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10 Tips for Hospitalists to Achieve an Effective Medical Consult


 

A medical consult is an amazing way to learn. Consultation challenges us to practice our best medicine while also exposing us to innovations in other specialties. It can forge new and productive relationships with physicians from all specialties. At its best, it is the purest of medicine or, as some put it, “medicine without the drama.”

As hospitalists, we are increasingly asked to be medical consultants and co-managers. Yet most training programs spend very little time educating residents on what makes a high-quality consultation. One of the first articles written on this subject was by Lee Goldman and colleagues in 1983. In this article, Goldman sets out 10 commandments for effective consultation.1

Many of the lessons in these 10 commandments continue to ring true today. As primary providers, we know that consulting another service can run the gamut from being pleasant, helpful, and enlightening to being the most frustrating, slam-the-phone-down experience of the day. In this article, we update these commandments to create five golden rules for medical consultations that ensure that your referring providers’ experiences are purely positive.

One warning about communication: If you do not agree with the primary team’s plan of care, make sure you discuss these concerns instead of just writing them in the chart. Any teaching moments should be reserved for those who are open to that discussion, not forced on providers who are not receptive to it at that time.

Five Golden Rules

1 Listen and determine the needs of your customer.

Understanding the needs of your requesting physician is paramount to being an effective consultant, and the first step is to determine the physician’s question. Some referring providers want the bird’s eye view of a general medicine consult, whereas others have just one specific question. In one study stratified by specialty, 59% of surgeons preferred a general medicine consult, while most non-surgeons preferred a focused consult.2

Next, establish the timeframe: Is it emergent, urgent, or routine? One rule of thumb is that all consults should be seen within 24 hours. But many consults need to be seen more quickly, or even immediately. For example, you may be correct to assume that a patient is stable enough to wait for your consult, but perhaps the lack of pre-operative medical assessment will cause her to lose her spot on the OR schedule. The orthopedic surgeon now operates late into the night. Truly understanding the needs of your referring provider might have avoided that scenario.

There are of course times when you really can’t get to a consult expeditiously, but you must let the referring provider know. Ultimately, once you agree upon the urgency, all parties, including the patient, will know when to expect the consultant at the bedside.


2 Look for yourself, and do it yourself.

We practice in an age in which we spend more time in front of computers than in front of patients. As Lee and colleagues write, “A consultant should not expect to make brilliant diagnostic conclusions based on an assessment of data that are already in the chart. Usually, if the answer could be deduced from this information, the consultations would not have been called.”1 Effective consultants always obtain their own history and physical—your special expertise may allow you to extract overlooked information.

In addition, simply leaving recommendations to repeat tests or obtain records often delays care. If you feel the information is vital, take it upon yourself to obtain it. This may include contacting outside primary care providers or medicine subspecialists, or getting outside records.

Although we are not the primary provider, our goal must always be to do what is best for our patients.


3 Make brief, detailed plans with contingencies.

Recommendations can easily be lost in the deluge of information bombarding the primary care team. Our goal is not only to make recommendations, but also to have them followed.

In a study looking at which aspects of a consultation lead to increased compliance, researchers noted that if dose and duration of therapy were not specified, 64% of recommendations were implemented.3 When only one was specified, implementation increased to 85%, and when both were specified, implementation rates increased to 100%. Sadly, only 15% of over 200 consults had both duration and dose in their recommendations. Another study on compliance found that when five or fewer recommendations were specified, compliance increased from 79% to 96%.4

Contingency plans are a way of life for hospitalists when we sign out. Consultations are no different. Patients we consult on are often critically ill, and their status is dynamic. Anticipating problems and giving recommendations if those problems arise can save valuable time later for both you and your colleagues.

As consultants, we often feel compelled to “do something,” yet we know as primary providers how frustrating it is to have a consultant ask for a battery of tests or treatments that don’t address the big picture. Never be afraid to recommend continuing current management if it is appropriate or even to recommend stopping treatment or avoiding additional testing when it does not help the patient.

In summary, consults are most effective when they are brief (five or fewer recommendations), are detailed, and provide contingency plans. What good is a great consultation if it is not followed?


4 Communicate, communicate, communicate.

When 323 surgeons and non-surgeons were surveyed, both groups agreed that initial recommendations should be discussed verbally. Direct verbal communication allows the primary team to provide important information that you may have missed. In addition, discussing recommendations improves compliance and allows everyone to agree on the next plan of action and provide a unified plan to the patient, improving patient satisfaction and adherence.

Lastly and most importantly, opening the lines of communication between consultant and requesting physician creates effective consulting relationships.

Developing this relationship with other services may mean that the next time you call them for a consult, you will already have good rapport to build on.

One warning about communication: If you do not agree with the primary team’s plan of care, make sure you discuss these concerns instead of just writing them in the chart. Any teaching moments should be reserved for those who are open to that discussion, not forced on providers who are not receptive to it at that time.


5 Follow up.

Several studies have shown that follow-up notes improve compliance with recommendations.3,5 Follow-up is also important to ensure that critical recommendations are followed and that any changes in patient status can be addressed. Furthermore, following up can provide valuable feedback on your own initial clinical judgment. Finally, it is bad practice to recommend testing and then sign off before these tests are completed. Either you feel they are important to patient care and worth obtaining, or they are not needed.

Following these five golden rules can ensure that you are the consultant who gives other physicians the satisfying experience of an effective and great consult. If it’s done right, the experience of a general medicine consult is the purest of medicine.


Dr. Chang is assistant professor, inpatient medicine clerkship director, and director of education in the division of hospital medicine at Mount Sinai Medical Center in New York City. Dr. Gabriel is assistant professor and director of medicine consult preoperative services in the division of hospital medicine at Mount Sinai.

References

  1. Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143(9):1753-1755.
  2. 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.
  3. Horwitz RI, Henes CG, Horwitz SM. Developing strategies for improving the diagnostic and management efficacy of medical consultations. J Chron Dis. 1983;36(2):213-218.
  4. Sears CL, Charlson ME. The effectiveness of a consultation: compliance with initial recommendations. Am J Med. 1983;74(5):870-876.
  5. MacKenzie TB, Popkin MK, Callies AL, Jorgensen CR, Cohn JN. The effectiveness of cardiology consultations. Concordance with diagnostic and drug recommendations. Chest. 1981;79(1):16-22.

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