This insult has more than a grain of truth. More and more hospitals have hired hospitalists like Damania to manage the non-surgical issues that patients on orthopedic wards face—so they don’t die after they survive surgery.
In fairness, I asked an orthopedic surgery resident who is training at one of the top hospitals in America if FOOBA has any truth to it. “I think some of it’s deserved,” said the resident. “It seems like we’re better off fixing bones.”
On the other hand, the resident says, you should hear what orthopedic surgeons have to say about the diagnostic skill of their internal medicine colleagues. “They don’t know how to do any kind of muscle-skeletal exam whatsoever,” the resident says. “They know that somebody’s knee hurts, so they get a consult in orthopedics.”
He and other residents have a name for that kind of referral. They call it a garbage consult.
Dr. Peter Kussin says it’s not simply a case of one specialty not knowing how to diagnose clinical problems that fall under another specialty. He says there’s a deeper problem—doing a superficial assessment of the patient instead of keeping close tabs. There’s even a slang term for that: LGFD, which stands for “looks good from door.”
“That would be probably the most derogatory thing I would say about a physician, because to me that’s just totally a professional lapse of their responsibilities,” says Kussin.
* * *
Bone surgeons may not have a great reputation for looking after the non-orthopedic medical needs of their patients. But at least they’re appreciated for their judgment and skill in the operating room. The same is not necessarily said of specialists in obstetrics and gynecology.
A third-year resident at one of America’s top hospitals told me a story that calls into question the awareness—if not the competence—of a resident in obstetrics and gynecology.
“We do about 95 to 99 percent of our Caesarean sections under spinal anesthesia and so, of course, the patient is awake,” says the resident. “In May of my first year of residency, [I was] working with an upper-level OBGYN resident who was having trouble closing the incision at the end of a Caesarean section. The resident kind of looked at me and said, ‘Is there anything we can do about the patient’s breathing? It’s kind of tough to close the wound. Can we turn the ventilator off?’”
There was no ventilator to shut off because the patient wasn’t on a ventilator. The anesthesiology resident tells me he had performed a spinal block—which meant the patient wasn’t under a general anesthetic, was breathing on her own and was awake (and listening in).
“Ma’am, could you hold your breath?” the anesthesiology resident asked the woman.
“It was just obvious that the resident had no idea what was going on, which was kind of astonishing. I wish that was the only story I had.”
* * *
Surgical cowboys are seen as health care’s unthinking doers. Internists—non-surgical specialists who are experts in diseases such as diabetes, heart failure and high blood pressure—are polar opposites: obsessive thinkers who don’t do much of anything. What do we call doctors like that? We call them fleas.
Dr. Ryan Madanick, a gastroenterologist, remembers the first time he was called a flea was when he was a resident in internal medicine. A resident in surgery “looked at me and called me a fucking flea,” Madanick recalls. “Then she explained that flea stands for ‘fucking little esoteric asshole.’ Surgeons don’t think like we do. They’re not as smart as us. Therefore, it’s actually a compliment. We’re smarter than they are,” says Madanick.
Not everyone believes the term flea comes from the acronym Madanick learned.
“I like the idea that the last thing that leaves a dead body are fleas,” says Kussin. “To me, that’s the most poetic.” He says he’s heard but doesn’t much like the idea that the term comes from comparing the stethoscopes internal medicine doctors wear to flea collars. “I find that pedestrian.” Another possible origin “is that there are more internal medicine people on rounds than fleas on a dog.”
One word that does ring true in the acronym for Kussin is esoteric. Internists are nothing if not that. “It is the ultimate disrespect for our sort of nattering around, never making decisions and arguing about esoterica in the face of someone who’s dying while not recognizing that they’re dying.”
Take dying of a gunshot wound, for example, says Kussin. “We would look at a gunshot wound and say, ‘That’s acute lead poisoning. Get a lead level.’ The surgeons would make fun of us for that.”
That’s the punchline to a joke; but is there any truth to the critique? “Of course,” says Kussin. “I think surgeons properly identify us as being focused on minutiae.”
But somebody has to do that. There’s a saying in medicine: “Common things occur commonly.” Rare diagnoses do not come quickly to my brain. But they do to internists. They revel in them. They even have a nickname for rare diagnoses; they call them zebras.
I was struck by the fact that Ryan Madanick immediately saw a compliment buried in a sandbox insult. At least cowboy conjures up a romantic image in our culture; not so the flea. But that doesn’t bother Peter Kussin. “I wear it pretty proudly,” he says.
Still, let’s not forget that to a non-internist, being called a flea is an insult. A veteran ER physician told me she thinks of the word flea whenever she’s desperate to get the internist on call to accept a referral but the internist is giving her a hard time. “Whenever that happens, the internist is asking some picky little question or asking if I have considered some obscure diagnosis,” says the ER physician. “Seriously, when I look at how busy my emergency room is, and I get that treatment, that’s when I know I’m dealing with a flea.”
* * *
In modern medical culture, specialists are seen as smart overachievers, while generalists such as family docs and ER physicians are seen as less intelligent and less ambitious. It’s an attitude that is reflected in everything from the status accorded the physicians to the money they make.
