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Are You Complicating Your Consults?

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kc_article_2012_consults

Are You Complicating Your Consults?

By Michael Howell, MD, MPH, Beth Israel Deaconess Medical Center

Related to: Communication, Diagnosis, Primary Care, Insight into Risks of Ambulatory Care

Dr. Howell is Director, Critical Care Quality, Silverman Institute for Healthcare Quality and Safety, Beth Israel Deaconess Medical Center.

Consultation is a cornerstone of modern inpatient care. As the pace and complexity of medical care have es­calated, the sheer volume of patients’ needs for both cognitive and procedural expertise have outpaced the abilities of any single physician.1 Recent studies show that—even among patients admitted to a general medicine service—almost half will receive a subspecialty consult.2 In my own medical center last year, more than 1,000 inpatients had four or more specialties involved in their care during a single admission.

As those of us who admit complex, acutely ill patients know, the quality of a particular consult can make or break a case. We know that there are good consults … and bad ones. Un­fortunately, there is a startling lack of research into what dif­ferentiates a good consult from a bad one. Many studies have evaluated whether patients who receive a particular specialty’s consultation or management have better or worse outcomes, higher or lower costs, or more or less efficient resource utili­zation.3–11 Most of these studies, however, treat the exposure to one consult as identical to exposure to every other consult, implicitly asserting that—like a tablet of aspirin—the quality of consultation does not vary from dose to dose. Experience would argue that that is far from the case.

My own clinical practice is pulmonary medicine and critical care. Since my ICU is a closed unit, I serve as the attending physician for our critically ill patients and, therefore, am in the position of calling for many consults. I also provide consultation for patients with incipient critical illness and with pulmonary problems. Thus, I have had the opportunity to both perpetrate and witness some spectacularly bad consultative episodes... and have learned to strive for better experiences.

Five Ways to
Call a Bad Consult

  1. Be vague about why you’re asking for the consult.
    Consultants are challenged to answer a question you didn’t ask, and a vague question engenders a vague response. To get the help you are looking for, ask a specific question. Lee’s seminal 1983 work showed that the consultant and the requesting team had totally different perceptions of the primary reason for consultation in more than 20 percent of cases.12 When this occurred, requesting physicians were significantly more likely to perceive lower value from the consult. This does not appear to have improved over the subsequent 25 years: a 2009 study found that more than one in four consult requests did not contain a clear question.13
  2. Be unclear about the level at which you want a consultant involved in the case.
    As a consultant, I need to know: Is your request for input about a particular clinical question? Do you want me to perform a procedure? Are we going to co-manage a problem? Should I write my orders in the chart? Shall I transfer the patient to my service? All of these levels of consultation occur fairly frequently.14–16
  3. Neither implement a consultant’s recommendations nor discuss with them why you’re doing something else.
    If my consultation is clear but you don’t agree, talk to me; if it’s unclear, contact me. 

    The patient’s attending physician is obligated to integrate incoming data, including consultants’ recommendations, into a coherent whole. A consultant’s job is to provide you with their best advice about the right way to proceed. If a consultant’s recommendations do not make any sense: 
    1. he or she may not have understood the question you wanted answered; 
    2. his or her note is inadequate; or 
    3. he or she may have missed some salient feature of the case. Most often, a simple phone call can clear up the confusion. 

    With the confusion cleared up, the consultant may have something meaningful to say that will change the course of therapy.
  4. Call for non-urgent consults at the end of the day.
    Inconsideration, or bad timing, can be a barrier to good patient care. If possible, avoid introducing unnecessary delays into the process: if you know you need help from nephrology at 9:00 a.m., call before 9:00 a.m. Give the consulting team time to talk with your team members (and factor in that trainees have to leave by a certain time and the consultants may be unable to talk to the physician who admitted the patient). Finally, if the consultant is likely to recommend additional labs or imaging, a recommendation received after 5:00 p.m. may mean delaying these recom­mended tests until the next day.
  5. Ask for a curbside, but write the consultant’s name in the chart and say that you consulted him or her.
    Professional dialogue about individual clinical cases is ubiquitous, well-regarded, and—when handled appropri­ately—helpful.17–19 If mishandled, informal consultation can be medico-legally complex.20

