MEdIC Series: The Case of the Cackling Consulting Resident

2017-01-20T12:30:40+00:00

Seth MacfarlaneWelcome to season 3, episode 3 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, and Teresa Chan) is pleased to welcome you to our online community of practice where we discuss difficult medical education cases each month. As usual, the community discussion will be reviewed using qualitative research methods to produce a curated summary that will be combined with two expert responses to create a functional teaching resource.

This month’s case features a problem that educators face when interacting with off-service residents. What is the role of an attending on one service when dealing with residents providing care from another discipline? Does it take a whole village to raise a resident? Please read the case and join in the discussion below!

MEdIC Series: The Concept

MEdIC: The Case of the Cackling Consulting Resident

by Drs. Teresa Chan (@TChanMD) and S. Luckett-Gatopoulos (@SLuckettG)

It was a long, busy night in the ED. Ellen was tired. The department was nearly bursting at the seams, and dispatch had called to notify her that another multisystem trauma was on the way.  As the only overnight attending, she had been constantly running throughout the shift.  She had just spent a half hour trying to find somewhere to discharge Mrs. Patterson, a mostly-well 83-year-old lady with early dementia. Mrs. Patterson had been dropped off at the hospital with a “positive suitcase sign” per the triage note and worsening urinary incontinence. Despite homecare, Mrs. Patterson’s family just could not provide the level of support that she needed to live at home anymore. Unfortunately, they were nowhere to be found when her workup came back normal. The nurses had heard them discussing their flights to Mexico.

***

CRASH

“Everything okay?” asked Ravinder, after witnessing some significant handset-on-phone violence.

Ellen had just slammed down the phone when her colleague Ravinder had walked by and was stopped in his tracks by the look of shock and frustration on her face. She had called the medicine service to request a social admission for Mrs. Patterson.

“No!” she replied emphatically.  “But maybe I’m just tired or something. Can I run this case by you?”

“Sure.”

Ellen recounted the nuances of the case back to Ravinder, describing the various red flags for elder abuse, and how Mrs. Patterson’s family had clearly just dropped and run.

“Sounds reasonable to me,’ Ravinder agreed with Ellen’s plan. ‘I mean, what else can you do? She needs an admission.  Sure, it’s mainly for social reasons, but still…”

“I know! But I told the resident on call and she laughed at me! I couldn’t even tell her the story because she kept interrupting with laughter. She said there was no way that I should even think about admitting her. I’ve been doing this for nearly a decade and never has anyone been so rude.”


Discussion Questions

  1. As her colleague, what advice would you give Ellen?
  2. Where should she go from here?
  3. How should she respond to the resident? What is your role as an attending from a different discipline?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts are:

  • Megan Boysen Osborn, associate residency director in the Department of Emergency Medicine and co-course director for Clinical Foundations at UC Irvine
  • Dara Kass, Assistant Professor, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine

On Dec 11, 2015 we will post the Expert Responses and Curated Community Commentary for the Case of the Cackling Consulting Resident.  After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Image from flickr.com

Eve Purdy, BHSc MD

Eve Purdy, BHSc MD

Queen's University in Kingston, Ontario, Canada
Student editor at BoringEM.org
Founder of manuetcorde.org
  • Dr Muhammad

    1/3
    THisis interesting that a resident is acting like this towards a
    consultant. It is not something that happens here in Australia- at least
    I have never seen it happen.
    I personally have been in situations as an ED Registrar when a consutlant refused an
    admission, I disagreed and I escalated the matter, and it went right
    up to the cheif executitve of area health who ordered the consultant
    to accept the admission. It took a couple of hours of my time (mostly
    because it was a night shift, and I had to wait till it was around 8 am
    and people were awake and ready to deal with daily grind).

  • Dr Muhammad

    2/3
    I
    also understand the concept of “selling” a patient to different
    services. However, my experience has been that if I give a good story
    with RIGHT points highlighted, admission can almost never be declined
    (not the exception above). As my language has
    improved over the years of work in Australia, I have learned the “right
    words” to utter to convey my concerns to the registrar/consultant.
    However,
    it is extremely important that no corners are cut and these words are
    not abused or used unnecessarily just to pass the buck on to someone
    else. If I am calling because I think patient must be admitted then that
    is what my story sounds like on the phone.
    IF I am not sure, I actually say it to them “I am not sure, I will give you the story and we will take it from there”.
    People really appreciate that honesty.

