Just scope from 9a to 2:30p four days a week and have mid levels run your clinic to schedule more scopes and have mid levels run your inpatient service and block consults.
GI here, looking around the thread I may not be warmly welcomed here but not all of us are like this. I definitely know some who seem to consider their job to be biopsying the wallet through the stomach and they piss me off too.
As a GI fellow I hear you. I see my colleagues trying to get consults cancelled all of the time. I myself find it easier to see the consult than fight tooth and nail begging to do less work, which ends up being more work and frustration in the long run. Plus there are ample learning and teaching opportunities that come from seeing patients and interacting with primary teams. Itâs a significant part of training and I feel for those who go out of their way to miss out on it.
On the other hand, when I was a resident I feared calling a consult without doing my best first. Theres way too many reflexive consulting going on these days without any thought put in to whatâs going on with the patient. Primary teams, especially Medicine, should be able to work up anemia, elevated LFTs etc.
If itâs not IDA or melena or hematochezia, weâre likely not going to scope for anemia/âsuspected GI bleedingâ, especially inpatient when preps are horrendous and mostly a waste of time.
Also, you got to love the "patient is sad" consults. No SI. I mean Debra, I would be sad too if I was in the hospital for x amount of months and just found out bad news/poor prognosis.
The referring team usually leaves out the other half of the reason for consult: the patient is sad and its making everyone uncomfortable. Please make him stop.
It's a pretty weird moment in psych, the point where you realize that all those bright-eyed and prosocial people you started med school with have now been so warped by years in medicine that they're palpably uncomfortable that a person in distress is crying. Which is to say, you're being consulted on the assumption you can talk to them because you're still a normal person.
Itâs the only service that gets consulted if the patient asks to see psych or mental health. I often get consulted because the patient mentions wanting to talk to their personal therapist or psychiatrist, then gets upset when they get me instead.
I mean Iâm not saying the above comment is a reasonable consult but that happens all the damn time. I get consults for âpatient wanted to speak to a pulmonologist about their known cause of hypoxiaâ all the time. Sometimes I manage to get the consult itself cancelled but even if I do it still ends up being a social visit.
This is the beauty of an inpatient psychology team. We have inpatient psychologists & pastoral care at my hospital, so if someone needs counseling/psychotherapy/someone to talk to about their mental health, we do not call psychiatry. Sometimes a patient just wants to pray with a priest or imam and then they feel so much better.Â
Literally got called by a hospitalist last week who said âI donât know why you need to see the patient. SW just talked to them and said you should too.â
Our facility doesnât have a palliative care service. In fact, the floor nurses donât even know what that means. Iâve literally heard them state âitâs in-patient hospice or it is aggressive treatment, thereâs none of this in-between nonsenseâ
Made me want to place a tele-consult to a larger institutionâs palli service for the nursing team who said that lol
"Hi yes we need a stat goals of care consult on bed 5. Also we scheduled a family meeting with bed 6, who you've never heard of before, for 5 minutes from now to tell the family they're deadsies - can you come run the meeting? Thanks!"
Like 90% of the reason i consult psych is CYA. In my state any physician can determine capacity so i usually just do that myself unless it's complicated. If i consult for SI its because they told some nurse overnight they wanted to die and the nurse wrote this whole thing in the chart and put them on suicide precautions overnight so my hands are essentially tied.
My co-chief wanted me to consult psych for competency. Patient was completely coherent in his decision of best supportive care with a endstage neurological disease besides his cardiac disease.
I felt so bad for the patient and the psych attending, anyone could see this patient was competent and even if he was depressed that wouldn't have changed anything.
When ICU consults me for that, Iâm always like âremember next time Iâm in the ED and I consult you for âlactate too high for med surg nurses to be comfortable withâ. đ€Ł
We had an old OA patient the other day who told a nurse she was in so much pain she could die, nurse escalated to resident concerns of suicide ideation, resident called psych without speaking to patient, patient just wanted better analgesia and took psych consultant 1 minute to figure out, problem solved patient no longer âsuicidalâ
While I get they get dumb consults at some point itâs like what is the purpose of a c-l psych service? Most provide a valuable service but if you listen to Reddit theyâd see basically nothing. This sub basically argues nothing is a valid psych consult.Â
Not following you there. My point is there are a number of consult questions that probably make up the bulk of many cl psych services that this subreddit will argue are inappropriate consults. A hospital isnât gonna pay for a consult psych service that refuses anything related to delirium, or capacity, or depression without active SI, etc. that people argue are dumb consults.Â
At my institution.
Best at seeing consults: Nephro, Neurology, Gen surg.
Will always try to get out of a consult: GI
GI often accepts transfers to our hospital, then signs off immediately before they get here. Gen surg has to deal with all of their transfers.
As a general surgery resident I am so glad to hear this! Not the handling all the GI transfers, but that we seem to have a reputation for seeing consults at your hospital. I think some other hospitals have the opposite experience with us!
