Wednesday, April 18, 2007

Dirty Laundry

Sharing many characteristics of humans, doctors can be assholes. Petty, venal, vengeful. Excessively political, and narrow-minded. I don't exclude myself. Here's how some of it goes. Went.

In training there was a tradition of oil/water incompatibility between surgeons and medical types. It was reflexive, legendary, cultivated, part of the air we breathed. But also superficial: we said bad stuff about each other, yet -- no choice, of course -- interacted to the benefit of all. Like your embarrassing uncle: talk behind his back, but get along at family gatherings. In private practice, it's a different game: the animosities, it turns out, are real and impactful. It's not just surgeon - medical doc hostility: it's any doc on doc. Join the wrong clan, expect open hostility; damn the party-favor pretensions. It's real and serious, and deadly unpleasant. Pocketbook precludes pleasantry.

When I arrived in town, young and naive, ready to become everyone's favorite surgeon, I walked down the halls of the hospital (often lost!) smiling at everyone I saw, uttering expectant greetings. Didn't take long to notice: some doctors not only failed to return the salutation, they literally looked away. Not a word. Knowing nothing about me other than that I was the new guy at the Clinic, they had no hesitation: I was one of THEM, and deserved not the slightest notice. Well, OK. To some extent I understood, once I understood: the Clinic had just opened its first satellite office, and had recently signed an exclusive contract with a health insurer. The non-Clinic docs felt threatened, saw the Clinic as actively trying to put everyone else out of business (not only was that not true, but as time went on and the Clinic continued to grow with the community, the non-Clinic docs increased in number and thrived as well. Still, I didn't entirely blame them.) So I was branded. Some of those docs wouldn't have referred a patient to me if I started raising people from the dead. (Well, as time went on, some referred themselves when they needed surgery -- just never a patient.) In my infancy, I operated on the mother-in-law of the son of a prominent family doc whom I happened to use occasionally as an assistant -- an older guy who did lots of surgery himself, not particularly well, but knew his way around the other side of the table. During an operation he told me how much the woman had appreciated my care, and said he was impressed as well. He went on to explain that I surely must understand that, as a Clinic doc, he'd never send me a patient. He, and many others. Quality was not the overriding issue: it was where you parked your car.

The emergency room, which disrupted our lives and saddled us with cases we'd rather not take, at times we didn't like using time we didn't have, was the petrie dish in which, like familiar pathogens, much of the interpersonal enmity grew. As a reader of many fabulous ER blogs (this, this and this, to name but a few), I'm now ashamed to admit it: I wasn't always above dancing on the fine print of the staff bylaws to stay in bed at night. The on-call rules were arcane here, fluffy there, and made for many a midnight merengue. And when it involved a pirouette across political lines in the sand, grit got in the tutu.

"No-doc" call, meaning being designated to accept patients who showed up in the ER with no doctor of their own, was assigned among each of the specialties. There was no refusing a no-doc patient if you were the one on call, but it got trickier when the receiving doc called another specialist. Politics being what they were, generally the doctor who took the patient called people in his/her own political sphere to consult. And in fact the rules were that once a doctor accepted a patient, that patient was no longer "no doc." So other rules applied. I have no obligation (other than pragmatic ones) to agree to a consult request from a fellow (non-ER) physician. And after a few years of being shunned by those on the other side of the aisle, there were few things that annoyed me more than getting a call from some doctor who'd never refer to me, to be surgeon to his no-doc patient, when the only times it occurred were for a patient with a particularly unpleasant problem, and with no insurance. Otherwise, they'd have called their pal. So when it happened, I'd mostly say no. More often than not, I'd also say why. Until they'd be informed later that I was within my rights, the jilted physician would usually threaten me with some sort of medical staff censure. Such were the realities of politics, and of being tired at two a.m. It nearly got me into big trouble once, when a surgical competitor tried to screw me. In the political sense of the word.

