The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Thursday, July 12, 2007

The Untouchables

I've never been able to figure out exactly what other specialties have against emergency medicine. As a general rule, emergentologists (I love that phrase) are seen as the cowboys of medicine-- they do the medical equivalent of balancing spinning plates on their fingers. Which also means one false move and they all come crashing down. Emerg docs seem to be viewed with a mixture of envy and derision. Generally speaking a few things make emerg docs different from other specialties. For starters, we have lives outside of medicine. We still make good money (not surgeon money, mind you, but why make buckets of money when you don't have time to enjoy it?). We play as hard as we work. When we leave the hospital, we leave the patients behind and don't get paged when problems arise. We have to know about a lot of things, but we don't know most of them beyond their initial stabilization and management (or as one of my preceptors likes to say, we know the first 10 minutes of every disease). We are always being pulled in multiple directions, often by people who are actively trying to die. We have to handle everything from the small benign stuff (like a sore throat, minor lacerations, sprains) to the worst cases (trauma, VSA, sepsis, anaphylaxis) and everything in between.

So emerg docs also end up being the scapegoat for any number of questionable medical encounters. When you're juggling several critically ill patients at a time, sometimes stuff can slip through the cracks. And sometimes, things don't get worked up as thoroughly as they could be before they're referred on. In the ED, the emphasis is on disposition-- in other words, where is the patient going to end up? If they have an acute abdomen, they're probably headed to surgery regardless of the results of their LFT's-- so it doesn't always make sense to wait for them before calling the surgeon. But then the surgeon turns around and bitches to anyone who will listen about how they got a 'bogus consult' for abdo pain that wasn't even worked up.

I think that the biggest problem in situations like this is that although emerg docs rotate through nearly every major specialty through the course of their training, specialists rarely are obligated to spend any significant amount of time in emergency medicine. So it's rare that a specialist can see things from our point of view. The surgeon might just see that they were referred something as a 'query appendicitis' on the basis of right lower quadrant tenderness, rebound tenderness, guarding, anorexia and an elevated white cell count. In spite of the increased use of ultrasound and CT, the reality is that appendicitis is still largely a clinical diagnosis. Take the same case two hours later, when the surgeon (or, more likely, surgery resident) emerges from the OR long enough to lay eyes on the consult. Suddenly, the patient's tenderness has 'magically' migrated a bit higher, there's no rebound tenderness and they're claiming to be hungry. So suddenly my 'classic appy' now looks a lot more questionable, and the surgeon rolls his eyes at the stupid consult that the ED wasted his time with.

I often feel sheepish, because I know that had I gotten the same story and/or clinical exam that the surgeon did I never would have consulted in the first place. But I have no control these things.

On Facebook (my new addition) there is actually a group devoted to "Stupid Consults from Stupid Doctors". Most of the posts to the group are from residents in academic centres complaining about things that have been sent to them from the ED-- consults which, in their eyes, are inappropriate. My response? It's easy to judge from your end of the filter. Maybe those obs/gyn residents feel like they must get referred everyone with pelvic pain or heavy bleeding, but since they don't see the 98% of patients that I send home it's hard to muster up sympathy. Refer pelvic pain? Only with a positive urine preg test. Heavy bleeding? Only with extenuating circumstances, like the woman I saw last week with the hemoglobin of 68 who was still bleeding heavily in spite of treatment with Ovral. I'm no gyne, but I think that warrants intervention.

The other side of the coin is the spread of defensive medicine. From what I understand from fellow emergency medicine bloggers, the problem isn't nearly as bad here as it is in the U.S., but it's starting to seem that way. Take ortho, for example. At the last two academic centres where I've worked, emerg docs do very few reductions of displaced fractures. As someone who wants to learn these procedures, I find this frustrating. Leaving a patient taking up an emerg bed for hours until ortho can organize themselves to come down and reduce the fracture is silly when we could get it done in just a few minutes. But as it was explained to me, "if something goes wrong with the reduction, the emerg doc would have a really hard time defending their choice to do it themselves when the experts (that would be ortho) are readily available for consult". Gah. A big part of the reason I chose to finish off my training with a year in this 'less-academic' centre is the fact that the attitude here isn't that the A-B-C's of primary assessment stand for airway, breathing and consult. Emergency medicine isn't just 'referology'. We actually do the reductions, the procedures, the conscious sedation, the airway management... it's a refreshing change.

Don't get me wrong-- inappropriate consults happen. And they probably happen more often than they should. Emerg docs aren't perfect. But we do the best we can. And until you've spent a few shifts in our shoes, give us the benefit of the doubt.

10 Comments:

Blogger Double Headed said...

So nice to hear from you Couz! Ofcause you are invited:) I hope your pregnancy is advancing nicely. Clerk and I are very happy for you.

1:01 AM

 
Blogger Liana said...

Dr. Couz, I loved this post. A similar thing happens to family docs, especially out in the tiny rural centres. CT? Nope. U/S? Well, they come out here twice a month and there's a two month waiting list. Stat labs? Only lytes... so yes, there are times when I consult someone in big city and send them in, and then by the time they arrive they're magically better. I think it's hard for specialists to put themselves in our shoes.

2:34 PM

 
Blogger RugbyGirlMD said...

At our hospital one of the EM staff started going to IM morning report every morning. Some of them just sat there and didn't say "boo" but most of them went to bat for decisions made in the ER.
It did a lot for inter-specialty relations.

10:45 AM

 
Blogger john3612 said...

No one gets our job unless they have done it. EM (and others when you are alone) is standing at on the front line of medicine. The front lines are loud, chaotic, smelly, cranky, dangerous and there is no other place I would ever want to work. Don't forget how lucky you are. Next shift when you are pissed at the prospect of seeing a family with colds remeber every once in a while you may get to save a life.

