Dear Director,
I called the surgeon for an admission. They thought the patient could go home and follow up in two days. I didn’t think this was a great idea but I’m new at my site and find it hard to push back against the older, more experienced consultants. Unfortunately, the patient had a bad outcome and needed emergency surgery. I know I’ll be in the situation again, so what strategies can I use to get them to admit my patient the first time?
There’s a moment in every emergency physician’s early career that burns itself into memory: the first time a consultant confidently says a patient can go home… and every cell in your body whispers No, they can’t.
You hang up the phone, stare at the chart, and feel it—that heavy pressure in your chest.
That’s not self-doubt. That’s responsibility.
And if you’re new, that weight feels even heavier. The hierarchy is steep. Consultants may have 20 or 30 years in the building. They know every nurse, every hallway, every unwritten rule. Meanwhile, you’re still figuring out where your favorite bathroom is located`.
How do you challenge someone who has been practicing longer than you’ve been a doctor, and should have more knowledge and expertise than you in their field? How do you advocate for a safer disposition without sounding confrontational or insecure? And how do you do it when you’re still earning credibility in a new department?
Whether it’s a patient with a possible acute coronary syndrome, a posterior circulation stroke, or an ectopic, I can guarantee you that you will have a consultant, who is at home, make a recommendation that you know in your gut to be wrong, but you’re unsure how to disagree with them after you called them for advice.
This isn’t about winning an argument. It’s about recognizing a leadership moment when it shows up—often quietly—and choosing not to step around it.
Why This Feels Hard (And Why You’re Not Wrong)
Even seasoned emergency physicians feel tension when pushing back on consultants. When you’re new, it’s amplified. You assume the consultant must know something you don’t. You assume your discomfort might be inexperience.
But here’s the part every young ER doc needs to hear clearly:
Your instincts matter. And in that moment, your assessment is often more accurate than the consultant’s. Not because you’re smarter or better trained, but because you’re closer to the patient.
They’re hearing a summary. You’re watching the trajectory. That subtle grimace when the patient moves. The new tachycardia. The labs trending the wrong way. The story that doesn’t match the exam.
Consultants see disease. We see danger.
Both perspectives matter. But only one determines whether the patient walks out safely.
There’s another reality that’s uncomfortable but important to acknowledge. When outcomes go bad, consultants who provided phone recommendations are rarely standing next to you. Standard lines I’ve heard from consultants in these scenarios include:
“I wasn’t given the full story.”
“My advice would have been different if I’d known X.”
“I was only offering guidance, not making the decision.”
If you felt something was off and the advice didn’t land right, you still have options—and you should use them.
Phone a Friend — Or Two
We all have had that “Oh, sh*t” moment when we hang up the phone with the consultant and can’t believe we agreed to their plan. If a consultant’s plan feels unsafe, you’re not stuck. And trust me, we’ve all had that moment in the middle of the night during our first year as an attending when we call back to our residency to say hi to the attending, and “oh by the way, can I ask you a question.” But we can’t always call our former attendings, so we need a better “phone a friend” plan. Here’s what you can do:
- run the case by a colleague working with you
- call a trusted friend at another site
- reach out to your medical director
- keep the patient for observation and repeat key labs
- get another consult from a different specialty
In emergency medicine, a second opinion is not weakness—it’s risk management. And if you need to call the first consultant back, stick to the framework below.
You Don’t Need a Script. You Need a Framework
A lot of physicians ask for the “magic words” to convince a consultant.
But this isn’t about phrases. It’s about having a structure that keeps you clear, calm, and confident—even when the other side isn’t.
Here’s the pneumonic that can serve as a conversation outline: ANCHOR. Think of it this way–these conversations are tricky and stressful and sometimes we just need to re-anchor ourselves around patient safety. AI helped me create it, but the process pulls heavily from crisis resource management, Harvard negotiation principles, and classic ED risk-management strategies.
ANCHOR – A framework for pushing back in high-stakes consults
A – Align on the shared goal
“We both want the safest outcome for this patient.”
N – Name the concerning facts
Objective data, trajectory, red flags, gut-check concerns.
C – Clarify your recommendation
Be explicit: admission, observation, surgery, or higher level of care.
H – Highlight the risk of the alternative
“My concern with discharge is X happening overnight.”
This is also an opening for a discussion, creating an opportunity to better understand their logic and ask more questions.
“What makes you comfortable with discharge?”
“What would change your mind?”
You’d be amazed how often this exposes incomplete thinking.
