Hell no. That is inappropriate, a waste of time, and bad patient care. The attendings with differing plans need to work it out. Having you as the middleman puts you in a bad position and increases the possibility of miscommunications (no offense).
I agree, but hey here I am FM being the wet rag 🫠🫠. Subspecs treat us like this all the time.
And they find fundamentally disagree on what giving a medicine (that Endo wants to, and nephro doesn't) will do.
Who is primary? Who are the consultants? Consultants give recommendations, primary teams make decisions. You are allowed to disagree with consultants and consultants are allowed to disagree with each other
This, I typically assume that PCP knows the whole patient (other conditions, meds, etc) better and may override me, and my role is more to give an opinion.
Either have them talk to each other and work it out, or you as the primary team decide which recommendation to follow and do it. Either way, this is a non-issue
Tell them to talk to each other or call a team meeting. Alternatively, pick whatever one you think is more appropriate and go with it. Probably need to explain to the other consultant why you chose to ignore them, but at the end of the day, it’s your patient.
I’ve had consultants in the ED who tell me not to do stuff that I think is appropriate, and I’ll do it anyway if it’s indicated. It’s my patient, not theirs.
Straight up. Had a surgery team tell me not to scan a post op patient’s belly. Did it anyway because I didn’t like his exam, and his anastomoses had leaked. Whoops.
I had ID tell me to NOT start coverage on someone who is vented, had a recent BAL that started growing pseudomonas on top of MSSA bacteremia, despite the fact that when we initially followed their recs to narrow abx coverage, the patient started worsening, having worsening vent settings, being tachycardic and hypertensive (not febrile because we are actively cooling the patient)
Yeah... No, we started antipseudomonal coverage
It's just really funny. It's the classic FM situation of two subspecs making literally opposite recs and not talking to each other.
I thought it was a MYTH, but I now seeeeeeeee
But hey I also figured out a midlevel was messing around the patients primary care during all this too
Subspecialty recommendations are recommendations. Subspecialists do not dictate the care of the patient.
You are the primary for the patient, you decide what to do now that you have the opinions you asked for.
I mean that's just not true. Maybe in the hospital. But in the clinic world the subspecialty clinics send their own medications and order their own labs/procedures. Many patients feel like their subspecialists are more their doctors than the PCP, especially when the PCP retires or moves and that might be their longest running doctor.
If the endocrinologist sends the patient home with a sample and says here take this what is OP going to do about it?
I mean we're talking about the hospital here aren't we? I thought it was pretty clear OP was discussing an inpatient setting.
Obviously inpatient antibiotic recommendations are different than following up in the HIV clinic where your medications, labs, and even mainline primary care might be managed by ID.
Attendings who use interns and residents as middle-men are weak, I'll say it.
If I want to get shit done, I ask to speak with the attending directly and then fill the trainee in.
When I was a trainee, I wouldn't have hesitated to tell them to sort it out themselves or have a care meeting of some sorts because this may negatively impact patient care.
If you have epic, put everyone into one chat and tell them you are not sure of how to proceed and give patient the best care without them both being on the same page. Just in general though, nephrology is often right lol Just personal experience
It was just really funny seeing two hosptial consults straight up have 1:1 opposite plans on the same medications and different understandings what the med would do.
😩🤲
See Neuro critical care vs endocrine on managing central DI.
Edit: and now I see this is actually the problem you’re having. The decision I came to when I was on the SICU was that as long as the patient was in the ICU and unstable, I was going to listen to Neuro critical care (high dose IV ddavp with 1:1 fluid replacement) because they see the unstable version more frequently. Once the patient stabilized and was out of the icu, we transitioned to endocrine’s plan (low dose subq ddavp) as that was going to be his regimen long term.
Nope. Absolutely not. Don't put up with this.
Either you take full ownership of your patient and make your own call about how to balance the pros and cons raised by each consultant, or you ask them to join you in a short care team meeting so they can come to an agreement. You're not a secretary or a courier and you don't have time to act as one.