“The nickname internal medicine uses for emergency room physician is triage monkey or glorified triage nurse,” says Dr. Nathan Stall. “I’ve heard that time and time again.”
Triage—which comes from the French verb trier, which means to sort or to sift—is the process of deciding which patients go first based on the gravity of their condition. When you come to the ER with an illness or an injury, the triage nurse is the first person you see. Using a combination of rules or algorithms, plus intuition honed by years of experience, the triage nurse figures out when it’s your turn. Get it wrong—for example, leave a woman with an ectopic, or tubal, pregnancy sitting too long in the waiting room—and there’s a good chance the patient will go into shock and die.
Triage nurses also have to field incessant questions and complaints from patients and aggressive family members wondering when it’s their turn. You could not pay me enough to do their job.
Calling me a triage nurse trivializes what triage nurses do shift in and shift out—which is to save our bacon by making sure ER physicians see patients in time to save them. And the term trivializes what I do as an ER doctor—by suggesting I assess patients too quickly and too superficially.
An ER colleague of mine who works in Ottawa told me about a similar slang term that describes ER physicians. “A referologist is the slang term that we use for an ER colleague who can’t make a decision and likes to refer everybody,” says the resident. “It tends to be used more by the consultants about us, but we use it amongst ourselves as well.”
Both referologist and triage monkey suggest that specialists are smarter than ER physicians and family doctors—a belief reinforced by professors in med school. Dr. Jason Quinn remembers first hearing it when he went to the University of Western Ontario in London, Ontario. “Every lecture is started and ended with the family physician screwing up and the specialist riding to the rescue,” say
s Quinn.
Now a psychiatrist in training, Quinn says fellow residents trade tips on which ER doctors are quick to refer patients with apparent psychiatric problems. “Doctor so-and-so is on duty in the emergency department,” says Quinn. “That means we’re going to get a lot of bad referrals.”
Like Quinn, Stall says residents in internal medicine trade the same intelligence. “If this guy’s on tonight, you can expect some shitty consults,” says Stall.
Loose talk like that is dangerous to hospital culture. Casual disparaging of a colleague to others is considered a breach of professional ethics; more than that, it’s a violation of the code of just getting along.
My research for this book has given me an unprecedented opportunity to hear other specialists complain not just about one another but about ER physicians like me. Internists think we order too many tests, like CT scans, and IV antibiotics without good reason. They’re probably right. Still, we work under time pressure that would frankly make most internists panic. We’re supposed to know a little bit about every field of medicine. We never know who or what kind of problem is coming through the sliding doors next. Like every other physician I know, we hate being second-guessed by a surgeon or an internist. By their nature, physicians love to point out the clinical shortcomings of their colleagues. Having a good story to tell at the expense of an ER physician more than makes up for any extra work.
It may be verboten for surgeons or internists to rail against ER doctors openly. But there’s one exception. It’s perfectly acceptable to talk down another specialty to try to prevent a colleague from changing career paths.
An ER colleague of mine discovered that while doing a residency in ear, nose and throat (ENT), when she told her mentors she wanted to switch training positions and become an ER physician. “‘Why would you want to be a triage doctor?’” she recalls them asking her. “To be honest, I was hurt by it at the time. I do think that ER physicians treat and discharge many patients who never see the specialist. They forget that. The bigger picture is that we actually save them a lot of unnecessary referrals.”
* * *
You may be getting the false impression that, in the us-versus-them world of hospital medicine, an honour code prevents members of a specialty from making fun of one another. That’s not true. Dr. Chris Kinsella is quite happy to rant about the cowboys among his surgical colleagues. ER doctors complain about each other in the same way.
A fellow ER physician once told me about a colleague who was known as a money-grubber. He worked too quickly for his own competence and saw double the number of patients as the second- fastest doctor. His histories and physicals were superficial. Despite his high-volume practice, he had an uncanny knack for leaving on time. By comparison, most of my colleagues and I see far fewer patients—which means we get paid much less—yet stay an hour or two beyond the official finish time of our shifts to tie off loose ends.
How did he do it? By handing over patients who had been worked up incompletely to the ER doctor on the next shift. Every once in a while, tucked away among the six or seven patients he had left for the next ER doc to finish up was a patient who contained what an ER colleague who works in another province calls a hidden bomb —a life-threatening medical problem the doctor doing the handover failed to notice and to warn colleagues about. I call my friend’s money-grubbing colleague the Bomb-maker.
Handing over patients is one of the riskiest things ER physicians do because the second ER doctor seldom has time to retake the history. If the first doctor got it wrong, the patient may be doomed.
Another colleague recalls working a morning shift in which he was handed the mother of hidden bombs. The patient had chest pain, and the doctor doing the handover said the patient could go home after a blood test ruled out a heart attack. No biggie. The night doctor went home, and the colleague decided to see the patient himself.
“I went in and he was literally on death’s door,” he says. “He had an aortic dissection.”
An aortic dissection is the hydrogen bomb of hidden ordnance. It’s a life-threatening condition caused by a tear in the inner wall of the aorta, the big artery that comes off the heart and sweeps around and through the chest and into the abdomen. Dissections that rupture have an 80 percent mortality rate.
