Pediatrician Flea posted about feeling like the jerk he was on the telephone with an ED physician. (I was going to type colleague, but one doesn’t behave boorishly to a colleague). He says they ‘have a history’ which explains why the ED physician was near tears during their phone call.
Flea’s been subject to nearly enough derision in the comments of his own post, and those on Kevin, MD (which is where I found the Flea post) and I have nothing more to add on that individual interaction. I do have something to say about the telephone and its use with the ED Consultant.
The vast majority of the consultant physicians I call are collegial, knowledgeable, and helpful. I personally don’t care if they’re “friendly” on the phone, but it’s a plus of they are. Typically I only have about 33 other things I need to get done while placing calls, so it’s a to-the-point quick presentation, respectful of the consultants’ time, and trying to use mine productively. I usually have a plan, lay it out, and we come to a conclusion that benefits the patient.
And then there are the four consultants in my practice history whom I utterly detest calling, as they’re condescending jerks of the first order (four in the entire history, and just two active now). After my usual presentation, which is the same as I give to everyone else (and, I do my utmost to keep my prior irritation hidden from them on the phone; no sense letting them know their awful behavior gets to me), it starts. Usually it’s the ‘why are you calling me?’ in a decidedly whiny tone, and when it’s explained (problem clearly in your specialty, you’re on call, etc) then comes the attempt to get me to change the diagnosis so it’s not their problem. Playing 100 questions, we go back over all the history, the physical (pertinent and not), labs, etc. Many ‘gotcha’ moments are tried with stated holes in the above, all in attempt to put me on the defensive, to defend the entire interaction and workup, not to help the patient but to get themselves off the hook. This doesn’t work with me, and I stand my ground. They get to do their consulting bit, and the patient gets appropriate care. And I hate calling them. To me they are physicians in title only; oh, they’re fully trained and qualified, but don’t embody what I’d call a physician.
There was one occasion with a consultant on the phone wherein the belittling of my ED and ultimately my personal professionalism and judgement wouldn’t stop. Finally I asked the consultant to come in and do their own eval, and before we hung up I asked him to feel free to repeat his diatribe to me in person. I was avoided when they came to the ED, and no direct confrontation occurred. I don’t think anyone had stood up to this jerk before, and we now have a civil working relationship. We’re not Christmas card pals, but we work together effectively.
Finally, the consultant who generates an acrimonious relationship with the ED is not doing himself or his patients any favors. We need each other to take effective care of our patients. And boorish behavior is for boors, not Physician Colleagues.
I find it disturbing that someone brings someone else to tears, and also has them to the point of being afraid to call him. His sending her a “make-up” card, in the mail, would not do it for me. That sounds to much like an abusive mate, who beats you up, and then wins you back by all his good deeds proving he is really a nice guy. This behavior scares me.
I’ll admit it: there have been times — usually when trying to get at least an hour’s sleep, or when in the middle of a day already destroyed by several emergencies, or when concerned about an upcoming big operation during which I’d rather not have interruptions — that I’ve been less than welcoming of that call from the ER. And the busier I got, the more things piled one upon the other, the more I was on call for the ER when people were on vacation, etc, the harder it became — at times — to be as civil as would be ideal. I’ll say this: after grumbling, I always came in and did the right thing. And the better I knew the ER doc, the smoother the whole process was. And there were complexities and subtleties: our system was such that a referral to a specialist was supposed to go via the channels established by the patients’ primary docs, assuming there was one. So it would occasionally happen that I’d get a call and partway into it would discover the wrong referral path was being made. In pointing that out to an ER doc whom I didn’t know, and then to be accused of dereliction of duty, threatened with “action” while I was trying to explain the realities of the local politics……well, it didn’t add to the general sweetness of the encounter.
Main point: there’s an inherent tug of war between the ER and its consultants. Things work a lot better when everyone knows everyone else.
I don’t feel obligated to use the on-call list except as a last resort. If I’m not familiar with the person on call or if it’s one of the jerks I can’t stand, then I often will call one of my colleagues that I know and trust to take the case, if they are willing. Over the years I’ve developed a good relationship with a handful of trustworthy considerate physicians in each specialty that I can count on to help me out when I need it, whether they are “on call” or not.
God Bless all consultants who take ER panel call and do it helpfully. We understand the disruption it causes in sleep, surgery schedules etc.