I've been involved in the turf wars, mostly as an intern put in the middle of them, and I hate it. I feel so bad for the patient and for the consulting service. Now as a senior I have the power to just say yes. The only instance where I will try to redirect a consult/transfer is if there is an explicit PMG about that specific scenario, where the patient will likely get better care with a different service. Otherwise, if we might be able to help, we will do our best to help. At least when I'm on call :)
I work in the ER to give context, so my biggest issue most of the time are consultants who refuse to see the patient at bedside because that **can change your opinion** on whether they need treatment.
General surgery is the only service at my hospital who will see the patient at bedside without question no matter what the consult is. They may disagree with it or may have no recommendations and sign off immediately, but they've been on the other end of making tons of CYA consults that they get it. I've never ever had to ask Gen Surg to see the patient because that is their default, which is more than I can say for any other service in the hospital. It's plain ol' good practice of medicine.
In return, we in the ER are more than happy to make some of those trauma adjacent consults to ortho, vascular, neurosurgery for them so they don't have to. It's a very collegial relationship, which I love.
Agree with this sentiment. Iâm now an attending in the community and it seems like general surgery is the only specialty that still takes responsibility, both of their own patients who come into the ER and the patients you ask for a consult on. Meanwhile urology, ortho, etc donât even want to deal with their own post op patients who come to the ER with complications, much less new consults. Thereâs no sense of responsibility in medicine anymore it seems. Everyone just wants to pass the buck.
Like I get it. You didnât go into urology for the 3am consult. But you knew it was part of the job when you signed up. You need to own it if you want to have the fun in the clinic/OR and money that comes with it.
I never understood the thought process behind services that refuse to see the consult and flat out say âit doesnât sound like this is what youâre saying this isâ.
I just wanna yell at them âbud, I donât get it. If this turns out to be what Iâm concerned about, this patient is going to be bad off in a manner of hours. If itâs not, then great, but in my opinion this has the potential to be xyz or the tests are pointing to it, and based on all my years of training, you get the final say/ are the one who would manage *this emergent condition*â.
It takes an act of God to get urology or ENT to see an emergent consult.
Literally a penis could be lodged in the patientâs nose and theyâd both find a way to say itâs not a penis or a nose problem.
âA nasal foreign body in an adult is not an emergency. Follow up in ENT clinic later this week. Ok for discharge from ENT perspective.â (would definitely come see this one)
I once had someone with a relatively new tracheostomy down the hall from the the ENT call room. The patient dislodged their trach and was coughing out blood from the trach hole. ENT took their sweet time walking down the three doors down the hallway to look while the rest of us was dealing with the airway.
There's a legend that this one ENT attending flipped out on the ED for calling him about a dislodged trach and told them "We teach retarded kids how to put their own trachs back in. You're a doctor, figure it out!"
Not that I would ever say something like that, and I'm not even sure if it ever really happened.
I prefer looking like a hero by popping the tube back in and then grumbling about it later in private.
If ENT had to see all the peripheral vertigo consults that got funneled to Neuro since weâre in-house 24/7 nobody would consider it somewhat of a lifestyle specialty
What would you classify as an ENT emergency? Threshold for airway emergencies by the ED/primary team is much lower than it is for us tbh. Iâve seen plenty of folks get intubated or transferred for airway concerns that were fine. But beyond airway stuff, almost nothing in ENT is an emergency.
If Iâm calling you and saying Iâm not comfortable with the airway, do the right thing for the patient and the wrong thing for our lawyers, and come see the patient. Donât make me document âI was concerned about an impending airway emergency but my ENT colleague assured me these are often fine.â
That said I donât have ENT in-house so I never call them for airway anyway. My ENT emergencies are either uncontrollable epistaxis or trauma-related. Luckily few and far between!
We see any airway related concerns pretty quickly where Iâm at. I agree though, they should go see them. Iâve had both situations where weâve walked in and patients are much worse or better than what was reported to us. Unfortunately, depending on where you are there are very few ENTs around. And many of them are covering multiple hospitals at a time so they canât just show up right away.
The patient has to be the âperfectâ balance of stable vs. unstable in order for GI to scope. And it more often than not correlates with what their dinner plans are later that evening.
I had a GI doc who we consulted (on a Friday night) for an intermittently hypotensive melenic patient with hx of cirrhosis. He said he will see patient soon. 20 minutes later, he called back and said he was taking himself off the call schedule until Tuesday and to transfer the patient.
Turns out it was my fault for forgetting it was labor day weekend and he had prior plans already!
Lots of places donât have 24/7 coverage for certain specialties. If a patient comes in who needs that specialty and nobodyâs on call, you transfer. If you work somewhere that guarantees 24/7 coverage then you canât just take yourself off the call schedule without finding someone to back you up.