In 2009, famed Canadian soprano Measha Brueggergosman nearly joined the list. She had chest pain and went to St. Joseph’s Hospital in the west end of downtown Toronto, where she was seen by doctors and sent home. Fortunately, she called her family doctor, who told the opera singer to go another hospital, where the correct diagnosis was made in time to save her life.
My colleague’s patient likewise made it. “That was a hidden bomb that was defused in time,” he says.
Those of us who have bomb-maker stories to tell should not get sanctimonious. Every ER physician has left a bomb or two behind, including me. It’s just that when you’re handed over a bomb that goes off, a patient can get really sick or die. If not blamed for what happened, at the very least you get sucked into a maelstrom of complaints and litigation.
And you learn never to trust that colleague at handover again.
* * *
When doctors use slang to talk about each other, it’s as likely to be about their attitude as about their competence.
As a neurologist, Dr. Grumpy has referred many patients to neurosurgeons to do everything from clipping aneurysms to removing brain tumours. His take on them is refreshingly candid: “I do think that they are good doctors with just crappy personalities.” He cares more about neurosurgeons’ competence than their attitude. “If my patient needs surgery,” he says, “I really don’t care whether or not you’re a jackass.”
It’s not surprising that Dr. Grumpy doesn’t care whether the neurosurgeons he works with are jackasses. Although he refers patients to them, he doesn’t have to work alongside them in a high-risk environment like the operating room. That’s the job of the anesthesiologists. They have strong opinions plus some graphic slang they use to describe the personalities of their surgical colleagues.
“I can only speak from my experience, but some of the orthopedic surgeons can be difficult,” says the first-year anesthesiology resident at one of America’s top hospitals. “Some of the general surgeons can be difficult. Some of the transplant surgeons can be difficult.”
A colleague of his who is in the third year of anesthesiology residency at the same hospital has a slightly different take. “Unequivocally, after [my] three years of training, the neurosurgeons and the cardiothoracic surgeons are the most difficult to work with.”
Volumes have been written about difficult physicians, of whom many are surgeons. But even cancer specialists make the list. Dr. Grumpy remembers attending a cancer conference in the U.S. several years ago at which experts in radiation and chemotherapy met to discuss the best course of treatment for patients with cancer. An argument broke out at the podium between a radiation oncologist and a chemotherapy guru. “It just kept escalating,” Dr. Grumpy recalls. “When one had a turn to present, the other kept interrupting him or making snide remarks. The argument became increasingly heated. At some point, they got up and began pushing each other and then began punching and had to be separated.”
When I was a med student, it was common knowledge that a well-known and highly respected surgeon was infamous for throwing scalpels at hapless assistants in the OR. But that was thirty years go. It would be nice to think doctors have evolved since then. But a 2004 survey published in the journal Physician Executive found a staggering 95 percent of hospital and clinic executives have to deal with disruptive physicians as a regular part of their jobs. A 2011 survey for the American College of Physician Executives found twenty-seven of nearly 850 physicians had exhibited disruptive behaviour at least once in their career.
There are several reasons physicians have been too slow to clean up their act. Ironically, at the top of the list is the
fact that colleagues tend to admire them. In a 2009 article published in the Journal of Medical Regulation, psychiatrist Dr. Norman Reynolds pointed out that difficult doctors are thought of as highly skilled, well-read, intelligent, articulate, hardworking, confident and persevering. Those characteristics kind of make up for arrogant, intimidating, inflexible, self-centred and unempathetic, don’t you think?
Dr. Thomas Krizek, a surgeon, wrote a scathing account of bad behaviour by surgical colleagues it was published in 2002 in the Journal of the American College of Surgeons. In it, Krizek argued that students and residents tolerate abusive surgeons—bad role models though they may be—because they see them as entertaining and charismatic.
“Students and residents are often in awe, albeit terrified at the same time,” wrote Krizek. “This behaviour may be interpreted by residents as reflecting the behaviour of ‘champions’ against the establishment; it is no wonder that residents wish to emulate their behaviour.”
I think that the hierarchical structure of hospital medicine tends to attract abusive physicians. Not surprisingly, nurses and residents—who are well below attending physicians in the hospital food chain—bear the brunt of abuse by attending physicians.
The 1993 article in Social Science & Medicine by Robert Coombs and his co-authors referred to an attending physician who attacks and shreds medical trainees without provocation as a “shark.” and residents referred to attending rounds as “offending rounds.”
A 2011 article by Barbara Barzansky and Sylvia Etzel in the Journal of the American Medical Association says the percentage of women in medical schools rose from 36 percent in 1990 to more than 48 percent 20 years later.
It has long been hoped—if not believed fervently—that women physicians are less likely to be disruptive than their male counterparts. But a 2013 story in the Washington Post puts paid to that. Reporter Sandra Boodman wrote about how a surgeon in the midst of a complex operation reacted when a technician handed her a device that didn’t work properly: “Furious that she couldn’t use it, the surgeon slammed it down, accidentally breaking the technician’s finger.”
The Secret Language of Doctors Page 26
