Published in the October 2015 issue of Today’s Hospitalist
ASK LOUIS O’BOYLE, DO, about his relationships with specialists, and he goes out of his way to tell you that those relationships are, for the most part, in great shape and that his engagement with consultants is just right: not too little, not too much. But there’s a small number of specialists whose behavior can be vexing at best and, sometimes, downright hostile.
There are, he says, specialists who wait a day or two to respond to a consult request, especially if the call comes on the weekend (too little engagement). There are cardiologists who want to be consulted on every patient with a heart problem (too much engagement). There was even one specialist who would “consult himself” by trolling the ED for business. If he saw a patient about to be admitted to the hospitalist service who had a condition that matched his specialty, he would ask the ED secretary to put in an order for a consult with him (way too much engagement).
“We’ve had some cardiologists stamping their feet at committee meetings, insisting on being consulted on every chest pain,” Dr. O’Boyle says. “They actually came out and said that hospitalists were hurting their bottom line.”
“We’ll see a different philosophy and approach at 10 a.m. on Wednesday compared to 3 a.m. on a Saturday.”
What can hospitalists do? Dr. O’Boyle, who is owner and medical director of Advanced Inpatient Medicine, a private group in Northeastern Pennsylvania, says the key is communication. “You have to keep talking,” he explains. “We have sat down with specialists and asked about their preferences and expectations.”
At first, he admits, some specialists maintained that they wanted to be brought in every time one of their patients was hospitalized. Some even reached the point of saying, “I don’t care what they are here for, I want to be consulted.”
Lots of meetings have helped soften those expectations, Dr. O’Boyle explains, but his group has also had to set some firm boundaries of its own. “We don’t believe in the ‘courtesy consult,’ ” he says, “but we’ll call you if there is a specific value to your coming in on the case to offer insider information.”
And while the group uses strategies like creating consult and admission guidelines and clinical pathways spelling out who does what, Dr. O’Boyle says that patience is key.
“Changing a culture that has been thoroughly entrenched for a generation is hard,” he says. “We haven’t been around as long as some specialists.”
Be careful what you wish for
Even when specialists and hospitalists agree to respect each other’s boundaries and expertise, keeping everyone on the same page in a busy hospital can be a struggle. Nicholas Honda, MD, a senior leader with Central Ohio Primary Care’s Hospitalists, which practices at four hospitals in the Columbus area, says this is particularly true with what he calls “re-engagement.”
According to Dr. Honda, the specialists he consults with on a daily basis are excellent clinicians with topnotch procedural skills who are extremely responsive to calls. But when it comes to getting answers to “hanging threads” that persist after a procedure, surgery or test has been done, his group sometimes spends time and energy chasing those same specialists down.
“You often have to prompt the specialist to be engaged,” Dr. Honda says. “The challenge is to get specialists to stay clinically engaged, not just procedurally engaged. We really need specialists to be both.”
But Dr. Honda is quick to note that hospitalists must walk a fine line when it comes to getting specialists’ attention. While it’s frustrating for hospitalists to chase down absent specialists, it can be just as difficult to deal with those who are overly engaged in the care of hospitalists’ patients. In other words, he says, be careful what you wish for.
Every time a new consultant is brought into a case, Dr. Honda explains, expect to add a day or so to that patient’s length of stay. That figure can explode when consultants start consulting other consultants.
Consider the patient who has heart failure and an existing relationship with a cardiologist. A hospitalist may order that consult almost as a courtesy, even if the patient is admitted not for heart problems but for a foot ulcer. But the cardiologist, trying to help, consults the podiatrist “who then calls vascular for evaluation of blood flow and consults infectious disease to help manage the antibiotics.
“At times, it can be a challenge to get everyone on the same page,” says Dr. Honda.
The clock and the calendar
Jacques Burgess, MD, MPH, section chief for hospital medicine at Munson Medical Center in Traverse City, Mich., and a hospitalist with iNDIGO Health Partners, says he sees two big factors that affect consultant communications: “the calendar and the clock.”
“We’ll see a different philosophy and approach at 10 a.m. on Wednesday compared to 3 a.m. on a Saturday,” Dr. Burgess explains. If your specialists are fine with having hospitalists admit a patient in the middle of a Saturday night without ordering a consult, but they insist on being involved when that same patient comes in mid-morning Tuesday, you have a problem.
“Some specialists want it both ways,” he says. “They want to yield the admission process to the hospitalist team, but then they want to direct and command the care once the patient is in a bed. That is a piece that requires continued dialogue.”
Moreover, Dr. Burgess insists that hospitalists should take the lead in such negotiations because the hospitalist movement has changed the rules of engagement, not the specialists. Besides, he adds, it’s the hospitalists’ job to do whatever is necessary to shepherd patients efficiently and effectively through hospitalizations.
He recommends starting a conversation about specialist engagement by saying something like this: ” ‘If you ask me to sit in the driver’s seat, that’s what I’m going to do. One of the ways I am going to do that is to talk to you and nudge you and ask you to come to the bedside or take the patient to the OR sooner than you would have, so we can decrease their risk of nosocomial infection or decrease their length of stay. That is my role, and I see that as something I own.’ ”
Dr. Burgess also says hospitalists need to explain why it’s not OK for specialists to ask hospitalists to yield the driver’s seat in the morning, when it’s convenient for a specialist to take over. It’s also not appropriate, he adds, to ask hospitalists to “put it in the garage for a few days while they decide what they are going to do and then call us back to take over again when it’s time for discharge.”
