While normally insightful and respectful, Dr. Alice has an interesting post that takes a shot at us Trench Docs. Ironically, it comes just a few days after my own "Stereotype" post. I couldn't resist, I had to respond.
Where I trained we had a surgical resident who was an absolute shining light in a surgical residency filled with weak, insecure, angry, cynical surgical residents. We'll call her "Dr. Sunshine". I never heard her utter a condescending word. She had a smile on her face no matter her hours, no mater how overworked she was. I had the pleasure of spending a month on her service. It made what is usually a brutal month, one of the most rewarding of my residency. She saw consults in the ER timely and fairly. She accepted patients without hesitation because in her words "someone has to take care of them". She never blocked. Never argued but had countless discussions regarding the best care for the patient. She involved interns in decision making. She was encouraging and inspiring. She was without a doubt the best "person" I have ever worked with in medicine. (and that's saying alot)
Alice, I wonder what Dr. Sunshine would say when faced with a consult in the ED that appeared to be everything BUT appendicitis. What about that medical resident forced to make a needless consult? Remember, there are always two sides to every story. "Examine the patient and think for two minutes!" is offensive. You're better than that.
But never mind, I enjoy your posts and think you too will be a ray of light in an often difficult, cynical and harsh specialty. Give my best to your chief and offer him my thanks. For even though its out of character for me, the next time a lazy surgical resident tries to block my admission or requests a "pre-op" or medical consult for a patient with diabetes or hypertension, I will simply respond with "You know, I'm not asking you to be a surgeon, just a doctor, now get down her and take care of a patient for once........."
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6 comments:
Your Dr. Sunshine sounds quite admirable, like one of my current chiefs whom I admire tremendously.
But seriously, would you address the basic question I raised? Is it good ER practice to call for a surgical consult on a someone who does not have an acute abdomen, without doing either a complete history or physical, and without obtaining labs? (We can leave the lack of imaging apart for the sake of argument.) (Also, this was from a senior resident, who should have known better, and who is allowed to pretty much handle their own patients without much pressure from the attendings.)
I don't do medical consults for diabetes or hypertension unless forced to. We come immediately to see every patient we're consulted on, no matter how ridiculous the reason or how inadequate the ER workup prior to us being called. We even admit a lot of non-surgical problems. Half my service right now has not had an operation, and will not get one during this admission. I think we'd get along ok in practice. :)
Alice, i would say a few things.
First, "is it good practice to call for a surgical consult on someone who does not have an acute abdomen?" Well obviously, calling a consult without seeing the patient is ridiculous. If indeed that is what happened, then I would be embarrassed for my "colleague".
Remember though, there are lots of reasons to call an early surgical consult. There are lots of reasons to call a consult without imaging. There are lots of reasons to call a surgical consult without having an "acute abdomen." I believe this would be echoed by your "good" attendings and seniors.
Second, Keep in mind how fluid the ER is. When you see a patient, things may have changed significantly since their initial presentation. I would guess this is often times the reason for your perceived "inappropriate" consults. Is it possible the resident thought there was indeed a surgical issue with the patient? His clinical judgement was different than yours. I could list forever the possible reasons or things he saw that made him think he needed your consult.
The point is, good doctors have discussions with colleagues about what they see and how their "judgements differ". If they have a history of "taking care of patients" instead of blocking them and being lazy, then often from my experience, those discussions are beneficial to both patients and physicians.
I'm glad we're having this discussion. I honestly believe the completely divergent opinions on basic patient flow and management between medicine, surgery and the ER is currently one of the worst patient care aspects within all of medicine.
SuburbanDoc
1) "Without seeing the patient" - the physical exam was gapingly incomplete, having omitted a key area which would have been suggested by a thorough history (and I mean thorough by ER standards, not medicine). There are good reasons to call without imaging, and there are good reasons to call without an acute abdomen. But you could send the CBC, and maybe have the result, if you don't think the patient needs to be in the OR within half an hour.
2) Yes, circumstances change. We do take into account, often, that between the ER evaluation and our own, the patient got pain and nausea medications.
Your last comment, divergent opinions on patient flow. . . - that's exactly it. Our ER seems to think that they need to disposition the patient immediately, without a proper workup. If the presentation suggests a surgical complaint, they call surgery without getting any evidence that the problem is in fact surgical. Our view is that, since we will not call our attendings until there is some evidence that we need to be involved (or not), it doesn't save time to call us early. The patient will not leave any faster because the ER wastes an hour calling us and waiting for us to see the patient, before sending the labs or imaging we insist on. But the ER residents seem to be trained to think that they've got the patient on the path out of the ER if they get surgery "on board" early. But you are very right about the underlying disagreement.
Sorry...I have to interject.
Labs? Really? Have they ever affected your management of an acute abdomen? Ever?
Question: Why do you order a CBC in diagnosing appendicitis (or a torsion or hernia, for that matter)?
Answer: To satisfy the surgeon. No other reason.
That's all. Obviously, you can't argue with the need for a complete H&P.
Wow... I read this at a lot of ED doc blogs; its something I never see. At our place, all patients are admitted to a hospitalist, with a consult to the surgeon. The only surgeons who admit their own patients are trauma...
I always wondered why...
Jeff - No, of course not. But if it's not an acute abdomen, a white count and some electrolyte abnormalities consistent with dehydration will make us a lot more interested in operating than if the labs are stone cold normal.
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