Sorry this is more of a rant than a real post however….
If there is one thing I can’t stand is whiny doctors – although I myself have been known to whine when I see 5 ambulances pull up or when the charge nurse throws 4 new charts in the “to be seen” rack. However, the whining I am talking about is done almost entirely by wealthy subspecialists – like Plastic Surgeons ( and sometimes Orthopods who also cover “hand” call but this rant is mostly about Plastics). I mean, please, you already make a crap-load of money doing lid lifts, breast augmentations, and injections of stuff into the lips (and I am not saying this is not occasionally necessary or useful). It’s all cash – no insurance to deal with and you get to act like Dr 90210 (but please don’t wear muscle scrubs). The whining comes from not making any (or enough) money on the OCCASIONAL uninsured, under-insured, or otherwise un-wealthy patient.
It may be a surprise to many of the lay public but the reality is that plastic surgeons RARELY want to come in a fix a laceration. The only ones that generally are enthusiastic are those that are just out of training and need money to get their cosmetic practises going. That is why they often take call from the more senior guys. That being said, NO doctor is psyched about coming in to see a clinic patient or self pay (young plastic surgeon or not). And it is near impossible to get a plastics guy (or gal) to come in and suture a minor facial cut in an uninsured patient – even if the patient demands it for cosmetic reasons (they sometimes ask the patient right then and there if will pay for the repair). This does have one good result – it allows ER docs and PA’s to get good at suturing and wound management. Still, I digress.
The thing that is really upsetting is that frequently we have minor cases that just require routine follow up care or that they need somewhere to go besides the ER if a complication develops (this is often the case with hand injuries – plastic surgeons are frequently on “hand” call). If I call plastics in for some minor hand laceration they will blow their gaskets. However, I think it is their obligation to see them at least once in the office for followup before they get into the clinic system (and it IS the rule in many hopsitals’ bylaws). I really don’t need to hear them whine that we keep sending them one or two cases a week that can’t pay their full office visit bill. They even piss and moan about patients WITH insurance! Most plastics guys accept no insurance so they are annoyed that if they see someone in the office, they will only get paid part of their bill (as and out of network provider where they nearly always get paid more than if they were in network) since they cannot bill them the remainder since they were referred to their office by the ER when they were on call. They would rather come in for these people (and sometimes suture excessively long to claim it is a more “complicated” repair) since then the insurance companies pay their full bill! BOOO HOOO HOOO! So they don’t make 1000 bucks on every case they see. So they do a little charity work. We all do! Do you think I get paid for spending an hour patching that day worker’s hand when it got crushed doing some guy’s landscaping?!!?! No. Do I complain? Well, maybe a little to myself but I accept that it is part of the job and I NEVER complain about a legitimate emergency no matter who the patient is – the money I make from the other patients makes up for it. And I don’t make NEARLY what a plastics guy makes when he does the exact same simple lac repair that I just did.
So Dr So and So Plastic Surgeon here is the world’s smallest violin playing just for you……Link
Ah, I love a good rant!
What exactly is wrong with you and your PA’s getting good at suturing lacerations? What’s wrong with you and your PA’s getting good at stopping nosebleeds? etc etc ?
I don’t understand why you would call a plastic surgeon in to repair a “minor laceration” (insurance or no insurance) as you yourself put it? Overworked? Get your staffing up.
It seems a lot of this is really about where you draw the line between your responsibilities and those of a consultant.
Excuse me Dr Kranky but I have no problem suturing lacerations – however some patients request a plastic surgeon (like faciall lacs on kids) but they won’t come in for a minor lac unless the patient is insured or is willing to sign something saying they will pay for it. I even tell patients WITH insurance that plastics is not necessary to closes thier cut – but many won’t hear of it.
In this particular case, I was annoyed that even when I DID not call him in for a minor case he was so money grubbing that he refused to even see them for a quick follow up in the office for a minor hand injury which would have taken him literally 3 minutes to see and discharge. Also he WANTED to come in for the bogus cases (during the day of course) with insurance so he could collect full payment from the insurance (which would not pay much in the office – or would not pay anything to them until the patient has met their yearly deductible). That is lame. If you can’t deal with these things, don’t be on staff and take call. Just do your breast augmentations in the office and make a BIG difference in the world.