“It is our responsibility to teach specialists how to interact with us,” he says. “It starts with respecting each other’s training, and communication has to be provider-to-provider.”
Setting ground rules
James Rooks, MD, a veteran hospitalist and practice management consultant in Tulsa, Okla., says that hospitalists’ best tool to promote subspecialist engagement may be their cell phones. “You call and talk to them,” Dr. Rooks says. “Communication on the chart is less than ideal.”
But that seemingly simple piece of advice “just call specialty colleagues and talk “may often be easier said than done. In Phoenix, Ariz., the academic hospitalist group at Banner-University Medical Center Phoenix identified communication deficits with general surgery teams as an area of opportunity. Problems included a lack of clear understanding of which team should admit particular patients and when and how some patients should be transitioned to different services without those services feeling dumped upon.
Emily Mallin, MD, medical director of the academic medical service of the employed hospitalist group, recalls specific problems that her faculty members reported: “very short notes, no clear process of how to consult each other, and no way to figure out who was on that day for that patient and what the hierarchy was.” That left physicians in both specialties as well as nurses wondering who to call with questions, the intern or the attending, Dr. Mallin explains. “Over many years, it led to a lack of trust and worse communication.”
When the leaders of the two services began a process-improvement project, they agreed to two seemingly simple interventions. First, they decided to share each other’s schedules (so the correct attending physician could be identified) and to make sure that residents stated in their chart notes which attending was on that day.
Second, both groups distributed a phone list. “Every faculty member got everybody else’s cell phone number,” Dr. Mallin says. Those changes have been successful, as measured by “how many complaints we got about each other.”
“Better communication improves trust, and more trust improves your communication,” Dr. Mallin notes.
When hospitalists overconsult
Dr. Rooks in Tulsa is all for improving one-on-one communication. But he points out that one solution to better subspecialist engagement is to not call so many consults in the first place. Hospitalists who overconsult often set themselves up for frustration.
Think of the hospitalist who acts as a “consultasaurus,” Dr. Rooks says. “There are new hospitalists who consult a specialist for every problem, as opposed to being comfortable managing things on their own.” Such hospitalists become impatient when specialists don’t meet their timetable, but they ultimately make the situation worse by annoying their consultants.
The specialists begin to think that their time and expertise are being wasted by clinicians who are acting more like residents than competent professionals. In their view, hospitalists who order consults willy-nilly without bothering to do the homework they are perfectly capable of doing themselves are revealing themselves as disengaged from the care of their patients. And that becomes a vicious cycle.
Colleen A. McCoy, MD, medical director of hospital medicine at Williamsport Regional Medical Center, which is part of Susquehanna Health in north central Pennsylvania, says that while hospitalists need to set boundaries with specialists, they have to observe some boundaries of their own. “The job of a consultant is to answer the immediate question and to teach you,” Dr. McCoy says. “The job of a consultant is not to do your work.”
So what is the secret to getting your specialists engaged in the care of your patients? Dr. McCoy says she’s asked subspecialists that very question, and the answer is simple: “Specialists are engaged with hospitalists who are engaged.”
Consults and night staffing
As for what hospitalist engagement looks like, Dr. McCoy says that if before you call a consult, you have attempted to try to answer the question by taking a good history and coming up with a few answers on your own, specialists will see that you’re working on the problem “and not just calling them in to do your work for you.
“When subspecialists feel they are doing the hospitalists’ job for them,” Dr. McCoy says, “they disengage because they are angry. They don’t want to show up and do basic scut work.”
And based on the feedback she’s received from specialists, Dr. McCoy has shaped her group’s staff and schedule to make sure only experienced hospitalists work those shifts that generate the lion’s share of all consult requests: nights. By staffing her overnights with mature hospitalists, many fewer consults are called, which means that very few specialists are called and woken up at night. Specialists “very much appreciate” staying asleep, she says.
Compare that approach to having a locum tenens physician work as a nocturnist because you are desperate, Dr. McCoy says. “When you make your least experienced people work nights, where you have to make clinical calls in isolation, you will irritate the hell out of your subspecialists.” They will be woken up, she points out, with questions that could and should have been handled if only the hospitalist had been capable and confident.
Hospitalists can avoid being perceived as a bother by the way they word consult requests. Explains Dr. Mallin in Phoenix, “We try to get a lot of anticipatory questions answered during important conversations we have during the day so consultants don’t perceive us as bugging them all the time.”
Physician-to-physician conversation might sound like this, she says: ” ‘I think we should hold off on another CT until these criteria are met. What would be your threshold for ordering another CT scan?’ ” Open-ended questions, she points out, both facilitate the sharing of information and communicate the sense of teamwork.
“It’s not just me asking you for help,” she says. “It’s creating a plan together. That way, they don’t just hang up the phone thinking that hospitalists aren’t capable of making a decision.”
Dr. McCoy points out that many hospitalists overconsult in the first place because they are managing too many patients at one time. Inadequate staffing means hospitalists don’t have time to think, research or even pose proper questions. In the long run, that’s going to hurt the hospitalist-specialist relationship.
If hospitalists are perceived as crying wolf every time they call a consult, Dr. McCoy says, “consultants are not going to rush in the next time because they won’t think anything is wrong.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.