Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, January 07, 2009

Insufferable Twits and "Shitty Consults"

One small agreement doesn't make for much of a truce, at least when certain insufferable twits post nonsense like this.

The topic is so-called "shitty consults." A certain hospitalist of ill repute reduces all consults into a punnet square of time and effort, in which any virtually every encounter with a consulting physician can be labeled "shitty." Qualities which enhance the "shittiness" of the consult include those that take time (too much, presumably) and dealing with patients who are awake, hospitalized, sick and/or have multiple problems. Of course the level of payment that can be expected is a major contributor to the "shit" factor, as are those consults that occur at inconvenient times of the day (or, more frequently, night.)

Look, I understand as well as the next guy that the internet in general and the medical blogosphere in particular is a place to vent. I don't deny that much about hospital medicine can be frustrating, and I have no problem with generalized bitching and moaning about it. But in spite of the world's wimpiest disclaimer ("Docs, you know it's true, however crass that statement is,") labeling sick people in need of help -- whatever their insurance status -- as "shitty consults" is over the line. Hey, emergency medicine has a set of patients they hold in similar contempt, but at least they have the finesse to use euphemisms like "frequent flyers" or cool neologisms like "fibromyalgeurs" and "crayzees." We in outpatient medicine have our PITA patients as well, but as a rule, even we call them "bullshit" instead of just plain "shit."

Tell you what: I think we should eliminate all payment to doctors for hospital services. Just pay the hospital and let them deal directly with the hospitalists, a profession that ought to expand to include inpatient versions of all the other specialties. Surgeons and OBs are moving to this with surgical hospitalists and "laborists." Expanding it to include interventional cardiologists, pulmonary intensivists and all the others HH has to consult with (but very rarely, because his skills are so broad he can handle just about everything his hospitalized patients may need) is just the logical next step. Let them all work out a schedule so there's all the in-house coverage they need. Hell, maybe the hospital can truly become operational 24/7 instead of shutting down at 5:00 every day (4:00 on Fridays until Monday morning.) If nothing else, they may come to realize that taking care of hospitalized patients is actually their job, as opposed to just a series of "shitty consults" imposed on them while they're trying to cobble together a living taking care of ambulatory patients.

Seems to me there are far more shitty consultants than there are "shitty consults."


At Wed Jan 07, 05:56:00 PM, Blogger Dustin said...

Damn, I just ran out of popcorn, too.

At Wed Jan 07, 06:12:00 PM, Blogger Ninja Pharmer said...

I'm dismayed. Truly, honestly dismayed.

At Wed Jan 07, 06:15:00 PM, Anonymous Anonymous said...

It takes a lot of stones (and a lot of compassion) to be a regular, general practice family doctor. You have to actually give a shit about your patients. In many ways you entwine in to their lives -- you need to know their histories, their habits, their "tells" (when they fib)...

And you have to give shit about them as people. They have to be more than a billing or diagnosis code. You have to be genuinely interested in their well-being and welfare. You kind of have to be interested in how they fare after they are out of your claws.

Patients (and their families) can tell if you're insincere, and don't give a fuck about their outcomes. They can tell that they are an onerous chore -- one more tick mark, one more code to enter. Setting aside the Press-Ganey bullshit that will engender, it's also likely to make the patient think the doc in question is a raging dickhead. In private practice (or specialty practice) it means patients are going to leave in droves. In a hospital setting, it means they will complain.

Once patients have been reduced to bed numbers, billing codes and dollar signs attached to treatments, that compassion is lost. Once you don't really give a shit, you're giving out shitty consults -- and likely, your patient think you're a shitty consultant.

(Anecdotally, I know at least one doc who was willing to drive forty-five minutes -- "bringing the mountain to Mohammad" -- to a patient who was in the throes of an ass-kicking asthma attack. Same doc called multiple times over a holiday weekend to check in, too.)

At Wed Jan 07, 07:07:00 PM, Blogger shadowfax said...

No offense, but I think you missed the point that Happy was trying to make. I have no brief for him, but as an ER doc, I know exactly what he was complaining about. It's not that *he* thinks the consults are shitty, but he gets grief from consultants who don't want the shitty consults. And the consultants will tell you up front that they think it's shitty. As an ER doc, I have to deal with the same thing. I can tell you in advance when it's going to happen. I call up the GI doc at 2AM for an uninsured encephalopathic liver failure patient with melena, and I'm going to get an earful. 100% of the time. Even the nice docs (and there are many of them) have been known to lash out at the consulting doc when faced with such a dump. I think Happy nailed it on the head -- a consult which is hard, time-consuming, and uncompensated will get you grief from the consultant, and his response is the same as mine, "I'm sorry, but I didn't make them sick/bring them in."

At Wed Jan 07, 07:09:00 PM, Blogger The Happy Hospitalist said...

