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.