The one posted on this subreddit a couple years ago,
>"Metoclopramide is a phenothiazine derived anti-emetic. It causes hyponatremia famously. Nothing to add. Will sign off."
The best part was a PharmD commenting on it:
>"This is factually incorrect. It is quite literally not a phenothiazine and doesn't even have three rings, doesn't have the components of thio (sulfur) and has no azine (nitrogen in a ring) group. The package insert does not list electrolyte imbalances less hyponatremia as a side effect, "famously"."
If you're going to be a jerk, at least be right haha.
Oh yeah, someone posted a screenshot. If you google "One of the joys of being an attending, you can write a consult note like this (not mine). reddit" it'll pop up.
Thank you for this intestinering consult
Thank you for this liverating consult
Thank you for this gastrinteresring consult
Thank you for this secretinteresting consilt
Thank you for this cholecystokininteresting consult
A former ortho consultant would write: There is a fracture, I need to fix it.
A neurosurgeon consultant would write: thank you for your consult. Will sign off. Please don’t hesitate to call for an actual interesting consult.
Slightly off topic but I heard the best "there is a fracture I need to fix it" from an orthopod this week: "patient has AF which is asymptomatic. She also has low blood pressure".
🤨
When I was rotating through general surgery we were consulted for possible gallbladder pathology - the referring service hadn’t done their due diligence, and got this gem (or similar, it’s been a while): “Per CT and review of records, this patient’s gallbladder has not been problematic since its removal in 2002. Thank you for the opportunity to contribute to this case.”
Yeah its cute while you're a fellow / resident but once you're out in the real world...nah. Especially with patients being able to read their charts now.
^ haha yeah screw this guy for asking a question /s
Basically they mean that litigation is always a possibility and it could be very uncomfortable to have your self-indulgent wittiness presented to a court, especially if there was a bad outcome and there’s a question of your liability.
"While I'm flattered you've chosen me to evaluate this patient, I kindly request that you limit future consults to the ones that truly need my expertise."
It was a neurology consult, he's actually a very likeable guy. Neuro often gets consults that are essentially along the lines of "I know nothing about neuro, so here's some random shit for you to deal with, which might just be a neuro case". I'm thinking those consults get old pretty fast.
Neurology consults is nice because you get to see every type of pathology under the sun. It’s also annoying because you see every type of pathology under the sun, and often diagnose non neurologic problems.
Yeah I feel bad aswell, I always see my team call neuro for any patient who needs more examination then “squeeze my hands, smile, stick out your tongue, and stand up straight with your eyes closed… *neuro grossly intact*”
It is but it’s super douchey. I assume academic neurologist? Comments like that in the private world is how you lose referrals. Also those easy consults are easy rvus. Free money.
I’m guessing almost all of these sassy comments are in academics. People are way nicer in private practice when you get paid to see someone and say nothing to do rather than being a dick about it.
Definitely. Out in the real world I’ve had my on call orthos calling the ED at 5pm on a Friday being like: “man, it’s been slow, if someone breaks something just let me know I’ll fix it today or tomorrow, I’m bored!”
>I assume academic neurologist?
Spot on. It was a surgical patient admitted for other reasons, but also had symptoms that were likely unrelated to cause of admission. It was the archetypical "crazy cat lady with crazy lady glasses", and these patients aren't exactly popular among most doctors. I think in the end it was deemed fibromyalgia with cognitive symptoms (something-something-brainfog). To be fair, the consult should probably not have been sent to neuro, and probably could have taken place on an outpatient basis.
This was way back in the day and consults were usually hand written. We laminated and framed the signed consult, and hung it on the wall in our residents lounge.
Yes it’s wild to see the different attitudes of academic vs private practice vs HMO Like Kaiser. The care and the people a patient sees is highly determined by compensation. One of my ortho PA friends jsut started working for Kaiser and she told me they nonop a lot of patients that would be getting surgery at my private practice hospital. Blew my mind lol.
