Medicine consults

i'd very much like to be believe that it's only my hospital that's like this, but medicine consults are the absolute worst. it's like bizarro world where i work; medicine doesn't try to diagnose things... they are way too focused on cutting first and thinking later. hey is that a superficial bump? let's call surgery to cut it open!

ring ring ring...
"surgery returning a page"
"hey, i'm calling in a consult. we've got a guy with an abscess that needs to be drained"
(note: this is the abbreviated version.. the actual consult involves useful details like "some guy with a medical history of hypertension, cataracts, and tonsillectomy in 1941 who presents with chest pain.... cardiac enzymes are negative x2, hemoglobin a1c is 5.9... ESR of 33...)
"is it draining?"
"yeah"
"ok so..."
"it was drained two days ago but i think it needs to be drained again. can you come do it?"

to make a long story short, what usually happens is that i ask a bunch of questions, #1 to find out what's really going on, #2 find any details for me to punt the consult to ortho, plastics, derm, etc, #3 see if i can delay the consult with a few studies. but in the end, someone has to be a doctor, so i usually just see the patient.

so i go see the guy. it's a firm growing mass. drainage had been attempted but nothing was expressed. interesting... oh he's also had unintentional weight loss and night sweats. oh and this "abscess" is rock hard. and there are two of them, located near a bunch of lymph nodes. and there's no surrounding erythema. and one of them is fixed. not painful.

it's not like i'm a great diagnostician. in fact i probably suck; there's a reason why i'm in surgery, and it's not to diagnose random congenital disorders or rule out #12 of my 15 point differential. anyway, the point is, come on man, there's a good chance there's more going on here than just "abscess, need I&D".

i know it goes both ways, and i know i've been forced to place my share of consults that make no sense, but i'll let an internist write about that in his or her own blog