Home On the Wards Consultants: their proper care and feeding

Consultants: their proper care and feeding

September 2010

Published in the September 2010 issue of Today’s Hospitalist

“My patient went to the operating room? I didn’t even know he needed surgery!”

“If Dr. Gotrocks doesn’t see patients on that insurance plan, why didn’t he tell me yesterday?”

“The consultant did WHAT?”

Do any of these complaints sound familiar? The problem may be that you’re new to the hospital, you’re using a consultant for the first time or you simply don’t have many consultants to choose from, but the bottom line is the same: Your patient has a specialist who isn’t doing things the way you expect.

The physician may not be a “problem consultant,” but the two of you sometimes seem to be working at cross purposes. And as a hospitalist, consultants who aren’t on board with your plan can drive up your length of stay and resource utilization “and hurt your patient satisfaction.

Before you go ahead and “fire” the consultant, consider the following strategies to make multi-doctor inpatient care run more smoothly.

The good, the bad and the clueless
As a hospitalist, you know that your length of stay and resource utilization are being measured and recorded. You use every inpatient resource as efficiently as possible, and you routinely plan for elective echocardiograms or follow-up endoscopies to be done as an outpatient.

The problem is that physicians with a limited inpatient practice “or doctors who are fresh from a hospital teaching service, where patients stick around until all their problems have been addressed “may not understand the need to avoid unnecessary hospital time. The neurologist who made a brilliant diagnosis of variant Parkinson’s or the rheumatologist who figured out what caused that fever of unknown origin may think it’s perfectly OK to keep the patient in-house until every abnormal lab value is explained. Or she may simply be unable to round on the patient until after you’ve left the hospital, so she writes a note that you read in the morning.

The obvious problem with that approach is that stating “OK for discharge” or “needs perfusion study” in a late-afternoon note can result in delays in diagnosis and care. It can also drive up length of stay, particularly when the afternoon is a Thursday and the requested study is done only on weekdays.

You need to be tactful and respectful when you call the consultant, but you must also be clear that you are available for a discussion any time they have those types of recommendations. If you spell out the effects on the patient rather than the inconvenience it causes you, the consultant may feel guilty instead of resentful, and guilt is a powerful motivator.

Behavior modification
While many physicians would argue that you need to re-evaluate a consultant who takes 24 hours to get to a patient’s bedside, there are good reasons why you might want to keep that physician on your list. Maybe he chairs several committees and you want him to like you; perhaps he’s the leading authority on a particular condition; or maybe you plain feel sorry for him for some reason.

Next time you call, explain to the nurse or secretary just how soon the patient needs to be seen, and leave a contact number. The doctor may be slow because he’s overworked, but it could also be that he doesn’t see enough hospital patients to realize the time pressures that we now face.

Keep in mind that some specialties are more challenging to work with than others. Surgeons’ communication skills, for example, are variable, and those skills among my surgeon friends have not always been good. If you find a surgeon who will call you either before or after the operation, cherish him. If not, ask the nurses to call you with updates so you don’t get calls from the family about a procedure you didn’t even know was needed.

And if a surgeon has stopped visiting a patient whose operation occurred several days ago, it’s both courteous and practical to notify her when the discharge date approaches. That way, postop outpatient visits can be scheduled. Many surgeons have assistants “usually PAs or RNs “who handle communications when the surgeon is in the OR. These folks are usually extremely well-informed, and they can often predict how their boss handles most of the problems that come up.

“Every doctor says something different”
Dealing with a single prickly consultant is easy compared to the bigger task we face every day: managing the horde of consultants who are involved in the care of many of our patients.

To start, if a patient has several consultants, it’s wise to read the notes of everyone involved and keep a list of current problems and recent test results, preferably as part of your own note.

Most complaints about “conflicting information” are simple misunderstandings, as illustrated by the following comment: “The kidney doctor says the bicarbonate is too high, but now you’re telling me I have a metabolic alkalosis. Which one of you is right?”

