Consults from the unit clerk

[VincentAdultman]

I've never really understood how this came to be acceptable.

Ever since residency if I needed a consult I resisted the temptation to order it like a CBC and actually talk to a physician. I do this because 1. I always found it frustrating to talk to a person who was completely clueless about the patient aside from what was written on an order (consult for knee pain) and 2. I think it increases accountability of you have to talk to a physician and it decreases unessecary consults.

Anyway this has been the norm for me since I started residency in 2008 and you'd think I'd be used to it by now.

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[deleted547339]

I've never really understood how this came to be acceptable.

Ever since residency if I needed a consult I resisted the temptation to order it like a CBC and actually talk to a physician. I do this because 1. I always found it frustrating to talk to a person who was completely clueless about the patient aside from what was written on an order (consult for knee pain) and 2. I think it increases accountability of you have to talk to a physician and it decreases unessecary consults.

Anyway this has been the norm for me since I started residency in 2008 and you'd think I'd be used to it by now.

One of the places I moonlit in residency did this for certain consults and for making followup appointments (I'm EM). It seems too....sterile. Some of the docs would come down, see a patient, write a note, not speak to me, then put in admission orders. It felt like some weird twilight zone where our MBA overlords outlawed social interactions. I went out of my way to introduce myself to everyone and talk about the cases with the consults and they seemed kind of freaked out at first, lol.

 

[vhawk]

yes it is very unprofessional

 

[Wordead]

Ill go out of my way to page the attending if the ****ing nurse or god forbid unit clerk pages for a non-emergent consult. And ask the attending a bunch of really annoying questions. It's so absurd that anyone thinks this is acceptable.

 

[kjamess]

Some of the docs would come down, see a patient, write a note, not speak to me, then put in admission orders.

There have been times where I was guilty of this. But its mostly because when I actually did speak to the ED resident, it wasnt uncommon for them to either say "dunno just came on shift/just covering for this person" or read from the chart verbatim (but to be fair, there are off-service residents who rotate through ED, so may not even be EM). Its also partially because you usually can glean everything you need to know from notes/orders placed/meds given.

 

[VincentAdultman]

While it is uncommon in academia, it's standard operating procedure in a lot of hospitals, so I'd be careful about the hostility, particularly if and when you ever encounter the real world.

Yeah. That's not cool.

The reason I made this thread is because I was just thinking about it and I can't see how physicians can be for this.

 

[Pir8DeacDoc]

During my career so far in PP both hospitals I've been at have moved away from this policy. Talking to me helps streamline things and organize my day. Maybe they get a CT while I finish my clinic. Or maybe it's more urgent than the consultant might appreciate. But to be fair I don't always call the hospitalists after I see the patient. They change around so much it's hard to know who to call. But I make my recommendations clear and make it clear to call me with questions

 

[vhawk]

Because once you leave the grind of residency...consults = money.

You don't call back consultants and belittle/berate them, because doing that means fewer consults (and less money) in the future. That game only exists in residency.

If the consult's BS? That's even easier money. A quick visit and a note, bill and sign off.

The correct response to a consult? "What's the patient's name and what bed are they in? Okay great, see them soon!"

I agree but you just chastised me above for thinking that it's unprofessional for the correct response to a consult to be "......."

It's unprofessional and its bad for patients. I am not belittling anyone and other attendings can do what they want but when I want a consult I call them and when someone consults me I talk to them. Period.

And it isn't even effective as a time saving or money making strategy anyway. The time you save by having these autoconsults is easily lost in wasted effort and miscommunication

 

[VincentAdultman]

Because once you leave the grind of residency...consults = money.

You don't call back consultants and belittle/berate them, because doing that means fewer consults (and less money) in the future. That game only exists in residency.

If the consult's BS? That's even easier money. A quick visit and a note, bill and sign off.

The correct response to a consult? "What's the patient's name and what bed are they in? Okay great, see them soon!"

But I'm not talking about berating anyone. That's childish. And yeah. I'm seeing the patient regardless of who is making the call.

But what is the rationale for having a clerk call consults? It doesn't make things more efficient for me because I'm calling the doc anyway. I can't triage something based on the scant info I'm given from the order. At least if I talk to the hospitalist I can get a sense of whether it can wait until after clinic or if its possibly emergent and I need to go now.