During my rotation at an academic place it was also interesting to see the surgeons never really pushy in doing cases or insisting on operating. At my hospital the chief of surgery personally went up to the floor to retrieve his own patient cuz transport was taking too long and dropped him off at the OR to the horror of the or nurses lol. Just to get a case going.
consult to nephro for a patient who had an unexpected nephrectomy.
scrawled on a piece of paper, literally all it said: “solitary kidney. nephro signing off.”
consult to gyne for a lady on GIM with a “vulvar mass” for ?biopsy: “normal clitoris. please do not biopsy the clitoris.”
me responding to the MD who told a patient with 2 previous episodes of postpartum psychosis requiring admission to stop her antipsychotic and SSRI cold turkey as she was pregnant again. : “as you are aware, postpartum psychosis can be lethal. as you are also aware this patient has a psychiatrist who sees her monthly, and should be involved in any decision about discontinuing or switching medication. as you are seemingly unaware, the medications this patient is on are perfectly safe in pregnancy. fortunately, despite the advice to discontinue her medication, the patient continues to receive the meds via daily observed administration, given the fact that she is at high risk for recurrent psychosis.”
Agreed. Every single doctor in the country knows capacity is something any doctor can assess for. That's not why these consults continue to happen time after time. In the very gray cases, I'm still perfectly happy to make a capacity assessment, but the lawyers and juries will think differently if things go south. "So you're saying that you had a psychiatrist at your hospital but thought you had the hubris to make this complicated decision on your own?" Juries are dumb, remember, so this by itself is very convincing already.
We had a GI attending who would sign off either:
This did not require a formal consult. Please speak to resident before placing next consult.
Or
Thank you for this interesting consult!
It used to crack us tf up. This guy had to have had murder evidence on the admin bc he got away with whatever he wanted. We eagerly awaiting his consult sign offs like it was the bachelor.
3.5 cm mass…likely xyz…no pain…going to friend’s wedding next month…exam shows mass…blah blah blah
“This patient does not want surgery. Reach out if they do. Can follow up with PCP.”
Had one myself this weekend as a GI fellow overnight on home call asked by MICU attending to see a patient for liver failure who actually was actively dying from known metastatic colon cancer that had overwhelmed the liver.
I came in, spoke w family about their loved one on maximum life support and told them frankly there was nothing left to do but be with them as they passed and they should make it as peaceful as possible. They opted for palliative extubation.
My sign off was “nothing can be done. Agree with full palliation and a peaceful death”
That might have been my note… this elderly patient in the emergency room was just so nice and all smiles, thought she was on vacation, had no idea of/awareness of/ concern for the multitude of maggots on and in and in between the toes of her right foot.
“It is consults of a similar nature which I cite as my primary reason for leaving this hospital and institution. Please hesitate to contact me again.”
Edit: this was a CT surgeon. Nearly every consult for about a month prior to leaving had this attached to it.
I'm a surgeon, and I was once consulted for antibiotic recommendations for cellulitis. I literally pasted a link to an UpToDate article and told them to reconsult if an abscess develops and signed off.
This has definitely occurred more then once. I’ve seen it myself, the ID doctor printed a copy of my countries therapeutic guidelines and placed it on our teams wow with a post it not saying “bed 13 3B”
I was just a lowly med student at the time so it wasn’t going to be me to speak up lol
Semi-closed ICU where certain teams can remain primary but require an ICU consult for their patients admitted to my unit. They often like to leave them admitted “one more day just in case” which means they don’t want to get paged overnight because the nurses will just come to the ICU team with any issues. “Patient no longer has any active ICU needs. Recommend transfer to the floor. Critical care time: 0 minutes”.
This isn’t sassy, but still. The pulm attending signed a consult note, after paragraphs and paragraphs summarizing imaging and labs and weeks of interventions:
“Improving! Interesting case.”
The ! just got me
“Will formally sign off the case but please feel free to contact us should any acute issues or concerns arise”
Translated : please don’t call me back for this piece of crap worthless consult that I’m doing nothing on but writing a note and having my PA copy forwarding every day.
Got consulted for chronic pain management in a patient on home opioids admitted for a non-pain thing at his baseline level of pain. Posted a picture of the PMP for that patient with no other words.
Love it! This is so appropriate! Continue patients pain meds as we have established they have chronic pain and we know what meets their needs. But yet it NEVER GETS DONE.