An ER doc can’t cry. Hold your ground and do the right thing. If I took all the phone “advice” from specialists throughout my career patients surely would have died and I would probably be in jail.
Nice hearing your side of those calls. There are boors, bears, and bulls in china shops in all professions. Think of those boorish docs as trapped ahead of their time…mindset back in the 15th to 19th century, when about as many people were bled, purged, or poisoned to death by physicians as were helped by them (George Washington included in that number).
When I put on my ER physician hat I have 2 surefire ways of dealing with this kind of consultant:
“I will inform the patient and their family that you refuse my request to see them and I will note it in the chart – sorry to bother you”
“Either come down and say that to my face or I will ask you about it the next time we meet”
I am 6’6 and 285 lbs and when I get to needing to use solution nr 2 – watch out fleas!
If our ED patients only knew how rudely their own physicians talked about them when we call and ask them to admit “their” patient.
Elderly lady with new left arm weakness, less than 45 minutes duration. No prior ED visits for similar complaints. I thought myself fortunate to be able to speak directly with her own personal Neurologist, who told me: “I think she’s bogus. Admit to her primary doc if you think she needs admisssion. I’m not wasting my time with her tonight.”
When I called the stroke team’s Neurologist, he declined to get involved because I’d already spoken with the patient’s own Neurologist. So I called the patient’s internist who was not on call of course, and whose covering partner had never seen her before, but he agreed to admit her for observation. While waiting for a bed, the patient came out of her room and mentioned she thought there was some sort of urgency to come to the ER if you thought you were having a stroke. Yes, Ma’am, but your Neurologist thinks you are bogus and didn’t want to waste his time with you tonight. Oh, how I wanted to say that.
An elderly retired physician with dementia has a syncopal episode and scalp hematoma. His family really wants the patient to be admitted for observation; they are having trouble managing him at home anyway. They talk glowingly about his Neurologist who has been trying to optimize his medications, at least before that physician refused to admit him, anyway. They were almost too stunned to speak at all after I told them that.
Yesterday (prior to reading your post) I had a discussion with a physician colleague regarding this same issue but in relation to inter-facility transfers. We were on a flight, transferring a post-code patient from a VERY little hospital to the regional area HUGE hospital. The sending ER physician’s accent was very heavy, making the initial report sketchy. The flight physician said he was referred to as ‘Sir’ multiple times during phone report. He then went on to explain his fear that the receiving physician would lambaste the rural ER doctor based mainly on communication difficulties.
After the flight, my physician colleague related the in-person discussion with the sending doctor who expressed his dismay at phone conversations, as he knows his accent can be the basis for his perceived competency.
Apparently we all must negotiate, not just the complexities of the health care system, but each other as well.
The cyber-lashing Flea is getting is starting to make me feel sorry for him.
I’m glad he sent her a card.
I’m going to side with the ER docs, however. First of all, it would be a complete nightmare to keep up with everyone’s primary physician.
Secondly, if the primary wants to be called, I think they should make it clear to their patients to “Please call me in emergencies. I won’t mind. I really, really, really want to treat you. Here is my card with my pager number on it.I will meet you at my office or the ED day or night, rain or shine.”
Many patients feel (or are made to feel) like they’re not worth their doctor’s time so they don’t call. Most patients would rather work with a doctor they’re familiar with instead of one they’ve never seen.
For a field which centers around taking care of others, it seems to contain the most non-empathetic egotistical jerks out of any of them. Cultural relativism is great!
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.”
Hmm…as a patient I once ended up in the middle of one of these pissing matches. And at the end of the day, I was the only one that got upset. The neuro staff was tired of the nurses on the cardiology unit paging the wrong neuro on call. One neuro resident even exploded on one of the nurses that called on my behalf until the neuro standing next to him realized that he was the one who should have gotten the page, and took the phone and smoothed things over. It happens because on the medicine and surgery teams, they have one pager that they pass from person to person for whoever is on call. But in neuro, they all have their separate pagers, and it’s pretty hard to tell who is on call – and sometimes the page operator pages the wrong person…because even THEY can’t keep up with it all. So if my neuro is paged at 4pm on a Sunday afternoon for an order of zofran when he shouldn’t have been, well….you can imagine what transpires…
I got tired of the ugliness – as a patient. I was well aware of it. So I said something. In front of attending neuro, resident neuro, and RN. Didn’t go so well – and now, looking back, I wouldn’t have expected that it would. And I ended up getting upset and when it was all said and done, the RN told me I had a job to stop worrying about such things…
But I really wanted something along the lines of, “Why can’t we all just get along?” And it wasn’t happening. And it was really me that was getting hurt in the long run. I don’t want to wait 8 hours for the zofran when I’m puking my brains out just because you guys all want to fight and scream and point fingers. Just get it done! Ahhhhhhh……
Just my 2 cents from being on the patient side of things…patients sometimes DO know how their physicians talk to other staff. I’m well aware…. And it’s not something I’d be very proud of, if I were that person. I worked in one office where the director would yell and scream at people right and left. Every time he’d come barreling down the hall, I’d shut my door. I didn’t need to be subjected to that. I don’t know where some people get off…
Having been on both sides of these calls, I can say there is no shortage of jerkiness on either the ED doc or consultant side. I have acted like a jerk more than once and almost always have regretted it and felt like a fool later.