  • Dr Muhammad

    3/3
    I
    would be very surprised if a patient genuinely needed an admission
    (like the patient in the story shared) and was declined- in Australia.
    If I sense that the registrar is way out of her/his league and has no
    clue what I am trying to tell him, the answer is simple:
    I
    call the consultant. They are much more sensible than an idiotic
    registrar. And that, I have done several times and never had any issues.
    In
    that rare situation that even the consultant does not agree- has
    happened only once or maybe twice with me- I escalate it to admin if I
    am the “in charge” doctor. If there was someone else supervising me in a
    clinical role (ED consultant when I was ED Reg) then I would involve
    them and then it is their problem to tackle the situation.
    I am not sure what rest of the group has to say, but this is my experience.

    • Loice Swisher

      Interestingly, I am not sure that that the case has been made that this patient needs medical admission.

      To me it seems that the options but forth have been in the hospital or out on the street. This seems to be a legal issue of elder abandonment (” the purposeful desertion of an elderly person by someone caring for that person”) It would seem that Adult Protective Services and the police should be contacted. In some cases, elderly can be placed in a protective place by APS. That would be a 3rd option.

      I find in my hospital that administration would want to know about the case and have case management involved- usually before the police are called (especially since the patient isn’t going anywhere). It is an unusual circumstance and I am willing to call administration, legal and case management in the middle of the night to develop a plan.

      Sometimes I find that they will want both a “second opinion” by medicine and psychiatry to have back up on that the patient is demented/unsafe to be alone (and thus abandoned) and that she doesn’t need to be hospitalized. In this case I would then call the resident back and explain the situation/what is required of them.

      My thoughts-
      1- Have the ward clerk contact the supervisor,(administration) legal and case management?
      2- If administration wants admission- contact medicine to admit and work it out during the admisison.
      If they do not want admission, ask specifically what they want done- (including if we should call the police and file elder abandonment with the state hotline) or wait to see if the family shows up at light of day. Contact additional folks as needed.
      3- Likely sign out the patient in the AM to have all sorted out by the light of day- but with a plan and contacts made.
      4- do a huge amount of documentation

      Yes, it could be done as an inpatient but it also could be done in the ER. It depends on the resources and cultures of the institution. And pushing it off to medicine can feel like dumping and the resident might feel that she will “take the blame” for an inappropriate admission.

      When things are at odds and both seem right, a 3rd option might be out there.

      Loice

      • Dr Muhammad

        Absolutely Loice. I am very clear about this case,and I am referring to this case as a “social admission”.
        In Australia, a “social admission” is a real and an accepted entity-ESPECIALLY for the elderly.We call it “acopia” and, geriatricians dont question it- AT ALL. I love it this way here. This is how the society should be. It reflects the civic sense of the society in general.
        I dont know about other countries, but sorting accommodation for an 83 year old suspected to have dementia is not gonna happen in one working day. It will take several days, and ED is not the right place for the patient.

        Even if it was gonna happen over next 8 hours of a work day, the patient would not be staying in ED. ED is for sick patients not for social admissions.

        • Loice Swisher

          I appreciate your comments. I added the additional comment to make it clear that I am in the US and it does work differently here. I love how you describe Australia and how society should be. It isn’t here. And because it isn’t I think it changes how we interact amongst consulting teams.

          In your country it would seem like the registrar was an idiot, in my country the laughing would be disrespectful but the admission refusal might be defended by admissions if the resident actually examined the patient.

          Certainly does put different perspectives on the case.

          Thanks,
          Loice

      • Loice Swisher

        Just to be clear- I am in the United States and social admission seem to be increasingly problematic (i.e.- not “real admissions”) and denied frequently. I find in my hospital that we are getting much more feedback on increasing denials on payment. I am aware other countries might be differently. I am sad to say that just recently I had a patient (somewhat different circumstances) who was in an ED bed for 37 hours.

        I think if it wasn’t for the financial issues that are so closely tracked here that perhaps we wouldn’t be at odds as much with our admitting services. It feels that many admitting docs seem to feel that they are scrutinized significantly if their denial percentage are too high and worry about reprimands.

        • Dr Muhammad

          Thanks for clarification Loice. In Australia, too, bedblock is a significant problem. SO much so that not for 37 hours, but sometimes upto two or three days patients were stuck in ED, and eventually were discharged home cause they got their treatment in ED 🙂

          • Loice Swisher

            Sorry to hear that multi-day hospitalization stays occur in your ED too. Overall, I don’t think it is good for patient care.