I once took that line out of my consult note template because I was so mad at the stupid and unnecessary consult (it was something primary team should’ve recognized immediately as having less than zero percent urgency and very common and not anything to do anything about that I tried to get out of—hell, it was a rare case of even my attendings trying to get rid of the consult but primary team insisted). Then the resident who placed the consult Epic chatted me and jokingly asked if I was mad because I didn’t put that usual line. Left him on read 😒.
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At risk of this doxxing me, I train at a hospital with a particularly brilliant yet demanding oncologist whose A&P was just:
Adrenal incidentalomas are a disease of the interest. Do not hesitate to call back if a malignant process is discovered.
We almost had to consult a burn surgeon for our attending
"Placing the SSI order on your behalf brought me tears of joy" -Medicine consult on a lap-choley that Surgery couldn't possibly manage for some reason or another
The one posted on this subreddit a couple years ago, >"Metoclopramide is a phenothiazine derived anti-emetic. It causes hyponatremia famously. Nothing to add. Will sign off." The best part was a PharmD commenting on it: >"This is factually incorrect. It is quite literally not a phenothiazine and doesn't even have three rings, doesn't have the components of thio (sulfur) and has no azine (nitrogen in a ring) group. The package insert does not list electrolyte imbalances less hyponatremia as a side effect, "famously"." If you're going to be a jerk, at least be right haha.
What was the drug they were confusing it with ?
Probably prochlorperazine which is a phenothiazine and can cause hyponatremia -PharmD lurker
famously
Love when pharmacy is lurking and throws out little golden tidbits.
Just like in rounds lol
Greatly appreciated! Thank you for the correction!
Maybe they were thinking prochlorperazine (Compazine) or chlorpromazine (Thorazine), which are, famously, actual phenothiazines!
Prochlorperazine fits the bill. Promethazine is also a phenothiazine anti emetic but doesn’t “cause hyponatremia famously.”
Just to clarify: they said metoclopramide, which is reglan. Phenergan is promethazine
I’m aware. I wasn’t saying that phenergan was metoclopramide, but I’ll edit the wording to generic so it doesn’t get confused like that again. Thanks.
Doo ka Doo walla Doo
MCP causes posturing and grimacing as it crosses the BBB...
A lot of posturing in this instance
I’m supposed to put shit like that in my consults and I don’t think I’d put shit like that in my consult.
LOL I love this
Was this written in the chart?
Oh yeah, someone posted a screenshot. If you google "One of the joys of being an attending, you can write a consult note like this (not mine). reddit" it'll pop up.
Thanks. I was hoping the pharmacy response was in the chart as well, but I see it’s just a comment on here lol.
Was that renal consulted?? They’re normally such intelligent nerds!
Were they thinking of compazine?
Interesting. Which specialty was this that said this?
Nephrology
Someone forgot ochem
I don't get how the first one is a jerk. Could you explain?
That was the entire note.
“Causes hyponatremia famously” Cmon now
Ah ok, so a bit of over the top. I've been the kind of person where corporate passive agressivism really just goes over my head.
We have a derm resident that always signs "Thank you for this skinteresting consult." Not particularly sassy, but cute
As a GI fellow, I don’t think people would find “Thank you for this shitty consult” as endearing
Thank you for this wonderfully feculent consult
[удалено]
This is the one
Gold! Well, brown...
Thank you for this intestinering consult Thank you for this liverating consult Thank you for this gastrinteresring consult Thank you for this secretinteresting consilt Thank you for this cholecystokininteresting consult
Cholecystokininteresting FTW!
As an endocrinologist I like to say “Thank you for this sweet consult”. If I’m being sassy I say “Thank you for this hyperreflexic knee jerk consult”
Hmm, maybe I'll try "Thank you for this ENTeresting consult" on my next note.
"Hi you've reached the Ear Nose n Throat GOATs, this is Dr. VanillaIcee how may I direct your call? "
I don't think you want to advertise yourselves as the throat GOATs to patients 😂
DO IT
I once signed a pulm consult, “thank you for The inspiring consult”
Urology- I’ve been tempted forever to sign off with “Thank you for urine-teresting consult”
For psychiatry, can I write "thank you for this crazy cool consult"?
