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
Before jumping in to the episode, take a few minutes for the
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.
- 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
- What to do when a consultant is dismissive of your concerns
about a patient
- Factors that may lead to questionable advice from a
- Bad advice is usually not malicious (even though it may feel
- Be aware of downstream effects of negative interactions with
- 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
- 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
- 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
- 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
- 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
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
- Blend - restate what you do agree on and
Redirect- see if you can align with them to help
- 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.
Before you go, take a moment for the ERCast listener
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.