Handling confrontations with consultants in the ED
(Editor’s note: This is the first of a two-part series on management of conflicts between the ED and other hospital departments. Next month, we will cover other departments, and a guest column will discuss why the ED is a frequent source of conflict in hospitals.)
Interactions with consultants are among the most challenging for ED staff, says Kathy Clem, RN, emergency medicine division chief at Duke Uni versity Med ical Center in Durham, NC. "Consultants really don’t understand what we do. They are convinced they can do what we do better and make a sport of second-guessing you. You need to have a proactive plan on how to deal with consultants." (See related story, p. 131.)
A training course was developed for residents and attending physicians based on the "ABCs of interaction repair with consultants" — A. Identify the consultant’s Agenda. B. Look at the Big picture. C. Communicate. The ABCs were created by Clem and a colleague at her former post at Loma Linda (CA) University Medical Center and Children’s Hospital.
Here are several commonly heard remarks by consultants and expert tips for how to handle each:
• "The patient doesn’t need to be admitted." Lis ten to the consultants first, because they may have information to contribute. After listening, if you still think the patient needs admission, don’t back down. "Acknowl edge their comment but hold your ground," she advises. Say, "I still feel the patient needs admission. Feel free to send me a copy of the discharge summary, or after you see the patient, let me know what you think.’ Sometimes you have to say, I’m the doctor seeing the patient right now, and this is my assessment.’"
• "That patient was in the ED for four hours, and you don’t know if his grandmother had hyper tension." Explain that you have done a complete work-up, but that bit of information didn’t help you care for the patient, she says. "You need to communicate with a sense of humor by saying, That’s right, I don’t know that. We did the ED work-up and left something for you.’"
• "I don’t care if I am on call. I’m not coming in." Before you react, give the consultant the benefit of the doubt. "Perhaps there was something about the presentation you weren’t clear about," says Clem. If that isn’t the case, be firm with the consultant. Say, "I can understand your position, but this isn’t the time for this discussion. Let’s discuss it at the staff meeting on Monday.’ Ask the consultant, If you’re not coming in, which colleague would you like to call to take your place?’"
• "Why didn’t you call me sooner [or later]?" The consultant may have wanted a call when the patient got to the ED or after the X-rays were read. "Explain to them, If I had known what was going on sooner, I would have called you sooner. It’s to my advantage to get you involved early. I’m glad to know what your preference is. Next time I’ll do it this way,’" she says.
• "I’ll be in to see the patient. In the meantime, get a stat mammogram." The consultant thinks a mammogram is needed but doesn’t realize that test isn’t typically done in the ED. "Say, Yes, I’m glad you thought of that test, but we generally schedule that after the patient is admitted,’" says Clem.
• "You dumb ED docs always admit every chest pain patient." This is one of the hardest scenarios to respond to, because the consultant is not only attacking your work-up, but also you and your colleagues, Clem explains. "All of us have heard something like this. Their agenda is they are angry you’ve called them, and they think you’re being overzealous."
The best strategy is to address the specific complaint, instead of the generalization. "Tell the consultant, No, we don’t always admit chest pain patients. In fact we’ve sent home four tonight, but this one needs to go in,’" she says. If a consultant is rude, don’t hesitate to confront him or her about it. "Say, There is no reason to be rude to me or my staff. Let’s talk about this.’ Sometimes they need a mirror held up to see how they’re reacting."
• "What do you mean, the X-ray hasn’t been done yet?" Consultants want the right tests and procedures to be done for their patients, and they’re impatient if they have to wait. "Explain that the lab is backed up, the nurses are all busy, and suggest they add it as part of the admission orders. Or have them admit the patient and call them later with the results," Clem suggests. The idea is to find creative ways to work around what is going on in the ED. "Explain to the consultant, I’ll be the first to admit things don’t always go as smoothly as we like. So let’s work together to solve this problem.’" she says.
• "Couldn’t I just see this patient tomorrow in my office?" You need to explain why, in your opinion, it wouldn’t be safe for the patient to wait. "Or the consultant may say, I just saw this patient today.’ Explain to them, Yes, that is the same patient, but things have changed,’" says Clem.
• "OK, I’ll come in and see the patient. Start an IV and put them on oxygen." Patronizing comments can be irritating. "But try not to take it personally because the consultant may just be thinking out loud," she says. "Instead, explain that Our medics do that. We are a full-service ED and have already done the basics.’ Convey that you know your stuff and that you’ve already done what they’re asking."
• "Don’t call me unless the attending radiologist has read the C-spine films." Consultants don’t want to come in unless it’s necessary, and they don’t trust your reading of the film. "You can tell them, The films don’t look normal to me. Come in and tell me what you think,"’ says Clem. "You can establish credibility by having the radiologist see for themselves and confirm what you are saying. Then the next time you call the consultant, I doubt they’d say that to you."
• "You can see the patient, but don’t do any labs or X-rays." The agenda here is often an HMO’s requirement, she says. "But the big picture is that the patient is in the ED. Legally and morally, we’re required to stabilize the patient, so communicate that to the consultant."
Source
• Kathy Clem, RN, Emergency Department, Duke University Medical Center, P.O. Box 3869, Durham, NC 27710. Telephone: (919) 684-5537. Fax: (919) 684-8489. E-mail: [email protected].
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