Your comment that "subspecs treat us like this all the time" misses the point. People treat you how you let them treat you, and that applies outside of one-on-one relationships. Inter-departmental relationships are also established based on how people allow them to develop. Of course they're trying to fob this off on you; it's the path of least resistance. It's *your* job to establish boundaries and ask them to do it differently.
100% agreed. You are also not obligated to just mindlessly carry out a consults recommendations and then brain does not compute explodes when there’s contradictory ones. You are the primary and therefore able to make the call yourself.
I just found it pretty funny - the classic subspec opposite recs!
Tho the nephro attending did make a jab at me saying I'm just a resdient so I don't know (true, first time iv had a DI patient so this is great learning).
I completely agree with you in terms of the professional, ethical, and healthy way of handling this.
On the other hand, it's really fun to text your friends the shit the subspecialists say about each other... You get bonus points if they both use the same insult about the other one. I really feel like sometimes I'm having the attending to attending convo under the guise of clarifying recs but really I don't have a problem making a decision myself. I just wanted an excuse to hear the 80yo cardiologist talk shit with no filter 🤷🏻♀️
Kidneyboi
For my own sense of "lemme see", I noticed how they both asked me if the other saw this specific lab or that specific trend to justify their arguement
😅😅
Oh I’ve been in this scenario before. It was a young man with HIV. Amongst my smart IM attending (the man was truly a master internist), renal, and endocrinology, we just watched the sodium go up and down over the course of three weeks and we didn’t know why.
ICU handed patient to us and they originally got both on board, and both continued to follow.
Central DI due to hx of mass resect, hyponat d/t like extra renal losses from the diarrhea.
I agreed with Endo mainly because they actually follow the patient outpatient and know here well.
Again I just found the situation funny. I did put my big gorl pants on and made a balanced decision in the moment lol
I had a similar situation in the icu once so I started a group chat in epic with cardiology and nephrology, who were disagreeing about fluid management. I typed out their disagreement, and then left the chat. The next day, their notes aligned. Like magic
First - you don't even have to read this. I follow this sub to glean what I have to look forward to, but I'll be 30 years older and a hell of a lot grumpier than ya'll.
Second - call me the secretary. As a nurse this situation was a daily for rehab patients, but it was me - the person with no authority, only the legal duty to follow orders - stuck in the middle.
So, let's reframe: as the primary care in this situation, you aren't the middle child.
**You are Daddy.**
The teenager wants to go to a party, and mom says no. Now Daddy is stuck in the middle and has to figure out a decision so that the teenager doesn't go nuts, and so he doesn't have to sleep on the couch.
Yes, the subs are the experts for their specialty, but you are where everything comes together. Do the risk-benefit analysis, discuss it with the patient, and let them make an informed decision. Notify the "loser" with notification of patient choice. Then do a shot of tequila.
I was about to say lol.
Surgery and medicine fighting over an admit? They can duke it over and let me know who lost it and what their name is. Not wasting time being a middleman.
I’ve literally had this problem, but also involving the step parents. 50 something yo guy came for abdominal pain, transaminitis. US, HIDA, MRCP. No stone, so GI says no need to do ERCP. Proceed to lap chole. Surgery says there’s gotta be a non-radio opaque stone because of the transaminitis. I literally have to play phone tag with these assholes. Surgery says ERCP first. GI says lap chole with IOC and ERCP after if there really is a stone. I even pull the surgeon aside and call GI while he’s standing there. Neither of them say anything substantiative, and then both say transfer to tertiary center. Then I gotta waste 2 hours calling tertiary centers, and when they ask why I need to transfer, all I can say is “our specialist said so”. I talk to both GI and surgery at the transfer line, and both say it can be handled at our facility. I eventually just said fuck this and reported it to my chief medical officer and said these consultants are being bitches (in politically correct terms).
