Dr. Rob recently posted a very good letter to consultants. Here's my response, in the form of a letter I'd (never, even in my most erotic dreams) write to referring docs. And may I state that I love reading Dr. Rob: his humor and brilliance and insight are like a cool breeze (it's been really hot around here). If I actually worked with him, I'm certain he'd not be the recipient of such a letter (nor I of his!):
Hi, howya doin'? By the way, thanks for the note. It's one of my favorite wines. Glad you liked it.
I'm intruding on your valuable time with a couple of comments on our relationship, hoping they can improve care for our mutual patients. If you don't have time to read this now, maybe when you get home. And then if you want to talk to me about it, give me a page: I'll be at the hospital.
- Surgeons aren't all assholes. I'm not an asshole. OK, I am, but NEVER to your patients. Ever had any complaints about how they were treated? Right. And you never will. By the way, sorry I yelled at you the other day.
- I actually know stuff. In training, we used to say "a general surgeon is an internist who can operate." Whereas it might have been more true back then, when we considered it a personal failure (to put it more correctly: attendings considered it my personal failure) if we needed medical help, I still take it as a point of pride that I'm aware of and can manage most of my patients' peri-operative needs. It's more efficient that way, and cheaper for the patient. Plus, I'm there. You're not.
- Rumors to the contrary, not every surgeon simply wants to cut no matter what. (How's Mr Jones, by the way? The one you sent for a chole who I discovered had gastritis?) Much as I like it when I don't have to think, I'm more than willing to do so. In fact, I'd be quite happy to be involved even before you send me a patient: working together, I bet we can get where we need to go and save a lot of the tests you'd otherwise have ordered. Give me a call. You may have noticed my nurse will get me right away when a doctor calls. (You may also have noticed that when I call you, I call you; I don't make you wait by having my nurse place the call.)
- There's nothing wrong with early referrals; or failing that, early phone consults. Much as you hate it if I make a reference to the care you rendered before I see your patients (I bite my tongue; I really, really do), it's beyond frustrating to see a patient days, weeks, or months after a problem that you knew to be potentially surgical was handled, uh, suboptimally, alone. HMOs and gate-keepers notwithstanding, it doesn't save money in the long run.
- In a related matter, how 'bout a call before ordering the interventional procedures recommended by radiologists on mammogram reports? If you think I'm trigger-happy... Seriously, lots of the things they see can safely either be followed, or are palpable and can be much more cheaply sampled by a fine-needle aspiration. I don't charge for phone consults, as you've noticed. I'll even have a look at the film if you'd like. Gratis.
- Placing all sorts of restrictions on me up front is, y'know, sort of insulting. "Consult only. No tests authorized. You must discuss any intervention with me." We've worked together a long time, buddy o' mine. If you can't trust me, I guess you need to find another surgeon. Have I ever done unnecessary testing or operating on your patients? Ever failed to keep you in the loop? Right. And I never will. I really hate those referral forms. Maybe you do, too. I know we can't get rid of them, but hey, let's make it as infra-onerous as possible. You want my reports short and to the point? You're singing my song, baby.
- I actually do think you're important. What you do isn't easy. If I liked sitting in an office all day, I'd have chosen to. Oh, and I have no idea what's fair compensation. I know you resent that I make more than you, but here's the thing: I get up every morning at 5 am to make rounds; on a good day I get home at 7:30 or 8 pm, assuming I'm not on call, which I am every third night and every third weekend. I take calls all night, whether I'm on call or not. I go back in, in the middle of the night, a few times a week. You? When I'm in deep doodoo in the OR, I can't take a break, or sleep on it, or have someone bail me out. I'm the bailer-outer. We both work hard; but doggone it, I work harder. And we both know our patients would be worse off if the garbage stopped being collected or the toilets backed up than if you or I shut down.
- One last thing: please don't tell your patients what operation I'll be doing and how and when I'll be doing it before I've had a chance to see them. It's embarrassing to all three of us when I have to unexplain and disabuse. Sort of related: there are differences among acute cholecystitis, biliary colic, and common duct stone. Surgical approach, urgency, and timing: not the same.
Hey, man, it's been great. I tried calling but your nurse said it was your day off.