LMAO
I had a PS refuse to come in one night for a complicated facial lac. (on an insured patient). So, I told him that in the next bed was a wealthy lady with small breasts. She was requesting an emergency augmentation. Would he come in for that? Before he hung up on me, he said that he “might have to discuss this comment with administation”!
Good one! I fortunately have never had one refuse to come in when I said it was a complicated facial lac or tendon injury – but getting them to see follow up cases in the office (where I did all the real work at 3am and did not wake them up and call them in) is a different story.
I agree so much with you on this one. I don’t begrudge the fact that they earn 8 times my income but how about a little pay back? I do all of the work…all I’m asking for is a little help with management when it is beyond my specialty. “Yes, send them right over” is the answer I want to hear!
You realize the average plastic surgeon salary is 300 while the average ED physician salary is 200? (http://www.physicianssearch.com/physician/salary2.html) And they’re working on average 15 hours more per week than you? After doing a residency that was twice as long and had twice as many hours worked per week?
There is nothing that annoys me more than ED physicians that think it’s the world’s obligation to happily come in at 3am for CYA consults. If you want to see why nobody is taking ED call anymore, LOOK IN A MIRROR.
Hey buddy, you don’t even take call, I’ve got a full day of cases the next day and now I get zero sleep because of a lac a third year med student could close? You want a tiny fiddle? It’s for you, playing for your tragic 3-shift-per week-no-call life.
Oh and for the record, like most people if I’m taking call I don’t mind being called in for serious issues. “I want a plastic surgeon” is no more an EMTALA emergency than “I want a pony”.
Dr Eyeroll,
Yes, I agree just saying you want a plastic surgeon for your lac (if it is simple) is ridiculous. And I bet that pony would make the kid even happier. However, talking of EMTALA, I HAVE to refer a patient somewhere. I can’t just say, “You are all done, you don’t ever need to see another doctor for this case.” Of course they are encouraged to come back to the ER as well, but I have to give a smashed finger follow up with someone who further specialises in hand injuries (ie can take to the OR if needed). If I don’t I have left the patient hanging and can get sued more successfully if a complication occurs. Did I call the PS in for the nail bed repair, debridement, and splinting of did I let him rest because I KNOW he has to work in the am (This my friend is one of the reasons I went into ER, this call issue you mentioned)? I let him rest. In turn, I expect him (and so does the hospital since he was on call) to see the guy in the office at least once whether he has insurance or not. I am not just going to call you in for the insured people so you can charge full out of network ER care. And, I can tell you PS’s I am sure make about the same as us INITIALLY after residency (which is NoT always double the length as ours – mine was 4 years and dedicated plastics residencies are 6 (see PENN’s webpage).- but after about 5-10 years, the practise has been built and the sky is the limit to where the salary can go! Mine stays pretty much the same!
That’s fair, although I think most ED programs are 3 years nowadays. Nobody faults you for having to arrange a hand followup. It’s when you said “And it is near impossible to get a plastics guy (or gal) to come in and suture a minor facial cut in an uninsured patient – even if the patient demands it for cosmetic reasons (they sometimes ask the patient right then and there if will pay for the repair)” as though we were in the wrong that I got annoyed.
Try to treat your specialists well. A lot of people are heading towards dropping hand privileges and BS consults really, really exacerbate it. I think it’s unfortunate, but then again the incentives are massively stacked against taking ED call (increased liability and awful lifestyle for the privilege of…?) so it’s not surprising.
Also, I’m mildly curious. If you refer them to a hand specialist for followup, that satisfies EMTALA, right? What if the hand specialist then refuses to see them in clinic without payment for non-emergent followup? Hospital call agreements aside, is anyone liable there if something goes awry?