 

[Gastrapathy]

But what is the rationale for having a clerk call consults? It doesn't make things more efficient for me because I'm calling the doc anyway.

Real World Doctor Edition:
You are in the OR. It's a simple consult for cholecystectomy with a slam dunk indication and I'm done with the ERCP. We've worked well together for a decade. I told the clerk to give the info to the scrub nurse and made the pt NPO after midnight. It's 6pm and you aren't calling me anyway. The guy who acted that way lost all the cases to you 8 years ago and went to work at the VA.

Oh, and once in a while, when you do have a real question, you text my personal phone and i call or text you back. We chat about our kids for a minute and get off the phone.

If I want help right now, of course I'm calling directly.

 

[deleted547339]

I feel like surgery is particularly sticky when thinking about this kind of thing. I think most conditions involving surgical consultation are more time-sensitive

When I consulted cards at the hospital at which I worked with auto-consults, the process is very different if the patient is a STEMI/post-arrest, etc. vs. the high risk chest pain getting admitted to the hospitalist. One was a page and immediate response. One was a call from the secretary saying "I've added this patient to your consult list for you to see them in the morning. They're admitted to Dr. x in bed Y." And for almost all of the medicine consults and some of the surgical sub specialties (ortho comes to mind), this works fine. It's fine for the cardiologist let the patient sit on the floor with an aspirin and a heparin drip while he decides whether or not to cath the patient.

The problem is that when you're dealing with a general surgeon in the ED or in house, the problems usually aren't "see them tomorrow" type problems. It's usually a question of whether or not they need an operation, which obviously can be very time sensitive. If I'm worried about nec fasc, I can't have a secretary calling telling you I need you to come evaluate a leg wound. A lot will get lost in translation and I see why this would upset you.

 

[VincentAdultman]

Real World Doctor Edition:
You are in the OR. It's a simple consult for cholecystectomy with a slam dunk indication and I'm done with the ERCP. We've worked well together for a decade. I told the clerk to give the info to the scrub nurse and made the pt NPO after midnight. It's 6pm and you aren't calling me anyway. The guy who acted that way lost all the cases to you 8 years ago and went to work at the VA.

Oh, and once in a while, when you do have a real question, you text my personal phone and i call or text you back. We chat about our kids for a minute and get off the phone.

If I want help right now, of course I'm calling directly.

If it's a slam dunk, then that's fine.

But at my hospital, it usually isn't. Usually it's a consult for "knee pain" which could mean anything from a simple ligament sprain to a septic joint. "Hand cellulitis" could be just that or it could.be flexor tenosynovitis. Or, the patient will be admitted overnight, the admitting hospitalist will order a consult for 'knee pain, r/o septic joint" and that will be that. Now that might be more an issue with the hospitalist not recognizing what an orthopedic emergency is, but at least if I get a direct call I can triage it appropriately.

Of course usually I can't talk to the hospitalist anyway because by the time I get the call they've gone home and I'm left with the daytime Hospitalist. Who doesn't know anything about the patient either.

 

[Gastrapathy]

We get 8-15 inpatient consults/day. We started having requests just put in electronically without a call a couple years ago (EPIC). If I have a question, I call them. If I don't, it saves me 5 min (call, wait, call back, talk, etc) which adds up to ~1 hr a day.

 

[VincentAdultman]

We get 8-15 inpatient consults/day.

Sy no more.

 

[Gastrapathy]

Sy no more.

Do you mean that's a lot or a little? Just seems normal to me.

 

[Wordead]

Real World Doctor Edition:
You are in the OR. It's a simple consult for cholecystectomy with a slam dunk indication and I'm done with the ERCP. We've worked well together for a decade. I told the clerk to give the info to the scrub nurse and made the pt NPO after midnight. It's 6pm and you aren't calling me anyway. The guy who acted that way lost all the cases to you 8 years ago and went to work at the VA.

Oh, and once in a while, when you do have a real question, you text my personal phone and i call or text you back. We chat about our kids for a minute and get off the phone.

If I want help right now, of course I'm calling directly.

