Disagreements with attendings

[bjmcell]

I have a few questions. I am a new graduate and have been in the ED for almost 5 months now. As of right now I am primarily in working in the fast track and as a provider in triage. I love working in the ED and I love almost all of the attendings. For another week or so until I hit 5 months I run almost every case by whoever the attending that is on shift. Some of the attendings have started to trust me and don't have me run the cases by them and let me work on my own except for when I have questions. There are 1-2 doctors that also work in the fast track and only in the fast track that are family practice doctors and are not board certified that I have been having disagreements with. How all have you approached this in the past? I will give you a few scenarios of what have been going on:

 

1) The Nexus/Canadian C-spine/Ottawa ankle/knee rules are not followed. If someone complains of neck/knee/ankle pain, they get imaging. Even if they have right trapezius pain after lifting weights and have no midline pain and full ROM. It doesn't matter, Cervical CT. If I am in triage they want imaging no matter what. No trauma? Doesn't matter. Every single patient with a complaint gets imaging. 

 

2) Every patient with a HA gets a head CT. No questions asked. Doesn't matter if they have a hx of migraines and they come to the ED because they are out of their Imitrex, they still need a CT

 

3) Every single patient gets antibiotics. Literally every patient. URI for 1 day without a fever and a normal PE, they get Augmentin. I feel as if this undermines the patients PCP's. Patients will go to their PCP and their PCP will tell them they don't need antibiotics so they come to the ED for antibiotics, and they get it every time. Every single laceration gets antibiotics. And not appropriate antibiotics. Strong antibiotics that are not indicated. When this happens, patients that have been coming to the ED for years expect antibiotics at every visit. When the non ED trained doctors are not there, I do not give them antibiotics because they are not indicated. Then the patients complain because they are not getting amoxicillin like it is candy.  

 

4) More of a continuation on my third scenario, every single conjunctivitis patient gets Tobradex eye drops. I asked this attending why not erythromycin and he said "It doesn't matter, erythromycin and Tobramycin are in the same class, they are both Macrolides." I know they are not, this is just frustrating. 

 

5) Every person that comes in with a gout flare, even if they have a hx of gout and and have a red hot joint with painful passive ROM needs to have a Uric acid level. I know there is no correlation with the level and an acute attack. 

 

6) Someone comes in with vaginal DC and a suspected STD gets treated with Azithromycin, Rochephin, Flagyl, and Difllucan because they don't want to wait for the results and want to keep the patients moving. I feel like this is how resistance gets built up and is not safe. 

 

The list goes on and on with the two doctors that are not emergency trained. Their priority is seeing as many patients as possible during each shift. I feel as if this is not how you are supposed to practice medicine and it takes away all of the clinical reasoning and thinking out why I love EM. I am worried that coming up, when I have a performance evaluation that one of these doctors will be in charge of my evaluation. How do I bring this up to someone/or one of the other attendings without coming off like I am going behind the doctors back? Also is there a way to approach these doctors without coming off like a smart ass? I know I am a new grad and have a lot to learn but I feel as if this is ridiculous. 

 

Thanks for the feedback, I appreciate it. 

 

[rev ronin]

1) Money

2) Money

3) Press-Ganey

4) Press-Ganey

5) Money

6) Press-Ganey

 

Conclusion: Don't even bother, you will lose if you press any of these issues. You're probably just not a team player are you?  Stop bringing that "evidence based medicine" nonsense around here... the purpose of an ED is to make as much money as possible, which means 1) get a lot of patients, 2) charge as much as possible, and 3) don't get sued.

 

All sarcasm aside, no one is going to get sued for giving too many antibiotics, even if C. diff results, unless someone is willing to stand up and testify in court that it is not standard of care and that the harm directly resulted from the poor practice of medicine.

[davidccs]

I know this won't help your situation much but not all EDs are like that.

If it bothers you enough you may need to find a different job, I doubt your complaints will get far.

[Guest ERCat]

Wow, even as a new grad I can say that all of the points you brought up are very valid!