Well, I know that I have satisfied EMTALA after I treat and deal with in a medically appropriate way the patient’s complaint – and that includes referral. Now in terms of the clinic – I am not sure. Our clinic meets regularly – but only for peds, medicine, OB, and general surgery. All the subspecialty clinics meet about once a month or so. Thus, patients cannot wait 2-4 weeks before they need to be seen – thus they go once to the office, and then to the clinic. If they refuse to see them – and a complication occurs (like uncontrolled infection or a unreduced fracture heals incorrectly), they are liable for refusing to see them when they were on call. The debate really comes down to whether or not the surgeon needs to be called by the ER before hand so a “relationship” with the patient is formed. It is my understanding that hospital privileges policy does not require this – although I am not sure what the technicalities of the law are in that case. I would imagine it would not be hard for a lawyer to win a case where a poor patient was refused follow-up when the surgeon was on call.
EMTALA applies only to in-hospital (or in-ER) care. So if you treated the patient appropriately and the consultant did not refuse to come in when asked, then there is no EMTALA issue.
On the other hand, I could be wrong, but I am almost certain there is a lot of case law that a phone consultation does not establish a doctor-patient relationship, nor does a referral, and the on-call doc is probably not liable for malpractice should he refuse to see the patient in follow-up.
It’s the law — just don’t expect it to make sense.
You may be right in terms of the technicalities of the law – however, I am sure it would be easy for a lawyer to force a settlement with a consultant who refused to follow up on the patient (I know just one exact case at our hospital – although in that case, the consultant was spoken to by the ER doc and gave some recommendations – but never saw the patient in the hospital or in the office). The other issue, is that most hospitals require the on call doc to be available for referrals in order to maintain privileges.
HMMMMMM maybe I’ve just been up way too late.
Sounds like we all just gather in a circle and point down the line and see who’s ox yelps.
I’m glad to know that a bunch of other people are working too.
When you cover for me and don’t call me at 3 am, Thanks
When you need to call and I’m groggy and you don’t yell, thanks
When you close it up and let me see em in 3 or 4 days in the office, thanks.
When the mom comes back 6 months after the little girls face is all healed and says she never knew ENT docs could do plastic surgery, Its all good.
Thanks
ya’ll quit ranting on each other.
Grumpy old doc who usually wins all the arguments anyway. Find you a new Chief of Surgery, I’m tired.
[...] about. I signed up for this so I know I have to do it so don’t accuse us of whining. This is whining. And on top of all this, you have to treat the TRULY sick people – ie people have to [...]
When my brother was younger and wilder, he got his face split open in a bar fight, and Dr. Greg Ganske came into that ER within a matter of minutes to sew up that nasty looking laceration.
A few years later, Dr. Ganske ran for Congress (and won) and my dad voted for him even though he didn’t agree with many of his views, and he didn’t like the other candidate either.
Yeah, Dr. Ganske probably thought, “Oh, great, another drunk” but we are all grateful because my brother barely has a scar.
As a 58 year old plastic surgeon who DID come in to repair 1 cm. lacerations because the ER doc was “too busy” to “mess with it” for 17 years and who NEVER asked the patient’s pay status I am personally offended by this rant. Give me a break, shift worker. After my evening and night ED visits, I had a full day of office and surgeries.I was on staff at 5 level one trauma centers for trauma call so this was not an “isolated time or two” that I took call. The repeat dressings that the no-pay patients used didn’t come out of your pocket like they did from my office. My “donation” to my community of my services and supplies was about $100,000 or more a year- more than I took home most years. I have left that community now- “used up” and thrown away.
Yeah whatever,
I’m a urologic surgeon. We are in shortage. We have enough trouble taking care of our own practices at this point and because of medicare cuts and rising overhead costs are just barely above breaking even.
On top of that……we get bombarded with emergency room call and hospital floor consults….and are told it is our privilige to take ER call.
I too am offended by your rant….tell you what….when you’ve been up all night in the ER doing a shift and you are whiped out…..how bout you come to my office for free and help out the community…..because emtala and the hospital says you have too and its your privilige to do so?
I mean…..really….shift worker…..do you think i really want to screw up another day of my life or plans I had or my kids or my girlfriend whether I am getting paid some chickenshit medicare fee or not? Guess what? the money is not worth my time.
Tell you what……why don’t you just take care of the shit yourself and I’ll pay you the thirty bucks to put the foley in that would get by coming in and bailing your dumb ass out.
I really wish we all had more balls to stand up to the payors and medicare and the sense of entightlment public and the hospitals for that matter and get paid an adequate sum for the level of training, degree of difficulty and the liability our services carry….not to mention the demand.
