Dr. Pookie said:
CL was the bane of my existence in residency. I'm not sure if it was because residents had zero power to refuse dumb consults (at least half) or because of the culture of "If there's no real psych problem, we'll find one."
This is a part of what I'm talking about in my above posts.
I'd love consults if all of them were valid requests and all of the people requesting were willing to work as part of a real team. I worked in 3 hospitals in residency, I don't know how many in medical school (over 10?), and as an attending over 10. In my work as a court officer I had to go to about 5 hospitals a week in Cincinnati (Summit, Mercy. VA, University Hospital, etc). After I moved out of Cincinnati I then worked in another hospital.
So I know what I'm talking about. Consults are dysfunctionally organized in every hospital I've seen. I've never seen any doctor like doing them no matter the field whether it be psychiatry, IM, surgery, Infectious Disease, whatever. It's even worse in residencies because the departments intentionally have the indentured-servants, "the help," er cough cough residents do them. At least when an attending complains the institution has some concern.
There's no protocols to prevent frivolous consults. There's no disincentives to prevent frivolous requests. There's no incentives for the consultant to do them. You don't get paid more to do them. If you do them and find this dysfunctional BS they don't listen to you if you want to fix the system.
Here's examples of protocols: 1-Why the consult (several of them did not state why). 2-Did you call the consultant before you requested to see if this consult was preventable? 3-Did you do the required protocols before requesting. E.g. if you requested a capacity consult did you discuss and document the discussion the risks and benefits of the procedure, the alternatives? What specifically calls into question the patient's capacity?
The reality is often times there was not even 1 reason requested. So we'd sometimes spend literally 30 minutes as to just why the consult was requested. So then this happens like 5x a day this was total BS. Often times with capacity consults the requesting physician never did the REQUIRED discussion on risks and benefits and alternatives. So then, and this is not appropriate, the psychiatrist would do them despite that often times the procedure/treatment/surgery in question was outside of the psychiatrist's field.
If I was the consultant in a hospital, had a decent baseline salary, had incentives to do consults such as more pay, and the requestor clearly stated why a consult was needed, and all the stuff was done so I didn't have to do the BS myself such as not spend 30 minutes on BS, I could see myself loving doing consults.
But hey what I wrote actually makes sense so it won't happen.
While I was a chief resident I put some of my plans in action and the head of the department backed me up. I knew I couldn't get away with all of my plans but did implement the ones I knew couldn't be argued against.
So I told the residents to refuse a consult if it was a capacity consult and the requesting physician didn't document they went over the risks/benefits and alternative treatments. The resident had to okay it with me. Within 24 hours a series of angry calls came in from attending physicians demanding to know why a capacity consult wasn't done and I told them to kindly talk to the hospital lawyer because they hadn't done the required minimum such discuss with the patient the risks/benefits and alternative treatments.
So for the next week I got several angry attendings, all of whom were asked to call the hospital lawyer, or I had the lawyer calling them. I had a lot of angry stares when I saw some of these doctors. The head of my department backed me up, and said "it's about time someone put their foot down" so I knew I was safe." On one occasion the hospital lawyer actually went to an angry doctor and told them I was correct and the physician was required to do what I requested. About 1 month later then all of a sudden capacity consults were having these minimal requirements done. The number of frivolous requests went down cause during the discussion the patient either changed their mind or picked the alternative treatment. Wow. So if you practice good medicine maybe the patient will be more prone to listen to you? What a shock.
On the flipside, the consultants on the other services (mostly IM) were happy with this especially cause I had our own residents do the same. They needed to try to avoid asking for an IM consultant using the same suggestions I put into place. The IM consultant told me is saved several frivolous requests.
I heard from a resident in the program the next chief didn't know WTF was going on and everything I pushed forward fell back to where it was. Not surprisingly the attendings didn't maintain what I did either. They were the ones who let this mess get to what it was in the first place.