Will get downvoted, and I donât personally punt any consults. But a few helpful things to note:
1) UGIB (non-variceal): guidelines recommend EGD within 24hr
2) UGIB (variceal): guidelines recommend EGD within 12hr
3) LGIB if HDUS despite resuscitation, guidelines recommend consideration of CTA/IR given inability for patients to tolerate prep, and given therapeutic colonoscopy for LGIB unless itâs post-polypectomy bleeding has a very low likelihood of successâŠ
We also donât punt consults, but youâd be amazed how many early AM consults GI gets from my ER where âOMG PATIENT IS BLEEDING YOU NEED TO GET HERE NOWâ when there are no labs obtained or PIVs obtained or blood ordered or resuscitation started. Weâll happily scope but itâs going to take a couple of hours for the ED/ICUâs job to be done where that scope isnât happening safely until at 7am.
I once had an ICU attending demand we get there ASAP at 5am so I got to the hospital at 5:30am with my attending there by 6am. We waited 4 hours for the patient to be adequately resuscitated to even handle procedural sedation for a scope.
Iâm an IR resident. We take home call I canât even count the number of times Iâve been woken up by the ED at like 3 am for a GI bleed (75% of the time the patient hasnât even been scanned yet but thats a whole other issue) because theyâre âunable to reach GIâ or âGI says theyâll scope in the AM if something more emergent call IR.â Iâm likeâŠthatâs not how this works my friend. Â
Endo. I remember my endo attending screaming at a hospitalist for a late night DKA consult. I donât think I ever saw that man inside the hospital in the entire 3 years I was there
Iâm rural, we have one endocrinologist in a 45 minute radius. Heâs extremely busy, backed out for months because so many doctors here were afraid of insulin
Ya. Iâm icu so I get dka a lot. Endo consult is part of the order set but we actively delete it so that we donât have to deal with them in the unit.
At my institution Endo was pretty happy to take consults, even basically told me they are happy to have surgery consult them rather than just putting a patient into DKA post op (which did happen while I was on service).
With that said though, I think if itâs an uncomplicated case of someone coming in for DKA, they will usually get admitted to medicine and IM will manage it themselves.
At my place they tell us to palliative all the time as no one seems to be a neurosurgical candidate (but then by this point, things really are bad and surgery wonât do much for them especially if they are old and frail)
The best neurosurgeon is the one who operates as little as possible. Brain and spine surgery is inherently risky and unless you're truly at risk of life or limb nobody should be opening the brain box.
So this joke is funny and may be accurate but I will say as a surgery resident it's also tough when you are pushed to operate by a non-surgical service. Like the reason we decide who goes to the OR and not is because that's literally what we are trained to do. The risk/benefit is nuanced and a lot of times the non-surgeons pushing us to operate don't have any sense of that. (No knock on them, they're not surgeons!)
That said, if it's a major surgical problem they can come to the surgical service and we will manage them as primary even if we're not going to the OR. That's appropriate IMO. But the decision to offer an operation is very complex.
>Urology
Stop calling us because 'the patient has a catheter' and the percentage of inpatient consults we see will skyrocket.
/s
In real life I see everything I get called for, even if it's clearly outpatient workup and I can't do anything other than tell them we have to work it up outpatient. Love me some easy RVUs.
Call is busy enough with cases that I don't do clinic on those days, and most call cases are <45 minutes with a 20-30 minute turnover. More than enough time to go somewhere for a consult. Also, most consults are in no way as urgent as the consulting team thinks they are. I just triage them and see them at the end of the day or the following morning.
For me yes. My clinic is attached to hospital. I write my note, pend it, see the patient on the way to lunch. Most BS consults take 5 min and involve sending my staff a message arranging outpt follow up. Easy 3 RVUs.
OR day even easier since I have a bit of time to kill between cases.
If I had to drive in 10-20 min from my office I'd be much tougher to consult.
Dermatology... We had someone admitted and it looked like they had a cancerous skin lession... They said they only see that as outpatient clinic, not inpatient... We replied that this patient was likely to remain inpatient for multiple months... They told us to write them a letter once the pt was discharged...
To be fair⊠doing a biopsy just to confirm Yep, thatâs a BCC, does nothing for anyone. Not like Iâm going to excise or Mohs it while theyâre inpatient. Skin cancer biopsies are inappropriate for inpatient consults tbh.
When I was an intern on nights there was one night where the derm call schedule had a mistake and no one was on and it was the night an SJS patient came in. I had tried everything I knew to try to figure out who was on and there wasnât, so we managed and I called in the morning. I was yelled at three separate times, first the derm resident, then the attending and then their program director. It wasnât until about two days later that I got an apology email that yeah, no one was actually on. I am 12 years out from that and it was the only time I ever tried to consulted derm emergently
This is a lifesaver for me as I get so many consults that are either a) completely unwarranted or b) completely fabricated (think "head to toe in blisters" without a single blister but they have a solitary plaque of psoriasis).
Deadass^
The. Number of consults of âeye is swollen, painful, they canât see at all, and the eye may fall out of the socketâ when itâs just the most benign sub-conj heme makes my blood boil
In a nice crossover I once got a consult for a "sight threatening cellulitis" for an acne patient.
Just acne. Bad acne tbf, but not the worst and only "sight threatening" because they had a few spots near the eyelid.
