“Steve," he said, "I’ve got a guy down here who is really sick. He rolled in and looked awful, so I intubated him. He’s hypotensive and looks like he’s going to die. I have no idea what’s going on, but he needs you to fix him. I’ll do the usual. Great, thanks. See you in a bit.”
Now, if you're a relatively new attending, physician assistant or nurse practitioner, you might well be shaking your head in disbelief, amazement, disgust, skepticism or any number of other emotions.
Why is this physician giving such a terrible, unhelpful and vague presentation? Where’s the differential? What if the patient needs a surgeon? What if he needs a lumbar puncture? Should he have blood cultures? What is the etiology of his shock? What if his aorta is ruptured? These are, after all, the sorts of questions that would have come hard and fast if you gave a presentation like that during residency.
Surely, the consultants and attending physicians at the hospital talk about this guy and wonder if he actually has a clue? They must doubt if he actually went to medical school or if he paid attention while he was there. He must be on the medical director’s radar as barely competent!
Relationships Make All the Difference
The reality is quite the opposite. The physician in question turns down repeated requests to be Chief of Staff. He gives presentations at national conferences, and the acute care provider community recognizes his skill in caring for critically ill patients. He's even a frequent guest on some of the most prominent EM critical care podcasts.
So what's going on here? You might hypothesize that we have easygoing consultants at our hospital and that anybody could show up, give a slipshod presentation and get an ICU doc downstairs. But you'd be wrong. (Ask one of our new docs who recently got the “hundred questions” routine after giving a much better and more complete presentation.)
So why can this guy get away with such careless and haphazard presentations? The answer: medical staff relationships.
The hospitalists and consultants respect him because he's given them many accurate presentations over the years. They know that if they ask questions, he’ll answer succinctly with references to the latest literature. They’ve sat through enough medical staff and committee meetings with him to know that when he says something, they should pay attention. And they know from experience that by the time they get to the ED, all differential diagnoses will have been considered and worked up, appropriate studies ordered, meds given, interventions made and so on. Rarely will there be anything they can add to the case.
Striking a Balance
One of the things that has stuck with me from medical school is something one of my wisest attendings once told me: “The art of emergency medicine is getting the consultants to do what you want — and like you for it.” There is a tremendous amount of truth to that.
Whether you’re starting a new job fresh out of residency or moving to a new hospital or position, you would be wise to proactively develop trusting relationships with the medical staff and consultants you work with. Good relationships will improve your workflow, make your shifts less stressful and most importantly, help you deliver better care to your patients.
With that in mind, here are a few tips that can help to enhance and hasten the process:
- Be polite and courteous. Thank your consultants for calling back and again before hanging up. Apologize for interrupting or bothering them when appropriate.
- Be humble and respect their expertise. Realize that none of us knows everything, and that we can all learn something about how to better manage patients from our colleagues. That being said, if you encounter resistance in getting what you know is right for the patient, remain politely insistent and see #10. Develop polite ways of letting the consultant know that you are concerned about the patient and really need their help and expertise.
- Shoot for brevity. Work hard early on to master concise and to-the-point presentations. Many physicians have told me there is nothing worse than getting a 3 a.m. call from a provider who rambles on, throwing in all kinds of unnecessary detail. What they usually want to know is whether or not the patient needs the OR, an admission or a simple follow-up. Start off by stating what you think the patient needs. (E.g., “I have a 12-year-old with an open tibial fracture who needs a washout and ORIF.”) The better the consultants know you, the shorter your presentation can be and the fewer questions they will ask.
- Batch calls … when appropriate. The on-call orthopedist would rather get a ring telling them about three patients you’ve sent for follow-up as you’re getting off your night shift then separate calls at 12:05, 2:23, and 3:08 a.m. Mention that you're streamlining your communications and why, and it is likely to be appreciated. By contrast, calling the hospitalist at the end of your shift to let them know you have three admissions waiting will generally be considered bad form. In each of those cases, call as soon as you have enough information to admit.
- Share the load. If your facility and EMR allow it, offer to write holding orders for the admitting physician or consultant. This usually gets the patient moving out of the department quicker, and your colleague will appreciate the help. These orders should be very minimal and include only pain/nausea control, hydration and other basics.
- Be honest. Nothing destroys your credibility faster than intentionally misleading your colleagues. If you don’t know the answer to a question, say so. If you need to go back and ask the patient when they last ate, do it. (Better yet, remember to ask this any time a patient may need surgery). If part of the reason you are admitting the patient is for “social” reasons, be honest. It will score you points later.
- Be flexible. Maybe you think the patient needs one thing, but the consultant offers an alternative. Consider it carefully. Is it safe? Is it reasonable? If so, be willing to go with it. Sometimes one of the hospitalists I work with will find some piece of information I didn’t or suggest an alternative to admission that I hadn’t thought of.
- Get involved. Ask your medical director how you can be more engaged with the medical staff. Go to medical staff meetings and volunteer for committee work. Show up for department and peer review meetings. Spend a little time hanging out in the lounge when you can. Engaging with the med staff community will strengthen your relationships and increase your credibility.
- Involve the patient’s physician. Try to keep the patient’s primary care provider (PCP) appropriately informed (if they have one). Because the PCP knows the patient, they can often offer valuable information, guidance and follow-up. Sending them a copy of your note or calling them during daytime hours will contribute to a great relationship.
- Always do the right thing. No matter what, your first responsibility is to your patient. If you are getting what you believe to be inappropriate or dangerous advice, or if the consultant's response isn’t satisfactory, be firm and polite, but be insistent. This may seem to contradict some of the advice above, but it doesn't necessarily. This is the “art of emergency medicine” — negotiating with colleagues while getting them to like you for it.