            I do think though that this does go to the varied thinking/priorities amongst the medical “tribes”. Maybe in emergency we have the priorities of moving the meat and believe we do the best for the patient-get them to where they should go. We (ED docs) feel best when we have dispositioned all our patients by the end of the shift. On the other side, the admitting time might be placing a higher priority on resource limited issues- such as bed distribution. Which patient goes to those beds is a more significant issue to them.

            Looking from other side- if there are truly sick medical patients staying in the ED for 24 or more hours then why can’t the ED wait a few to see if the family comes back in or if social service can work some magic. At least at our place, this type of admission viewed from the other side is that we want them to”babysit” the patient while social service works out the issues- and they are told they won’t get paid for the admission. It seems to feel like we are passing our problems off to them to deal with because it is just too hard and too long yet we have other patients have their entire admission in the ED. I’ve been told “you guys just want to have a disposition at the end of your shift!” I’m not sure I can say that is wrong. (Can’t you hear the comments that will happen at sign out in the morning if not?… That’s going to destroy your length of stay metric.)

            I agree with you that honesty with the right highlights and that we shouldn’t cut corners is the best policy.

  • Dr Muhammad

    In short, if you are genuinely convinced that patient needs admission and it is not safe for patient to be discharged back home, then one MUST escalate the matter to admin and higher authorities (clinical or otherwise) and let them make an executive decision which, keeping view how a wrong decision could come back to bite them, they will always be more cautious with.
    You MAKE IT CLEAR that in your clinical opinion , patient needs admission and must not be discharged because it is unsafe.
    You document that , put the names with all those whom you have discussed this with, and escalate it to next higher level. Obviously, hospital admin have to call police to get a patient out of the ED but they can do that ONLY if a doctor states that patient does not need to be in hospital. Make sure you are not the one doing that for this patient.
    I understand that we should be nice to all people and especially our colleagues get some extra decency even if they are sometimes being obnoxious. However, We can not continue to be nice or apologetic to people who just do not get it that “it is not safe for patient to go home”. If they are unable to make the “right decisions”, then someone else will make it for them- and they (docs) wont like it.

  • Dr Muhammad

    Summary:
    1) No need to have a prolonged argument with resident- its not gonna help.
    Talk to his/her consultant.
    IF even the consultant is not accepting admission-
    ESCALATE:
    1) If there is someone else in supervisory role, to involve them (Director of Emergency Department).
    2) Escalate it to hospital admin.
    3) Presuming that you are convinced about your assessment of patient, make sure you are not the one discharging the patient out of hospital (unless of course it was appropriate clinically and socially).

  • Loice Swisher

    Again this is a great case for discussion- and I think an excellent example of tribalism in medicine.

    Often we in emergency medicine feel we know what is best for the patient (or the quickest way to move them out of the emergency department); however other tribes might have other priorities or beliefs which are at odds. I would guess that someone doing emergency medicine for 10 years or so would be well versed in the Sell/Block relationship between emergency medicine and lots of other tribes- and has “handled it” on many occasions. The different aspect here is laughter. That would be a disarming response that I suspect few have had experience with in dealing with a junior.

    So as with most tribal confrontations that don’t go well, the adrenal pushed the brain an emotional level and the concern for the patient seemed to be secondary to fuming over the personal interaction.

    Victoria Brazil gave a great talk at SMACC GOLD specifically on this topic with the text being reprinted in last months Emergency Medicine News…..
    http://journals.lww.com/em-news/Fulltext/2015/11000/News__The_Pitfalls_of_Competing_with_Other_Tribes.5.aspx

    Video- http://lifeinthefastlane.com/timing-tribes-stemis/

    So where to go from here? Perhaps it would help to have a pathway/options/resources for social service problems that not uncommonly land in the safety net of the ED. Since it is going to happen again- and almost certainly at night or on weekends- get the tribes together (ED, IM, case management, administration) to make a plan.

    Loice

    • S Luckett G

      Hi Dr. Swisher, we always appreciate your thoughtful commentary!

      Does your organisation have a safety net plan for these sorts of patients who land in the ED as a last resort? What does the plan look like? Any advice for Ellen after her disarming experience?

