hangingbatI admit a 52 year old lady to the surgery service to have the nasty stone-filled inflamed sac “formerly known as her gall bladder” removed.

I call up the resident and describe the case. High white count. Ugly ultrasound. The patient looks sick. She got her antibiotics and an IV fluid bolus. The resident asks about her medical history. Actually, the patient was fairly healthy. She had controlled hypertension, a bit of arthritis in her knees, and that was it. Heck, if it wasn’t for this gallbladder looking like some sleeping bat hanging upside down off of her liver, she’d be in great shape.

“We’re not taking her. You’ll have to admit her to General Medicine for pre-op clearance and then consult us.”
“OK, fine. I’ll admit her to medicine, but you’re still going to need to come down here and see her.”
“Did you consult Ortho?”
“For what?”
“Her knees.”
“What about her knees?”
“You said that she had arthritis in her knees.”
“So? She’s had arthritis for 10 years.”
“You’re going to have to call an Ortho consult.”

It was the end of the shift and I was getting irritated.
“Listen. Maybe you didn’t hear me. This lady is sick. I’m not consulting Ortho for a chronic knee problem. I’m not consulting Dermatology for the zit on her forehead. I’m not consulting Plastics for the frown lines on the bridge of her nose, and I’m not calling Psych because she forgot the name of her antihypertensive medicine. Now get down here and evaluate the patient.”

“Never mind. Just let Medicine know about her and send the patient upstairs. I’ll see her when she gets to the floor.”

This interaction made me wonder about the apparent lack of insight about the urgency of a bad gallbladder over chronic arthritis in the knees. Is our residency training getting so specialty-specific that the graduates no longer feel comfortable providing basic medical care in other specialties?

“Sorry, you’ll have to go to the “high risk” hypertension clinic. I only treat systolic pressures up to 170.”

Picture credit here


  1. I transcribe for an attending like that. First words out of his mouth are the patient’s name. The next string of words is the 2-5 consults needed for every minute problem under the sun. Ridiculous. There’s definitely a pattern, though. There’s a lot of back scratching and favoritism that goes on, I’ve noticed.

  2. You hit it on the head with “change of shift.” The surgery resident saw an opportunity to not have to deal with this patient for the remaining time in his shift, but wait for medicine to “clear” her, knowing by then she would be someone else’s problem. Very mature of him.

  3. Are you not at the sort of institution where medicine would say no to that sort of dump?

    I used to get a lot of that sort of blocking, but not so much any more. Part of it is that I’ve got the local practice patterns figured out (i.e. I know that gallstone pancreatitis goes to surgery but an SBO goes to medicine, according to the service agreements our inpatient teams have negotiated). The other part of it is that I have learned to be, um, assertive, when someone tries a weak-ass block like this. As in, “I’ll be happy to call medicine after I have seen your sorry ass down here at the bedside examining the patient, if you still think it’s necessary.” Well, without the “sorry ass” bit; that’s usually in my inside voice.

  4. Any doc who causes me to make an extra call is annoying. In an ideal world, we could dispo patients with one call, or better yet a couple of clicks on a computer screen.

  5. These are the kinds of assholes who I play pager games with. They get paged to Wal-Mart, Pizza Hut, the impotency clinic, anYoud about 15 other places. If I have to jump through hoops, I make sure they do, too.

    You just don’t want to piss off your nurses. They can be a nasty lot…..

  6. that reminds me of the notify hospitalist to follow post op for medical management…

    on a patient whose only problem is hypercholesterol…

    on a patient whose only problem is stable depression…

    Dear doctor, if you want someone to take all your annoying pages, hire a full time 24 hour a day P.A. My job is not to make your job easier. It’s to take care of patients with medical problems. When I sign off the case, please don’t get mad at me. You have doctor abilities in there somewhere. It’s time to put them to use.

  7. You’ll have to admit her to General Medicine for pre-op clearance and then consult us.

    Sorry, medicine didn’t clear her based on her chronic arthritis. Sheesh, looks like we’re going to have to let her die of a ruptured gallbladder and sepsis unless ortho comes down here and does an emergency bilateral knee replacement or cortisone injections. Darn.

  8. ER docs also try to dump their entire service before their shift ends. Medicine docs like me try to stall near the end of shift. It’s human nature.

    What exactly is the medicine doc supposed to do with pus in the gall bladder? If you had a surgical emergency, would you want an internist and no surgeon taking care of you?

  9. From the guy who does the consult:

    Do you have any idea how annoying it is to be consulted for something and then:
    * see the patient,
    * explain the problem to the pt and the family
    * write and dictate the note
    * write orders

    and then have the surgeon who consulted me:

    *send the pt home on post-op day #1 with none of my plan followed? OR
    * change all my orders without asking me and then call me at 2 AM to tell me the pt is crashing OR
    *cancel all my orders but then ask for 2 more “medical management consults”

    Would you like it if I sent the pt home after you had planned a surgery, pulled out a drain, or changed your orders for dressing?

    Work with me here, docs – or don’t ask me to see your pts.

    OK – to be honest, there are lots of great surgeons (at least in my hospital) that a great to work with and really help us act like a team – but they are boring to gossip about.

  10. Do the surgery attendings support that kind of behavior? Biliary colic I might put up a discussion about; but acute cholecystitis is one of the most straightforward surgical admits I know. Like Erik says, it wastes time for both sides to make needless consults whose recommendations you don’t particularly need.

  11. This almost makes as much sense as the OB who needed a hospitalist consult on his gestational diabetic because she was insulin dependent…Said hospitalist was really not happy when he was asked to see the patient in the OR during her c-section! He said no and walked away…

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