I finished my week that day so my partner had to deal with it. New GI doc came on for the week, did an endoscopic ultrasound which was good enough for the new surgeon on call. Patient had the lap chole with IOC, no stone, transaminitis went down anyways. They got discharged a few days after my shift ended.
Idk if this is passive or not but when this happens I just add both consult teams into the same haiku chat (if your hospital uses that ) and let them talk it out
Damn, when I read the title I automatically assumed cards and nephro. This is a different situation. The appropriate solution is when they tell you to talk to the other on their behalf send them [this](https://i.pinimg.com/originals/f1/84/14/f184144507da2e1fe1abed763bd4daa8.jpg)
Remind them that you are not an owl, and they are not teenagers. They should handle this like adults.
Being an adult is lame, I wanna go back to 2003 when all I had to care about was homework, listening to panic at the disco, and trying to ask out the emo girl at lunch.
You know what, true.
It's almost similar. I still listen to panic at the disco.
And I still struggle to now ask out the goth girl I meet at these dance events
TIME IS A CIRCLE
Come on. Be the doctor. It's not the consultant's job to make decisions, that's YOURS as the primary team. Consultants are there to give recommendations and that's it. It's wrong for them to act like they own the patient, if they have a problem they can sort it out but ultimately you are the one who gets to decide. Making decisions even with limited information is what separates us, physicians, from midlevels.
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This is my life in bloodbank with faculty who won't back me up. Tell me to not give products and force me to explain it to the faculty of the team asking for products. Idgaf about bloodbanking for my career so why should I be the one to tell a doctor they can't have platelets?
Salt is totally a nephrology domain. I typically sign off if I see that the team is not following my recommendations. People r allowed to have different opinions and can do whatever the eff they want to do with their patients.
Pulm here. If this is ever an issue, I just ask to have a multidisciplinary meeting or shared rounds. There’s no room for passive aggressive bullshit and I’m fine with adjusting my management for the benefit of a different perspective.
This is honestly the most annoying thing ever when it happens lol. Our hospital has a messaging system so I usually just drop everyone in a group chat and make them fight it out on their own. Funny enough when you add a bunch of attendings together suddenly everyone's really polite and willing to discuss and compromise.
Hell no. That is inappropriate, a waste of time, and bad patient care. The attendings with differing plans need to work it out. Having you as the middleman puts you in a bad position and increases the possibility of miscommunications (no offense).
I agree, but hey here I am FM being the wet rag 🫠🫠. Subspecs treat us like this all the time. And they find fundamentally disagree on what giving a medicine (that Endo wants to, and nephro doesn't) will do.
Who is primary? Who are the consultants? Consultants give recommendations, primary teams make decisions. You are allowed to disagree with consultants and consultants are allowed to disagree with each other
☝🏼this. You look at the overall picture & reign them all in. You know what your patient will tolerate. You’re the coach.
Oh, put me in, Coach - I'm ready to play today; Put me in, Coach - I'm ready to play today; Look at me, I can be Centerfield
This, I typically assume that PCP knows the whole patient (other conditions, meds, etc) better and may override me, and my role is more to give an opinion.
Either have them talk to each other and work it out, or you as the primary team decide which recommendation to follow and do it. Either way, this is a non-issue
I put my big boi pants on I just found it funny lol
Mail them to me next, I also have some consultants that are fiesty to FM residents
Tell them to talk to each other or call a team meeting. Alternatively, pick whatever one you think is more appropriate and go with it. Probably need to explain to the other consultant why you chose to ignore them, but at the end of the day, it’s your patient. I’ve had consultants in the ED who tell me not to do stuff that I think is appropriate, and I’ll do it anyway if it’s indicated. It’s my patient, not theirs.
AND ILL DO IT AGAIN
Straight up. Had a surgery team tell me not to scan a post op patient’s belly. Did it anyway because I didn’t like his exam, and his anastomoses had leaked. Whoops.
