[Ed. Time for another new author on the site. John Cronin is an EM trainee in Ireland and currently a paeds EM research fellow in Dublin. Find out some more here]
One of the issues in our specialty is that sometimes we are on the receiving end of guff/disrespect/unpleasantness (call it what you will) from our colleagues up the house. On the whole I think this is relatively rare and hopefully doesn’t happen in the vast majority of referrals/communications.
I often wonder though, when I find myself in these situations, how others would have dealt with it. So here’s my chance to find out. Please let me know what you would have done (if anything) – all comments welcome. This is a case I saw a good while back
6 y.o. fall onto L elbow, attends your ED one evening:
Crying; swollen, bruised elbow; no open wounds; no distal NV compromise
You quickly supply appropriate analgesia, a backslab and send to X-ray
You call ortho and the (relatively junior) registrar attends promptly. You give the whole story. The ortho reg sees the patient and, after talking to his boss, consents them for OT. The ortho reg says that he does not want to take down the back slab as it will cause too much pain to the child, preferring to wait until the child is under anaesthetic in theatre (sounds reasonable). And he asks a second time:
Ortho reg: “Is there definitely no wound?”
You: “No, definitely not.”
Ortho Reg: “Good, cos if we go up there and there is one when we take down the back slab, my boss will have my head, and then I’ll come down here and have your head!”
Your reaction:
- This is a perfectly reasonable thing for him to say, don’t know why we’re even discussing it
- The ortho reg is probably under some stress – have some tea and buns ready for him when he’s finished in theatre, and invite him to give a teaching session to the ED physicians on the management of open fractures at his convenience
- Don’t say anything and discuss it with your boss the next day
- Tell him that that’s not a very nice thing to say, and that you don’t appreciate that kind of tone in the ED
- “Have his head” there and then
- Say nothing, decide that someone with that kind of attitude is not worth conversing with, let it fester and write a blogpost about it sometime later
- Something like this:
httpvh://www.youtube.com/watch?v=lQkpes3dgzg
8. Something else entirely – let me know what?
John
This is from a podcast Iistened to long time ago “How to Communicate with Consultants”
http://www.emrapee.com/episodes/teaching-residents-how-to-communicate-with-consultants/
Responses to conflict adapted from business model:
1. Forcing (competition): Task oriented, but destroys relationship
2. Smoothing: Accommodation technique, holds relationship, but downgrades the task
3. Avoidance: Gets you nowhere, destroys relationship and gets nothing accomplished
4. Compromise: Comes up with a plan, can be OK for the relationship and the task at hand
5. Confronting: best in emergency medicine. Getting everything you want. thinking outside the box: shared problem solving, think about the issue and come up with a solution. Good for the task and the relationship
http://www.ncbi.nlm.nih.gov/pubmed/21620608
http://lifeinthefastlane.com/2010/04/referring-patients-from-the-emergency-department/
You’ve got to take the “high” road, and make it all about the patient, and not get wrapped up in whether this guy is disrespecting you or not. If he is…so what. You are the professional. You must approach this from an angle of patient safety, I.e., what is in the best interest of the patient. Even if you say something to this physician that he doesn’t want to hear, if you adopt the right medical and moral stance, he will not have a leg to stand on when it comes to complaining about you, or even continuing to disdain you.
Acknowledge his concern that an open fracture would mean a much more serious procedure (needing an incision, pins, plating, iv antibiotics, chance of osteomyelitis, potential long term disability or restricted activity for the patient), AND…
Offer to assist him, as gently as possible, examine the patient himself with your assistance, even if that means requiring additional analgesic medication.
This guy will respect you for this response and approach (to whatever limited degree that is possible for him). From an American Anesthesiologist, who gets dissed just like you did. When I tell a surgeon that he or she can’t do something, I make it clear to them that it’s not about me, it’s about their patient.
Thanks Jimmy,
A number of people have replied to me in person saying they would essentially fight fire with fire. However, I tend to agree with you and I didn’t sink to his level. I had no problem about him asking a second time (“to be sure to be sure” as one might say), but telling me how he would have to scold me was inappropriate and bewildering frankly. He was a couple of years behind me in med school as I recall, and interestingly his more senior colleagues were very pleasant and professional to deal with. However this is not about seniority either as I would not talk to a med student that way.
The problem as I see it with being drawn into an argument here is that it is unlikely to change this individual’s behaviour, and is likely to cause you more stress. It will certainly not benefit the patient.
Here’s what I learned from Rob Rogers podcast on EMRAP Educators Edition:
Responses to conflict adapted from business:
Forcing (competition): Task oriented, but destroys relationship
Smoothing: Accommodation technique, holds relationship, but downgrades the task
Avoidance: Gets you nowhere, destroys relationship and gets nothing accomplished
Compromise: Comes up with a plan, can be OK for the relationship and the task at hand
Confronting: best in emergency medicine. Getting everything you want. thinking outside the box: shared problem solving, think about the issue and come up with a solution. Good for the task and the relationship
http://www.emrapee.com/episodes/teaching-residents-how-to-communicate-with-consultants/
http://lifeinthefastlane.com/2010/04/referring-patients-from-the-emergency-department/
http://www.ncbi.nlm.nih.gov/pubmed/22905961
I would have laughed at him.
I agree with Cliff and Jimmy. Playing nice in the sand box if always better, but the thought that he would “have your head” is laughable. Sounds like you handled it well, taking the patient first and not adding fuel to the fire. And you won’t change his behavior with an argument, only cement further the resentment.
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