Expecting a Specialist

If you go to the ER expecting to see a specialist, go during the day. Your odds are a little better than at night. Very rarely do specialists come to the ER in the middle of the night. The rest of Big Medicine—besides the ER—does not really operate 24/7. Yes, at large hospitals, there are always many specialists on call. But it takes a real emergency for them to actually come to the ER.

Cardiology and surgery are the two specialties I see regularly in the ER overnight. Virtually no one else. Ever.

And I’m not saying your specialist will come during the day either. Physicians are not just waiting around for calls from the ER. They are scheduled to be in clinic, in the operating room, or doing procedures, depending on their specialty. And based on the call schedule, they may or may not be the person answering calls from the ER. There are no guarantees.

Try to go to the same hospital or hospital system where you had your procedure or surgery. The more specialized the surgery, the more you need to be at the place that did it. Surgeons function with the mentality of “you broke it, you bought it” (sort of like taking your two-year-old to a store with breakable items on shelves close to the floor). That sounds a little crude, but the idea is that if you did the work, you are responsible for dealing with any downstream consequences of the work. Most of the time, those downstream consequences are a healing patient at a post-op clinic visit. Sometimes the consequences are a sicker patient in the ER.

It’s true that many surgeons can do routine appendectomies and cholecystectomies, but none of them want to deal with another surgeon’s patient when a complication happens. They do—they cover for each other based on the physician group they are part of and who is on call—but they don’t want to. As a patient, without an understanding of the back-end system (like on-call coverage and who belongs to which physician group), you may think your surgeon will be called in to see you. This is not the case unless you have a real emergency and your physician happens to be on call. And no, if your surgeon is not on call, I’m definitely not calling them.

Night docs tend to function a little differently than daytime ER docs. We generally reserve our calls to specialists overnight for things that really need an acute intervention. I don’t wake someone up just for an opinion or to confirm a treatment plan I already know how to do. Having done this for many years, I’m aware of what the first steps of managing most conditions involve. I’m aware of what someone would actually want to know about in the middle of the night. And generally speaking, most things can wait for the light of day.

As an example, I regularly admit patients with bowel obstructions and kidney stones to the hospital. These are almost always managed conservatively on the front end. That means symptom control, and surgery or urology, respectively, will see them during daytime hours. (There are only very rare exceptions, like severe infections from a bowel perforation or sepsis from an infected kidney stone.)

As a general rule, almost no one goes rushing to the OR in the middle of the night. Severe trauma is the exception, and occasionally other surgical emergencies, but even things like appendicitis are often just scheduled for first thing the next morning.