09 April 2010

Friday Flashback

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.

Originally published 30 April 2007


  1. May I give you an 11, from the receiving perspective? Treat your consults with respect and remember that they have clinical judgement as well as you do. Examples:
    a) Please, do NOT call me, saying you'd like me to admit a CHF exacerbation with a "wet CXR" and dyspnea when he has a bnp of 32 and no edema. Rather than freaking out and demanding it's CHF, just ask me to evaluate and/or admit for dyspnea of unknown origin.
    b) Please do not think I'm an idiot for not wanting to admit a young, healthy patient for a lingular pneumonia and a PORT score of 62 (class 2 = outpt management); and please stop bolusing her for a systolic BP of 85 when you can see as well as I can that she's never had an outpatient BP >105.

  2. As I read the recipe, I couldn't help but think of the passage from The House of God in which The Fat Man teaches the interns his tips and tricks for successfully turfing gomers and how to keep a turf from becoming a bounce...

  3. Thank you.

    We have a core group in our ER (or ED if you so prefer)...those who I trust and those, who, quite frankly, are idiots.

    And you know what, I get more "Can I bounce this off of you?" calls from the ones I trust. I don't mind that.

  4. I'd like to add another-

    When consulting a specialist, its polite to have the ED physician speak directly with the on-call doc. PAs and other mid-levels can be quite good, but many really miss the mark. Certainly, in an academic ED, this system works differently, but the Harborview trauma-doc days are over. Asking a sleepy doc at home to come in to see a patient should be a doc2doc discussion.

  5. what does notorious blocker mean exactly? blocking inappropriate stuff that shouldn't be admitted that shifts the crapwork from one person to the next?

    tries not to admit even appropriate stuff and checks to see if any other service on the earth could reasonably be expected to admit the patient?

    does it concern you that you seem to have such a better reputation than your partners? :)

  6. “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)

    WIN. And so true.