      • Loice Swisher

        We often have so many competing issues going on at the same time that one of the problems can be which issue to tackle first. Clearly the laughing resident is inappropriate but we honestly don’t know why.

        It could be that this resident has been up for 24 hours- has a toddler at home that woke her up before coming in for her 24 hour call and was just going to lie down for a few minutes of sleep when she said to her friend “if I try to do that the ER will kill me with a patient that Dr X will rip me apart in the morning”. Then the call comes and punchy from lack of sleep and decision overload can’t stop laughing. It might be a temporary moment of jerkdom-fatigue meltdown.

        On the other hand, this resident could potentially a certified jerk.

        Depending on the situation, the response likely should be different. However, likely both should be addressed at some time. The first might need some support/sleep/understanding and perhaps an embarrassed apology might flow out. The second should get some professionalism guidance and higher intervention.

        The question though is “when is the right time”. Unless a person is a master of “Crucial Conversations” it probably isn’t right in a middle of a shift when one is trying to take care of patients/problems and the personal emotions are running high (perhaps even unchecked).

        It can be best to take some time to get out of your system “what you want to say”and then work on “what you want that resident to hear”. If you come at them guns ablazing most people will become defensive and not be able to listen. To truly find out what is going on it can be best to have it in your heart that you will maintain safety, respect and purpose (what you want them to hear). Sometimes this will take another person to help mediate adrenal surges which feed emotions and take out brains.

        People often find that they feel >> act. The other person made them “so mad”. Really, it wasn’t the other person. It was you that heard something>> told yourself a story about it >> then felt mad. If you told yourself a different story- or were curious about the story- yours might have been entirely false.

        My thoughts are- try to “be curious” about why someone said or acted a certain way. See if it helps bridge the gap of understanding. Then read Crucial Conversations: Tools for Talking when the Stakes are High by Patterson etal. To own that skill can change everything.

        Interested in your thoughts.

        Loice

  • Sean Kivlehan

    I see this in three parts. First, the laughing over the phone when discussing the best care of a patient is disrespectful not just to the person calling but to the patient and the entire profession of medicine. This should be immediately referred to that residents superiors and a hospital/GME professionalism committee. Second, a decision should be made if elder abuse is a true concern, and if so proper authorities should be notified and the patient should not be discharged to the unsafe environment. Third, if there is no clear concern for elder abuse (which generally in these situations there is not) then a determination needs to be made if the patient is safe at home until outpatient services can be arranged. If not, then the patient should be admitted. If the admitting service declines, then it should be escalated to hospital administration. If you make it clear that you feel discharging the patient is unsafe then they should not be discharged. I feel most hospital administrations would support that. In the event that they didn’t you could hold the patient in the ED as you pursued other recourse, such as with county/state department of health or social services.

    • S Luckett G

      Thanks for reading and replying!

      I agree with your assessment; there is nothing respectful of our profession found in laughing in the face (literally or figuratively) of a colleague in the middle of a patient care discussion. Yet, it does happen! Do you think there are ever any mitigating factors? Would you always escalate the discussion? Is it ever worth talking to the resident beforehand?

      • Sean Kivlehan

        It is always best to avoid escalation if possible. I think pulling aside Ellen and talking to her about the conversation may help. Ask her how she presented it, and you may find that there were some flaws in her approach that could have prevented the response she received. (Of course, that does not absolve the laughing resident). It is always hard dealing with this type of admit, for people on both sides of the phone. I generally approach it honestly with the admitting physician. I explain that we have a difficult situation, and ask for their help in trying to solve it. When framed that way, usually we can tackle the issue as a team. This is when having a good relationship with your consultants can really make life easier for everyone.

        When a ‘social’ admit is recognized, it is probably a good idea to speak with your resident beforehand and prep them on the approach to the call. I would explain my approach to, but I’m sure many other people have their own that could also work. If despite that, the conversation still went poorly, I would probably speak with the admitting resident directly and explain my perspective. I would likely also explain my concerns with professionalism (re the laughing). The response would inform my decision to escalate, however at a minimum the resident’s program director should be made aware in case this is a pattern.