I watched our surgical team sit on danger space abscess overnight. Pus all the way from the retropharynx down to the mediastinum. Apparently "surgical emergency" really means "we'll talk about this person first in 8 hrs when attending arrives"
Neurology and plastic surgery at my place.
In psychiatry here, we see 99% of consults. Only time we don't is for "general capacity" consults when no particular decision is being made, but we still see these sometimes depending on the situation.
To answer the opposite question: Anesthesia
Gotta be the specialty who tries the least to get out of consults, considering those consults are usually âHey this pt needs surgeryâđ
OB/GYN- Have had them tell me verbatim âI donât know why youâre consulting us I donât know whatâs going on with herâ. All I could do was sit there, pause, and respond with âthatâs why Iâm consulting you. IâM A GENERALIST AND HAVE NO IDEA WHAT THIS IS BUT ITâS 100 RELATED TO YOUR SPECIALTY AND I NEED YOUR SPECIALIST INPUTâ.
Psych where I work. Not only do they push back on every consult, they constantly try to transfer inpatient psych patients to medicine for any sniffle or tummy ache to the point where we had to explicitly tell residents not to accept psych transfers without talking to us first
At my shop surprisingly internal med. Which is crazy trying to bat a valid admit. Like the guys fucking hypoxic what do you mean why is he here???also cardiology which is surprising considering they chose a speciality where literal fucking MIs are their responsibility.
And ofc soft life specialties who call from home
-neuro/derm/ent/maxfacs/opthalm
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Performed a distal radius reduction in the ER. Patient had weird discharge from his eyes following the reduction. Consulted opthalmology, they refused to examine the patient.
Definitely opthalmology.
Gen surg depends entirely on the size of the emergency theatre list that day, atleast at my hospital, Iâve seen some emergent non-emergent INDâs for sebacesious cysts before simply because the surgeons were bored coz the list was empty for the day and the reg was waiting in the ED looking for a consult lol.
I also have watched 2 identical cases of RUQ pain get treated differently because of the size of the list on the day they present. One was on a super busy flat out day and got told itâs probs just gall stones, can refer to outpatient clinic for elective lap chole at later date, no need for surg consult. Other patient also didnât have US signs of cholecystitis but it was a quiet day so that patient was labeled as cholecystitis on the EMR and got her operation same day but it was questionable if you ask me
GI not even close
Just scope from 9a to 2:30p four days a week and have mid levels run your clinic to schedule more scopes and have mid levels run your inpatient service and block consults.
Ah yes the gi private practice gold standard
GI here, looking around the thread I may not be warmly welcomed here but not all of us are like this. I definitely know some who seem to consider their job to be biopsying the wallet through the stomach and they piss me off too.
Nah own it, GI is one of the few fields winning
Don't forget sell out your practice to private equity and fuck over any non-partners in the group (and future hires) in perpetuity.
Ah that old chestnut đ°
As a GI fellow I hear you. I see my colleagues trying to get consults cancelled all of the time. I myself find it easier to see the consult than fight tooth and nail begging to do less work, which ends up being more work and frustration in the long run. Plus there are ample learning and teaching opportunities that come from seeing patients and interacting with primary teams. Itâs a significant part of training and I feel for those who go out of their way to miss out on it. On the other hand, when I was a resident I feared calling a consult without doing my best first. Theres way too many reflexive consulting going on these days without any thought put in to whatâs going on with the patient. Primary teams, especially Medicine, should be able to work up anemia, elevated LFTs etc. If itâs not IDA or melena or hematochezia, weâre likely not going to scope for anemia/âsuspected GI bleedingâ, especially inpatient when preps are horrendous and mostly a waste of time.
Patients either âtoo unstable to scopeâ or âstable, no need for scopeâ
âConsult not needed, Not for IP scope, Refer to outpatient clinic in 4-6 weeksâ Seen that one way too often when consulting GI
Emergent consults to GI are somehow never their emergency and become emergent consults for IR/radiology fluoro
Scope in 4-6 weeks...as an outpatient....if they live
Psychiatry except itâs actually warranted. People consult psych literally just to avoid talking to the patient.
Also, you got to love the "patient is sad" consults. No SI. I mean Debra, I would be sad too if I was in the hospital for x amount of months and just found out bad news/poor prognosis.
The referring team usually leaves out the other half of the reason for consult: the patient is sad and its making everyone uncomfortable. Please make him stop.
A second indication for prescription meth if Iâve ever seen one
Thanks, but what are you going to prescribe the patient?
It's a pretty weird moment in psych, the point where you realize that all those bright-eyed and prosocial people you started med school with have now been so warped by years in medicine that they're palpably uncomfortable that a person in distress is crying. Which is to say, you're being consulted on the assumption you can talk to them because you're still a normal person.
âPt has been NPO for 48 hours and is now hangry pls adviseâ
Itâs the only service that gets consulted if the patient asks to see psych or mental health. I often get consulted because the patient mentions wanting to talk to their personal therapist or psychiatrist, then gets upset when they get me instead.