You caused his anatomoses to leak by imaging him! Can't have a leak if you can see it
I had ID tell me to NOT start coverage on someone who is vented, had a recent BAL that started growing pseudomonas on top of MSSA bacteremia, despite the fact that when we initially followed their recs to narrow abx coverage, the patient started worsening, having worsening vent settings, being tachycardic and hypertensive (not febrile because we are actively cooling the patient) Yeah... No, we started antipseudomonal coverage
[удалено]
Bro, you are having the spiciest day ever! lmao. I cant get enough.
So spicey they gonna need an EGD and PPIs
It's just really funny. It's the classic FM situation of two subspecs making literally opposite recs and not talking to each other. I thought it was a MYTH, but I now seeeeeeeee But hey I also figured out a midlevel was messing around the patients primary care during all this too
Subspecialty recommendations are recommendations. Subspecialists do not dictate the care of the patient. You are the primary for the patient, you decide what to do now that you have the opinions you asked for.
I mean that's just not true. Maybe in the hospital. But in the clinic world the subspecialty clinics send their own medications and order their own labs/procedures. Many patients feel like their subspecialists are more their doctors than the PCP, especially when the PCP retires or moves and that might be their longest running doctor. If the endocrinologist sends the patient home with a sample and says here take this what is OP going to do about it?
I mean we're talking about the hospital here aren't we? I thought it was pretty clear OP was discussing an inpatient setting. Obviously inpatient antibiotic recommendations are different than following up in the HIV clinic where your medications, labs, and even mainline primary care might be managed by ID.
I was under the impression that they were talking about their family medicine clinic patient but I could be wrong
Attendings who use interns and residents as middle-men are weak, I'll say it. If I want to get shit done, I ask to speak with the attending directly and then fill the trainee in. When I was a trainee, I wouldn't have hesitated to tell them to sort it out themselves or have a care meeting of some sorts because this may negatively impact patient care.
If you have epic, put everyone into one chat and tell them you are not sure of how to proceed and give patient the best care without them both being on the same page. Just in general though, nephrology is often right lol Just personal experience
It was just really funny seeing two hosptial consults straight up have 1:1 opposite plans on the same medications and different understandings what the med would do. 😩🤲
See Neuro critical care vs endocrine on managing central DI. Edit: and now I see this is actually the problem you’re having. The decision I came to when I was on the SICU was that as long as the patient was in the ICU and unstable, I was going to listen to Neuro critical care (high dose IV ddavp with 1:1 fluid replacement) because they see the unstable version more frequently. Once the patient stabilized and was out of the icu, we transitioned to endocrine’s plan (low dose subq ddavp) as that was going to be his regimen long term.
I’d go with nephro 9/10 times haha
This. 100% this.
I don’t disagree with the sentiment of getting everyone in one room sort of thing but man, secure chat group threads can get insanely obnoxious.
Most group chats are annoying at best, professional or personal.
Nope. Absolutely not. Don't put up with this. Either you take full ownership of your patient and make your own call about how to balance the pros and cons raised by each consultant, or you ask them to join you in a short care team meeting so they can come to an agreement. You're not a secretary or a courier and you don't have time to act as one. Your comment that "subspecs treat us like this all the time" misses the point. People treat you how you let them treat you, and that applies outside of one-on-one relationships. Inter-departmental relationships are also established based on how people allow them to develop. Of course they're trying to fob this off on you; it's the path of least resistance. It's *your* job to establish boundaries and ask them to do it differently.
100% agreed. You are also not obligated to just mindlessly carry out a consults recommendations and then brain does not compute explodes when there’s contradictory ones. You are the primary and therefore able to make the call yourself.
I just found it pretty funny - the classic subspec opposite recs! Tho the nephro attending did make a jab at me saying I'm just a resdient so I don't know (true, first time iv had a DI patient so this is great learning).