Most ED docs would do well by appropriating much of the recent post about how nurses should call doctors in the middle of the night. You don’t have to kiss up to the consultants but being nice and saying you’re sorry to wake them up doesn’t hurt.
The big thing with borderline or social admissions is just be straightforward and acknowledge it. If you are stuck and see no good options say that. As an attending I don’t like to hear I should admit someone because the family really wants it, to me it says the ED doc is deferring the decision to the family. What carries a lot more weight is saying flat out the family is unable to care for the patient in his present condition, then say why (ie, the patient cannot get out of bed without two nurses helping, he is exhibiting bizarre behavior, he’s lethargic, whatever).
It’s also good to understand Medicare admission guidelines. If you say this patient meets Medicare admission criteria that’s a hard thing to argue with. I was at an ED meeting once where an ED doc argued he shoudn’t have to learn medicare guidelines because the attending staff should know them. That makes no sense at all since the initial decision is coming through the ED.
Obviously you will still run into jerks no matter what but there are things you can do to mitigate them.
I didn’t go into medicine to make friends. I’d rather be friends with my colleagues, because it’s far easier to get patients taken care of that way, but it’s by no means my professional goal.
The reality is that some people seem to require a bit of holding-their-feet-to-the-fire to do the right thing.
Just as an aside, it’s a very foolish physician who abuses the ER staff; an angry, passive-aggressive ER physician is every consultants worst nightmare. Such a physician can continually awaken the consultant, interrupt their clinic, insist they come to see the patient during the night… they can also cut into your referral base. I know an ER group that got so angry at a local cardiology group that they began calling a rival group for all their AMIs, ACSs, etc. The offending group eventually came into the ER and apologized (it was cutting into their bottom line).
You don’t want an ER doc as an enemy, particularly with all the legal hammers EMTALA allows us to swing. I’ve been the reason for the revoking of privileges several times for physicians unwilling to shoulder their on-call responsibilities, and I make no apologies for it (there’s not a hospital administrator anywhere who doesn’t understand what losing medicare funds does to the hospitals’ bottom line, and I’ve generally found them supportive).
As far as continually calling jerk consultants all night long for revenge, I’m not vindictive that way, but I’ve seen colleagues of mine absolutely torture consultants who were repeatedly rude… it was painful to watch, let alone be on the receiving end. Most of those guys eventually got the hint… good on Flea for apologizing early and moving on.
Just as an aside, it’s a very foolish physician who abuses the ER staff; an angry, passive-aggressive ER physician is every consultants worst nightmare. Such a physician can continually awaken the consultant, interrupt their clinic, insist they come to see the patient during the night…
An ED doc that unnecessarily does those things to “punish” a physician has become as big of a jerk as the physician he’s punishing.
“You don’t want an ER doc as an enemy, particularly with all the legal hammers EMTALA allows us to swing. I’ve been the reason for the revoking of privileges several times for physicians unwilling to shoulder their on-call responsibilities, and I make no apologies for it (there’s not a hospital administrator anywhere who doesn’t understand what losing medicare funds does to the hospitals’ bottom line, and I’ve generally found them supportive).”
Double-edged sword, colleague, be careful how you wield it. EMTALA does not give squattle to me as a surgical consultant, nor does it apply to me. It applies to the ED, and indirectly to you. It requires a screening examination and stabilization in the ED; it does not obligate admission.
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.
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.
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.
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.
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.
Sorry – Canadian , eh- what is EMTALA and does it need a safety catch ?
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.
http://www.emtala.com/faq.htm
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.
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.
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.