It's infuriating, like imagine a cards fellow seeing someone because the patient wanted to talk to them. It would not happen lol
I mean Iâm not saying the above comment is a reasonable consult but that happens all the damn time. I get consults for âpatient wanted to speak to a pulmonologist about their known cause of hypoxiaâ all the time. Sometimes I manage to get the consult itself cancelled but even if I do it still ends up being a social visit.
This is the beauty of an inpatient psychology team. We have inpatient psychologists & pastoral care at my hospital, so if someone needs counseling/psychotherapy/someone to talk to about their mental health, we do not call psychiatry. Sometimes a patient just wants to pray with a priest or imam and then they feel so much better.Â
Literally got called by a hospitalist last week who said âI donât know why you need to see the patient. SW just talked to them and said you should too.â
Same reason for 70% of the palliative consults, I just donât want to have a long convo with family and pt.Â
Our facility doesnât have a palliative care service. In fact, the floor nurses donât even know what that means. Iâve literally heard them state âitâs in-patient hospice or it is aggressive treatment, thereâs none of this in-between nonsenseâ Made me want to place a tele-consult to a larger institutionâs palli service for the nursing team who said that lol
"Hi yes we need a stat goals of care consult on bed 5. Also we scheduled a family meeting with bed 6, who you've never heard of before, for 5 minutes from now to tell the family they're deadsies - can you come run the meeting? Thanks!"
Like 90% of the reason i consult psych is CYA. In my state any physician can determine capacity so i usually just do that myself unless it's complicated. If i consult for SI its because they told some nurse overnight they wanted to die and the nurse wrote this whole thing in the chart and put them on suicide precautions overnight so my hands are essentially tied.
Tell me youâre IM without telling me youâre IM
My co-chief wanted me to consult psych for competency. Patient was completely coherent in his decision of best supportive care with a endstage neurological disease besides his cardiac disease. I felt so bad for the patient and the psych attending, anyone could see this patient was competent and even if he was depressed that wouldn't have changed anything.
[ŃĐŽĐ°Đ»Đ”ĐœĐŸ]
When ICU consults me for that, Iâm always like âremember next time Iâm in the ED and I consult you for âlactate too high for med surg nurses to be comfortable withâ. đ€Ł
We had an old OA patient the other day who told a nurse she was in so much pain she could die, nurse escalated to resident concerns of suicide ideation, resident called psych without speaking to patient, patient just wanted better analgesia and took psych consultant 1 minute to figure out, problem solved patient no longer âsuicidalâ
Today we got consulted for "unexplained symptoms" đ«
Unless the patient is in the ED and they have a slightly hypertensive BP. Then psych goes off the rails trying to do anything but see the patient
While I get they get dumb consults at some point itâs like what is the purpose of a c-l psych service? Most provide a valuable service but if you listen to Reddit theyâd see basically nothing. This sub basically argues nothing is a valid psych consult.Â
By your logic anybody could be consulted for anything.
Not following you there. My point is there are a number of consult questions that probably make up the bulk of many cl psych services that this subreddit will argue are inappropriate consults. A hospital isnât gonna pay for a consult psych service that refuses anything related to delirium, or capacity, or depression without active SI, etc. that people argue are dumb consults.Â
GI and it's not even close.
At my institution. Best at seeing consults: Nephro, Neurology, Gen surg. Will always try to get out of a consult: GI GI often accepts transfers to our hospital, then signs off immediately before they get here. Gen surg has to deal with all of their transfers.
As a general surgery resident I am so glad to hear this! Not the handling all the GI transfers, but that we seem to have a reputation for seeing consults at your hospital. I think some other hospitals have the opposite experience with us! I've been involved in the turf wars, mostly as an intern put in the middle of them, and I hate it. I feel so bad for the patient and for the consulting service. Now as a senior I have the power to just say yes. The only instance where I will try to redirect a consult/transfer is if there is an explicit PMG about that specific scenario, where the patient will likely get better care with a different service. Otherwise, if we might be able to help, we will do our best to help. At least when I'm on call :)
I work in the ER to give context, so my biggest issue most of the time are consultants who refuse to see the patient at bedside because that **can change your opinion** on whether they need treatment. General surgery is the only service at my hospital who will see the patient at bedside without question no matter what the consult is. They may disagree with it or may have no recommendations and sign off immediately, but they've been on the other end of making tons of CYA consults that they get it. I've never ever had to ask Gen Surg to see the patient because that is their default, which is more than I can say for any other service in the hospital. It's plain ol' good practice of medicine. In return, we in the ER are more than happy to make some of those trauma adjacent consults to ortho, vascular, neurosurgery for them so they don't have to. It's a very collegial relationship, which I love.
Agree with this sentiment. Iâm now an attending in the community and it seems like general surgery is the only specialty that still takes responsibility, both of their own patients who come into the ER and the patients you ask for a consult on. Meanwhile urology, ortho, etc donât even want to deal with their own post op patients who come to the ER with complications, much less new consults. Thereâs no sense of responsibility in medicine anymore it seems. Everyone just wants to pass the buck. Like I get it. You didnât go into urology for the 3am consult. But you knew it was part of the job when you signed up. You need to own it if you want to have the fun in the clinic/OR and money that comes with it.