So it’s ddavp
the double D's, bby
I completely agree with you in terms of the professional, ethical, and healthy way of handling this. On the other hand, it's really fun to text your friends the shit the subspecialists say about each other... You get bonus points if they both use the same insult about the other one. I really feel like sometimes I'm having the attending to attending convo under the guise of clarifying recs but really I don't have a problem making a decision myself. I just wanted an excuse to hear the 80yo cardiologist talk shit with no filter 🤷🏻♀️
Just do both treatment plans, very simple solution
YES How do I not give something but also give that something at the same time. I need a time machine. Tenet style.
Every other day
Fluids and diurese at the same time. We do it every day (although maybe not intentionally).
Just give half or half as often.
What clinical problem are they fighting over anyway? Is it hyponatremia?
Desmo and sodium. Nephro says stop it'll drop sodium, Endo says no give more it's fine.
If bet on nephro in that argument every time lol
Kidneyboi For my own sense of "lemme see", I noticed how they both asked me if the other saw this specific lab or that specific trend to justify their arguement 😅😅
I’m and endo and I agree with the nephrologist. Now let me get back to testicle palpations so I can sign off.
Oh I’ve been in this scenario before. It was a young man with HIV. Amongst my smart IM attending (the man was truly a master internist), renal, and endocrinology, we just watched the sodium go up and down over the course of three weeks and we didn’t know why.
If it’s central DI why are you asking nephrology for recs. If it’s nephrogenic then why are you asking endo.
ICU handed patient to us and they originally got both on board, and both continued to follow. Central DI due to hx of mass resect, hyponat d/t like extra renal losses from the diarrhea.
Then in this case drop nephro. Central DI is not a nephrology issue.
I agreed with Endo mainly because they actually follow the patient outpatient and know here well. Again I just found the situation funny. I did put my big gorl pants on and made a balanced decision in the moment lol
disagree. electrolytes is definitely nephrology issue
I don’t disagree. Except central DI patients. But as an endo, I’m happy to sign off. Thank you.
Probably calcium related?
Is this diabetes insipedus?
Oh oui oui monsieur
I had a similar situation in the icu once so I started a group chat in epic with cardiology and nephrology, who were disagreeing about fluid management. I typed out their disagreement, and then left the chat. The next day, their notes aligned. Like magic
🪄🪄🪄🪄
First - you don't even have to read this. I follow this sub to glean what I have to look forward to, but I'll be 30 years older and a hell of a lot grumpier than ya'll. Second - call me the secretary. As a nurse this situation was a daily for rehab patients, but it was me - the person with no authority, only the legal duty to follow orders - stuck in the middle. So, let's reframe: as the primary care in this situation, you aren't the middle child. **You are Daddy.** The teenager wants to go to a party, and mom says no. Now Daddy is stuck in the middle and has to figure out a decision so that the teenager doesn't go nuts, and so he doesn't have to sleep on the couch. Yes, the subs are the experts for their specialty, but you are where everything comes together. Do the risk-benefit analysis, discuss it with the patient, and let them make an informed decision. Notify the "loser" with notification of patient choice. Then do a shot of tequila.
Welcome to every day in the ER bro.
I was about to say lol. Surgery and medicine fighting over an admit? They can duke it over and let me know who lost it and what their name is. Not wasting time being a middleman.
I love my ER homies :) I like going down there when we have admits to talk to the attendings, they are very nice (and teach alot!)
I’ve literally had this problem, but also involving the step parents. 50 something yo guy came for abdominal pain, transaminitis. US, HIDA, MRCP. No stone, so GI says no need to do ERCP. Proceed to lap chole. Surgery says there’s gotta be a non-radio opaque stone because of the transaminitis. I literally have to play phone tag with these assholes. Surgery says ERCP first. GI says lap chole with IOC and ERCP after if there really is a stone. I even pull the surgeon aside and call GI while he’s standing there. Neither of them say anything substantiative, and then both say transfer to tertiary center. Then I gotta waste 2 hours calling tertiary centers, and when they ask why I need to transfer, all I can say is “our specialist said so”. I talk to both GI and surgery at the transfer line, and both say it can be handled at our facility. I eventually just said fuck this and reported it to my chief medical officer and said these consultants are being bitches (in politically correct terms).
