...you forget which of these situations the resident found himself in...
Nope, I don't forget. I recognize the resident is in academic setting and the patient of concern is in an
academic ICU.
...My argument would be on several levels:
1) the resident was in house, so the time suck is a little different.
Alas, after five plus years, I have come to realize the plight of residents need NOT be one of stupidity and innefficiency. The continuous beating of run to every patients bedside because the medicine resident is incompetent and every patient will die...
except when you are on vacation, at the annual graduation ceremony, in the trauma room or in the operating room, etc.... enough already
2) he's a resident, so his ability to determine over the phone who needs to be seen emergently and who doesn't isn't as well developed as your own.
I pray it does not take so much to ask for vitals and insist the MICU or his/her senior back-up actually look at the patient. Some things may actually be determined by the phone even for a poorly developed resident
3) After the initial conversation with the marginal medicine resident, I don't think I'd trust their assessment of vaginal versus rectal bleeding even if I somehow forced them to look and report back to me over the phone....even if we think a janitor should have those simple skills.
Again, with the bravado of the almighty surgeon unable to trust anybody thus vanquished to a life of saving the world from the marginal other resident, other attending, other specilialist.... resident in
MICU... in academic setting. My limited experience (SICU 1 res on-call; MICU 3 res on-call) was that MICU residents usually had a flock of additional residents in MICU more senior and junior.... and then the mighty MICU attending within close reach... If there is anywhere that a marginal medical resident can get a second opinion via perineal inspection... well it is in an
academic MICU.
Yes, I believe most janitors can tell the difference between the vagina and the anus. I dare say, if you have such doubts about a medicine resident's ability to distinguish between these two structures... you now have a true obligation... report to their program director and report to license board. Otherwise, it is just so much hyperbole of surgical residency. Great glory in the ability to do very little more then what one probably could do in the back seat of a car at night in high school.
4) While all of your demands are being met, the clock is ticking, and the actually sick and exsanguinating patient is dying in their MICU bed.....sure this patient would have done fine, but you really can't decide that based on the information the med resident could give to you..
Yes, I do demand that a consult requesting physician act to the very basics that a MS2/3 could do. Check the vitals and actually look at the patient. Those basic demands actually save lives; as believing such basics wait until the mighty surgeon gets to bedside kills patients.
Let's be real, dispense with the surgeon melodrama & savior complex. The "massive transfusion protocol" was already initiated.
If the patient was going to die because time was taken to look in her shorts... running would not have helped. Yes, in the community hospital with less residents, etc... somehow the patient would survive a vitals check, physical exam, and surgeon drive accross town! The further you go in residency the slower you find yourself walking to so called "emergencies".
5) If you're called to see a patient for rectal bleeding, and you say you want the GI doc to do the scope, you are not going to get the next consult....it will go to the GI doc...
And, in an
academic setting, most surgery residents would be very happy if every vaginal bleed consult went to GI first.
It's not like an open ended "who else is involved" question. The resident gave an impression of wanting other doctors to handle the problem. What if GI and IR had gotten involved in this case at the surgery resident's request? Obviously that would have wasted even more people's time when a simple bedside exam could reveal the diagnosis.
Well, at my GSurgery residency program, there was a routine protocol in the MICU for "GI Bleeds". It did routinely involve GI being called first and often IR simultaneously to ensure the crew & gear were ready to go. I read the residents post on this subject rather similar to the standard questions used in my residency. I can not chastise him/her for asking reasonable questions of the consult requesting physician.
.... I humbly disagree. As a resident in an academic environment.....whose in house on call.......once you've identified over the phone that the person giving you info is incompetent, and that a patient is possibly actively dying, the next move is to see the patient emergently...
It might be the under-called consult with "you can see it in the morning, no big deal" (only to find dead gut an hour later) or the over-called vaginal bleed... Patients will die. Every patient of every consult to surgery "is possibly actively dying". The truth is residents and residency programs have spent a great deal of time trying to indoctrinate new residents into total self sacrifice with these arguments... akin to the ever prevalent "the patient comes first". We as surgeons wrap ourselves in this like a patriot wrapped in the American flag. It is too often a technique to justify abuse, failure to have time to educate residents, and failure to fix problems. Remember, you're running to the MICU because you have doubts in the physician's ability to distinguish between the anus and the vagina.... Or maybe it's because you should read the numbers on the monitor or inflate the blood pressure cuff.
We will just have to agree to disagree. I just speak from my own experience as a recent general surgery resident. Too often the emergency at an academic center with numerous house staff, midlevels, resources, and attendings with too much time on their hands do not seem so emergent when you strip away all of that. Yet, I don't see so much death as you might expect.
JAD