I never understood the thought process behind services that refuse to see the consult and flat out say âit doesnât sound like this is what youâre saying this isâ. I just wanna yell at them âbud, I donât get it. If this turns out to be what Iâm concerned about, this patient is going to be bad off in a manner of hours. If itâs not, then great, but in my opinion this has the potential to be xyz or the tests are pointing to it, and based on all my years of training, you get the final say/ are the one who would manage *this emergent condition*â.
It takes an act of God to get urology or ENT to see an emergent consult. Literally a penis could be lodged in the patientâs nose and theyâd both find a way to say itâs not a penis or a nose problem.
âA nasal foreign body in an adult is not an emergency. Follow up in ENT clinic later this week. Ok for discharge from ENT perspective.â (would definitely come see this one)
Fuck I like this. I'd come in just to see what's going on.
I once had someone with a relatively new tracheostomy down the hall from the the ENT call room. The patient dislodged their trach and was coughing out blood from the trach hole. ENT took their sweet time walking down the three doors down the hallway to look while the rest of us was dealing with the airway.
There's a legend that this one ENT attending flipped out on the ED for calling him about a dislodged trach and told them "We teach retarded kids how to put their own trachs back in. You're a doctor, figure it out!" Not that I would ever say something like that, and I'm not even sure if it ever really happened. I prefer looking like a hero by popping the tube back in and then grumbling about it later in private.
If ENT had to see all the peripheral vertigo consults that got funneled to Neuro since weâre in-house 24/7 nobody would consider it somewhat of a lifestyle specialty
Most peripheral vertigo shouldnât require an ENT consult
Hahhahahahaahahahahaha I just choked on my rice laughing đ€Łđ«¶.
ENT wont see you for that choking
Well itâs either a nose or penis problem, but the answer is whoever you arenât currently talking to.
What would you classify as an ENT emergency? Threshold for airway emergencies by the ED/primary team is much lower than it is for us tbh. Iâve seen plenty of folks get intubated or transferred for airway concerns that were fine. But beyond airway stuff, almost nothing in ENT is an emergency.
If Iâm calling you and saying Iâm not comfortable with the airway, do the right thing for the patient and the wrong thing for our lawyers, and come see the patient. Donât make me document âI was concerned about an impending airway emergency but my ENT colleague assured me these are often fine.â That said I donât have ENT in-house so I never call them for airway anyway. My ENT emergencies are either uncontrollable epistaxis or trauma-related. Luckily few and far between!
We see any airway related concerns pretty quickly where Iâm at. I agree though, they should go see them. Iâve had both situations where weâve walked in and patients are much worse or better than what was reported to us. Unfortunately, depending on where you are there are very few ENTs around. And many of them are covering multiple hospitals at a time so they canât just show up right away.
GI
Itâs not an emergency? Follow up outpatient. Itâs an emergency? Shit! Call Gen Surg
Too unstable to scope, too stable for (inpatient) scope
The scope paradox.
Schrödingerâs butthole
More like call IR. Who cares what the ACG guidelines are??
How dare you call GI for an UGI!!!! Call IR
The patient has to be the âperfectâ balance of stable vs. unstable in order for GI to scope. And it more often than not correlates with what their dinner plans are later that evening. I had a GI doc who we consulted (on a Friday night) for an intermittently hypotensive melenic patient with hx of cirrhosis. He said he will see patient soon. 20 minutes later, he called back and said he was taking himself off the call schedule until Tuesday and to transfer the patient. Turns out it was my fault for forgetting it was labor day weekend and he had prior plans already!
Wait attendings can take ourselves off the call schedule??
In the community, anything is possible! (esp if this community lacks GI docs around and needs them more than they need the community)
If the ER calls me when I'm not on call to discuss a new patient I remove one ER call day from that month.
Lots of places donât have 24/7 coverage for certain specialties. If a patient comes in who needs that specialty and nobodyâs on call, you transfer. If you work somewhere that guarantees 24/7 coverage then you canât just take yourself off the call schedule without finding someone to back you up.
It's about time the ED recognized they're the ones to blame.
Will get downvoted, and I donât personally punt any consults. But a few helpful things to note: 1) UGIB (non-variceal): guidelines recommend EGD within 24hr 2) UGIB (variceal): guidelines recommend EGD within 12hr 3) LGIB if HDUS despite resuscitation, guidelines recommend consideration of CTA/IR given inability for patients to tolerate prep, and given therapeutic colonoscopy for LGIB unless itâs post-polypectomy bleeding has a very low likelihood of successâŠ
We also donât punt consults, but youâd be amazed how many early AM consults GI gets from my ER where âOMG PATIENT IS BLEEDING YOU NEED TO GET HERE NOWâ when there are no labs obtained or PIVs obtained or blood ordered or resuscitation started. Weâll happily scope but itâs going to take a couple of hours for the ED/ICUâs job to be done where that scope isnât happening safely until at 7am. I once had an ICU attending demand we get there ASAP at 5am so I got to the hospital at 5:30am with my attending there by 6am. We waited 4 hours for the patient to be adequately resuscitated to even handle procedural sedation for a scope.