 

I am in ER as well with a similar set up (presenting cases to attendings. Most of the time I learn something new but sometimes I flat out disagree with their reasoning. And generally I say so and we end up bringing up a source online and they say "Hmm, interesting, I didn't know that!" So they've been pretty good about it. I would recommend doing just that - respectfully disagreeing and then casually pulling up a resource on your phone.

[Guest ERCat]

So you know you're not alone here are some of the things I've disagreed with my attendings about.

 

: 1) Dilaudid for headache - really? I don't think narcotics are appropriate for the vast majority of headaches, especially because they are associated with dependency and rebound headache.

 

2) They never seem to be concerned about cosmetic outcome. We don't even have plastics on call. I was closing a vermillion border lac on a mentally handicapped woman and discussed my concerns about scarring with my attending and she looked at me and said, "Do you really think it matters if THAT woman has a scar?" Shudder.

 

3) Every pediatric head trauma case gets a CT if Mom wants it. The doc will go in to quickly see my patient before I do, Mom will say "I want a CT" and the doc does no explaining of why a CT isn't clinically indicated, and how the risks of radiation outweigh the benefits. No one is telling these parents of 18 month old kids that the scan they "want to be sure" for a simply head bunk without concerning mechanism, LOC or exam findings is associated with a 1/500-1000 chance of fatal brain cancer in the future.

 

4) I had a patient with a known history of HTN who presented with a sudden onset of tearing chest and back pain, dizziness, and numbness in the legs. He was hypotensive on presentation. I saw him in triage and ordered a CTA as I was concerned abut aortic dissection. The doc who saw him cancelled it because he found a small infiltrate on x-Ray indicating pneumonia and he apparently felt that meant he should stop his work up.

[db_pavnp]

Thank-you for posting these.  I think ER employees know that this stuff goes on, but often it isn't well itemized.

 

Tread lightly and look elsewhere if you want to practice better medicine.  You are describing a dangerous culture in that ER and if you get any push back on your suggestions you will soon have a big target on your back.

[ajnelson]

This is one of the downfalls of being a PA. Having to do things as your attending would.

As I've gotten further into my career, I rarely get any pushback from docs on doing things 'their' way any more, even in a new job where none of them know me.

This being said, you will almost always run into someone that practices a little different from you (think bounce backs). When someone has a different opinion, orders more or less, I try to pick their brains about WHY. Maybe I can learn something new. Maybe I can teach them something.

In your case, maybe discuss hear CTs in kids or HA patients with them. Why they get them. Show them some of the newer research on limiting scans, etc that are pertinent to your concerns. Being that they aren't board certified, they may not be as aware of this.

I also know, in a few of my old facilities, we were being measured on CT utility, especially head CTs. I thought it was a national measure, one linked to reimbursement (but I may be wrong).

The one thing I'd be cadeful about doing (as others have stated), is bring up your concerns with others. This can cause animosity, make you out to be the difficult one to get along with.

Good luck in handling these issues. They aren't easy! (this also tends to be an interview question in new jobs too)

[FfIghter23]

*Red Alert* Family Docs in an ER who don't want to play by the rules shouldn't be in EM.

 

In recent years EM has become more academic. There are reasons why we do what we do in the ER. Yes, the early days of EM were interns running the department. Not anymore. I would find a different job. I know several FM docs that work in ERs. They keep up with what's going on in the EM world and have adjusted their practice accordingly.

[ventana]

few choices

 

1) just di it their way and document that in the chart "D/W Dr SoAndSo and they advised to do ......"

2) have a very open honest, non confrontational discussion with the medical director about these issues..... certainly the narcotics for headaches is an issue that directly effects the ENTIRE department.  I would approach this as asking advice on how to deal with the differences in SP and bring up points - DO NOT ATTACK the doc - you will loose.....

3) stop talking with them about your patients......  might be the easiest....

4) quit

 

 

I would say #2 as long as you do it in an educational way with out attacking the doc's at all

[Reality Check 2]

The basis of a lot of our medical issues is that the words Profit and Medicine are allowed in the same sentence.

