Caring for patients in the inpatient setting is complex and often requires consultation from specialists. Yet the actual skill of obtaining a consult is rarely taught. Medical students and residents usually learn by trial and error, becoming targets of frustrated consultants and suffering humiliation and much anxiety. To facilitate communication between the primary team and the specialist, we propose that the student and/or resident start by asking the following questions.
1. Why Call This Consult?
To decide whether you need a consult, first determine the type. Consultations can be broken down into three different types: advice on diagnosis, advice on management, or arrangements for a specific procedure or test. Advice on diagnosis or management is typically required when a clinical issue has reached the bounds of knowledge, experience, or comfort zone of the team or physician (e.g., idiopathic leukocytosis). For procedures, a consultant who is licensed to perform the procedure may be required (e.g., endoscopy for GI bleed).
2. What Should Be Done before a Consult Is Requested?
First, ask yourself, “If I were the consultant, what would I want to know?” Before calling, put yourself in the shoes of the consultant and consider the available data carefully to develop your own hypotheses. For example, infectious disease consultants typically make judgments based on relevant culture data, current and/or past antibiotics, imaging, and signs or symptoms of active infection. Reading about the problem beforehand allows you to anticipate possible questions and consider additional studies that may be requested by the consultant. It also helps ascertain whether the consultation is actually necessary or targeted to the right team.
3. What Is the Clinical Question?
Bergus and colleagues found that a well-structured clinical question clearly identifies the treatment the primary doctor is proposing and the desired outcomes for the patient.1 For instance, rather than asking, “What should we do for this 75-year-old man with chest pain?”, a better question might be, “Will the addition of ranolazine increase exercise tolerance in our 75-year-old man with angina who is already taking a beta blocker and nitrates?” When both components are present, clinical questions are more likely to be answered.
4. How Do I Best Present the Case to My Consultant?
Requesting a consultation requires a succinct presentation that focuses on the aspects of the case most pertinent to the specialist. To do this, again put yourself in the shoes of the consultant. For example, a patient’s history of venous thromboembolism (VTE) will always be relevant to a hematologist, whereas a history of GERD may not be needed in your initial conversation. Limit the initial presentation to two to three minutes and organize using the four I’s:
- Introduction: “My name is X with blue medicine team; I am calling to request a consult.”
- Information: Patient name, location, medical record number, attending physician.
- Inquiry: “I am requesting evaluation for an EGD in a patient with an upper GI bleed.”
- Important items (the story): “Mr. X is a 55-year-old male with history of peptic ulcer disease presenting with abdominal pain.”
5. What Data Requests Should I Anticipate?
Have your clinical data easily accessible in case additional information is requested (i.e., keep the chart open when calling). If certain tests are predictably going to be needed by the specialist (e.g., renal ultrasound for a nephrologist), make sure that the results are available or in process. Also, be prepared to take notes if the consultant requests additional tests up front.
6. How Urgent Is the Consult?
Consultations can be emergent, urgent, or elective. Directly communicate any emergent or urgent consults in order to clarify the issues expeditiously. For more routine consults, consider delaying the call until enough laboratory data or imaging is available for the consultant to answer the question. Do not call a nonurgent consult at the end of the day or on a weekend.