How do you handle unprofessional attendings and residents?

[DelusionalEnthusiasm]

Today I went into a trauma center that I occasionally go to for the practice to see one of our patients on the weekend, a post bleed day 8 ruptured aneurysm patient.  If anyone has experienced these cases they are very complicated patients that have multiple electrolyte, renal, cardiac disturbances.  Anyway, i see the patient and note that he is on inappropriate medications for his condition including long acting narcotic meds.  I inform the family of the changes, put in the orders, and walk out to find a PGY 3 resident in the ICU.  I review the case briefly and explain to him which medications I've changed when he simply turns to me and says "no your not" and makes up some reasoning about how he is "like one of those pain management patients".  Later, I check my orders and he has canceled them and resumed his own medications.  I let my attending know who says she got into a fight last week with the trauma ICU attending and called him out for being unprofessional, rude and condescending.  

Several months ago I had another situation at this hospital where I was on call at night and had an inpatient s/p cabg develop stroke symptoms.  The problem was he was last seen normal almost 9 hours earlier because the cardiothoracic team did not wake the patient up post op to do a neurological exam (which we are pushing more for recently to avoid these type of things) I informed the resident that a mechanical thrombectomy at this time, in the literature, can only be treated up to 6 hours after last seen normal due to poor recovery for patients beyond that time as well as risk of hemorrhaging.  Later, the attending of the resident called my attending directly and convinced her to come in and do the case (as he was some chair of the hospital or some nonsense), of course the patient didn't improve.  The next morning I came in and this attending rounding in the hallways in front of the patient's room, in front of his 4 residents and medical students, asked who had made the initial decision.  I admitted to it, he asked why I would do such a thing as a PA.  I informed him of the literature and he told me I had no idea what i was talking about and that the concept of last seen normal was clearly bullshit and I should never be able to make any decisions as a PA.  I calmly just walked away before I said things I would have later regretted.

In any case on the way home I realized that I have 6 years experience in this position, while this resident barely has 3, and is only doing an ICU rotation.  I am very non-confrontational myself which makes it difficult to handle these situations, so i'm looking to see how you would all handle this.  In the end I just put in a note that this resident had refused to implement the attending neurosurgeons orders.

Any advice?

[UGoLong]

From what you shared, I'd say that you work in a non-supportive place and your SP doesn't sound like her or she is respected there either. 

I doubt that you are going to are going to move the needle much with respect to there law of the jungle culture. If they respected your SP, you'd have a chance. 

[Boatswain2PA]

First example - pgy3 changed them, you told your boss....I'm sleeping well at night.

 

Second example - I tell the attending to pull his head out of his ass so he can use the correct orifice to autofellate himself, then walk down the hall without a regret in my head.

[SERENITY NOW]

I'm a little bit confused with the picture you're painting, and if I've misunderstood what you are trying to say, I apologize.  It sounds like you're on a neurosurgical consult service, is this correct?  Or is your neurosg attending the primary attending who is taking care of the patient on your own service, with medicine / ICU team on consult?  In your hospital, is it typical that the consulting teams change the orders of the primary team before even touching base with them?  That isn't what I have seen in the hospitals I've worked at... usually the consult services would provide recommendations but ultimately the management of the patient is up to the primary team/service and not the consult service.  It can certainly be frustrating when the primary team doesn't follow the consultants advice, but at the end of the day its their primary patient so they can do what they want.      

With regards to the second case, I'd again just be careful depending on what service you are on.  Maybe regardless of the fact that you are a PA, they could be trying to say that the decision of whether or not to intervene on a stroke should be up to the neuro-stroke team or neuro-IR, and not neurosurgery, which I think is a fair assessment.  I've heard of IR going in for thrombectomy up to 12 hours out, and I've seen lectures/presentations where people say we are starting to get data to support extending the intervention window for specific situations, sometimes even up to 24 hours out.  A quick google search is pulling up a several studies and I can link a few below.  It sounds like you might know much more about this than I do, which is totally fine and I'd be happy conceding ignorance, but these are just the things they taught us while I was on the neuro-stroke service.

http://www.nejm.org/doi/10.1056/NEJMoa1503780

http://www.bmj.com/content/353/bmj.i1754

http://www.nejm.org/doi/full/10.1056/NEJMoa1706442 -  

[David the Nome]

This sort of behavior/attitude is a major reason why I left a position working in ICU at an academic medical center in exchange for an ER gig at a community hospital. No regrets. 

[skyblu]

“Last seen well” concept is bullshit? Oh, good to know, given that it is literally the guiding principle of the stroke center ED where I spent my whole career. Granted, different providers have different comfort levels with windows for procedures, but the concept itself is at the core of stroke management!

I’d say that whomever “owns” the patient, writes the orders. Whose name/service is the admission under? If under the intensivist, then they write the orders. If under neurosurg, then you write the orders.

And nobody should ever speak in a disrespectful or unprofessional manner. Address it with someone. This is not okay, and it’s not okay for that person to call into question your ability to make medical decisions.

I would have said something like, “I am a medical professional and am trained to make clinical decisions. You are allowed to disagree with them, but you are not allowed to belittle my profession.”