Russian sailor shows up in the ER right after his ship docks in port. Story is he'd been sick for several weeks, with no way off the boat. He had a history of vomiting, abdominal pain, and bloating. No fever, no evidence of infection; vital signs OK, abdomen soft and not tender. The initial call from the ER doc went to the no-doc gastroenterologist, who'd ordered some lab work and a CAT scan, choosing not to see the guy until the results were in. The scan showed nothing specific except for fluid in the abdomen. "Call the no-doc surgeon," sez he. "Thanks, but no thanks," sez I. "Free fluid in the abdomen is a surgical emergency," sez the ER doc. "Not in a guy who's stable, got a soft belly, no signs of infection. What about ascites?" queries I. The ER doc, a new one whom I'd never met nor even heard of, quickly implies I'm derelict in my duties, in the most unpleasant terms. I reply that since Dr. GI accepted responsibility for the patient by ordering and evaluating tests, the man was now his patient, and I had no obligation to see him. The GI doc, of course, had never referred me a patient in his life.

What I actually said was I'd be happy to see the sailor as a consultant if after appropriate evaluation it was determined he had a surgical problem, and if, in the light of day, Dr. GI still wanted me to be his surgical consultant. I stated it did not sound like a surgical problem, and certainly not an emergency, at that time. There were a couple more calls. The ER doc, I realize, was stuck in the middle; on the other hand, he'd been exceedingly rude to me when I'd simply pointed out a medical and a political truisim. As far as he was concerned, I was criminally negligent, and said so rather gracelessly.

By rule, the only person who was actually derelict was the GI doc, who, having initially ordered tests, refused any further care. He managed, after I was temporarily out of the loop, to punt the case to the on-call family doc who generously admitted the man, and arranged for another GI consultant in the morning, who in turn asked me to see the man, which, of course, I did, and my exam confirmed my impression that he was not a "surgical" patient. He never became one, either, and shipped back to Russia a few days later.

As this post threatens to get too long, I'll skip ahead to when I'm sitting in the hospital medical director's office, having been called in to respond to a letter she'd received from the original GI doc, claiming I'd refused care of this patient and that it was a well-known pattern on my part. "Acts like he's the alpha-surgeon," was a nicely-turned phrase in the letter. I pointed out that the man's course proved I was right in concluding he was not a surgical patient, and that since Dr GI had de facto accepted the patient, I had no obligation even if he'd needed a surgeon; I then asked if she'd found any instances where I'd refused to come in to see a surgical patient, or if there were any prior complaints from ER folk about my responsiveness or my care. There were none. Quite, in fact, the opposite. And she agreed, after checking it out (like that ER doc, she was new in town), that I was right about the laws of succession. But, of course, the letter went into "my file."

I don't know what happened to that ER doc; I never saw him again. I sent a letter to all the GI docs in town (they'd recently actually worked out community call-sharing across political lines) saying that I would refuse ever to respond to a consult request from Dr. GI and they should either arrange their call schedule accordingly, or expect to need to refer surgical patients elsewhere if we were on call together. I even explained why: the letter. A certain amount of fecal matter on a few ventilation devices ensued, and as luck would have it, not long thereafter the two of us found ourselves together in an otherwise empty elevator. "That was a pretty strange episode," I said. "Especially the alpha surgeon part. We've never worked together. Where did you come up with that one?" Sheepishly, he offered, "Well, you're right. And you were right then. Actually, [surgical colleague of his, competitor of mine] was the one who said it was a well-known pattern. He encouraged me to write the letter. I wish I hadn't." "Me too," I said. "I guess I could give it a shot, forget about it, work together if it ever comes up." "Me too," he said.

And with that, hell froze over.


Greg P said...

The wisdom of experience.
When we're young and just out of training, it's amazing how we get sucked into things we later regret.
Many years ago I learned my lesson, having been called about admitting a man who a general surgeon said had a stroke. There wasn't much we could do back then, it was late at night, I said, "Sure, go ahead and admit him to me" and waited until morning to go see.
Well, it turns out the guy's neurologic problem was severe carpal tunnel syndrome, and the real issue was failing kidneys. But there I am the attending physician.
So now I don't admit anyone without taking a look at them first; I don't accept them as a patient without taking a look at them first, even if it's 1, 2, 3 in the morning.

