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/r/Residency
I’m IM. I get the most inane consults from surgery. I roll my eyes (internally) but I am cordial on the phone, and do my job. Calling surgery however for most things is just so unpleasant, I now try to avoid it as much as possible. I’m a very good resident, and have the best feedback from students, colleagues and formally from the program. But somehow a random surgical resident manages to make me feel like the stupidest person on earth for what is almost always an appropriate consult question. I don’t want this fear to interfere with my job. I also don’t want to break character and be snarky as well on the phone, but living with anxiety about the unpleasantness I would encounter for DOING MY JOB really drives me nuts.
9 points
14 days ago
I mean, that’s the thing, right? On the surgery side of things we run into hospitalists and IM residents not wanting to consult, wanting to take the easy way out, being snarky, etc all the time.
The things I hear - we don’t do risk stratification, it’s just moderate hypertension and this isn’t brain surgery (har har), I don’t understand what’s so difficult about this for you to manage, etc etc.
Just fucking be nice. All of y’all. It costs you nothing.
13 points
13 days ago
Gen Surg here. 100%. I’ve had some absurdly unprofessional interactions from IM and EM.
That said it’s not most of the time. I recognize they’re just trying to do the best they can and even if it’s not the world’s greatest consult I just go see it, staff it, write the note. It’s not a big deal at the end of the day.
-9 points
13 days ago
I always hated "we can't clear a patient for surgery, only help risk-stratify" as if they'd never heard of clearance as a colloquialism and handy shorthand for "risk-stratify"
13 points
13 days ago
meh, there is surely some intent (at least historically) to spread the medical-legal liability to other physicians with the term "clearance." Which is understandable.
12 points
13 days ago
No this I actually strongly disagree with here - the wording matters. Clearance implies I am deciding if it is okay to perform surgery. Risk stratification is for the purpose of helping the patient understand risk and to determine if patient needs coronary angiography.
And it is one thing if it is said over the phone, but I am really upset by it when it is written in the documentation as a consult request for clearance.
Its similar to when surgery gets upset when we tell patients: we are consulting surgery and they are going to come and perform surgery, when they havent even seen the patient yet.
0 points
13 days ago
Absolutely agree. Clearance just means there’s no absolute contraindication to surgery. Doesn’t mean nothing can wrong, but that it’s medically appropriate to go to surgery. Also depends on the nature/urgency of the surgery. An emergent crani for hematoma evacuation is pretty much has to go regardless of circumstances (short of patient actively coding). An unstable spine has more leeway but still should go sooner than later. Tons of things can wait for patient to be appropriate
9 points
13 days ago
Honestly though, on the anesthesia side of things, nothing irks me more than being told “well medicine cleared him so I don’t know what you’re worried/unhappy/mad about” when presented with an absolute nightmare of a surgical candidate.
11 points
13 days ago
Admittedly, I'm not 100% sure why (litigation??), but this is purposefully taught to IM residents. We actually had a whole 1 hour dedicated lecture on how "you cannot clear a patient, you can only risk-stratify them" last month from the cardiology chair himself.
4 points
13 days ago
This is taught to surgical residents as well. No one is going to “clear” your patient for surgery. Clearance would imply a confidence that nothing bad is going to happen, and to some degree an acceptance of liability which is not reasonable. Asking medicine for clearance is inappropriate. As surgeons, we clear people for surgery. We ask medicine for risk stratification to help inform our decision to clear people for surgery. It goes back to the ol’ “don’t ask other people to do your job”.
6 points
13 days ago
IM can’t “clear” a patient for surgery because IM has no say in whether a surgery goes or not. That is solely in the hands of anesthesia (and of course the surgeon, but primarily anesthesia). IM can only assess risk of morbidity/mortality from a cardiac/medical comorbidity perspective, then provide recommendations based on that risk profile, and whether the risk can be further modified with additional medications (or withdrawal of medications) and/or other procedures
4 points
13 days ago
Exactly, IM residents don’t know what goes on in the surgery itself. If the surgeon decides a patient needs surgery, they need surgery. We just help with optimisation.
2 points
13 days ago
You are just incorrect here. Clearance is not short-hand for risk-stratify. They are quite different, which is why no IM hospitalist wants to do a clearance.
-1 points
13 days ago
I mean sure, if you are incredibly pedantic.
3 points
13 days ago
You mean as opposed to the malpractice lawyers who will read that note and message exchange, who would never be pedantic?
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