    If you seek a curbside consult, be clear to the consultant that a) your goal is to confirm your pre-existing clinical impression and, b) the consultation will not be part of the record. Consider, also, that those who are asked to provide curbside consultation often feel that there are important gaps in this type of communication that do not occur with formal consultation.16,18 For example, in one study, research­ers found that 80 percent of specialists felt that information communicated in curbside consultations was insufficient, and 77 percent felt that important clinical detail was not described.19

    The American College of Obstetrics and Gynecology (ACOG) professional statement on consultation sums it up very well:

Often… relationships among clinicians lead to profes­sional dialogue. In professional dialogue, clinicians share their opinions and knowledge with the aim of improving their ability to provide the best care to their patients … In professional dialogue, a second clinician is typically asked a simple question and he or she does not talk with or examine the patient… The second clinician does not make an entry in the patient’s medical record or charge a fee, and the first clinician should not attribute an opinion to the second clinician.17 [emphasis added]

Five Ways to
Provide a Bad Consult

  1. Tell me that the consult is inappropriate and that I shouldn't be calling you.
    Although the specifics may be obscured, a physician calling for a consult is, primarily, asking for one thing: help. Either I am calling an appropriate consult that legitimately needs your specialty expertise, or I am in over my head and don’t know what to do. In either case, both my patient and I need your help. Don’t disregard a consult request just because it’s poorly articulated. Over the phone, a request may, at first, seem to have no relationship to your specialty—particularly when it comes from a cross-covering physician. On further investigation, however, most of these requests turn out to be quite reasonable.
  2. Don’t see the patient when I ask you to.
    Heed the second of the Ten Commandments for Effective Consultations:“establish urgency.”21 If another physician is on the phone asking for your help right now, assume there is a good reason; accept that I truly am asking for help (even if you think I don’t need it). Better to see a few cases early that could have waited than to delay seeing a time-sensitive disease too late to improve the patient’s outcome. Embedded here is Goldman’s third commandment: “look for yourself.” Good consultants see the patient and review the data themselves.21
  3. Don’t answer the question I asked.
    Although you will undoubtedly have other recommenda­tions, please also address the specific reason we called. If we are really on the ball, we will have written this question in our note for the day (“Consult cardiology: would they recommend left heart catheterization in this patient who is unable to wean from the ventilator because of recurrent acute pulmonary edema?”). Good consultants always address the specific question asked, in addition to other issues that they uncover.
  4. Do things to the patient without talking to me first.
    Because it is my responsibility, as the patient’s attending physician, to integrate all incoming data, including your recommendations, into a coherent whole—and to review this with the patient and his/her family—we need to talk before you act (excluding a few truly emergent procedures when a few minutes’ delay might be life-threatening). The ethics committees of the American College of Physicians and ACOG use similar language to describe this facet of consultation.1722

    ACOG’s statement:
    A complex clinical situation may call for multiple consultations. Unless authority has been transferred elsewhere, the responsibility for the patient’s care should rest with the referring practitioner. This practitioner should remain in charge of communication with the patient and coordinate the overall care on the basis of information derived from the consultants. This will ensure a coordinated effort that remains in the patient’s best interest.

    Similarly, transfer of the patient from my service to yours should happen only after we have spoken directly.
  5. Communicate poorly. 
    The need for “better communication” is ubiquitous; in consultation more is better. If it is urgent or important, call me. Nothing is a substitute for direct, verbal communication between the consultant and the requesting physician.16,21,23 Also, please write legibly, sign your name so that I can read it, and leave clear and specific recommendations in your note. All of these things improve the chances that I will follow your recommendations.24 

    Inpatient consultative care is a complex clinical endeavor, both in the afferent and efferent limbs of the consultative episode. In spite of research about the virtues of consultation by particular specialties, little research has focused on what differentiates a good consult from a bad one. Clinical experience, though, argues strongly that attention to a few details—in both requesting and providing the consult—can enhance the experience for the requesting physician, the consultant, and the patient… and help ensure that your next consult contributes to the best possible patient outcomes.

