Toxic doctors and other absentees

Here is my April column in Emergency Medicine News:  official title pending

There are some toxic doctors out there! Unfortunately, I wonder how often our interactions with them, or our avoidance of them, leads to bad patient outcomes. How often do we see the patient with troubling abdominal pain, but no clear diagnosis, and elect not to call the surgeon? How often do we fail to call the pediatrician for the sick child because it’s just too much trouble to cajole him into seeing the child? And how frequently, in community hospitals especially, do we make the decision about that TIA by ourselves? Involving the neurologist is just too much work. I’ve faced this many times, from internists to cardiologists, ENT’s to orthopedists. Call the specialist and you’re in for one of two things: whining that only dogs can hear, or a tongue-lashing you never deserved.

This may be why our specialty is often singled out for ordering too many labs and obtaining too many CT scans. I suspect that much of what we do could be eliminated if a physician specialist would simply come and see the patient in question.

I really respect their knowledge, you know! When a physician is seasoned, has seen enough sickness and examined enough human beings, that physician develops intangible skills. Those skills can’t be reproduced by anything but time and experience. Diagnostic tests certainly don’t replicate those abilities. One of the things I love most about my job is that I have accumulated expertise. I can usually tell, with reasonable accuracy (and occasional inaccuracy) just who is sick. I can tell how short of breath the asthmatic is without applying the magical stethoscope. I often know which chest pain is an MI before the EKG tech ever darkens the door. This is the gift of medicine, conferred only by diligent waiting and earnest practice.

So I suspect that if my esteemed specialist and generalist colleagues would lay hands and eyes on questionable patients, they could make decisions faster than I can when the problem lies in their bailiwick. But this does not tend to happen, does it?

As our specialty has grown, others have often abdicated. Why come out at night? The ER is there. Why see my freshly admitted patient? The emergency physician saw her! Why close that complex wound in the drunk? That’s what the ER is for. Why evaluate the abdominal pain? The emergency room doc will get the CT and call me.

Which, I suppose, is how a career is made. We do what others won’t, and we are paid for it (sometimes). In a kind of professional evolution, we have found an ‘ecological niche.’ But the problem is, we aren’t well suited for the niche in every situation. And so, we need others to help.

But now, having established our place we have set up an expectation. So when we call and say, ‘this patient has chest pain and I don’t know what to make of it,’ we get ‘what do you want me to do?’ When we say, ‘this patient has abdominal pain and it’s a little odd, can you examine him?’ We get: ‘Order some labs and a CT. Call me back.’ And if it’s still uncertain, ‘what am I supposed to do with a negative CT?’

Sometimes the answers are simply unpleasant. ‘Did you even examine the patient? You didn’t examine him did you?’ Or bitterness: ‘Fine, stack them up. I’m just here to take abuse. I’ll be in.’ Or ‘I’m not coming in, so don’t bother asking!’ I’ve even been cursed, to my face, when the consultant finally showed up. My partner was once told, while attempting to transfer a child with a retropharyngeal abscess, ‘and just how is that my problem?’

I suppose it all probably happened even before our specialty was in the forefront of emergency care. In the pre-EMTALA era, there was no way to put any ‘teeth’ into on-call requests. And there were few docs in the old emergency rooms who had enough training to hold their consultants accountable.

And I understand some of it. Medicine is getting harder to practice. The financial constraints are remarkable. It’s hard to get enthusiastic about going to the ER at night when a full office, or OR schedule, awaits in the morning. All of us, in every specialty, just get fatigued over time. Fair enough.

But all I want, all we want is just a little help. Just a little extra knowledge. Some experience to add to our own in the care of the sick and injured. Here I confess (as we all should): I don’t know it all. I’m not a surgeon, orthopedist, internist, pediatrician, ophthalmologist, radiologist or anything else (though I play each part in my shift). I desire the expertise and wisdom of my colleagues. But I want it in person, not over the phone as if I were their intern.

And when I call for it, I don’t want excuses, toxicity or whining. I promise, I don’t call unless I really feel I need to call. I don’t call unless I think it’s best for the patient. And in the case of certain physicians, I try to never call. It isn’t worth the pain I’ll endure on the phone.

I only wish those few consultants understood that their toxic attitudes may have far-reaching implications. Not for me when I call, but for the patients who don’t get to benefit from their knowledge and skill.