30 April 2007

Advice for Emergency Medicine Interns

I thought I would steal a page from the sadly departed but still remembered Barbados Butterfly, and give some sage advice to those still in training.

I will pause a moment here for those who personally know me to recover from their shock and horror at the notion of someone like me providing anything approximating “sage advice.” They may need to clean the coffee off their monitors. . .

There, all better now? Off we go, then.

How to deal with consultants:
The last couple of posts involved exchanges in which I presented an uncommon or hysterically improbable set of facts to a surgical colleague, and they took the case as presented. Charitydoc alluded to a similar experience in the comments. This sort of thing pretty much never happened in my training. For one, the ED and surgeons regarded one another as natural enemies. Also, more than half the time you didn’t really know the person on the other end of the phone. I have been in private practice now for about seven years. There are a number of critical differences between training and private practice. One is that you tend to work with and refer to the same individuals over a prolonged time, rather than the rotating groups of short-time consultants you get in academic institutions. You build relationships, view one another as colleagues and (gasp) friends, and develop a history with your consultants – be they hospitalists, surgeons, what-have-you. They come to know you, and hopefully trust you, and their response to your requests is predicated on their opinion of you. I cannot emphasize this point enough:

Credibility is the sole currency you have in this relationship. Hoard it carefully and spend it wisely.

You, as an ER doc, have one and only one job: to keep your patients alive long enough for them to become someone else’s problem. To accomplish this end, you are entirely dependent on the good graces of your consultants. I have many times watched my partners, especially some of the junior ones, chase their tail for hours trying to get a patient admitted, because they couldn’t get their consultant to bite on their presentation.

This my patented recipe for success:

1. Never call without first knowing exactly what it is that you want. If you call with a wishy-washy “do you think that you should get out of bed and do a lot of unpleasant work?” then human nature dictates that in many cases the consultant will seek out the easiest solution, which may not be appropriate, since you have seen the patient and they have not. They may well embarrass you by asking irritably “Well, you’ve seen them, what do you think I should do?” It’s quite deflating to have no ready answer to that question. Know in advance what the desired outcome of the conversation will be.

2. Be direct when presenting on the phone. The consultant doesn’t want to chat, especially if it’s after midnight. The FIRST thing they think when their pager goes off is “Oh, shit, it’s the ER; what the hell do they want?” So answer that question first: “Hi Dr Jones, I’m sorry to bother you but I have a patient for you to admit/consult in the ED/take to the OR/see in the office/give advice on.” Don’t make them wonder; if they know where you are going from sentence one, they can prepare a response as you talk and are much less annoyed than they would be by a rambling presentation.

3. Make a compelling sales pitch. You are calling them because you have already decided that you need something from them. (See #1) You need to convince them that what you need is in fact reasonable. I begin with the diagnosis, present the supporting facts in an order designed to logically lead to the conclusion I have already reached, then reiterate the diagnosis and required action. Don’t present a rambling review of systems, and don’t lead with the chief complaint or narrative history. We love to “tell the story” but at 2AM with a sleepy surgeon on the phone, he or she does not care about the story. Just make the sale and convince them as succinctly as possible. Three sentences is as long as this should take:

“I have a patient with Pneumonia. 66 y/o, fever and cough.
Needs to be admitted because the O2 is 88%.”


4. Never lie or shade the truth. They will find out. If there are facts counter to your working diagnosis or proposed plan, you must acknowledge them up front. It’s tempting to try to pull a fast one, especially on those borderline cases – just get the internist to agree to admit and send the patient on up, right? Wrong. You may or may not get an earful from their department director later, but even worse, the next time you try to admit to them, they’re not going to believe a word you say, and you’re fucked, me boyo. In some cases you need to be very up front. I frequently begin the conversation with “I am sorry but this is a social admission, and it is necessary because…” or “I do not know what is wrong with this patient but they need to be admitted because…” The nice thing about this is not just that you don’t have to contort yourself to make a medical case out of it, but you get a reputation for not trying to put lipstick on the pig, which pays dividends when you have the more genuine medical admissions.

5. Don’t shoot yourself in the foot. If you start off your presentation with the adverse facts, you are making it hard to convince your consultant. Start with the case FOR your diagnosis and plan, then acknowledge the countervailing facts. When possible, do so linked to an immediate explanation why those facts do not negate your overall impression. Be assertive and speak in short declarative sentences. If they hear uncertainty or ambivalence in your voice, they will pounce and you are lost.

6. Anticipate and pre-empt obstacles. It’s no secret that some consultants are hesitant to see/accept an ER patient until they have been fully worked up. You want to get them upstairs as quickly as possible. Figure out what the roadblocks may be, address them in your presentation, and have an answer for the objection before it is even uttered. Examples:

  • Blocker: Have you ruled out PE? Preempt with: I considered PE, but they are not tachycardic and have no risk factors (blah blah) and so my clinical concern is low.
  • Blocker: Altered mental status? What about an LP? Preemption: I think meningitis is unlikely because of (insert clinical reasoning), so I did not do an LP. After you have seen the patient I am sure you will agree with me.
  • Blocker: Did you order (insert reasonable but obscure and time-consuming test)? Preemption: Yes (as I write it on the admitting order sheet) and it should be resulted by the time you see the patient on the floor.
  • Blocker: Can you hold the patient in the ED until (sometime in the future)? Preemption: I have ordered tests X, Y and Z, but the patient is stable and I have 40 patients in the waiting room, so with your permission I will write holding orders, and you can see him on the floor.
  • Other popular ones are “Is the patient stable enough for the floor/sick enough for the ICU/well enough to go home?” (Often all of the above amusingly applied to the same patient) Or “shouldn’t this be admitted to (some other specialist)?” If you can anticipate the concern and address it in advance, you are much more likely to move the patient out of the ED in a timely manner.
7. Be reasonable. Don’t try to admit an abdominal pain to medicine without a CT (or surgical consult, as appropriate). If there is reasonable concern for PE, rule it out or at least get the process started before you make the call. Sometimes the specialists know more than you do (really!) and may legitimately have an alternative strategy which may be effective. Listen to them.

8. Close the deal. Once you and the consultant have agreed upon a plan, be very concrete in defining the next step. “I will write holding orders and you can see them in the morning,” “I will see you in the ER shortly,” “I will send the patient to the cath lab/OR/ICU and you will meet them there.”

9. Be pleasant. Get to know their names, chat and joke as the situation and time of day allow. Social niceties lubricate and facilitate these interactions. You may even become friends(!).

10. Become involved in your hospital medical staff. The better your consultants know you, the more credibility and trust you will accrue. Many docs view the ER docs as itinerant locker-docs and glorified paramedics. When they work with you on the medical staff, they are much more likely to view you as a valued colleague. What’s more, they are much less likely to be a dick to you over the phone when they know that you will sit next to them at the X Meeting tomorrow. And if they know that you will be reviewing their credentials the next time their appointment comes up for renewal…

I had a nice interaction with a hospital internist recently. I had a really borderline case where there was no clear indication for admission, and I apologized for that as I presented it to the hospitalist (who was a notorious blocker). She responded, “That’s OK. We don’t mind because with you we know that you’re not going to admit for a stupid reason, and when we see the patient on the floor they will be exactly as billed.”

I felt really good about that.

12 comments:

  1. This was a very interesting and informative post. I never noticed these problems with the ED staff I worked with. Maybe because it was a smaller May Berry RFD type of hospital? Patients were in the ED for hours sometimes but I thought it had more to do with tests and how busy the ED was. However, they did have to wait a long time for some of the specialties like plastics or ortho for example, but I thought that was because that doc had to come from another site. Now I know differently.

    There is wisdom in your words and if I were going to be working in these situations - I would print them out and keep them with me until I had it all down pat.

    Who Knows? Maybe if I do decide to go back to work at a hospital, I will be able to apply some of your advice to my work encounters, different - but same principals. :)

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  2. Great post! Keep'em coming! The more generally-unwritten advice that you learn from experience, not textbooks, the better!

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  3. Very nice job of covering the topic.

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  4. Well said, I couldn't agree more. Maintaining credibility is key.

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  5. It runs the other way, too. In some places, EM has a lot of pull, and other services risk some inconvenience if they disrespect that fact.

    One of the weirder things I do as an ER tech is to man the phones during the critical/trauma cases. We had a guy the triage nurse brought in after a quick sweep of the department showed no free rooms for an acute asthma attack. He gets three nebs, an EKG, and some labs... and our team decides he should be admitted. I call the Medicine service -- middle of the day, big academic center, I'm not waking anyone up -- and don't hear back. Most teams call back within 90 seconds, no exaggeration.

    The bed request goes in as a step-down because they want to watch him overnight, the patient goes out to the cubes because now there's a room, and still no callback from Med. I'm setting up the room so it'll be ready for the next case, and the clerk calls me in the trauma room: Med called our desk instead (what the...?), and says to tell the pit boss "we don't come down to the ER" (this is... new).

    Next critical case comes in, and so this is the next time I see the pit boss and the attending. I relate this news. They agree it's weird, and say no, we'd like the Med resident to see the patient, since we're admitting him and Med will be the service.

    The new case ends, and again I'm cleaning up between cases, when the phone rings. It's the Med resident. I make sure he knows I'm just the tech, but here's what I know and could you please come down since the patient is hanging out here.

    Nahh, says the resident, we'll see him upstairs. And by the way, he doesn't need monitoring, so change the request to a regular floor bed. I say I'll pass along the message.

    Half an hour later, the patient is ready to go up to the step-down bed and I've already run this floor bed thing by the attending. The response?

    "They haven't seen the patient, and they want us to change the bed request? Yeah, we don't do that." heh heh.

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  6. Your advice is spot on. I worked as an internist for 5 years doing both inpatient and outpatient and you have to develop relationships with the ER. I never forgot the PA that lied to me about the GI bleeder and I never listened to a word she said afterwards. Alternatively, I knew the guys who were stand up and trustworthy and I would do whatever they asked without hesitation.

    If all the ER guys did what you do, they would find their jobs much easier in the long run.
    b

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  7. Fantastic post! Couldn't agree more.

    (Hoikey-hoikey)

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  8. Thanks. I used these comments as the foundation of a resident orientation meeting dedicated to "how to sell a patient" I learned these the hard way, through mistakes, so now these lessons are a part of our R1 orientation

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  9. What would you like to see in a good ER consultant? Maybe make a top 10 for that?

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  11. I got important tips from the emergency training article. Thanks
    First Aid Olds

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