Pushing Back On Pushback

I was working on writing this gigantic 4,000-word monstrosity of a post where I tried to align specialty services with the old-school Dungeons and Dragons “Lawful/Chaotic vs Good/Evil” axes for character generation, and it was exactly as complicated as it sounds.

As I worked my way through it, I realized that half of what I wrote was about convincing specialists to come down to the ER and see my patients. At large academic centers where we residents train, we are almost always calling other residents for this task – and therein lies the rub. Like us, they are overworked and underpaid a flat salary to do their jobs. When I call the surgery resident for a consult, for example, I am creating work for them.

In the real world, this means the consultant gets paid for their time and effort. In residency, it’s just one less hour of sleep.

Over four years of asking, cajoling, pleading, outright begging, demanding, requiring, and escalating, I have developed a highly sophisticated and scaled system for getting consultants to please do what I ask.  This skill – called “managing pushback” – is actually taught to us in medical school and in the early days of residency.

“Pushback” is medical woke-speak for “Haha! The guy you called told you to go fuck yourself! What now, you ER peasant-doctor?”

This might be a bit of inside baseball for some, but if nothing else I thought maybe I can provide a service to those junior residents who might one day remember the salty grad who imparted such wisdom.

Over the course of training, everyone develops their own style for practicing medicine – including how to deal with pushback. My own style might be described as Machiavelli Rides the Short Bus. I’m manipulative, but everyone knows it and rolls their eyes. Still works, though.  

Disclaimer: as always, this is supposed to be funny. It may not be funny, which is a failure of comedy and is my problem. If you find it offensive, that’s your problem.  Don’t @ me, as the youths say. I also write this as a consultant-to-be in approximately two weeks, so I am sure I will look back on this post and laugh at my own naivete.

Without further ado, I thus present: Nate’s Pushback Manual!

This is, of course, location and hospital-specific. Your mileage will vary.

LEVEL 0 TACTICS. If you are calling pediatrics, pulmonology, stroke neurology, or podiatry: No pushback is likely to occur. Simply ask them to please see the patient. Thank them for being wonderful consultants. With pediatrics, if pushback occurs, simply say “No problem! I figure kids are just tiny adults anyway” and they will come running to the patient shortly thereafter.

LEVEL 1 TACTICS. Appropriate for minor pushback from specialties such as internal medicine, general surgery, psychiatry, ophthalmology, and most (but not all) medical subspecialties. For cardiology, nephrology, and most surgical subspecialties, skip this section and go directly to Level 2. For neurosurgery, skip to Level 983.  

The Damsel in Distress: This script plays off the assumption that all ER doctors are stupid. This works especially well for medical subspecialties who enjoy feeling superior at all opportunities. This works less well for surgical specialties as they typically feel superior at all times already. This is too transparent a tactic for them.

The conversation goes something like this: “If I’m being totally honest with you, I’m just a little bit lost about how to manage [insert medical condition here]. I would really appreciate any help or advice you could provide here. It’s been awhile since I’ve seen [insert medical condition here], and you guys are the experts. Can you help me?”

It is important to explicitly ask for help, as Level 1 consultants have difficulty declining these direct requests.

I’m Just A Dumb ER Doctor: I must admit, this one is my go-to multitool of scripts. Again, this plays off the superiority complex of most Level 1 consultants and is the preferred option when dealing with ophthalmology, as we ER people truly know like two things about eyeballs.

Caveat: If dealing with a surgeon, just get the CT scan. Then feel free to utilize this script. Surgeons believe that the only reason we do not CT scan a patient is to annoy them, so just save yourself the energy and scan whatever it is that hurts before calling. Don’t argue, just scan.

“I gotta say, this looks pretty bad and I don’t know what to do about it. I’m just a dumb ER doctor, but I did an ultrasound and it… well, I don’t really know what I’m looking at but it ain’t good. Can you come take a look?”  

Bonus points added here if you sneak in a reference to ketamine, or better yet a fluid bolus.

LEVEL 2 TACTICS. This bag of tricks is useful when the consultant or admitting team sees through your playing-dumb techniques and continues to refuse to help you. Cardiologists are, somehow, especially savvy at ignoring the I’m Just A Dumb ER Doctor line. This failure has caused me a great deal of dismay.

The Verbal Puppy Dog Eyes. Most of my ER friends hate it when I do this one, because it makes us seem helpless. I, however, have no such conscience and am not averse to debasing myself. When the consultant pushes back on Level 1, this script goes like this:

<silence for 3-5 seconds, then in a stammering voice> “…So.. wha- what do you think I should do?”

That’s it. That’s the whole script. Usually the consultant will sigh, ask for a couple of labs, and then try to hang up. The kicker here is to then say, “Oh okay thank you so much. I’ll get those tests and call you back with the results!” and then hang up.

When you call back with said results, your consultant has already mentally planned their trip to the ER. Unless you did something stupid, like followed this script for neurosurgery.

The ‘Let Me Call You Right Back.’ This one works best with subspecialists that do not deal with critically ill patients often. It works well with surgical specialists, as it reminds them that we do occasionally do work beyond rock climbing and clicking the “CT SCAN” order on the computer. It is a slam dunk with ophthalmologists, who are absolutely terrified of anything resembling a vital sign.