The reality is that you have plenty of uncomplicated patients who need only five minutes of your time. That allows you to spend more time with complex patients going through the problem list to assure them that all the doctors are on the same page. After a few extended visits with those patients, you’ll find that you spend less time as patients and family members realize they don’t have to obsess over minor differences in the way you describe the situation.

Juggling multiple consultants
While juggling multiple consultants can be time-consuming, there are some benefits to casting a wide net. While you love Dr. Gastro and wish he would see all your GI bleeders, it’s wise to spread some calls among his colleagues. This keeps you on good terms with a larger number of potential friends (who may ask you to admit their next patient with a relapse of Crohn’s disease) and gives you a backup plan for when Dr. Gastro takes a vacation or isn’t covered by somebody’s HMO.

Then again, there are some limits to how much you want to spread your business around. If a patient has been admitted previously, for example, try to keep the same consultants from one admission to the next. That continuity of care prevents unnecessary second tests, and the consultants will be grateful for the referral, especially if they know you only slightly or are aware that you don’t use them often.

And if you work in a teaching hospital, you also have to decide whether or not to expose your patient to doctors in training. It’s true that sometimes you’ll need the resources of an academic service, but you can be selective. If the attendings rotate coverage, for example, you can sometimes wheedle their secretary into telling you who’s on duty this week before you give out the patient information. That lets you consult Dr. Awesome when he’s on service but avoid Dr. Pompous.

Remember that relationships within a hospital are much like those in a small town. Gossip is exchanged in the doctors’ lounge and at nursing stations, rivalries develop and alliances change. Keep your relationships positive whenever possible. Maintaining ties with other specialists will help you build your place in the community, and it will pay off in a healthy and growing practice.

When to fire a consultant
What constitutes grounds for firing a consultant? No. 1 should be practices that are dangerous to patients, such as unapproved treatments or disregard of infection control measures. But after that, your answers may vary: refusal to see non-resource patients (provided that more generous consultants can be found), slow response, rudeness and so on.

If you do decide to stop using a consultant, make the decision as quietly as possible. Unless his behavior was unprofessional or dangerous enough to justify a formal complaint, any third party who asks why you stopped calling him should be told that you just want to spread business around.

If the reason is a slow response or poor communication, others will find out for themselves. If doctors who refuse non-resource patients ask why you haven’t consulted them lately, explain that you feel obliged to pay back the specialists who have helped your patients free of charge.

And when someone asks your opinion of a consultant you don’t use, be evasive if you can’t be nice. You will win points for taking the high road and avoid having your negative comments get back to the person who prompted you to make them.

Stella Fitzgibbons, MD, has been a hospitalist since 2002 and has worked at numerous hospitals in the Houston area. She is currently “learning” a new hospital and has great sympathy for others undergoing the same experience.

Not all specialties are alike

LIFE IS UNFAIR, and so is payment for medical services.

Here’s a good example: Since the 1970s, patients requiring long-term dialysis have qualified for Medicare coverage after the first year. While that benefit applies to people with renal failure, it unfortunately does not apply to those with AIDS or end-stage liver disease.

If it seems that the nephrologists are more generous with their time than specialists in infectious disease or gastroenterology, particularly when it comes to renal failure patients, it should come as no surprise. Doctors respond to financial incentives “and pressures “the same as anyone else.

You’ve probably noticed that it’s often easier to get intensive-care help than a pulmonary consult for a patient on a med-surg floor. That’s because there’s a huge difference in the payment rates for the two services.

On the flip side, your group may have trouble finding consultants willing to help the unassigned patients you admit from the ED, particularly when the specialists get little or no pay. In these cases, try asking the hospital administration to offer a solution like a financial subsidy or (at the very least) round-the-clock help in getting patients transferred to a hospital where they will get the care they need.

And if the hospital is large enough to have meetings within individual specialties, suggest that an administrator attend the meetings of those who are the least helpful. The idea may not be one you were taught in training, but if it helps a sick patient, it’s worth the trouble.