Improving relationships with difficult consultants
At times, relations between ED physicians and on-call consultants can be strained, or even downright adversarial. "When you are an emergency physician dealing with a difficult consultant, it's an awkward situation," says Alfred Sacchetti, MD, FACEP, research director of the ED at Our Lady of Lourdes Medical Center in Camden, NJ. "You are balancing the fact that you need a consultant versus trying not to alienate somebody whose services you need."
Consultant issues are one of the most challenging areas for ED managers, says Charlotte Yeh, MD, FACEP, chief of emergency medicine at New England Medical Center in Boston. "It's a very difficult, dicey area for the ED, because on the one hand, our first and foremost obligation is to our patients, making sure they receive medically appropriate care in a timely fashion," she notes. "At the same time, you need to be cognizant of the political importance of maintaining good working relationships with the medical staff."
Here are several ways to avoid hostility and improve relationships.
Consider the consultant's point of view. "It's always easy to jump to the conclusion that it's the consultant's attitude which is problematic, but it's also important to explore circumstances that may be making it difficult for them to respond," says Yeh.
Avoid criticizing the consultant and emphasize patient care. "Instead of pointing fingers at individuals, focus on what is the best practice," advises Yeh. "If you come from a perspective of what is best for patients, in most cases you can resolve the problem."
Document difficulties. It's important to record problems in the minutes consistently, and forward them to the appropriate committee, recommends Sacchetti. "Document how many consults there were in the past six months, and how the other three neurosurgeons come in but this one refuses," he says. "By putting it in writing, you create a paper trail that hospital administrators will respond to."
Don't take abuse. Typically, consultants are viewed as revenue producers for the hospital, and some take advantage of that perception. "An issue may center around a very heavy admitter to the hospital who doesn't feel he has to follow normal procedures," says Sacchetti. "There is a problem when an entire department has a stranglehold on the hospital and wants to play by different rules."
The first step is to try to reason with the medical staff member, says Sacchetti. "If you've been at the hospital long enough, you probably have a personal relationship with them and can rely on that to some extent," he adds. "If that doesn't work, you need to tell them, you haven't given me a viable option, and may also want to remind them they are running the risk of losing their Medicare privileges."
Use federal requirements as leverage. Remind abusive consultants of federal requirements. "If somebody growls at you when you ask them to come in, you should not be intimidated by that," says Sacchetti. "EMTALA has given us a lot of power. The reality is that the most powerful admitter to the hospital cannot overcome the amount of money the hospital loses if they get sanctioned by Medicare."
Stress that the application of COBRA/EMTALA applies to the entire hospital, not just the ED. "The ED may be the focal point where issues come to the forefront, but the solutions have to be institution wide," says Yeh. "Remember that consultant responsiveness does not just apply to a patient in the ED. It applies to any patient with an emergency medical condition, wherever they are in the hospital, such as an inpatient who is not yet stabilized."
Don't compromise patient care. "If you have a critically ill patient who absolutely needs a consultant because it's life or limb threatening, it's basically no holds barred," emphasizes Sacchetti. "Tell them, you are needed in this time frame, you are the radiologist, I need this study done immediately because we don't know if this person has an aneurysm or not. In a critically ill situation, it's rare for the consultant to be that obstinate."
If they won't comply, call the chairman of the department, urges Sacchetti. "If the chairman won't back you up and the consultant you desperately need won't come in, your next step is to call the hospital administrator and tell them the following: I am packaging this patient up to transfer them to another hospital because they need this service immediately and I can't obtain it here. Just so you know, this violates every federal regulation I am aware of, but if I don't do this, this patient may die," he says.
The administrator will almost definitely convince the reluctant consultant to come in, Sacchetti says. "If the consultant absolutely refuses to come in, the emergency physician is obviously violating the EMTALA regulations by transferring the patient, but given the circumstances, I doubt anybody would hold them responsible," he notes.
In such an extreme scenario, the ED physician would probably not be liable for a violation. "If you follow the letter of the law, you would be allowed to transfer the patient if those consultant services are not available to that facility at that time," says Sacchetti. "Technically, you could say, it's true that we have angiography here, but that service wasn't available to me because the consultant refused to come in."
Be flexible. At times, it may be possible to compromise with consultants. "This strengthens the ED physician's relationship with the medical staff, and assures immediate service when a consultant is needed quickly," Sacchetti explains. "Obviously, this presupposes that the patient is not inconvenienced or placed in any danger."
A consultant may offer a reasonable alternative to an immediate consult. "For example, a patient presents with a severe dog bite to the hand, but no nerve or vessel injury," says Sacchetti. "The hand surgeon wants the ED physician to clean and debride the wound, dress with an antibiotic ointment, splint and sling, but do not suture. Instead, the patient would follow up the next day for a delayed primary closure." This course of action would be acceptable to most ED physicians, he notes.
