patient within a reasonable time or that consultant is potentially liable for the full penalties which are prescribed by that statute. <b>The penalty is up to $50,000 per violation, btw.</b> In addition, the actions or inactions of that consultant physician may subject the hospital to the possibility of exclusion from participation in the Medicare program, which is a much bigger penalty, as far as your job security is concerned. Yes, EMTALA is a double-edged sword, as it cuts both of us equally. And we in the ER are very careful indeed how we wield that weapon, but rest assured we are not afraid to ask you to help us bear that burden. While that statute does not obligate you to admit any patient, it certainly does obligate you to come to the ER and evaluate anyone we ask you to, at any time of day or night, no matter how busy or sleepy you might be. If your evaluation determines that the patient may be discharged, then so be it. Please write a note in the chart before you leave. I, for one, would rather not have to demand a consultation or threaten anyone with the reminder of the consequences of this statute. But although I think this law sucks, as long as it is on the books I will gladly share the pain with you as often as I must. EMTALA does apply to you and every other consultant who takes unassigned call for a hospital. If a physician of any specialty is on call for the hospital, they may be called by an ER physician if that physician believes the services of the on call physician are necessary in order to stabilize the condition of the patient presenting for treatment.

If a patient needs to be admitted, than an admission must be performed. A consultant who is on call and who is requested by an emergency physician to evaluate a patient is required by EMTALA to evaluate the patient within a reasonable time or that consultant is potentially liable for the full penalties which are prescribed by that statute. The penalty is up to $50,000 per violation, btw. In addition, the actions or inactions of that consultant physician may subject the hospital to the possibility of exclusion from participation in the Medicare program, which is a much bigger penalty, as far as your job security is concerned.

Yes, EMTALA is a double-edged sword, as it cuts both of us equally. And we in the ER are very careful indeed how we wield that weapon, but rest assured we are not afraid to ask you to help us bear that burden. While that statute does not obligate you to admit any patient, it certainly does obligate you to come to the ER and evaluate anyone we ask you to, at any time of day or night, no matter how busy or sleepy you might be. If your evaluation determines that the patient may be discharged, then so be it. Please write a note in the chart before you leave.

I, for one, would rather not have to demand a consultation or threaten anyone with the reminder of the consequences of this statute. But although I think this law sucks, as long as it is on the books I will gladly share the pain with you as often as I must.

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