ER and internal medicine docs, arguing over a patient admission

Dr. Erdoc happened to look up when the internist walked into the emergency department.

“Oh no,” he murmured under his breath. The consulting psychiatrist was sitting next to him, typing a note. She looked at him and raised an eyebrow.

“I hoped it wouldn’t be him. Unlike his colleagues, Dr. Internist seems to have a deep loathing for us emergency docs,” Dr. Erdoc explained as he stood up. Dr. Internist was frowning as he approached.

“Dr. Erdoc,” Dr. Internist opened, “why are you admitting cellulitis to the hospital? Didn’t they teach you how to treat a bacterial skin infection during your residency?”

“Yes, they did,” Dr. Erdoc said. “They also taught us when someone with cellulitis needs a hospital admission.”

“This man has schizophrenia,” Dr. Internist went on. “Why can’t he be admitted to the psychiatry unit? The medicine consult service can see him there.”

The psychiatric consultant glanced at Dr. Internist, though kept typing.

“Because psychiatry has already assessed him—twice—and they don’t think he has any urgent psychiatric issues,” Dr. Erdoc said. “I agree with them.”

“Twice? What do you mean, twice?”

“If I had a chance to tell you the history, you’d already know,” Dr. Erdoc curtly said. “He’s a 43 year-old homeless guy with hepatitis C and schizophrenia. He came here four days ago with a hot, painful left leg and was diagnosed with cellulitis. Psychiatry saw him then. He was sent back to the homeless shelter with oral antibiotics, but he returned today—”

“His schizophrenia must be affecting his ability to take the antibiotics as directed,” Dr. Internist cut in.

Dr. Erdoc cleared his throat. “He was sent back to the shelter with oral antibiotics, but returned today because the cellulitis has gotten worse. He brought in his medications—including the stuff he takes for schizophrenia, which psychiatry looked at when they saw him today—and the expected number of antibiotic pills are gone. To prevent—”

“Did you call the shelter staff to get more information? Like if he actually swallowed the antibiotics?” Dr. Internist interrupted.

Dr. Erdoc looked blankly at him before replying, “No.”

“Why not?” Dr. Internist demanded. “You didn’t get a detailed timeline of events.”

“Because that wouldn’t change my management. To prevent the cellulitis from getting worse, he needs IV antibiotics, which means he needs an admission to the hospital,” Dr. Erdoc said.

Still frowning, Dr. Internist continued, “Did you draw blood to see if his body is mounting an attack against the infection?”

“Yes, but the results aren’t back yet.”

“I’d like to see them before I admit him.”

“Dr. Internist,” Dr. Erdoc said, taking a step towards him, “his cellulitis isn’t getting better. They did teach you in your internal medicine residency that you don’t need to draw blood or do x-rays to diagnose someone with cellulitis, right? It’s a clinical diagnosis.”

Dr. Internist looked darkly at Dr. Erdoc, but said nothing.

“The best thing for the patient is an admission to the hospital so he can receive more aggressive treatment for his cellulitis,” Dr. Erdoc continued. “Your dislike of emergency medicine docs isn’t going to make patients get better. Now, we can continue to stand here, argue about this patient, and waste our time, or you can do the noble thing and admit this man to your service so we can all move on with our lives.”

Dr. Internist glowered at Dr. Erdoc.

“Fine. I’m doing you a favor,” Dr. Internist said before walking away to see the patient.

“No, you’re doing your job,” Dr. Erdoc muttered.

Sighing, Dr. Erdoc walked back to the computer where he was typing his note. The psychiatrist was finishing up her work.

“The contempt he has for us is fascinating,” he said.

The psychiatrist gave a small smile before commenting, “Sure, though the reasons why he dislikes emergency docs may be much more interesting.”

Maria Yang is a psychiatrist who blogs at In White Ink.

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