 

Not that we shouldn't be payed a fair wage for working - the idea that there is profit in illness or injury is just wrong.

 

We have lost the ART of medicine and helping people to a revolving door profit model that has no place in caring for people - especially in an ER.

 

We have taken the last 2 generations of folks and bred out common sense and self care and self responsibility and turned it into - Oh My Gosh - I have the sniffles - STAT antibiotics. Folks don't even know how to use a thermometer or tell the difference between virus and bacteria. There just HAS to be a cure for every ailment.

 

The job environment the OP describes is outrageous. It is unacceptable that the prevailing attitude is lacking in knowledge and true medical practice. So, they will go on creating antibiotic resistance and over treatment leading to bad outcomes and perpetuating the myth to the public that medicine is McDonalds or Burger King.

 

A "happy" patient isn't necessarily a "healthy" patient. And, NO, you cannot have fries with that…...

[eighthnote24]

To the OP:  is your primary supervising physician one of the EM trained ones, or another one?  If your SP of record is a reasonable physician, discuss these concerns with him/her.  If they're reasonable, they can review some charts and raise the issues with the group or individual and leave your name out of it.  Record medical record numbers and make notes of what was inappropriately ordered and why it was inappropriate, with references and present that to your SP. If they blow off your concerns, time to look elsewhere for employment.

 

I work with an incompetent physician who should have retired 10 years ago.  For 2 years, I've been sending charts, patient comments, complaints etc. to our department chief, to no avail.  This is also the only physician in our group who insists on seeing my ESI 3 or higher patients before they're discharged.  Frequently, I'll have a workup completed and either discharge or admission orders completed, and he'll go in to do his 10 second "I saw the patient so now give me RVUs and money" visit and tell me to add tests or treatments, most frequently non-indicated albuterol nebs for CHF (even those with good O2 sats and good breath sounds).  I refuse to order them.  Usually I just pretend like I didn't hear him.  :D  If he wants to order them, he can put the order in the computer and have his name tied to it himself.  Then, if I see he did order the unnecessary tests/treatments, I'll document in my note, timed, that Dr. X ordered it.  

 

The latest and worst incident in a long line of incidents happened a couple of months ago. This physician literally got in a screaming match with a patient's wife over completely unrelated issues (they were arguing about his lazy eye....no joke).  The patient had an NSTEMI with a troponin over 1 and had pulmonary edema and a history of COPD and a crappy pH and needed to be intubated.  The patient was very wary of healthcare in general and actually wanted to leave AMA but ultimately his wife convinced him to stay.  Afterwards this physician went in there and told them he didn't know if it was "worth his time" to intubate him because they had been "wishy-washy."  And things deteriorated from there....myself and one of our nurses had to literally remove the wife from the room because we couldn't get the physician to leave the actively infarcting patient's room.  Just picture a hysterical screaming wife, screaming obese physician, son alternating between attempting to console his mother and getting in between her and the physician, and a patient sitting in the tripod position, and we have no security officer to call.  Finally got the patient somewhat stabilized and transferred.  Patient ended up dying 3 weeks later, who knows if this incident had anything to do with it, but it certainly didn't help.

 

Guess what?  Not only did absolutely nothing end up happening to this physician because of this behavior (even though the wife filed a complaint), I was told I was no longer allowed to raise concerns or complaints about his practice.  I'm just supposed to wait for something bad to happen, I guess.  Except I won't be doing that, because I turned in my notice yesterday :)

 

Found out last week that he was really rough with a kid who's being treated for cancer and had horrible mucositis, shoved a tongue blade halfway down her throat and she ends up bleeding and coughing up blood from the tongue blade trauma....but I'm not supposed to say anything....turns out, dad of said child is the assistant district attorney.....ohhhhh snap.  

 

Maybe I got a little off track here, but the bottom line is....you don't have to put up with this crap.  Regardless of what any stupid administrator tells you, your responsibility is to the PATIENT, not to their surveys or their financials.