Their answers may also reassure you that their logic and decision making is reasonable and well thought out. Part of our professional responsibilities is having the ability to have thoughtful and meaningful discussions with other physicians to determine the best course for our patients. I don’t expect you to change your mind frequently, but we should be open to the discussion.
O – Offer collaboration, not conflict
“What would make you more comfortable admitting?”
“Is there another service we should involve?”
R – Record and escalate if needed
Document the discussion and escalate respectfully if risk remains.
Escalation isn’t a threat; it’s a safety mechanism. I don’t get a lot of cases escalated to me. Most frequently for me, it’s about an issue where the ICU docs don’t think a patient needs their beds or the hospitalist won’t admit someone (the recurring situation that comes to mind is a patient with liver failure who really needs to be transferred for a transplant).
In these situations, I’m usually talking to the ICU or hospitalist medical director (who also likely is not involved with that patient) and we’re doing an independent review trying to figure out what’s best for the patient. Typically, it’s not hard for the department leaders to be on the same page in a short amount of time and get a final plan in place.
Once you start using ANCHOR, I promise—your conversations will get smoother, and your confidence will grow.
Here’s a few other points to consider.
Advocacy Isn’t Optional. It’s the Job.
How often do you tell patients that we think in worst case scenario? Emergency medicine is fundamentally about risk management.
If the consultant is wrong, the consequences can be catastrophic.
If you’re wrong, the patient spends a night in the hospital.
That asymmetry matters.
Consultants often minimize risk because they focus on pathology: This doesn’t look like a surgical abdomen. Emergency physicians focus on uncertainty: Something is happening, and this patient isn’t safe for home.
And protecting patients in uncertainty is our specialty.
As one of my colleagues used to remind the cardiologists:
“We see a lot more patients in the ER presenting with chest pain who have a STEMI or die, than you will ever see walking into your office.”
That perspective isn’t arrogance—it’s reality.
Tone Matters More Than Words
You can be assertive without being confrontational. Firm without being disrespectful. Confident without being combative. Tone matters.
Try:
“I hear your perspective, but here’s what I’m seeing.”
“I want to make sure we’re aligned on the risk I’m worried about.”
“From the ED standpoint, I don’t think discharge is safe.”
These keep the door open while anchoring the conversation firmly in your lane.
Document Like the Future You Is Reading It
When you disagree with a consultant:
- document your concerns
- document their recommendation
- document why you believe admission was safer
- Request they see the patient in person and leave a note
Avoid:
“Patient safe for discharge per consultant.”
Instead:
“Consultant recommended discharge. I expressed concerns regarding X, Y, Z. We discussed risks and options. In my judgment, admission was safer, but consultant proceeded with discharge.”
Professional. Neutral. Protective.
Credibility Gets Built Before the Disagreement
Consultants form an opinion of your judgment long before your first conflict.
Build trust by:
- calling with complete, crisp presentations
- being reasonable when cases can go home
- following up on admissions to learn outcomes
- asking questions outside of tense situations
When a consultant knows you’re thoughtful—not prone to oversell your admissions or just admit everyone—your concerns carry weight.
You Will Be Wrong Sometimes. That’s Okay.
Sometimes you’ll push for an admission, and everything turns out fine.
That’s not a failure. That’s emergency medicine.
A cautious admission is an inconvenience. A premature discharge is a catastrophe.
There’s no comparison.
Bad Outcomes Leave Scars — But They Also Shape You
The case you described will stay with you. We all have one. It doesn’t mean you failed. It means you’re playing a high-stakes game where even correct decisions can have bad outcomes. Use it to grow.
What to Say Next Time
Here’s a go-to script you can adapt:
“I understand you think the patient can go home. Here are the findings that concern me: [two specific points]. Based on their trajectory and the risk of deterioration, the safest disposition from the ED is admission. Why don’t you come see the patient yourself or if we’re not aligned after this phone call, I’m happy to involve my chair or another service so we can make a plan that protects the patient.”
Conclusion
While maintaining professionalism, our job isn’t to be agreeable—it’s to be accountable. When your clinical instincts say a discharge is unsafe, that’s not the moment to obey hierarchy, but rather you should step into your role as the final safeguard. We’re usually calling consultants for advice and don’t expect to need to push back.
And while professional differences of opinion are to be expected (particularly with our hospitalist partners), if the recommendations just seem wrong, you will need to push back. Use a structured framework, communicate clearly and respectfully, escalate when necessary, and never apologize for advocating for safety. Unnecessary admissions are inconveniences. Unsafe discharges change lives.
Photo Credit: Engin Akyurt
