I HAD BEEN OUT OF RESIDENCY for several years when a critically ill patient needed a decision between two equally risky treatments. I turned to the intensivist and asked what he wanted to do.
“Not me, doc,” was his reply. “YOU are the attending and it’s YOUR call.”
That was the first time anybody had put it that way. Here was a med school faculty member looking to me for a decision—and making it clear that I was the one in charge.
You are the Big Dog
Consultants are often hugely necessary, steering us away from bad decisions and performing procedures we aren’t trained to do.
We need to listen to their knowledge and experience, but we need to do so critically. If something sounds off—a consultant refusing to transfer a patient to a hospital that can provide additional treatment, for instance, or delaying surgery that we know can’t wait—it’s time to get even more critical.
“I didn’t want to offend the surgeon” does not sound good in a hospital review committee, let alone in court.
Stella Fitzgibbons, MD
Get a second opinion, research the problem, talk to other doctors who have worked with the consultant and ask questions as tactfully as possible. At the same time, remember who has primary responsibility for the patient and act accordingly. “I didn’t want to offend the surgeon” does not sound good in a hospital review committee, let alone in court.
The same goes for family meetings. The pulmonologist can explain interstitial lung disease and its consequences better than you can. But when the patient and/or family has to make a decision, you’re the one who needs to sit (not stand) there and talk and listen.
“I’m just the weekend rounder”—NOT!
Or night doc, or filling in while your partner goes on a middle-school field trip. Stuff happens, you see a developing problem that needs to be addressed today or the patient wants to leave AMA for his mother’s funeral. Step in, doc—you’re the Big Dog now, remember?
Subbing for another doctor is not just a matter of saying, “Howdy, everything OK?” and dashing off to see the next patient. Read your partner’s sign-out notes and at least part of the progress and consult notes. Check recent labs and scan the med list because importing those to your note does not ensure that they have passed through your brain. After saying hello, discuss enough of the medical problems to let those present know that you’re ready to handle whatever may come up.
Also remember that your consultants are probably covering for associates, too, often at more than one hospital, so don’t depend on them to read your morning note before sundown. Call or text if you need to be sure that they’re up to date and that they have your cellphone number.
Calling your own consults
Have you noticed how busy those nurses and unit secretaries are? How soon do you think they’ll get around to calling the consultant’s office or answering service once they notice your order?
Go ahead, put in the order (for payment purposes), but by now you surely have important consultants’ cellphone numbers. Document in your note that you spoke with or texted Dr. Gotrocks. Sometimes you have to settle for talking to a receptionist or answering service. If so, make sure they can spell your name—and that they know you are a doctor!
If you sound young, foreign or female, many receptionists will be inclined to take you less seriously. I can hear you thinking, “Oh, Dr. Fitzgibbons started practicing in the 80s, but women doctors are more accepted now.” Wrong. Many phone receptionists are still incapable of believing that women can graduate from medical school.
Experience is not leadership
When it comes to filling leadership positions, “I’m too junior for that job” may not be a realistic answer. The gray-haired senior specialist may not want that assistant chief or committee chair position—and he or she may not be a good leader. Whether the position to be filled involves a large hospital or a five-doctors hospitalist group, look at individuals, not age.
When our national hospitalist group started insisting that every group have a leader, I turned down the offer in favor of a physician 20 years younger. That doctor not only was great at settling disagreements but organized our call schedule to something we could all handle. It’s a good reminder that occasionally, the least experienced doctor can accomplish things we jaded oldsters think impossible. A family who insists on futile treatments will sometimes be more receptive to a doctor whose concern for the patient isn’t mixed with memories of previous frustrating discussions.
Sympathy and respect
We old dogs don’t just look to younger doctors for help with the EMR. We also expect you to be more up to date on recent research findings, and we will listen when you explain them. We’ll lend our experience and do our best to steer you right, because we remember somebody doing that for us.
Feel free to complain to us; we were once at the same stage in our careers as you are now, and it doesn’t seem that long ago. We remember learning to trust the nurses, to back off when a respiratory therapist tells us the vent settings are right and to reach for a phone first in an emergency to be sure all the personnel we need are on the way.
You’re going to do fine. Stick to your guns, communicate well and put the patients first.
Stella Fitzgibbons, MD, received her MD, residency and fellowship training at Baylor College of Medicine and has been a hospitalist since 2002. She currently practices part time at hospitals and volunteers at three clinics for uninsured patients.
Published in the May/June 2022 issue of Today’s Hospitalist