So….since we don’t get compensated adequately for what we do and we are required to go in and bail out you ER guys whether we are getting the chickenshit medicare compensation or not……SHUT UP BITCH!!!
This whole thread is a perpetuation of misinformation, whining and bullshit by the ER (okay, we’ll call it an ED if it makes you feel better) community. Bottom line:
1. Your description of a typical plastic surgeon who makes orders of magnitude more than you do is, in most communities, a complete myth. Most of us work our asses off every day curing people with cancer, making women feel whole after mastectomies (boy are we greedy SOB’s), and reconstructing faces and hands of people who, for the most part, earned their injuries by engaging in risky behavior. This last group typically is noncompliant, and these patients routinely have no insurance to cover their care, while simultaneously believing they are entitled to not wait in our waiting rooms for more than 5 minutes and have the right to sue us into permanent insolvency. The image of the Park Avenue/Beverly Hills muscle-shirted plastic surgeon is solely the product of the E! channel, and that catastrophe of a hack, “Dr.” Rey. Our median compensation, on the whole, is in close approximation to that of ER physicians. The lucky outliers, many of whom make more $$ despite poorer credentials, have sullied the reputation of plastic surgery immeasurably, to the point that even physicians in other specialties have no clue about the truth.
2. Why should we be indebted to hospitals that conscript our services under duress (under the auspices of a totally unfunded federal mandate that is responsible for the overcrowding of our ER’s) and buy legal risk with our time, especially time we would otherwise spend resting for our next day of cases, or spending quality time with the families we abandoned for, typically, 7 years or more during residency? Why should we be eager to do this when the hospitals will sell us out in every risk management scenario, our personal livelihoods are at stake when every new patient is a potential future legal adversary, and we get no compensation for these forced relationships? Would your plumber come in and fix your leaking faucet, or a locksmith come open your locked door, pro bono at 2AM? Give me some semblance of a fricking break.
3. The indications for calling a plastic surgeon are simple: complex operative facial fractures (read: no nondisplaced maxillary sinus fractures), hand injuries (if the plastic surgeon is stupid enough to take hand call), and soft tissue/skin injuries that are beyond the scope of routine emergency room care. Mommy wanting a plastic surgeons for her 2 year old angel (devil)’s rinkydink 1 cm thigh lac is no more appropriate than her asking a vascular surgeon to come in to put in an IV. Mommy’s refusal to accept the ER doc sewing up the lac is tantamount to child abuse and should be actionable. If our medical school’s still taught anatomy and educated students in basic suture technique, you guys wouldn’t be afraid of linear cuts in ears and noses that simply require lining up what goes where and stitching it together.
Just to let you know Tim, we (at least I do) suture about 90% of all lacs that come into the ER. We call plastics for the really difficult ones and lately, we call them for simple, well-insured lacs (usually on the face) that request plastics. In this economy, the surgeons are very happy to come in. This particular surgeon however, is a 4+ pain in the ass regardless. He whines all the time about referrals, throws miniature tantrums when he comes in and yes, he is a boat-load richer than I am.
Hi,
As a medical student I was very entertained by the article. If you are so bent out of shape with asshole doctors making too much money, then perhaps you should solve the woes of our society by taking physics, chemistry, biology for four years, going without sleep for another four in medical school, and then finish a five year residency working 70 hours a week for 50,000 a year. The most costly price of this process is a complete absence from family life for 20 years. Having to listen to people bitch about our greed is only an unpleasant additive. Do doctors deserve to be rich? Your damn right. Do you want doctors to be poor? You sound smart enough to understand the caliber of physicians America will be left with if that be the case. Personally, I am excited to work with the underserved someday. However, I get so tired of hearing those who have less presume to tell others how to spend their money or time. A statistic that will surprise you: Doctor’s more than double the closest profession in volunteer work, 7 hours/week.
Hiya Brad. ERP is an Emergency Room Physician. So actually, he did go through the years of physics chem and bio, and he did go through four years of med school, and yup, hes done his residency and hes and attending physician.
So one day he might be your boss, IF you finish med school. Read, before you speak.
muchos gracis for the new blog.