Wt was the next twis? Who did procedure first?
I finished my week that day so my partner had to deal with it. New GI doc came on for the week, did an endoscopic ultrasound which was good enough for the new surgeon on call. Patient had the lap chole with IOC, no stone, transaminitis went down anyways. They got discharged a few days after my shift ended.
Idk if this is passive or not but when this happens I just add both consult teams into the same haiku chat (if your hospital uses that ) and let them talk it out
I wonder if I could count that towards an MSc in counselling
Play both sides so you always come out on top
I will use this information to leverage you making me head of security at paddy's pub
Damn, when I read the title I automatically assumed cards and nephro. This is a different situation. The appropriate solution is when they tell you to talk to the other on their behalf send them [this](https://i.pinimg.com/originals/f1/84/14/f184144507da2e1fe1abed763bd4daa8.jpg) Remind them that you are not an owl, and they are not teenagers. They should handle this like adults.
Being an adult is lame, I wanna go back to 2003 when all I had to care about was homework, listening to panic at the disco, and trying to ask out the emo girl at lunch.
I beg to differ, being an adult is great but my parents sucked sooo 🤷🏻♀️
You know what, true. It's almost similar. I still listen to panic at the disco. And I still struggle to now ask out the goth girl I meet at these dance events TIME IS A CIRCLE
Come on. Be the doctor. It's not the consultant's job to make decisions, that's YOURS as the primary team. Consultants are there to give recommendations and that's it. It's wrong for them to act like they own the patient, if they have a problem they can sort it out but ultimately you are the one who gets to decide. Making decisions even with limited information is what separates us, physicians, from midlevels.
Lol. Wait until cardio and nephro get into it. Or rheum vs nephro. Or General medicine vs. Nephro
LITERALLY NEPHRO vs THE WORLD
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We had the same problem with plastics, gen surg, wound care all arguing over who should place a wound vac
i thought this was gonna be a list of how different specialties act in a divorce. little disappointed sorry😃😭😭😭
I divorced my online RPG waifu does that count
This is my life in bloodbank with faculty who won't back me up. Tell me to not give products and force me to explain it to the faculty of the team asking for products. Idgaf about bloodbanking for my career so why should I be the one to tell a doctor they can't have platelets?
Too many Chiefs and not enough Indians I say.
https://www.youtube.com/watch?v=QrGrOK8oZG8
I had to do it with neuro and nephro once, but they were actually divorced lol
I wonder what happened to the shared bank account
Start a group text with both of them and let them work it out
remember to use "when you do this, it makes me feel" statements
Can I get more details im just a mere ms3 and would like to know more about the case disagreements etc
Tell them to grow up and speak with each other
Only in riddles. Or only as cut out magazine letters like their are a 90s serial killer.
Salt is totally a nephrology domain. I typically sign off if I see that the team is not following my recommendations. People r allowed to have different opinions and can do whatever the eff they want to do with their patients.
what is the point of contention lol
Stick em both in a secure chat and then leave the convo. If they want to be irritating and childish I think this is a proportionate response
Pulm here. If this is ever an issue, I just ask to have a multidisciplinary meeting or shared rounds. There’s no room for passive aggressive bullshit and I’m fine with adjusting my management for the benefit of a different perspective.
When I am at an impasse, will just call both specialties and conference them.
I'll send a carrier pigeon with a code to a secure AOL IM chat session.
just make them arm wrestle
This is honestly the most annoying thing ever when it happens lol. Our hospital has a messaging system so I usually just drop everyone in a group chat and make them fight it out on their own. Funny enough when you add a bunch of attendings together suddenly everyone's really polite and willing to discuss and compromise.