Sure, if you've worked together for a decade and you can trust the other attending to have his ducks in a row this might make sense. I don't think this is the scenario the rest of us are talking about. I wouldnt be upset if my buddy in the ED that I know and trust called my nurse and said I have a patient that needs ____ done, patient npo preop labs are done etc etc. But some resident or attending that you dont personally know decides to call a consult through a secretary? **** that. What imaging has been done, what labs have been drawn, what abx/meds have been started so far, what is the clinical status of the patient are standard questions that should be known by whoever is calling the consult. Which a secretary will not.

While it is uncommon in academia, it's standard operating procedure in a lot of hospitals, so I'd be careful about the hostility, particularly if and when you ever encounter the real world.

Fair enough. Maybe my tune will change as an attending. I doubt it though - a 3 minute phone call is not that much time, helps triage, and I can order supplies and meds that I need ahead of time so it's ready when I get down there and I'm not wasting time dick in hand waiting for the nurse to grab something out of the med room. And the easy $$ for BS consults is true, but - and this may just be my naivete - I feel pretty annoyed on the patients behalf when we walk, wave our hands around for 2 minutes and walk out and the patient gets a $400 bill for it. Its a huge disservice to everyone in my opinion.

And honestly I'm pretty surprised to hear that this is your view - how many appendicitis/acute abdomen/etc etc consults do you get where you show up and the patient has a completely different clinical picture? When you could have asked a few questions that would have changed what you ordered?

 

[VincentAdultman]

Do you mean that's a lot or a little? Just seems normal to me.

When I'm on call I may get 1-4 inpatient/ER consults .

 

[Wordead]

I think I can count on my hands how many times my conversation with the consultant has dramatically changed anything.

If it's a simple consult it's a simple consult. If it is complex, confusing, or misleading then I'm pretty much having to start from scratch and do a thorough chart review/patient interview regardless. And my conversation with the primary ends up being the part that's a waste of time because I don't need them to spend forever meandering through some complex history by phone.

Most of the ones were you show up and get a totally different clinical picture - the primary team is just asking for your help. Period. Their consult question was wrong because they didn't even know what to ask, they just needed another set of eyes.

Like I said almost always all you need from the consulting team is name and bed number.

Hrmm, well oftentimes my conversation changes whether or not I order imaging or if I believe the patient actually has x condition. And sometimes I show up and the story is different, but sometimes it saves me an extra 2 hours of waiting for a CT to be done after Ive seen the patient. Or waiting for steroids/nsaids to kick in.

 

[anonperson]

Ill go out of my way to page the attending if the ****ing nurse or god forbid unit clerk pages for a non-emergent consult. And ask the attending a bunch of really annoying questions. It's so absurd that anyone thinks this is acceptable.

That will go over real well in private practice. If you make life challenging for requesting physicians, they'll just consult your competition. If you're the only game in town, feel free to act how you want but it may come back to bite you in the ass.

In an ideal world, a physician to physician call would happen with every consult no point in taking out frustrations on an overworked hospitalist.

And the easy $$ for BS consults is true, but - and this may just be my naivete - I feel pretty annoyed on the patients behalf when we walk, wave our hands around for 2 minutes and walk out and the patient gets a $400 bill for it. Its a huge disservice to everyone in my opinion.

1. Consults that you think are easy or BS may not be so to the requesting physician
2. Medical legal reasons are probably a reason for a decent number of consults
3. If you think the consult is that unneeded, feel free to refuse if you can. I'm sure the requesting doc won't mind and will continue to send business your way.

 

[DoctwoB]

I find that direct contact from consultants is essential. A lot of the time the reason for consult isn't clear from the primary teams note or the EMR. A lot of these things that are put in as consults could have been dealt with by a simple phone call (e.g asymptomatic microscopic hematuria, get X study and have them see me in office for cysto), saving time and the patient money. Finally many things that have been put in as routine consults have turned out to be anything but. Had the primary team spoken with me rather then put in a routine order for a clerk to call at their leisure (often hours later) a lot of time could have been saved.

 

[OTOSwap]

I've never really understood how this came to be acceptable.

Ever since residency if I needed a consult I resisted the temptation to order it like a CBC and actually talk to a physician. I do this because 1. I always found it frustrating to talk to a person who was completely clueless about the patient aside from what was written on an order (consult for knee pain) and 2. I think it increases accountability of you have to talk to a physician and it decreases unessecary consults.

