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Monday, May 28th 2012

Resident Physicians As Colleagues

I was half asleep typing a consult note as my last call creeped closer to finishing, about one in the eerie morning, when a string of pages awoke me. Amongst them was a consult for a patient who the neurosurgical service had recently discharged with a non-operative traumatic subdural and who had returned with an episode of vomiting. As the other resident talked and mentioned that the repeat head CT looked exactly the same I made an off handed remark, “Yeah, doesn’t sound like there is anything really to do.” But I take down the patient’s location and the call ends.

Less than 5 minutes later I get a page to the same number. On returning it it’s the resident’s in house attending who picks up to chastise me a little and make his expectations for this bounce back patient clear. Take the quotes with a grain of salt but the jist is there,

“You need to come lay eyes on this patient and examine him. And you need to drop a note. And if you think this patient can go home then you need to do that sooner rather than later, not three hours from now, so we can get him out. Is that understood?”

No yelling, nothing unprofessional but certainly putting me in my place.

Apparently my line above about not doing anything had drawn some concern from the resident that perhaps I wasn’t coming to see that patient, despite the fact I went on in the conversation to ask where the patient was located. That aside, what if I had truly thought the patient could go home without being seen?

It would’ve been a completely clinically appropriate decision that this patient did not need to be seen by a neurosurgeon again. One that plenty of neurosurgeons would have made. I can envision rare scenarios where the above lines of commands would’ve been given to a private neurosurgeon at 1 A.M. if he had decided he didn’t need to see this patient.

“You need to come into the hospital, examine this patient and drop a note. Yeah, he’s GCS 15, completely intact and his scans look exactly the same from the last time you saw him, but you need to get your ass in here,” just does not happen. And certainly not at 1 A.M. If it does, that’s maybe the end of neuro specialty coverage for that physician who called.

But there is something different about academics, and not for the better.

Resident coverage gets taken for granted. I’ve discussed this before as it relates to nurses. It appears okay to call at 2 A.M. about an incentive spirometer for a patient at an academic hospital because you’re only paging a resident and they’re already in house but it’s not okay to make that same call to a private physician at home. Something similar was going on here.

But I think we deserve a little bit more respect.

Let’s imagine the attending who called me is both young and has spent his entire practice in academics. Let’s imagine that because it highlights the problem.

What if I was a fifth or sixth or seventh year resident? I would be getting these lines from an attending who essentially I had been an M.D. as long as he or she had. And these interactions certainly happen between residents in specialties with lengthy training and young attendings on other services.

The point is, while there was nothing unprofessional per se about what happened, it would’ve been far more appropriate for this attending to have a less teacher-pupil/parent-child conversation and more of a colleague-colleague one with me.

“Hey, I’m just giving you a call back to see if you’re gonna come see this guy, I guess it was unclear if you thought we could just send him out or not. I’d really appreciate it if you’d see him, I think it’s really important for him to talk to the neurosurgery team again because he has some questions and concerns.”