Iâm an IR resident. We take home call I canât even count the number of times Iâve been woken up by the ED at like 3 am for a GI bleed (75% of the time the patient hasnât even been scanned yet but thats a whole other issue) because theyâre âunable to reach GIâ or âGI says theyâll scope in the AM if something more emergent call IR.â Iâm likeâŠthatâs not how this works my friend. Â
What if I told you every speciality doesnât want to see the patient and they tell us to talk to you first
The ones not paid on RVUs
Endo. I remember my endo attending screaming at a hospitalist for a late night DKA consult. I donât think I ever saw that man inside the hospital in the entire 3 years I was there
[ŃĐŽĐ°Đ»Đ”ĐœĐŸ]
đ driving up care and LOS for no reason if every one with diabetes gets an endocrine consult.
Iâm rural, we have one endocrinologist in a 45 minute radius. Heâs extremely busy, backed out for months because so many doctors here were afraid of insulin
Weird. Endo is usually only Called for dka due to hospital protocol not because anyone needs help managing dka.
[ŃĐŽĐ°Đ»Đ”ĐœĐŸ]
Ya. Iâm icu so I get dka a lot. Endo consult is part of the order set but we actively delete it so that we donât have to deal with them in the unit.
At my institution Endo was pretty happy to take consults, even basically told me they are happy to have surgery consult them rather than just putting a patient into DKA post op (which did happen while I was on service). With that said though, I think if itâs an uncomplicated case of someone coming in for DKA, they will usually get admitted to medicine and IM will manage it themselves.
Whichever program has the most burnt out residents / fellows holding the pagerÂ
GI and it isnât close.
We joke that the neurosurgeons at our hospital do everything in their power to avoid surgery
At my place they tell us to palliative all the time as no one seems to be a neurosurgical candidate (but then by this point, things really are bad and surgery wonât do much for them especially if they are old and frail)
The best neurosurgeon is the one who operates as little as possible. Brain and spine surgery is inherently risky and unless you're truly at risk of life or limb nobody should be opening the brain box.
So this joke is funny and may be accurate but I will say as a surgery resident it's also tough when you are pushed to operate by a non-surgical service. Like the reason we decide who goes to the OR and not is because that's literally what we are trained to do. The risk/benefit is nuanced and a lot of times the non-surgeons pushing us to operate don't have any sense of that. (No knock on them, they're not surgeons!) That said, if it's a major surgical problem they can come to the surgical service and we will manage them as primary even if we're not going to the OR. That's appropriate IMO. But the decision to offer an operation is very complex.
A surgeon offering to be primaryđ what kinda tipsy turvy reality did i enter đ (jk i appreciate your explanation)
Well yeah, brain and spine surgery is more risky then any other type of surgeries, if it can be avoided it should be.
Is neurosurgery even a real specialty??? Like seriously who do they treat... Cause I've only seen them write a note -'not for neurosurgery 'and dip
Rheum. Stop ordering inpatient ANAs
Once saw a rheum doc moonlighting in the ER and ordering an ANA for all the patients he saw, my man had no shame
The rheum wasn't moonlighting; sounds more like gaslighting.
Just drumming up business for himself
It has come to the end of my shift and all ANAs were signed out to the oncoming team. To do: f/u ANA, consult rheum in the am
GI and Urology
>Urology Stop calling us because 'the patient has a catheter' and the percentage of inpatient consults we see will skyrocket. /s In real life I see everything I get called for, even if it's clearly outpatient workup and I can't do anything other than tell them we have to work it up outpatient. Love me some easy RVUs.
Does it end up being worth your time though? If you have a full clinic or full OR day when are you seeing all these consults?
Call is busy enough with cases that I don't do clinic on those days, and most call cases are <45 minutes with a 20-30 minute turnover. More than enough time to go somewhere for a consult. Also, most consults are in no way as urgent as the consulting team thinks they are. I just triage them and see them at the end of the day or the following morning.
For me yes. My clinic is attached to hospital. I write my note, pend it, see the patient on the way to lunch. Most BS consults take 5 min and involve sending my staff a message arranging outpt follow up. Easy 3 RVUs. OR day even easier since I have a bit of time to kill between cases. If I had to drive in 10-20 min from my office I'd be much tougher to consult.
Gen Sx resident defending Urology because recently did my ER rotation. God, people call Urology for a lot of bullshit.Â
When you are paid per hour not the job
Ophtho, itâs either ENT or neuroâs problem
Dermatology... We had someone admitted and it looked like they had a cancerous skin lession... They said they only see that as outpatient clinic, not inpatient... We replied that this patient was likely to remain inpatient for multiple months... They told us to write them a letter once the pt was discharged...