2:01 PM

 
Blogger Double Headed said...

Hey, I checked out this Facebook group you mentioned. Guess what? There are at least a dozen of people I recognize there. Out of those, I know for fact, 2 do not own a stethoscope. Do you think if you are so narrow specialized that you don't need a steth, you have no right to whine about ER docs who deal with every complaint that an average folk can come up with? I guess I am feeling a little defensive, since I am in the ER rotation right now... and loving it, btw... I remember you commenting on one of my posts while back saying that there is no better career than career in EM... I think I am getting more and more convinced...

12:45 AM

 
Anonymous Anonymous said...

Dr. Couz, I am not a doctor and am blessed that I can count my visits to the ER on one hand:

- a sick infant with a terribly high fever;
- with my six year-old daughter who cracked her head open on the asphalt in the parking lot at school;
- with my elderly mother-in-law who, fell and gashed her scalp open;
- with my husband who was having chest tightness, nausea, cold sweat, and tingling in his arm.

I thank you for being there in the ER when I need you!!!!

--Christina

3:44 PM

 
Anonymous Anonymous said...

Why the ER-Everyone else tension? As a medicine resident, I rotated through the ER. I continue to work regularly (and quite amicably) with our ER as a fellow. A couple of thoughts:
1. I agree that lack of understanding is a problem. Everyone (surgery, medicine, cardiology, etc) has to recognize that the goal of the ER is NOT to cure really sick people, it's to stabilize and triage correctly. Volume and time management are the ER's biggest obstacles, figuring out why someone is ill and how to treat them are someone else's problems. Of course, many problems are handled very well by ER physicians.
2. At my hospital (a large academic center in a major city), medicine and surgery residents rotate through the ER. The ER residents spend 2 WEEKS-out of 4 years-rotating on medicine; none on surgery except the ICU's. Perhaps if they did, there may be more understanding as to why we would want labs before a phone call (to use your example, sometimes LFT's with abd. pain can change a diagnosis and disposition).
3. Because of the time crunch, things DO get missed in the ER. It's inevitable. I have 1 hour to admit a patient; the ER gets 30 minutes generally speaking. Some of the mistakes do make people angry (I admitted a patient with "left arm pain" to rule out for MI only to find out that it was not arm pain, it's that "I can't MOVE my arm." Stroke; not MI).
3. There sometimes seems to be an overabundance of bravado in the ER.
4. I have made my share of mistakes. I don't think anyone is necessarily more important than another. I think we would all get along better if we checked our egos at the door, thought of each other as colleagues (if not friends), worked hard, and thought of how hard it is to do someone ELES's job, even if our own job is tough...

6:09 PM

 
Anonymous MLO said...

I'm coming late to this post, but I see this in every profession - ER doctors should not feel like they are the only ones that always take the blame. Someone is always blaming someone else. Yes, I know I am pissy about the ER incident I had, but, let's face it, who wouldn't be?

Doesn't matter what you do for a living, sometimes you are the blamed and sometimes you are the blamer in the food chain. I do find that it tends to be more prevalent among professions that attract a certain personality type (arrogant), though not all in the profession are like that.

If I remember my college Organizational Psychology, this is classic organizational behavior, so just take it for what it is, people being people.

Pax,

MLO

11:01 PM

 
Blogger Midwife with a Knife said...

This isn't meant personally, so please bear that in mind when you read my comment.

I spent a month rotating through the ER as an intern. In that month, I feel like I got a pretty good taste of what ER docs do. My take on the situation is as follows:

1) ED docs tend to order consults when they are having a hard time sending people home who should go home. They say, "she's been her 3 times in the past 3 months for dysmenorrhea, you really need to do something about this", and dysmenorrhea (as well as most other gyn problems) is an outpatient workup and treatment. Often times this ends up in a "You can do what you want with the patient, she doesn't satisfy any reasonable criteria for admission, we're not admitting her, and we've given her our gyn clinic number."

2) ER docs tend to expect their consults right now. You say, "She sounds stable, I'm in the middle of a surgery, nobody will be available for 3 hours, but we'll see her then." tends not to be a good excuse for them. (If she were unstable, we'd find an attending to see her, but I'm not asking an attending to go see yet another pid)

3) ED docs tend to want patients admitted for things that don't warrant inpt treatment. PID, if the patient is tolerating oral food and fluids is an outpatient treatment.

4) They tend to be too focused on disposition. They don't want me to do my workup to see if someone needs admission, they just want the patient out of their ED. It's not appropriate to admit someone if they just need a test and can get out of there in a couple of hours.

6) The rest of medicine tends to view Emergency medicine as the one specialty where you don't really see the end results of what you do.

5) Nurse practitioners from the ED consulted ob-gyn on everybody with a vagina. It's easy for us to confuse them with real doctors and have bitterness towards the entire emergency room.

ED residents do sometimes call stupid consults. Most consults are legitimate. It's not unreasonable to ask a gynecologist to wander by if you're sending a patient home on ofloxacin and flagyl (or whatever) for PID. It's certainly appropriate to ask a gyn to consult on an ectopic pregnancy. First trimester spotting with a known intrauterine pregnancy? She doesn't need a stat gyn consult, she needs to follow up.

Having said that, a large number of ED docs are good and reasonable. It's just the few who are unreasonable or demanding or simply not good clinicians that leave the rest of us with such a bad taste in our mouth.

(Oh, and I'm still bitter that we let the ED residents who rotate with us go to lecture but they didn't let our interns go to lecture. )

3:17 PM

 
Anonymous Anonymous said...

After working at an academic center, I can only come to one conclusion: ER doctors are stupid.

6:00 AM

 

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