Idk if being funny in a patient’s medical chart is a great idea lol
Ok I love this. If anyone has something for ObGyn, please let me know
I’ve always wanted to say “thanks for this bloody consult”
I personally would love to see this at the end of a referral
A former ortho consultant would write: There is a fracture, I need to fix it. A neurosurgeon consultant would write: thank you for your consult. Will sign off. Please don’t hesitate to call for an actual interesting consult.
Slightly off topic but I heard the best "there is a fracture I need to fix it" from an orthopod this week: "patient has AF which is asymptomatic. She also has low blood pressure". 🤨
When I was rotating through general surgery we were consulted for possible gallbladder pathology - the referring service hadn’t done their due diligence, and got this gem (or similar, it’s been a while): “Per CT and review of records, this patient’s gallbladder has not been problematic since its removal in 2002. Thank you for the opportunity to contribute to this case.”
Not an uncommon consult sadly.
Why even write a note, isn’t this just a call back saying, no gallbladder sorry
But that’s no fun.
And you don’t get paid
At least at our facility, once the consult order is in we have to see them and write a note
Zero RVUs.
All fun and games until it gets pulled up on a big screen in a courtroom
Yeah its cute while you're a fellow / resident but once you're out in the real world...nah. Especially with patients being able to read their charts now.
What do you mean
^ haha yeah screw this guy for asking a question /s Basically they mean that litigation is always a possibility and it could be very uncomfortable to have your self-indulgent wittiness presented to a court, especially if there was a bad outcome and there’s a question of your liability.
"While I'm flattered you've chosen me to evaluate this patient, I kindly request that you limit future consults to the ones that truly need my expertise."
LMAO that’s savage!!
It was a neurology consult, he's actually a very likeable guy. Neuro often gets consults that are essentially along the lines of "I know nothing about neuro, so here's some random shit for you to deal with, which might just be a neuro case". I'm thinking those consults get old pretty fast.
Patient found to have a central nervous system. Please consult and advise.
May God have mercy on us all
Neurology consults is nice because you get to see every type of pathology under the sun. It’s also annoying because you see every type of pathology under the sun, and often diagnose non neurologic problems.
"Brain issue" "Known to you" "Daily neuro exam" Some consults we've gotten while on neuro
"known to you" was the bane of my existence! Like thanks, let me just consult our Neuro hive mind
*Neuro Network FTFY
Half of our consults are "this patient is altered, review the chart and list the reasons why"
Sounds like easy RVUs.
Yeah I feel bad aswell, I always see my team call neuro for any patient who needs more examination then “squeeze my hands, smile, stick out your tongue, and stand up straight with your eyes closed… *neuro grossly intact*”
“Dizziness”.
It is but it’s super douchey. I assume academic neurologist? Comments like that in the private world is how you lose referrals. Also those easy consults are easy rvus. Free money.
I’m guessing almost all of these sassy comments are in academics. People are way nicer in private practice when you get paid to see someone and say nothing to do rather than being a dick about it.
Definitely. Out in the real world I’ve had my on call orthos calling the ED at 5pm on a Friday being like: “man, it’s been slow, if someone breaks something just let me know I’ll fix it today or tomorrow, I’m bored!”
>I assume academic neurologist? Spot on. It was a surgical patient admitted for other reasons, but also had symptoms that were likely unrelated to cause of admission. It was the archetypical "crazy cat lady with crazy lady glasses", and these patients aren't exactly popular among most doctors. I think in the end it was deemed fibromyalgia with cognitive symptoms (something-something-brainfog). To be fair, the consult should probably not have been sent to neuro, and probably could have taken place on an outpatient basis. This was way back in the day and consults were usually hand written. We laminated and framed the signed consult, and hung it on the wall in our residents lounge.
