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ERcast Lite

Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Feb 11, 2018

Sam Ashoo is an ED doc practicing in Tallahassee, Florida. He has been an ED director, coding and billing chief medical officer, international educator, and runs the Admin EM blog. That blog name might sound nerdy (and it is) but his short write ups on common clinical problems are famously high yield.

In this episode, Sam gives his strategies on what to do when the consultant on the other end of the phone call is giving questionable advice.

Before jumping in to the episode, take a few minutes for the ERCast listener survey.The survey lets me know who you are, what you do, and what you need when it comes to medical education. Thanks in advance.


Discussion topics

  • Are you disagreeing with your consultant or is the information you are being given simply wrong?
  • Why determining the root cause of the bad advice can help lead to resolution of conflict
  • Should you apologize for bothering a consultant when you call them?
  • What to do when a consultant is dismissive of your concerns about a patient
  • Factors that may lead to questionable advice from a consultant
  • Bad advice is usually not malicious (even though it may feel that way)
  • Be aware of downstream effects of negative interactions with consultants


Bonus Content

  • What follows is a summary of a conversation with Dr. Jim Adams, Chairman Northwestern University Emergency Medicine. He is a master of conflict management, resolution, and prevention

How to insulate ourselves from the stress of conflict with consultants

  • Get to know them personally. Build social capital and friendships. We underestimate the power of social connection to prevent negative interactions.
  • Slow down before you make the call and think about why you're calling. Know your needs and know your ask. (example of rambling vs focused).
  • Don't give your consultant an order, call with a specific need.
  • Speak at a measured pace. While you may think you sound calm and friendly, it's possible that what's heard on the other end of the line is pressured, pushing, and curt. Trainees and new attendings are especially vulnerable to this. It's not a mystery why this happens-your work environment is the perfect setup for the opposite of a calm phone presence. At baseline, the ED is high pressure and there are myriad demands for your time and attention. When you sound pressured, the person on the other end of the call feels pressured, then they match your tone... and then YOU think that THEY are the problem!
  • Consider reciprocity when dealing with an irritated consultant. If you're irritated, they're irritated. It's infectious. If you choose to be happy and express appreciation for the consultants advice or coming in, that changes the dynamic. If you lead with irritation when they come into the ED to evaluate a patient, what do you think is going to happen 9 times out of 10? Your consultant will be more irritated!
  • When you get a hard time on the phone, your brainstem screams "threat, aggression!" You start to get angry and want out of the conversation. That is a primitive conversation. Your emotion is now driving you. Take some reset breaths, try combat breathing, recognize and be in control of the emotional response
  • At the end of the conversation, show appreciation for the consultant's expertise. If it's a surgeon, Jim says, "It looks like this patient needs your hands." If it's an internist, he might say, "It looks like this patient needs your time and wisdom." That may sound lame/dorky/fake/etc but you are doing two things: expressing gratitude and making them feel needed. Feeling needed is irresistible for doctors (or pretty much any human) - it makes them feel good about their jobs. Even if they're tired and cranky, making someone feel needed and valued leads to better interpersonal results.
  • In any conflict, there is a moment when you should stop listening to what they're saying and focus instead on why they're saying it. Often a consultant that is giving you a hard time or is dismissive may not be in  position to help you at this moment (they might busy, tired). you may also have a consultant who acts like a bully and tries to dominate you in a conversation. They may in fact just be a bully, but sometimes it's a case that where they have nothing to offer the patient. When a person is not giving you answers that are not acceptable, find the things that you'd agree on that are acceptable.
  • When there is a negative interaction, let your department chair know. On investigation, what's often uncovered is burnout, depression, substance abuse, going through a divorce, etc. Of course, some people have grown accustomed to exhibiting rude behavior and it has nothing to do with other life circumstances.


The Case

  • You are seeing a patient with a VP shunt who is having repeated seizures. They are followed by a neurosurgeon for all of their neurologic related needs (the family called the neurosurgeon who recommended they come see you). After a workup in the emergency department, it's still not clear why the patient is having seizures.
  • You call the neurosurgeon and the response is something like this, "Why are you calling me? This patient doesn't need surgery. Do you understand what I do? I am a neurosurgeon, that means I do brain surgery. This patient doesn't need that."

  • You reply, "I understand that, but you recommended the patient come to the ED, they are your patient and have complex brain hardware so I thought you'd like to know what's going on and we could discuss treatment options."

  • "I'm not sure why you can't understand what a neurosurgeon does. Are you a doctor..."

  • If the consultant has a truly pathologic personality, there's no magic fix or workaround. Just don't take their derision toward you personally. You'll find that they are exhibiting the same behavior in every part of their life.
  • There are other paths you can take besides wanting to smash the phone into the desk in a fit of rage. Your primitive brain is exploding right now, begging to go full caveman here. Take a breath, stay calm and measured and use the technique of BLEND and REDIRECT
  • Blend - restate what you do agree on and Redirect- see if you can align with them to help the patient.
  • Blend "I think we can agree this is a really complex patient. There's nothing suggesting they need acute surgery."  Redirect "But they're having this problem and I need some guidance on how to best help this patient and family." You are blending with what they're saying and redirecting them toward your need and seeing if they can help provide a solution.


The solid

Before you go, take a moment for the ERCast listener survey.

It's short, sweet, and full of info that will help me help you. And since you've gotten this far on the blog, I'll also tell you that there's a $50 Amazon gift card up for grabs.