  • Dan Furmedge

    Dan Fumedge
    Geriatrician and Internist from the UK
    There two issues which need to be looked at and could be looked at seperately:
    1. The patient needs to be admitted and there is a clear indication for admission overnight – in the daytime there might be safer other options available but overnight there is no other choice. The attending could either try the resident again – offering little choice in accepting the patient, or just call the on call attending, this sounds like it would be most appropriate given the time pressures they are facing at present – this also meants that the attending will have
    to contact the resident to let them know of the accepted referral. If you aren’t getting anywhere, discussion must escalate up for a senior decision.
    2. The seperate issue arises of the bahaviour of the resident towards another colleague (I don’t think it really matters if this is an attending or an intern – this behaviour is not acceptable. The attending will need to make a judgement as to if/when and how to raise this. It may be enough to raise this with the resident themselves, to contact their direct supervisor on call or their educational supervisor or equivalent. I think it would be worthwhile the attending trying to discuss the issue with the resident before making a definite decision to escalate this – but this of course depends on time and other factors and may not always be achievable.

    • S Luckett G

      Hi Dr. Fumedge, thanks for taking the time to read and reply, especially with your unique perspective as a geriatrician and internist.

      How do you suggest attendings address your second point? Is there a way to open the discussion that will hopefully both improve the situation and avoid friction between Ellen and the consulting resident in the future?

      • Loice Swisher

        My take on this is since the interaction clearly activated Ellen’s emotional side and brought out her own unprofessional behavior that a productive discussion has the potential to be helpful.

        As a way to open up discussion, well, at a rested time with emotions in check I would consider going to the resident saying something like “Hi Jill, wanted to get your thoughts on our phone conversation the other night. It didn’t go well and wanted to hear what you thought went wrong.” Then do the best to listen- don’t interrupt, have good active listening body language and seek to understand. For honest dialog, Ellen will need to keep the conversation safe, respectful and her eye on her primary purpose.

        In general I think people value being able to give their side of the story- perhaps be able to apologize or to ask to start over or to give some feedback on some not so great behavior that Ellen had but might not have recognized or the resident does have a ongoing problem that needs to be addressed at a higher level.

        If it is done well, Ellen has role modeled a way to handle these situations. In addition, I’ve heard PDs lament that they get complaints (you have a resident that is rude and you are going to have to do something about it) but find that the complainer rarely talked to the resident about their concern. The PD sits down with the resident and in discussion the PD finds a totally different interpretation of what happened.

        How does this ring to you? I’d be interested in PDs thoughts too. What approach would they wish would be taken before they are brought in or should they be brought in to mediate from the start?

        Loice

  • @signindoc

    Some ramblings …

    Despite a somewhat outrageous response by the cross covering resident, the issue throughout this case is one of Professionalism.

    The Referring ER Attending, while advocating on the patient’s behalf, was already affected by being told of the “positive suit-case sign” and the departure of the family. What condition(s) are characterized by a positive suit-case sign, and what are the operating characteristics of the sign? What like symptoms signs are part of the ER culture? GOMER comes to mind.

    The cross-covering resident was unprofessional in approach. This needs to be reflected
    back to the individual in no uncertain terms.
    The real question, however, is why?

    The Attending Staff for the potential admitting service may have left instructions that no “social admissions” were to be accepted. This is very common and can be discussed at
    the Attending level (ER to admitting Attending).

    [Be aware that by admitting someone who is a purely social admission has the following consequences:
    (i) A bed is blocked in the Acute In-Patient Unit which results in someone who could be admitted to that bed being looked after in the ER (two beds blocked)
    (ii) The myth that Internal Medicine should take those admissions that no-one else wants is perpetuated.

    So, back to professionalism:

    Has the Attending Staff on the Admitting Service given the cross covering resident free-reign to be unprofessional to the ER Attending by overtly or covertly saying that no “dumps” should be admitted? How are social admissions discussed during in-patient rounds on the Acute Medicine (and other) Services?

    Has the Program to which the cross covering resident belongs a similar policy which encourages residents to practice patient admission avoidance? This is commonly phrased as “I don’t know what is wrong with the patient, but it is not Xology” (Where X can be very varied, and even end with –ics).

    Ramblings on how to deal with this:

    Directly inform the resident of their lack of professionalism and document it.
    Call the Attending staff to discuss the admission and the resident’s unprofessional behaviour
    Inform the Program Director of the resident’s program.
    Reflect on how patients are presented to each other by different Health Care Professionals (since this is not Physician-only issue)

    • Eve Purdy

      Dr. Morton, Thanks for sharing your thoughts.
      Agree that there are professionalism issues all around here.

      You mention that we should reflect on how patients are presented to each other by different Health Care Professionals. What do you mean by reflection? How do you reflect, how do you teach your residents to reflect?