This ruse depends on the subspecialist’s perception that the ER is a lawless, disorganized anarchy zone and that we ER doctors are basically agents of chaos. Here’s how it works: when engaged in a debate with the consultant, you must appear distracted for a minute (whether real or pretend). Interrupt whatever meandering reason the consultant is giving you for not coming in, and say, “Hey, I’m so sorry, let me call you right back, this other patient is crashing.” Then, hang up.

Wait at least five, but preferably ten minutes, and then call back. Apologize profusely for interrupting your discussion. Bonus points are added if you make reference to something unusually disgusting, like geyser-strength bloodvomit, or if you can hint at doing something dramatic like a chest tube. By this point your consultant is likely to have realized their resistance to coming in is trivial compared to whatever your patients are experiencing and will often relent.

Strangely, this never works with a urologist.

Full disclosure: while I routinely use this script, ophthalmologist/comedian Dr. Glaucomflecken has a hilarious bit on this.

The Theatrical Attending Punt. This one applies only for us residents. Usually, when employing this tactic, you have the added benefit of actually telling the god-honest truth: your attending is forcing you to call this consult.

Aside: there is a popular move among some academic faculty members called “Get the Consultant On Board.” For instance, if you are admitting someone who has a rare thyroid condition to the hospital for something unrelated (like a stroke), sometimes the attendings will request that you call the endocrinologist so they are aware this patient with a rare disease is being admitted.

(Endocrinologists manage thyroid stuff, all of which I have long since forgotten.)

We residents hatehatehate this request. For starters, we’ve been taught since year two of medical school that when you call a consult you should – all together now – ALWAYS HAVE A QUESTION. When we do not have a question, there is no reason for a consultation! Invariably, when we call a service to “get them on board” they give deserved pushback. I have had a consultant tell me to my face, “I don’t understand what you want me to do.” My reply? “I honestly don’t know.”

…anyway. One popular, if emasculating, move is to admit after the first round of pushback that your attending is forcing you to call this consult. This does no one any favors. However, if the consultant continues to give you a hard time it allows you to offer up the dreaded ER attending-to-consult attending phone call. This results in the consulting resident getting yelled at for being a dick.

The key to executing this simple script is to leave the room you’re in, under the auspices that you’re sneaking in this talk away from your boss.

“Hey, let me step out of the room for a minute… yeah, I’m really sorry, and honestly, I think this is a stupid consult. Unfortunately my attending is demanding it so, yeah, I really do need you to come see the patient. I’m sorry.”

This script works, but it always makes you feel vaguely bad about yourself.

LEVEL 3. Now we get into the real shit.

The Silent Treatment: This almost always is my instant go-to when a consultant raises his or her voice, gets angry, or starts yelling at me (it happens about once a shift). I sit there quietly, wait for the consultant to blow off all their steam, and then I… remain quiet.

Usually the consultant makes it about five seconds before they start going, “…hello?” despite knowing I’m there (you can hear tons of background noise when you call down to the ER). My reply to their query is then a dejected, “…yeah. I’m here,” followed by more silence.

This works about 25% of the time.

The Skeptic: Used only when the consultant is, against their better judgment, recommending an insane course of action because the sane course involves them coming down to the ER and doing their job. This typically happens when a service that does not admit that many patients, like neurology or orthopedics, does not want to admit someone that clearly should be brought in to the hospital.

Usually, the admitting-service-to-be will instead recommend a crazy plan, like sending a clearly ill person home with follow up in two or three weeks. When you hear this plan, first Allow For Silence for 5-ish seconds, then restate their plan – slowly! Slowly is the key – as a question:

“So for this patient… who is tachycardic, febrile, and vomiting… and who had six seizures in the emergency department for no obvious reason that I can see… you want me to, uh, send… him… home?”

Then wait.

This works about half the time.

The School Bully: This one requires absolutely no shame on your part. It’s incredibly simple and has a stunning one hundred percent success rate. To use this, wait until your consultant is done yelling at you or sternly explaining why you are an idiot. Then say in a very small voice,

“Why are you yelling at me?”

And that’s it. That’s the whole script. You’ll feel the anger on the other line dissipate like an air mattress deflating. This always works – once.

LEVEL 983: NEUROSURGERY. If you’ve made it this far, I am terribly sorry – you’re consulting neurosurgery. I have no great advice here except to encourage persistence, calm, and multiple MRIs. To improve your odds of neurosurgical consult success, I recommend the following four-step process:

  1. Order the CT or MRI before you do anything else.
  2. Engage in your best mindfulness techniques, be it yoga, meditation, or Xanax. Remain calm.
  3. Neurosurgeons will often use Let Me Call You Right Back against you. Don’t take it personally. They’re operating on brains.
  4. If multiple discussions and pages fail to achieve success, the only method that works with a neurosurgical resident is to jovially offer to call their attending.

But really, you’re just screwed.

Here’s a picture of Otis reluctantly wearing my sunglasses.

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