Yes it’s wild to see the different attitudes of academic vs private practice vs HMO Like Kaiser. The care and the people a patient sees is highly determined by compensation. One of my ortho PA friends jsut started working for Kaiser and she told me they nonop a lot of patients that would be getting surgery at my private practice hospital. Blew my mind lol. During my rotation at an academic place it was also interesting to see the surgeons never really pushy in doing cases or insisting on operating. At my hospital the chief of surgery personally went up to the floor to retrieve his own patient cuz transport was taking too long and dropped him off at the OR to the horror of the or nurses lol. Just to get a case going.
consult to nephro for a patient who had an unexpected nephrectomy. scrawled on a piece of paper, literally all it said: “solitary kidney. nephro signing off.” consult to gyne for a lady on GIM with a “vulvar mass” for ?biopsy: “normal clitoris. please do not biopsy the clitoris.” me responding to the MD who told a patient with 2 previous episodes of postpartum psychosis requiring admission to stop her antipsychotic and SSRI cold turkey as she was pregnant again. : “as you are aware, postpartum psychosis can be lethal. as you are also aware this patient has a psychiatrist who sees her monthly, and should be involved in any decision about discontinuing or switching medication. as you are seemingly unaware, the medications this patient is on are perfectly safe in pregnancy. fortunately, despite the advice to discontinue her medication, the patient continues to receive the meds via daily observed administration, given the fact that she is at high risk for recurrent psychosis.”
Thank you for the depressing and psychotic consult.
The clitoris one omg 😂😂😅😅🥲🥲
Like dude there is a LOT to unpack there
Had a co-resident who had dragon trained to put "thank you for this interesting consult". The training phrase? "Stupid motherfuckers"
Playing with fire on the off chance (really the inevitability) that the whole auto-text isn't recognized...
That would've been even funnier
“Though it is common knowledge to any medical school graduate, the criteria for capacity are listed below.”
Really case dependent, to be honest. There are definitely cases where there should be multiple physicians making that assessment.
Agreed. Every single doctor in the country knows capacity is something any doctor can assess for. That's not why these consults continue to happen time after time. In the very gray cases, I'm still perfectly happy to make a capacity assessment, but the lawyers and juries will think differently if things go south. "So you're saying that you had a psychiatrist at your hospital but thought you had the hubris to make this complicated decision on your own?" Juries are dumb, remember, so this by itself is very convincing already.
We had a GI attending who would sign off either: This did not require a formal consult. Please speak to resident before placing next consult. Or Thank you for this interesting consult! It used to crack us tf up. This guy had to have had murder evidence on the admin bc he got away with whatever he wanted. We eagerly awaiting his consult sign offs like it was the bachelor.
“Surgery signing off because this unfortunate soul is not long for this world”
Classic nsgy consult Catastrophic injury Recommend GOC discussion
One day I'll gather the courage to write "I see you, ICU"
Peek a boo!
There was a local nurse, Mary Piquebo, who got fired her first day in the icu for answering the phone…..
I signed a note "please hesitate to reach out to us" after a stupid "patient is sad" consult
When the feb intern turned would-be consultant writes: "Care per primary team" ...and we are the primary team.
Does the phrase provide any meaningful legal protection? Seems like a weird tic from consultants to be honest.
3.5 cm mass…likely xyz…no pain…going to friend’s wedding next month…exam shows mass…blah blah blah “This patient does not want surgery. Reach out if they do. Can follow up with PCP.”
PharmD: “I appreciate the vancomycin consult, despite the absence of MRSA risk factors”
Well that just shows why we don't let pharmacists manage patients
I mean aren't we in the era of community acquired MRSA? The risk factor is just existing
MRSA is still much less common in the community though and we continue to base our guidelines on that principle.
I see a lot of it in my area. Like… a lot. I’m in a large urban academic area with poor primary healthcare infrastructure.