Hey doc. I'm not the one who stopped me and said, "Thanks for the shitty consult."

I'm trying to define a shitty consult as viewed through the eyes of people I ask for assistance.

I'm a hospitalist. Those issues I brought up don't apply to me, in general, because of the way my practice is structured.

As far as bundled payments, I welcome it. Hospitalist medicine would thrive even more because of the value we bring to the table. Gainsharing in hospitalist medicine would be wonderful.

It's nice to see you linked to me twice in one week. I feel honored by your generosity. Deep down I know you really love hospitalists. And Happy ones too. :)

At Wed Jan 07, 07:13:00 PM, Blogger The Happy Hospitalist said...

shadow fox. I just saw your comment. You pretty much, nah, you nailed it on the head. Thanks for saying what I thought was obvious, at least for those that understand.

It wasn't even a rant. It was more of an explanation of why others act the way they do.

At Wed Jan 07, 07:16:00 PM, Blogger The Happy Hospitalist said...

Oh, and I just realized I've been called a twit, twice in a week. I must be doing something right.

At Wed Jan 07, 07:35:00 PM, Blogger Nurse K said...

...but very rarely, because his skills are so broad he can handle just about everything his hospitalized patients may need...

95% of Happy's posts in a nutshell right there...

At Wed Jan 07, 09:18:00 PM, Anonymous Anonymous said...

I spent too much time resenting "bad consults" The way insurance works in my state, my specialty is usually not paid for inpatient consults. I viewed a consult as "bad" as one where my services weren't really needed. I realized that I resented inpatient consults because I didn't really own them as my responsibility; they felt like an unfair imposition from the hospital. Now I try to tell myself "there's no such thing as a bad consult" If I can't help the patient, I look at how can I help the hospital (or the family or the attending or the social worker). I feel less resentment now.

a good consult is one where the patient needs someone with only the knowledge that my specialty has! A consult where it matters what I do!

Now that we have hospitalists, I see less lab results that have not been followed up on when I do inpatient consults.

(obviously I still haven't fully come to terms with the requirement to do consults)

At Thu Jan 08, 12:20:00 AM, Anonymous Anonymous said...

I haven't followed your pissing match with the HH, so I don't know the details, but I'm so f-ing sick of physicians bad-mouthing each other constantly, be it on blogs or in "real life". There is this constant need by so many of us to talk about how dumb another doc or group of docs is and how stupid their treatment, workup, etc. and how they're wasting our time. Is it because deep down most of us are insecure and worry we'll be "found out" and that degrading other docs makes us feel less insecure?

We're all in this together. I would argue that very few of us know EVERY medical fact and have PERFECT medical judgment in every situation. That means essentially all of us are able to learn something from somebody else. Let's look at consults as chances to learn from each other and all become better doctors and quit bad-mouthing each other.

At Thu Jan 08, 02:49:00 AM, Blogger Sara said...

All hospital doctors here are salaried - some senior ones can receive additional payments for patients requesting their "private" services but it isn't the rule. It seems to me like a system that works, even though the salaries are shitty and I probably wouldn't be willing to work for one. But if the salary were fair, I would.

It also cuts down on procedures - they do them if they are there, but there's no financial incentive. (The downside - there's also no financial penalty as "the system" pays for everything, so no one ever thinks about cost control.)

A subspecialist makes a little more than a hospital-based internist, but not much (the last conversation I had - a general hospital pediatrician's daily rate was about 175 NIS a day, and the peds GI made 215). No one would do it for the money, that's for sure. The incentive is the lifestyle - subspecialists do more clinic and consults, not the inpatient grind every day. And if someone is career/research oriented, then they stay in that system because there's nowhere else to do that.

At Thu Jan 08, 10:09:00 AM, Blogger The Happy Hospitalist said...

anon 0249: The pissing match is one sided. I have nothing against Dr Dinosaur. My patients love me. The ones that wish to be patients. The ones that just want to abuse me, they hate me, because I won't allow it.

As far as my shitty consult post, I was extrapolating a comment directed at me. I was neither offended nor disgusted. It was said, and that's reality.

At Fri Jan 09, 07:37:00 PM, Anonymous Anonymous said...

Please do tell the difference between "bullshit" and "shit". Jeez, nothing more than a play with words. But, since you haven't managed a patient in the hospital since W's dad was prez how would you know what it is like eh?

Nurse K: don't you need to go beg for money via paypal on your own website?

At Fri Jan 09, 10:23:00 PM, Anonymous Anonymous said...

You insult radiologists, pharm D's, lab, surgeons, medicine subspecialists, hospitalists, AND patients on your website and you get your get pissed over a "shitty consult" Wow, what a hypocrite.

At Fri Jan 09, 10:26:00 PM, Anonymous Anonymous said...

PS: I forgot ER docs, RN's, and anybody associated with insurance or pharma.


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