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[ventana]

if you are not the admitting service, don't write orders..... write recommendations..... let them figure it out... if they don't follow your recommendations and bad outcome - their problem, if they don't (maybe they do know more specifics) then no harm as you likely would never know...

 

As to the Case #2 - who cares.... At times I have my doc "make the decision" as he gets pai 2-3X's more then me and he can shoulder it......  I am certainly more then capable of making it, but ultimatly we are "dependent" and so be it...

 

(hence why we need to be Independent)

 

In the surgical subspecialities the attending many times think they are god.  Let them, I will take my really great pay, and give them the crappy decisions...

[DelusionalEnthusiasm]

Thanks for the input everyone. 

Serenity now - yes this is a Neurosurgery consult service for a trauma center.  There is new data coming out to allow intervention up to 24 hours but there must be a special CT done which shows core infarct volume and pneumbra volume. This is not available yet in most places, and was not done on this patient. 

You have all brought up good points. We are a very agressive service and often change and write orders because my attendings want me to because it seems no one ever reads or implements plans well enough. 

[jwells78]

" he asked why I would do such a thing as a PA.  I informed him of the literature and he told me I had no idea what i was talking about and that the concept of last seen normal was clearly bullshit and I should never be able to make any decisions as a PA."

 

When I read this, I think the veins on the side of my neck bulged out while I clenched my teeth.

"Hey, Mr A-hole, care to step outside and I will provide you with some free 'wall to wall' counseling?"

 

There is absolutely no need for that type of disrespect.

Spit in my face and I fight back.

[CornellSPA]

I always like the "The physicians here have credentialed me, working w Dr _______ to perform X Y Z.. Can I get you a copy of my credentialing commitee list?"  That usally stops them.

Also I agree w above when you start thinking "I do not get paid enough for this" its usually time to defer to decision to a higher pay grade!

[sas5814]

I often find "who the **** do you think you are talking to?" shuts down the conversation. It isn't for everyone.

 

Don't feed the trolls. People like that act like that because they get away with it. If you act humbled or in any way intimidated it will go on.

[Gordon, PA-C]

Consulting services should NEVER write orders unless they have the clearance of the primary team.  They are there to advise, not supercede previously written orders or change meds.

Now maybe the primary team is composed of a bunch of idiots who don't know what they are doing -- that's an attending to attending conversation, and if necessary get the medical staff committee of the hospital involved.

Sounds like these issues go far beyond a rude resident or attending.  The entire continuity of your ICU is broken.

 

[CAAdmission]

11 hours ago, sas5814 said:

I often find "who the **** do you think you are talking to?" shuts down the conversation. It isn't for everyone.

As an alternative, "Who the f*** do you think you are?" also works pretty well.

[sk732]

23 hours ago, sas5814 said:

I often find "who the **** do you think you are talking to?" shuts down the conversation. It isn't for everyone.

 

Don't feed the trolls. People like that act like that because they get away with it. If you act humbled or in any way intimidated it will go on.

I found that when I was in school as a military guy in civilian hospitals, I didn't put up with the crap - if some snot nosed resident (or attending for that matter) looked up their nose at me, I tended to look back down mine and say "not happening" or "you can stop right there"...it almost never happened with an attending, since the Crown was paying them to teach me.  Myself and fellow classmates more than once had to pull senior residents aside (we'd do it in private for hopefully obvious reasons) and tell them we weren't allowed to talk to our soldiers the way they were talking to their clerks/residents and that they should, in no uncertain terms, put the verbal safeties to "S" to allow their frontal lobes time to catch up, for both career and personal safety reasons.  I've made a lot of people cry in my office by using a calm, cold, disappointed dad voice...being a bit physically imposing helps (I'm 6'2"), but being calm, cold and calculating in your tone and choice of words is usually enough.  If they're a resident, ensuring the wanker gets a shyte review sent to the academic staff at the facility helps a lot too :-D...getting HR and union/professional association reps involved with attendings sometimes makes them ponder things, but there's nothing like a public, personal tongue lashing in front of subordinates if the in private thing doesn't fix it.  The only thing you need to realize is that there will likely be a backlash if you publically humiliate an attending, even if they are a tool, in front of learners/subordinates, though in the current  #MeToo environment, more things will likely come to light, hopefully in your defence.  

 

SK

[lkth487]

I'm just a resident but I would get very annoyed if a consulting service wrote orders.  I've told and made a big deal out of an attending surgeon and an attending cardiologist changing orders on my patient (and it was "A Big Deal" that they did - the ICU team and the hospital totally had my back).  It's dangerous and they aren't the primary service.  The consulting service have their own experience but they may not know the whole picture of why we are or are not doing something - they aren't there on a minute to minute basis.  Like one time a surgeon made the patient NPO and didn't order appropriate fluids - almost had a hypoglycemic coma because they weren't aware of the other conditions that the patient had that we were managing.  Thankfully at shift change, an experienced ICU nurse (thank God for those...) noticed that the fluids were all wrong for this particular patient as she has taken care of this patient before, and alerted the night team and it was fixed (at which point the glucose was 31....).  

In the second case - I am sorry that it happened to you.  Its unfortunately all too common in medicine, and it shouldn't be.