If you call for a consult between 6 and 7 a.m., cross your fingers. The odds are decent during this witching hour that the on-call physician won't take the consult because his call duty is almost over or he won't call back at all. If we consult earlier, at 3 or 4 a.m., we're prone to hear indignation for waking him up. No matter what time we call, God help us if the call schedule isn't correct and we call someone who isn't actually on call.
How friendly a physician is to the nocturnist EP is a true test of character. I know, as the night doc, that nobody wants to hear from me. I don't want to wake my colleagues in the middle of the night, but it's my job.
Specialists who agree to be part of the on-call roster are bound by EMTALA requirements, and they and the hospital are at risk for a violation if the physician does not respond in a timely fashion. When a STEMI comes in at 6:45 a.m. and my relief hasn't arrived, I don't get to say, “Hold on, the day doctor will be here in 15 minutes,” because my shift is almost over. Specialists shouldn't ignore a call near the end of theirs.
Consultant delays in calling us back impede our ability to provide care quickly. EPs are judged by lengths of stay and patient satisfaction, and consultant response time affects those. They track our time to patient disposition, and should also track consultant decision time, which accounts for 33 percent of LOS for admitted patients and 54 percent for discharged patients. (Emerg Med J 2014;31:134.) Patients get frustrated when their visit runs unnecessarily long because consultants don't call back quickly, and EPs get frustrated when we can't explain why the consultant isn't returning calls.
All EPs struggle with needing a consultant and not wanting to alienate somebody whose services we require. Our foremost obligation is to our patients, making sure they receive appropriate care in a timely fashion, but we also have to maintain good working relationships with our colleagues, and advocating for the patient's health can conflict with staying in the good graces of the medical staff.
Perception and Reality
On-call physicians are sometimes unenthusiastic about coming into the hospital or admitting patients, so some may make it difficult for EPs. Reluctant consultants add a tremendous amount of anxiety and risk to what EPs do. They may prevent us from providing care that patients deserve or even try to convince us to transfer or discharge unstable patients. It's a Catch-22: Risk the patient's health or the consultant's wrath.
Finessing less-than-enthusiastic consultants has me apologizing for bothering them in the middle of the night. Basic manners such as “Thank you for your time/returning my call” are always appropriate, but we should not feel guilty for trying to get patients specialty care. Running the entry point to the hospital while most physicians are sleeping is worthy of appreciation. We shouldn't have to apologize.
EPs and consultants need to see each other's vantage points. On-call issues and refusal of consultants to respond is the second leading source of EMTALA citations. (ED Manag 1998;10:37.) Both sides have room for improvement. EPs need to realize that consultants are sometimes forced to deal with unreasonable requests from the ED. Just as we don't like it when a practitioner sends us a patient he could handle in his office merely because it's late in the day, a consultant doesn't like it when an EP requests an unnecessary in-person consult merely because he doesn't want to manage a patient most other EPs would treat easily.
We might assume that a specialist isn't answering right before shift change to avoid the inconvenience or that they're rolling over and going back to sleep intentionally, not because they are exhausted too. Maybe they are covering more than just our hospital and are as busy as we are. We don't know the circumstances that may be making it difficult for them to respond. One of my favorite cardiologists jovially asked me to give him a few minutes to call back because he has to extricate himself from his CPAP machine.
Consultants also think we are trying to pass the buck or get out of work by calling them, but it's often more work to call. They may think we call right before shift change so we don't have to deal with disposition and can just sign out “waiting for surgery.” But we feel responsible and want to communicate the information to the patient before we leave. Consultants might think we are bothering them with trivialities, but sometimes we don't know that until we talk to the expert. And honestly, we have to protect ourselves from an overly litigious society so we err on the conservative side.
We all bear some responsibility in this system and may be sanctioned when it fails, so we need to work together. Our common goal is taking good care of our patients. Let's keep ED consultations from being the most frustrating, slam-the-phone experience of the day (or night) and instead work toward pleasant collaboration. EPs are not the enemy. We are guardians of patient care, just trying to do our job.
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