      • @signindoc

        Great question:
        I have taken to pointing out when I catch myself delivering the hidden curriculum. I hope I am sufficiently light-hearted about it that others are encouraged to point it out to me too.
        We need to realize that (despite what we would like to think) we all say unprofessional things and ask ourselves “why?” from time to time.
        My commonest answer to the lack of professionalism evoked in the case you gave is that it is an escape from the amount of pressure I (and others) are under because our system is not designed to deal with the (predictable) influx of elderly people who need more help.
        I think the best anyone can do – in terms of reflection – is to be honest with themselves: after all we don’t always like what we see in the mirror, but there are some things we see that we can change.

  • Michelle Gibson

    Commenting again not as an ER doc, but from my world of working in outpatient geriatrics.

    I’m a bit late to the game, and I’ve now read all the comments. As Dr. Morton says, it is not helpful that from the triage note on (re: “positive suitcase sign”), there is a tone (in my oversensitive reading) of condescension. Perhaps this was conveyed in some way to the laughing resident – that there was definitely nothing “medical” going on. It doesn’t excuse the laughing resident, but it’s worth reflecting if it had contributed. A “normal” work-up doesn’t always exclude something actually being wrong, if the wrong work-up was ordered. 🙂

    Regarding how to deal with the laughing resident … the patient must come first. With that type of reaction from the resident, I would likely have told them that I would be speaking directly with their supervisor as I am concerned for the welfare of the patient. If that brings about a change in tone, then I would deal with the patient first, and then provide feedback to the resident about how she approached the phone call, as this does not sound like someone saying something they didn’t mean, but rather, it is concerning from a professionalism point of view. If the awareness that a supervisor would be contacted does not bring about a change in tone, then I would end the conversation as quickly as I could and be civil. 🙂

    I would also worry how this resident is treating other patients – are all the old people on her service getting the same approach?

    Ideally, I would try to discuss it with the resident later, but in my world (working at a non-acute hospital) it is sometimes hard to a) get the name of the resident I was talking to and b) find them again.

    In cases this significant, I do think the supervisor needs to know what happened regardless- but there are very different ways of how this conversation can happen. The first instance (in short- your resident did/said this, but we had a good discussion about it and he/she appeared to understand/apoligize) is something that can show that a resident can learn from difficult interactions. The second instance is never fun – but it needs to be reported.

    And yes, this kind of thing has happened to me, as an attending. As noted, I work outside of acute care, and this seems to cause some residents (and other attendings) to feel we don’t know anything. I’ve been told in a hugely condescending tone that I should be doing things that are frankly impossible at my institution (we have, for example, no imaging at all except plain radiographs, and those only on non-holiday days, and only from 0700 to 1500).

    I will note that this is not the majority of the time, but it’s still often enough that I always stick around when my housestaff are calling many of our acute care colleagues – because I want to be there in case they’re being treated badly. Fortunately, it’s not the all the time, but it still happens often enough that I am generally around if I can possibly be.

    Fortunately, I think it is getting better. It is lovely to deal with people who actually ASK what we can/can’t do in our setting, and who indicate they appreciate our challenges. A constructive dialogue is often educational on both sides, so why not make it pleasant?

    • Eve Purdy

      Dr. Gibson, thanks for your thoughts and very interesting perspective. You are entirely right in thinking this case can be turned around to be about any learner-attending interaction. Should regular off-service attending evaluation be apart of resident assessment? Or just when there is a problem? In a place like Kingston, word travels fast (good and bad!) but what about in a setting that is bigger – is there a good way to capture inter-disciplinary communication when not directly observed?

  • Michael

    “Social admissions” are not reimbursable. In this case, advocating for the admissin is not right but perhaps delaying until SWK can interview and develop a plan is best. Hospital admin would go bonkers with this one. Many hospitals have on-call SWK for the overnight work just as described here.

    • Eve Purdy

      Thanks for your contribution Michael. Help me understand what you mean by not reimbursable and “social admission”. How does one decide what is a social admission and what is not? The line often feels quite blurred to me.

      • Michael

        CMS does not reimburse claims that do not have 1. Medical order for admission 2. MD certification 3. 2 midnights. Social admission is nomenclature used by hospital staff to describe folks as depicted in the vinnette. Without medical necessity not only would CMS withhold payment so will 3rd party insurers. Hospital bearing heart generally eat these costs.