DB:

Very bad form on the part of your GI consultant. I am a specialist. Whether my consult takes place in the hospital or (more commonly) in my office I NEVER presume to personally call another consultant. Not only that but I routinely call the referring general specialist (owzat?!) and ask them to either personally order any significant tests and copy me, or grant approval for me to order said test.

IMO it is necessary for a single physician to function as the hub of the wheel, the conductor as you call it, for all of the care received by a patient. I think your GI consultant needs a reminder…

Ugghh! We see this constantly. From last week, patient has a fall & breaks 4 ribs (right 2nd-5th). Trauma doc sees “A. Fib” on the diagnosis list and automatically consults cardiology. Never mind that he is adequately anticoagulated and his rate is well controlled. Echo echo is ordered (it’s been ordered previously, but not with this admission) by cardiology NP doing the consult so that it will be there when the cardiologist does show up. I’m not sure it’s possible to get a cardiology consult in my town without getting an echo ordered. Again, probably no harm done to the patient, but I’m sure the needless consult & echo added at least $500 to the bill.

Technically, the primary is supposed to order the consults, but how many specialists actually follow those rules? Not many.

This drives me nutz. Hearing a specialist tell me we should get a hematology consult on an old man with a platelet count of 100K. Or having the cardiologist order a pulmonary consult, then sign off the case. It’s the equivalent of me consulting a second cardiologist on the same patient. I am a board certified internist. I know my limits. I know I don’t need a specialist telling me how to manage something outside of their expertise any more than I tell them how to do their job. If you have a problem with the care I am providing, you need to call me and discuss it.

would the gi guy/gal have done the procedure without the stress test? ours would not have. so perhaps the stress test was done because of the practice pattern of the gi specialist. are you going to insist the gi guy do the procedure when s/he is not comfortable proceeding without the stress test?

communication definitely broke down here. but frequently it is hard to get ahold of primary docs as well. and waiting to get a consult might increase the length of stay a day or more if that communication is delayed. i assume db has residents. maybe they were in one of their mandatory conferences somewhere or in clinic or just didn’t answer their page. even in private practice, the wait time to get ahold of the physician can be 15-20 minutes. do you want them pulled out of the room? i can’t make any progress seeing clinic patients if i am pulled out of the room every time someone wants to talk to me. i really prefer to be called for important messages only. i personally don’t like to get called when i send someone for a screening colonoscopy and the answer back is normal. just leave that message with the nurse.

Personally, I don’t mind too much when one specialist calls in another. That said, I’m a FP working in a small rural hospital without much specialist depth. We’ve got a handful of specialists and a handful of general internists and FPs.

What drives me a little crazy is when some patient comes into the E.R. needing admission for some purely specialist oriented problem and the E.R. doc is told by the specialist “Admit it to drsam and consult me.”

That way, they can just buzz in and do less paperwork and get paid more as the consultant and for doing their procedures. Meanwhile, I get to do all the lower paying scut work on some patient where I really have nothing of substance to contribute to the case.

If I were a hospitalist, I don’t think I’d mind it so much, but I’m not a hospitalist. I have an outpatient clinic that is 12 miles away from the hospital. I don’t usually have many patients in the hospital, and most frequently have none. When I do, it means a lot of extra driving and time taken away from my clinic patients, personal life, etc.

When it is one of my established patients that gets admitted, or when there is a genuine need for my involvement, I don’t mind being the admitting physician. When this is not the case however, and I’m only being involved so the specialist can have less busy work, I do mind that. I didn’t become a family medicine physician simply to be a scut-monkey for the specialists.

Unfortunately, our hospital is too small to support a hospitalist program since Hurricane Katrina. It is slowly growing back as the community slowly returns and some day will be busy enough for a hospitalist program to be an option. I look forward to that day!

That was an excellent post. Just wanted to let you know that you were named as an honorable mention for the Scrubby award.

Common courtesy requires that the primary service doc be in the loop for all consultations. I work at a small hospital and most of our consultants toe the line. However, some of the surgeons will ask for “a hospitalist and intensivist consult” if their patient develops A Fib. I don’t know whether this is because they don’t realize how much overlap this entails, but I do notice that I get these types of requests when the surgeon is too busy to make rounds before 5pm and they have been harrassed by phone calls. Much easier to have the hospitalist (and intensivist) get involved than come in and figure out what’s going on, then choose the best consultant. (This is only a few of our surgeons. I’m not trying to make a sweeping generalization.)

When there is no one driving the boat, so to speak, there is so much more opportunity for error. I’ve been the hospitalist on cases in which there is a general surgeon, a nephrologist, an intensivist, and a cardiologist involved, and all the docs start writing orders that contradict each other. Potentially disastrous.

As a hospitalist, part of my demonstration of value is in resource utilization and efficiency of care. In a complex patient, this is derived from close coordination of multiple consulting services.

If one of my clinical evaluation metrics is the average cost per case on the patient’s I admit, then I need to be the one making the final decision on whether additional consults need to be called or whether more tests need to be ordered.

Fun anecdote — I was once asked to consult for hypertension and diabetes on an orthopedic surgery patient. Two days later, I see in the chart that Ortho (the PRIMARY team) has decided to “sign off.”

Diora,

I think you are in agreement with most of the comments and DB’s original rant. The “resource utilization” that Stalwart Hospitalist mentioned works in the opposite way that you’re thinking. Doctors are rewarded (or at least not reprimanded) for having LOWER costs/admission, not higher.

You are absolutely right that “no harm done” isn’t a good defense and I think DB would agree with you (correct me if I’m wrong). I think he was just saying that in this one case, nothing bad happened but we shouldn’t risk it.

In short, I agree with you and think most other doctors do too.