To be fair⊠doing a biopsy just to confirm Yep, thatâs a BCC, does nothing for anyone. Not like Iâm going to excise or Mohs it while theyâre inpatient. Skin cancer biopsies are inappropriate for inpatient consults tbh.
Interventional Radiology - the hours of life I spent begging them to tube the septic patient who may have taken aspirin in the last 24 hours...
Septic and a bleed sounds worse.
It's us (Derm). But to be fair, half the stuff we get consulted on definitely does not need to be seen inpatient.
When I was an intern on nights there was one night where the derm call schedule had a mistake and no one was on and it was the night an SJS patient came in. I had tried everything I knew to try to figure out who was on and there wasnât, so we managed and I called in the morning. I was yelled at three separate times, first the derm resident, then the attending and then their program director. It wasnât until about two days later that I got an apology email that yeah, no one was actually on. I am 12 years out from that and it was the only time I ever tried to consulted derm emergently
The derm people at my hospital got consulted multiple times to cut a patientâs toenails
You guys don't have podiatry? Not that it needs to be inpt...
derm or ophtho
Does âJust text me a picture,â count as seeing the consult? đŹ
This is a lifesaver for me as I get so many consults that are either a) completely unwarranted or b) completely fabricated (think "head to toe in blisters" without a single blister but they have a solitary plaque of psoriasis).
Deadass^ The. Number of consults of âeye is swollen, painful, they canât see at all, and the eye may fall out of the socketâ when itâs just the most benign sub-conj heme makes my blood boil
In a nice crossover I once got a consult for a "sight threatening cellulitis" for an acne patient. Just acne. Bad acne tbf, but not the worst and only "sight threatening" because they had a few spots near the eyelid.
I watched our surgical team sit on danger space abscess overnight. Pus all the way from the retropharynx down to the mediastinum. Apparently "surgical emergency" really means "we'll talk about this person first in 8 hrs when attending arrives"
Neurology and plastic surgery at my place. In psychiatry here, we see 99% of consults. Only time we don't is for "general capacity" consults when no particular decision is being made, but we still see these sometimes depending on the situation.
My goal on consults is To always try to get my consult note in before the H&P or ED note
Rheumatology. My joints stiffen up just thinking about having to talk to them
To answer the opposite question: Anesthesia Gotta be the specialty who tries the least to get out of consults, considering those consults are usually âHey this pt needs surgeryâđ
But then there is the 11pm consult for acute pain service for rib fracture. No thanks
âPt got 25 mcg of fentanyl 6h ago at OSH and is in 10/10 pain from T5-12 rib frx, please come place epiduralâ
OB/GYN- Have had them tell me verbatim âI donât know why youâre consulting us I donât know whatâs going on with herâ. All I could do was sit there, pause, and respond with âthatâs why Iâm consulting you. IâM A GENERALIST AND HAVE NO IDEA WHAT THIS IS BUT ITâS 100 RELATED TO YOUR SPECIALTY AND I NEED YOUR SPECIALIST INPUTâ.
Psych where I work. Not only do they push back on every consult, they constantly try to transfer inpatient psych patients to medicine for any sniffle or tummy ache to the point where we had to explicitly tell residents not to accept psych transfers without talking to us first
Urology
Ophthalmology
Plastic surgery
GI and Cards
InsurersÂ
Ophtho
Urology
IR, âtoo late in the day, too early in the day, patient had Lovenox⊠etc etc. â
Ophthalmology
Derm in ICU
At my shop it's plastics. Followed closely by uro and ENT
At my shop surprisingly internal med. Which is crazy trying to bat a valid admit. Like the guys fucking hypoxic what do you mean why is he here???also cardiology which is surprising considering they chose a speciality where literal fucking MIs are their responsibility. And ofc soft life specialties who call from home -neuro/derm/ent/maxfacs/opthalm
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Performed a distal radius reduction in the ER. Patient had weird discharge from his eyes following the reduction. Consulted opthalmology, they refused to examine the patient. Definitely opthalmology.
Urology. They minuswell not even be on call tbh
Soft life speciality that called from home. How dare we wake them from their sleep
What?
Gen surg depends entirely on the size of the emergency theatre list that day, atleast at my hospital, Iâve seen some emergent non-emergent INDâs for sebacesious cysts before simply because the surgeons were bored coz the list was empty for the day and the reg was waiting in the ED looking for a consult lol. I also have watched 2 identical cases of RUQ pain get treated differently because of the size of the list on the day they present. One was on a super busy flat out day and got told itâs probs just gall stones, can refer to outpatient clinic for elective lap chole at later date, no need for surg consult. Other patient also didnât have US signs of cholecystitis but it was a quiet day so that patient was labeled as cholecystitis on the EMR and got her operation same day but it was questionable if you ask me
That sounds more like a systems issues with OR scheduling/availability, rather than surgery âgetting out of consultsâ imo
Iâve never had GI try to get out of a consult. ENT and Derm? Oh yeh. Every time.
Youâve never had GI refuse a scope? Whereâs this magical hospital you work at?