Bongi said...

so far only having dabbled in private practise i'm amazed at the politics of it all. i've already been placed in a camp and i'm therefore already unwittingly at war with the other faction. not that i'm at war with them but they are at war with me. in the words of many a beauty pagent contestant, "why can't we all just get along?"

Anonymous said...

I stumbled onto your blog and must say I love it. As a vetran OR nurse and been caught in the middle of 'turf wars', I find myself chuckling. Whether it be about the schedule not moving fast enough or Dr. So-and-So needing to bump Dr. What's-his-name, there is nothing (and I mean NOTHING) worse than an Orthopedic surgeon scorn.

Charity Doc said...

The best solution to an ER consult is to go in and see the patient, lay hands on the patient, put a note on the patient's chart and deem the case nonsurgical, non-GI, non-renal, non-ENT, non-plastics, non-OFMS, non-neuro, non-neurosurgical, non-ortho or non-whatever. Saves a bunch of headaches, not only for the consultants involved, but also us ER guys. As an ER doc, once a surgeon has seen the patient and deem the case nonsurgical, I am armed to tell the medicine folks, "Listen, the surgeon has seen the patient and he doesn't think it's an acute surgical problem." Or the other way around.

The reality of things is that ~95+% of the time the ER doc intuitively knows if the problem is surgical or non-surgical, at least for an old coot like me who's been around the block a while anyway. The remaining <5% of the time, the case is iffy in which only time and serial abdominal exam can tell because more often than likely, an imaging study such as a CT scan with PO and IV contrast has already been done. It's that <5% of time that the medical and surgical folks invariably butt heads on as to who will admit primarily. To me, I don't see how it matters as to who admits if both the surgeon and the medicine doc are on the case. Two heads are better than one, right? But it never fails that both will refuse to admit and punt to the other. In situation such as this, I always apply the big umbrella or big circle approach. I draw everyone, all the consultants, under the big umbrella or into the circle, then I walk out and let them pow-wow among themselves.

"Dr. Surgeon, I am formally consulting you to see this patient in the ED. By staff bylaws, you have 2 hrs. to respond and see the patient. If you choose not to, I will be forced to report the incidence. To be fair, I have also consulted Dr. Medicine on call to see the patient as well, since you think that this case is more of a medical problem but the medicine doc does not. The two of you can hash it out amongst yourselves as to who will admit primarily. All I know is that I have a sick person who needs to be taken care of on an inpatient basis. If you disagree, you can discharge the patient home yourself. Thank you."

"Doctor Internist/GI/Nephrologist/Cardiologist/etc.., remember that patient that I called you on earlier? I have already consulted the surgeon, who will be seeing the patient in the ED. To be fair to him/her, I am also formally consulting you to see the patient in the ED since the surgeon thinks that it's more of a medicine case and you do not. By staff bylaws you have 2 hours...I'll let the two of you pow-wow with each other as to who will admit the patient primarily. If you disagree with my assessment that this patient needs admission, then you can discharge the patient yourself. Thank you."

I've done this countless of times over my career and never once had a patient discharged by either consultants. There was this one time when a young, fresh out of residency internist refused to even come to the ED and see the patient after the surgeon laid his hallowed hands on the man and agreed with me that the case was nonsurgical (the gastroenterologist, of course, was only willing to be a consultant on the case). Needless to say, that young internist was dearly reprimanded and eventually had his clinical privileges revoked as we established a pattern of dereliction on his part. The surgeon was kind to admit the patient and consulted another internist as well as gastroenterologist.

The majority of times the argument concerns acute pancreatitis and small bowel obstructions. Most of the time the medicine folks will balk on these cases when all the patient really need is bowel rest and NGT decompression if it's an SBO.

SeaSpray said...

Very interesting post. I think you were meant to run in to each other in the elevator and I think it is great that you were able to work it out.

Obviously though, that instigating surgeon was was feeling threatened by you and underscores your point about competition and egos, etc. What a waste of energy, although I suppose those egos help get you through the grueling residencies.