I well remember my first few years of practice. I was a new graduate, fresh from the world where specialists, especially older specialists, were people I held in Olympian regard. Fortunately, I came from a very pleasant residency, as residencies go. I was treated well and met plenty of wise, courteous older physicians. And only a few who needed electroshock therapy.
But early into practice in my small, rural hospital, I learned that transfers were terrible things. One of the neurosurgeons in a nearby town would routinely return our pages via collect call. It was funny, in addition to being passive aggressive and pathetic.
My partners and I encountered unscientific madness, such as this little gem, also with a recalcitrant neurosurgeon: “Great. You've given him succinylcholine! How am I supposed to examine him?”
“Well, wait about five minutes, or the entire hour it takes him to get to you ....”
I once encountered a threat for daring to talk back to a specialist, who alluded to being on the state medical board and told me I had better be careful. One specialist told me that I was simply dumping, like doctors at our hospital always did on Friday. And one nearly drove me to distraction with additional tests and forms before accepting the psychiatric patient. When I told her it was ridiculous, she said, “Oh, Dr. Leap, life can be ridiculous.” Argh.
Trauma teams weren't as well formulated, so we would call the neurosurgeon for a head injury, and he would berate us for calling him instead of the trauma team. Then we called the trauma resident, and we were told the neurosurgeon needed to accept the patient. It went round and round.
Eventually, I learned how to conduct myself, what to expect from each physician, and how to stand up to doctors with personality disorders. My skin became tougher, my mind (and tongue) a little sharper. I realized that I had to stand up for the right thing for my patients. If not me, then who?
And I began to see that frustration in other specialties was as legitimate as my own. Everybody gets tired of doing and seeing the same difficult situations and dysfunctional people. No wonder the docs I called were angry!
But over time, two wonderful things happened. First, I began to encounter more female physicians when I called to arrange transfers. I'm not pandering or trying to butter anyone up and there are exceptions, but as a rule our female colleagues are nicer than we are. Whether it was surgery or pediatrics, neurology or psychiatry, I found that the female consultants I called to arrange transfers were gracious, polite, willing to listen, and understanding of anything I had or had not done. None of the old school gamesmanship: “Did you do the rectal exam? Did you get the liver function tests? Did you even examine the patient?” Nope.
It was more like this: “That's fine. We'll just have to do it here again anyway. I'll take care of it when he arrives.”
I trained with a number of women, but they were friends. We were on the same team, even across most specialties. We expected one another to be nice. But to call a referral hospital and have courtesy? To have a sweet voice and a gentle disposition talk to me about the patient and willingly accept the transfer? To hear the physician at Large General Hospital say, “How's your evening going, Dr. Leap?” Well, be assured that I was simultaneously bumfuzzled and flabbergasted.
Gradually, of course, I learned that it was the new normal. Maybe it was changes in residency work hours. Maybe it was a new emphasis on wellness. Some of it is the use of nurse practitioners and PAs on call, who are generally easier to deal with than their very busy, very harried employers. And probably, as I postulated, women are just nicer than we are. After all, I've never had a hallway shouting match with one of my XX coworkers. But I've gone all redneck on my brothers-in-arms at one time or another. (When the highway patrolman came to check on us, I realized I had perhaps raised my voice too much. But that's a story for another day.)
Whatever the source of this new feminine grace, I am all for it. I'm too old to argue with anyone if I can help it. And I don't enjoy arguments, endless subterfuge, or avoidant behavior. Thanks, ladies! You've made medicine a nicer place.
Now here's the second thing that made life so much better. The referral center transfer line. Those of you my age and older can recall the labyrinthine exercise of calling answering services and out-of-town emergency departments, hospital switchboards, and office answering machines. You can remember that you'd call for a cardiac surgeon, tell the whole story, and discover that you actually had reached the cardiologist. You'd call the child's pediatrician only to learn that he no longer was admitting anyone, and you had to talk to the hospitalist. On and on it went. I've known transfers of complex patients, like transplant recipients, to take literally hours to activate.
The transfer line was sent directly from heaven as far as I can tell. As you know, it connects a smaller center with less specialty capacity to a larger center with all of the bells, whistles, special centers, and specialists in everything from trauma to left eyelid surgery, from psychiatry to those who focus on the final five centimeters of the small intestine.
When referral centers like this step up, they make institutional changes. They seem to raise the bar, so that everyone knows that courtesy is the key to reputation and (hopefully) income. I notice younger accepting physicians, fresh from training, also seem to have trained in a different way, in a manner that gives them a sense of grace and understanding.
And when all else fails, the interaction is recorded and a third party (often a nurse in charge of transfers) is listening on the line. There's little of the old school harassment. And there's no “why are calling me about this *!&%*$ at 3 in the $*!%*& morning?” If there is, it's recorded for all to hear later, and it seldom reemerges.
What we do is already very difficult. Every practice location has its issues and troubles. I feel for the accepting doctor in the large center, who is just a doc who can't say no. I try to cushion the blow, and I try to keep what I can in-house. But I also feel for others, like me, who work in centers with limited capacity, where transfers for higher levels of care are just a part of life.
So let me say a special thank you to all of the young and older women who bring their elegance and kindness to patients and colleagues. Let me say another to the originators of the transfer line and those physicians who endure our endless calls while being monitored and recorded. Both have made my life a lot easier, and I'm grateful.
Besides, I just couldn't bring myself to accept another collect call!
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