References

1. Berwick DM. The Epitath of Profession. Br J Gen Pract. 2008; Advance online publication.

2. Jordan MR, Conley J, Ghali WA. Consultation patterns and clinical correlates of consultation in a tertiary care setting. BMC Res Notes. 2008;1:96.

3. Ahmed A, Allman RM, Kiefe CI, et al. Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care. Am Heart J. 2003;145(6):1086–1093.

4. Auerbach AD, Hamel MB, Davis RB, et al. Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Ann Intern Med. 2000;132(3):191–200.

5. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167(21):2338–2344.

6. Fallon WF, Jr., Rader E, Zyzanski S, et al. Geriatric outcomes are improved by a geriatric trauma consultation service. J Trauma. 2006;61(5):1040–1046.

7. Girre V, Falcou MC, Gisselbrecht M, et al. Does a geriatric oncology consultation modify the cancer treatment plan for elderly patients? J Gerontol A Biol Sci Med Sci. 2008;63(7):724–730.

8. Huynh T, Jacobs DG, Dix S, Sing RF, Miles WS, Thomason MH. Utility of neurosurgical consultation for mild traumatic brain injury. The American Surgeon. 2006;72(12):1162-1165; discussion1166–1167.

9.  Jenkins TC, Price CS, Sabel AL, Mehler PS, Burman WJ. Impact of routine infectious diseases service consultation on the evaluation, management, and outcomes of Staphylococcus aureus bacteremia. Clin Infect Dis. 2008;46(7):1000–1008.

10.  Puig J, Supervia A, Marquez MA, Flores J, Cano JF, Gutierrez J. Diabetes team consultation: impact on length of stay of diabetic patients admitted to a short-stay unit. Diabetes Res Clin Pract. 2007;78(2):211–216.

11.  Regueiro CR, Hamel MB, Davis RB, Desbiens N, Connors AF, Jr., Phillips RS. A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Am J Med. 1998;105(5):366–372.

12.  Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74(1):106–112.

13.  Conley J, Jordan M, Ghali WA. Audit of the consultation process on general internal medicine services. Qual Saf Health Care. 2009;18(1):59–62.

14.  Katz RI, Barnhart JM, Ho G, Hersch D, Dayan SS, Keehn L. A survey on the intended purposes and perceived utility of preoperative cardiology consultations. Anesth Analg. 1998;87(4):830–836.

15.  Pausjenssen L, Ward HA, Card SE. An internist’s role in perioperative medicine: a survey of surgeons’ opinions. BMC Fam Pract. 2008;9:4.

16.  Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med. 2007;167(3):271–275.

17.  ACOG Committee Opinion. Number 365 May 2007. Seeking and giving consultation. Obstet Gynecol. 2007;109(5):1255–1260.

18.  Keating NL, Zaslavsky AM, Ayanian JZ. Physicians’ experiences and beliefs regarding informal consultation. JAMA. 1998;280(10):900–904.

19.  Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280(10):905–909.

20.  Fox BC, Siegel ML, Weinstein RA. “Curbside” consultation and informal communication in medical practice: a medicolegal perspective. Clin Infect Dis. 1996;23(3):616–622.

21.  Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143(9):1753–1755.

22.  Snyder L, Leffler C. Ethics manual: fifth edition. Ann Intern Med. 5 2005;142(7):560–582.

23.  Stoller JK, Striet R. Inpatient consultation: results of a physician survey and a proposed improvement. J Healthc Qual. 2003;25(1):27–35.

24.  Lo E, Rezai K, Evans AT, et al. Why don’t they listen? Adherence to recommendations of infectious disease consultations. Clin Infect Dis. 2004;38(9):1212–1218.


September 1, 2009
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