Anyway this has been the norm for me since I started residency in 2008 and you'd think I'd be used to it by now.

I find it to be totally wrong as well. The clerk cannot answer questions about this patient and many times the consult is put in a way that isn't clear. It is better for patient care to contact the consult service either through a HIPPA complaint means to tell them or directly.

When I needed a consult, I always called the physician directly rather than dump a random clerk call on them requiring them to review the chart to figure out the reason.

 

[vhawk]

Real World Doctor Edition:
You are in the OR. It's a simple consult for cholecystectomy with a slam dunk indication and I'm done with the ERCP. We've worked well together for a decade. I told the clerk to give the info to the scrub nurse and made the pt NPO after midnight. It's 6pm and you aren't calling me anyway. The guy who acted that way lost all the cases to you 8 years ago and went to work at the VA.

Oh, and once in a while, when you do have a real question, you text my personal phone and i call or text you back. We chat about our kids for a minute and get off the phone.

If I want help right now, of course I'm calling directly.

You say real world edition when what you mean is best case edition.

 

[droliver]

I don't consult anyone without calling them 1st unless it's just letting someone's PCP that they're admitted to me. It's poor form to make a habit of just putting an order in without peer to peer communication most of the time.

 

[mimelim]

I just assumed that that is how everyone does it in private practice because that is all I see.

Complicated patient or potentially complex management, call consultant and put order in computer.
Routine consult, nothing out of the ordinary, ask nurse to put a consult order into EPIC and walk away.

I was used to calling all the consults early in my residency, but after taking a step back, I understand why people do it this way. Now, when it breaks down and the should have been phone call got missed until 12 hours later, it is a **** show, but that is a different story.

 

[VincentAdultman]

I just assumed that that is how everyone does it in private practice because that is all I see.

Complicated patient or potentially complex management, call consultant and put order in computer.
Routine consult, nothing out of the ordinary, ask nurse to put a consult order into EPIC and walk away.

I was used to calling all the consults early in my residency, but after taking a step back, I understand why people do it this way. Now, when it breaks down and the should have been phone call got missed until 12 hours later, it is a **** show, but that is a different story.

I mean, I've been in practice for a few years and unless you're calling like ten consults a day I just don't get it.

I agree it's bad if a call gets missed for 12 hours. If your calling the doctor though that doesn't happen.

 

[ACSurgeon]

I had a nurse call me to ask me a question that the hospitalist wanted to ask surgery. I was on the floor a few minutes later and heard the nurse talking to the hospitalist on the phone and relaying what I said. That made no sense, because there was no time saved on my end or the hospitalist's end- she was just the middle woman.

 

[kitsunepixie]

I've never gotten that kind of consult before but can see how it can be annoying. Once while I was operating on a patient at the va I got an unfortunate med student who called me about a patient with a subdural and ams...couldn't tell me if it was acute or chronic, GCS score, midline shift...y'know, things I need to know to call for backup to go see the patient and get set up for surgery if that's what was needed. And why charge a patient for a bogus consult? Yeah, I can see it being different if it's someone you know and trust consulting you but some things really do need an MD-to-MD conversation...

 

[cpants]

MD to MD communication is best, but this scenario makes me a lot less angry now that I'm in practice than it did when I was a resident. This is because I can see the consult at my leisure and I actually get paid to do it. I used to track down all these FM and IM residents to explain to them why they didn't need an inpatient urinary retention, management of chronic foley/SPT, or microscopic hematuria consult. Now, I just don't see the point. Rather than waste my time tracking down the hospitalist, I just spend 5 minutes doing a low level consult and get paid for it. Life's too short -- who cares?

They also know we are not going to see anything we are not called about until the next AM on rounds. So our hospitalists will call us with anything they deem urgent, and they are generally pretty good. I have seen some patients have substandard care because no one called me about an urgent consult, but that's not my problem. What am I supposed to do, sit in front of my computer refreshing EPIC all night? If they don't know they should call me for a septic stone, priapism, etc, then they are the ones failing the patient, not me. I usually call them and explain why the situation was urgent in these cases.