For years, scholars have thought the perfect surgery consult was impossible. Comedic ophthalmologist Will Flanary, a.k.a. Dr. Glaucomflecken, characterizes the golden consult as one in which the surgeon is not consulted too soon — because the patient is not sick enough to require his or her services — and one in which the surgeon is not consulted too late, or else the patient may die.

For a consult to be “golden,” timing is everything. In addition, the length of the consult matters. If the consult is too long, the surgeon will lose interest, and the patient will be shuffled off to the medical service. If the consult is too short — one word, for example — an orthopedic surgeon will be called in.

The real-life Dr. Will Flanary knows quite a bit about surgery because he is a survivor of recurrent testicular cancer. His admirers — 2.5 million subscribers across TikTok, YouTube and Twitter — claim he brings truth to stark medical realities while poking fun at his colleagues and the profession, nudging doctors away from what can be a monastic self-regard.

Dr. Glaucomflecken’s take on surgical consults got me thinking about the relationship between surgeons and psychiatrists. Psychiatrists don’t often consult surgeons, but I did so twice during my PGY-1 residency year. The first time was for a newly admitted psychotic woman. When her lab values came back indicating thyrotoxicosis, the surgeons whisked her away for subtotal thyroidectomy. It was the quickest cure for psychosis I had ever witnessed.

The second consult was not so golden. It was for a woman who had been struggling against restraints while psychotic and began complaining of arm pain as her psychosis (due to benzodiazepine withdrawal) resolved. An orthopedic resident diagnosed frozen shoulder and recommended “aggressive PT.” There was no review of the case by an attending surgeon.

The actual diagnosis was bilateral humeral fracture/dislocation, uncovered months after the patient was discharged from the hospital – too late for surgical intervention. The patient suffered chronic pain and eventually committed suicide. Her children initiated a lawsuit against the hospital and all doctors involved in her care, including myself.

The name of the orthopedic resident was never known — his name was illegible on the consultation form, and he had completed his residency and left the institution for private practice. The orthopedic resident was listed as a John Doe on the complaint. A settlement was reached prior to trial. I don’t think I ever consulted a surgeon again.

However, I performed many consultations as a psychiatrist working on an academic consultation-liaison service. Like Dr. Glaucomflecken, I believed there was such a thing as a “golden consult.” For psychiatrists, it was one in which the referring physician understood the gravity of the patient’s psychiatric condition and the criteria for inpatient hospitalization. The admission should not be requested for convenience, a social disposition problem, delirium, dementia or a combative or unruly medical patient.

Physicians possess varying levels of expertise depending on their areas of specialization. Specialization drives differences in diagnostic practice and creates a clinical imbalance that may cause some of us to have a jaundiced view of our colleagues.

We all have our own notion of what constitutes the golden consult — from our own perspective, of course. Treatment disagreements and turf wars often result from disparities in our medical sophistication — our depth of knowledge and ability to understand clinical nuances. The consultant’s knowledge obviously runs deeper than the consultee’s. Why else would a consultation be requested?

I was consulted by a surgeon in my final year of residency. Although I was accustomed to the practice of dumping patients in our psych unit, the opposite situation presented itself. A prominent head-and-neck surgeon refused to have his patient admitted to our inpatient psychiatry unit after his patient had attempted suicide. The patient tried to asphyxiate himself because he could no longer endure the disfigurement caused by extensive surgery for oral cancer.

To make matters worse, the surgeon was the father of one of my medical school classmates. He actually taught us the anatomy of the neck on our cadaver during our freshman year. He did not remember me now, nearly eight years hence, but I surely remembered him. I was able to convince the surgeon that his patient would be better served in the psych unit, where we could thoroughly evaluate his mental status and institute treatment to improve his self-esteem, all in a setting of safety.

Both the surgeon and the patient consented to treatment, and the patient was discharged in much better spirits without suicidal ideation.

Most of what I’ve read about power asymmetry in medicine has addressed the dynamic between doctors and patients and how it prevents shared decision-making. However, understanding the power hierarchy among physicians is equally important, and for the same reason — it skews treatment decisions in the direction of the powerful. Apart from one’s area of specialization, there are numerous sources that contribute to conflict and imbalance of power between physicians, such as differences in training levels (e.g., medical student versus resident versus attending), gender, race, and ethnicity, particularly as they impact Black women in medicine.

It may not be readily appreciated that power imbalances among physicians often surface around consultations. Perhaps joking about it is one way of dealing with it. However, given that power imbalances can become toxic and destroy the workplace experience for many physicians, residency programs and health care systems must look carefully at the wide-ranging consequences of tolerating and rewarding the unacceptable behavior of high-performing physicians at the expense of trainees, staff and the medical community.

It’s been said that “Flanary’s best material balances the specificity of an expert with the nose for hypocrisy that typically comes from an incisive observer.” Shouldn’t we all pay closer attention to the way we treat each other and avoid microaggressions and other demeaning and hurtful remarks, even if we believe (erroneously) that power permits us to take such liberties? If we’re going to talk in jest about inequities in medicine, shouldn’t we all be in on the joke?

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. His forthcoming book is titled Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.

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