Another scenario is a patient who comes to the ED at 1:00 a.m. in no respiratory distress, but, on inspection of the posterior pharnyx, there is suspicion of a peri-tonsilar abscess. "In a telephone consult, the consultant suggests hydrating the patient, administering antibiotics and a large dose of steroids, giving a reasonable analgesic and observing the patient," says Sacchetti. "The consultant will stop by at 7:00 a.m. on the way to the operating room."
Since the steroids will take between four and six hours to produce an effect, there is no need for an immediate exam by the consultant, says Sacchetti. "The patient needs this time to declare what type of disease is present or evolving," he explains. "If the medications work and the patient improves, then the consultant can discharge them when they see them in the morning. If the medications do not work, then the patient has failed conservative treatment, but at that point the consultant will now be there in the ED."
If, in the interim, the patient's condition changes, the ED physician can call the consultant and request an immediate exam, Sacchetti says. "Also, the ED physician needs to be very comfortable in their own assessments of the patient," he stresses. "If for example, the physician was afraid that patient might develop airway problems, then regardless of the consultant's recommendations, the consultant must come in."
These compromises can go a long way toward improving relationships with consultants, he notes. "These types of acts are courtesies, and we are by no means obliged to practice in this manner," he says. "But if I can reasonably hold a patient in the ED until morning for a consultant to see before rounds, or stack two or three admissions together and wake an admitting attending just once rather than three separate times, then I created an ally on the medical staff."
Make smart use of observation units. When it's necessary to hold patients in the ED's observation unit, that time can be used for the convenience of consultants. "Observation units are a gold mine when what you really want is a little tincture of time to help define the case for the consultant and for you," says Sacchetti. "We use our pediatric observation unit frequently for that purpose, when the consultant doesn't need to see the patient right away, and you're comfortable with that."
Work on your presentation. "If you present your request as if you're going to force the doctor to come in no matter what, you will probably meet with resistance," says Sacchetti. "The doctor is more likely to come in if you have a flexible attitude. As long as patient care isn't compromised, you can make those deals."
Keep patients informed. If a consultant is reluctant to come in, let the patient know why they are waiting, but resist the urge to place blame. "Let the patient know early on that you're having a little trouble getting ahold of the consultant, who is tied up at the moment, but assure them they will be taken care of," Sacchetti recommends. "That way, they will understand why they are waiting and not take out their anger on the ED."
Don't request unnecessary consults. ED physicians shouldn't vary too widely in how often they request consults, says Sacchetti. "Every ED has variations, but you want those to be as narrow as possible, so that most people are consulting about the same amount," he explains. "In defense of consultants, they are sometimes forced to deal with unreasonable requests from the ED."
Try to look at the situation from the consultant's point of view. "Most emergency physicians don't like it when the ED is very hectic and a practitioner sends a patient they could very well handle in their office to the ED just because it's late in the day," notes Sacchetti. "A consultant is likely to feel the same way if an ED physician requests an unnecessary in-person consult just because they don't want to treat a patient most other emergency physicians would have no difficulty with."
Still, even if an ED physician frequently requests unnecessary consults, the burden is on the consultant to come in. "If the ED physician is uncomfortable for whatever reason, the consultant is still obliged to believe that patient is at risk," says Sacchetti. "Even though one of the reasons the patient may be at ris is the physician is not competent, the consultant still has to come in."
The consultant then has the right to request that the ED physician provide additional education, says Sacchetti. "If you have an outlyer who is annoying the medical staff by doing too much consulting, the medical staff has a right to insist that doctor take some additional courses to raise their competency to the rest of the ED."
Manage pain of patients waiting for consults. If it's necessary to wait for a consultant to come in, be sure the patient's pain is managed adequately. "If the consultant doesn't want to come in for several hours, give the patient plenty of pain medicine to make him comfortable," says Sacchetti. "However, if the urologist doesn't want you to give any pain medication and isn't going to come in for four hours, that's a different story. In that case, you're compromising the patient, which is unacceptable."
Let the consultant know when you did something for his or her convenience. "You can let the consultant know up front that you're going to put a patient in the observation unit overnight, so they can see them in the morning," Sacchetti suggests.
Another approach is to avoid calling the consultant during the night shift. "In that case, call the consultant right before your shift ends at 6:30 a.m., and tell them, I've got this patient who came in at 3 in the morning, and I just didn't think it was worth waking you up from a sound sleep for this, so this is what I did," says Sacchetti. "They will be extremely grateful, and when you do wake them up, they know you really mean it."
Be educated about federal COBRA/EMTALA requirements. "You need to be aware of the rules and explain it to the hospital administrators," says Sacchetti. "Tell them, I understand this guy admits 4000 open heart cases a year, and the hospital does great with it, but if you stop getting paid for 3000 of them because you get sanctioned by Medicare, we will have a problem. That's where EMTALA has empowered emergency physicians to do the right thing."
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