[EMEDPA]

BEST option ever....work solo like Boats and I do...attending doesn't like my choice? noted (2 weeks later when they see the chart).

[eighthnote24]

EMEDPA....soooo working on that solo thing....why does Montana have to be so expensive to get a license in? :D looking at a place in Oklahoma as well...

[LT_Oneal_PAC]

Can always come work for the military and have NO chart review. :)

[EMEDPA]

Can always come work for the military and have NO chart review. :)

too old for military or phs...can't do 20 before age 65.

[ajnelson]

EMEDPA....soooo working on that solo thing....why does Montana have to be so expensive to get a license in? :D looking at a place in Oklahoma as well...

I'm in Wisconisn and am working on getting into rural solo practice here ☺️

[EMEDPA]

I'm in Wisconisn and am working on getting into rural solo practice here ☺️

talk to the mayo folks. they have a few solo coverage gigs in WI.

[Evolute]

EMEDPA....soooo working on that solo thing....why does Montana have to be so expensive to get a license in? :D looking at a place in Oklahoma as well...

 

we're trying to keep the riff raff out. lol 

[bjmcell]

Thanks for all of the replies. My SP is not the family docs I am referring to. If they were, I would already be looking for another job. I tend to only work with this particular FM doctor about once per week. Since PA's are new to the EDs at the hospitals I am working at the EM doctors who were working in the fast track with the FM doctors are now only in the main ED. I believe that the FM doctor is trying to transition to being our supervisor but without actually being our supervising physician. 

The situation that I wrote about in the opening post is not at all how the ED is ran, it is basically about a singular individual. Every other EM trained MD is awesome and very evidence based and they take the time to talk about why you do and do not do certain tests and order certain medications. If anything changes going forward I will go to my SP with concerns. During my PA training, I was trained by amazing EM PA's and MD's who were all very evidence based and it will leave a lasting impact on how I practice and I don't intend to change due to money or press-gainey scores. 

 

I would consider working solo in the distant future but I still have a lot to learn before I do. 

Thanks for all the comments!

[FutureResusMachine]

Good luck to you. It is certainly difficult when you are the new kid on the block and don't want to raise a ruckus. But to put it lightly, it sounds like the place you are currently working at is a hole. Treat your patients how you would want your family members treated. Would you want your child getting his head scanned when you knew it was completely unwarranted? It's called iatrogenesis. And when that patient you saw 2 weeks ago comes back with severe c. diff because you told him he should take ABX for his viral URI? People who don't know any better are trusting you. Put a year in and leave. If that is the "culture" (sadly, some places it is), you are not going to change it anytime soon. Go somewhere where they practice this little thing called evidence base medicine. Better yet, go somewhere where you can practice common sense.

[FutureResusMachine]

Thanks for all of the replies. My SP is not the family docs I am referring to. If they were, I would already be looking for another job. I tend to only work with this particular FM doctor about once per week. Since PA's are new to the EDs at the hospitals I am working at the EM doctors who were working in the fast track with the FM doctors are now only in the main ED. I believe that the FM doctor is trying to transition to being our supervisor but without actually being our supervising physician. 

The situation that I wrote about in the opening post is not at all how the ED is ran, it is basically about a singular individual. Every other EM trained MD is awesome and very evidence based and they take the time to talk about why you do and do not do certain tests and order certain medications. If anything changes going forward I will go to my SP with concerns. During my PA training, I was trained by amazing EM PA's and MD's who were all very evidence based and it will leave a lasting impact on how I practice and I don't intend to change due to money or press-gainey scores. 

 

I would consider working solo in the distant future but I still have a lot to learn before I do. 

 

Thanks for all the comments!

 

Just saw this. Glad it is mostly one individual. Maybe you can talk to someone about your concerns? There's a thin line sometimes between a difference of opinion and a duty to report someone. I certainly wouldn't want this person near me or my family. And I definetly would not want their name with mine on a chart. At the very least I would steer clear of this person.... good luck!