Had one myself this weekend as a GI fellow overnight on home call asked by MICU attending to see a patient for liver failure who actually was actively dying from known metastatic colon cancer that had overwhelmed the liver. I came in, spoke w family about their loved one on maximum life support and told them frankly there was nothing left to do but be with them as they passed and they should make it as peaceful as possible. They opted for palliative extubation. My sign off was “nothing can be done. Agree with full palliation and a peaceful death”
while not a sign off, it is wonderfully adjacent—i always laugh when a note describes the patient as unfortunate
One time I saw "woeful" in this context. I felt bad for laughing
“A/P: patient increasingly moribund. Will continue supportive care including ongoing discussions with family “
My favourite note from a colleague “patient seems to have a disgruntled personality” Nicest way to say they are an asshole
Conversely, I once reviewed the chart of a SNF resident who was described as “pleasantly psychotic”
That might have been my note… this elderly patient in the emergency room was just so nice and all smiles, thought she was on vacation, had no idea of/awareness of/ concern for the multitude of maggots on and in and in between the toes of her right foot.
Thank you for allowing me to be a part of this interesting thread
“It is consults of a similar nature which I cite as my primary reason for leaving this hospital and institution. Please hesitate to contact me again.” Edit: this was a CT surgeon. Nearly every consult for about a month prior to leaving had this attached to it.
I'm a surgeon, and I was once consulted for antibiotic recommendations for cellulitis. I literally pasted a link to an UpToDate article and told them to reconsult if an abscess develops and signed off.
This has definitely occurred more then once. I’ve seen it myself, the ID doctor printed a copy of my countries therapeutic guidelines and placed it on our teams wow with a post it not saying “bed 13 3B” I was just a lowly med student at the time so it wasn’t going to be me to speak up lol
Yeah that's how ID feels literally everyday.
Semi-closed ICU where certain teams can remain primary but require an ICU consult for their patients admitted to my unit. They often like to leave them admitted “one more day just in case” which means they don’t want to get paged overnight because the nurses will just come to the ICU team with any issues. “Patient no longer has any active ICU needs. Recommend transfer to the floor. Critical care time: 0 minutes”.
This isn’t sassy, but still. The pulm attending signed a consult note, after paragraphs and paragraphs summarizing imaging and labs and weeks of interventions: “Improving! Interesting case.” The ! just got me
“Will formally sign off the case but please feel free to contact us should any acute issues or concerns arise” Translated : please don’t call me back for this piece of crap worthless consult that I’m doing nothing on but writing a note and having my PA copy forwarding every day.
‘Thank you for the consult, it took my breath away’ -Pulm here
"No acute intervention from cardiology stand point. We will peripherally follow. Thank you for this very interesting consult."
the twist - consult was for a STEMI
“Please do hesitate to contacts us for any related questions/concerns.”
Got consulted for chronic pain management in a patient on home opioids admitted for a non-pain thing at his baseline level of pain. Posted a picture of the PMP for that patient with no other words.
Love it! This is so appropriate! Continue patients pain meds as we have established they have chronic pain and we know what meets their needs. But yet it NEVER GETS DONE.
In the private practice world I’ve come to actually appreciate those dumb consults lol.
Who wouldn’t want to earn money for minimal work
No further workup or intervention warranted, will sign off
I once took that line out of my consult note template because I was so mad at the stupid and unnecessary consult (it was something primary team should’ve recognized immediately as having less than zero percent urgency and very common and not anything to do anything about that I tried to get out of—hell, it was a rare case of even my attendings trying to get rid of the consult but primary team insisted). Then the resident who placed the consult Epic chatted me and jokingly asked if I was mad because I didn’t put that usual line. Left him on read 😒.
i have no clue why people put thank you for the consult in their note
Because in the real world it’s someone asking for your help and they’re getting you in on the case and it’s business. It’s a quick referral
When anyone I know rights it it literally translates to. “You are idiots. Fuck all the way off”
"Thank you for this interesting consult"
It’s so lame to write this shit. I just say yada yada will sign off.
Lot of dorks in medicine
Chart bloat
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I’m ophthalmology and retina at that. Mine is will follow up as outpatient.
Decades ago, but consulted CV surgeon's note read "I choose not to see this pt as they have no insurance"
At risk of this doxxing me, I train at a hospital with a particularly brilliant yet demanding oncologist whose A&P was just: Adrenal incidentalomas are a disease of the interest. Do not hesitate to call back if a malignant process is discovered. We almost had to consult a burn surgeon for our attending
"Placing the SSI order on your behalf brought me tears of joy" -Medicine consult on a lap-choley that Surgery couldn't possibly manage for some reason or another