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The hospitalist guide to consultants

April 2009

As hospitalists, we typically introduce ourselves as physicians who will be coordinating patients’ care while they are in the hospital, as well as treating them. In fact, coordinating care is a big part of what we do, given how complex many of our cases are.

Care coordination often involves consultations. Dorland’s Medical Dictionary defines medical consultation as: “a deliberation by two or more physicians about diagnosis or treatment in a particular case.” I bet that we are more often on the requesting end of that process than on the delivering end.

What’s behind our requests for a consult? Are they appropriate or, better still, meaningful from a patient’s perspective? Do consults improve outcomes, affect length of stay, either positively or negatively, provide more satisfaction to patients and families, and improve the careers of hospitalists?

I don’t know of any evidence to that effect, but here are the reasons I see behind the consults we ask for:

The “slam-dunk’ consult. Patient comes in with chest pain, is diagnosed with unstable angina and the cardiologist is consulted. Or patient comes in with abdominal pain, is diagnosed with mesenteric ischemia and general/vascular surgery is consulted. No two ways about these clear-cut situations.

The “hold-my-hand” consult, which in my opinion is valid. As practitioners, we are not omnipotent, all-knowing beings (sad but true!), and ultimately what we do is about the patient, not about us.

If we aren’t sure of something, we need to set aside our intellectual ego and ask for a consultant’s help. Most specialists respond positively to statements such as, “I am not sure how best to proceed or manage, and I would appreciate your input/assistance.”

The “cover-my-rear” consult. Come on, own up; we’ve all done it. We’ve been in situations where we know what to do but are compelled more by a legal argument than by medical necessity to get a consult. I have on occasion labeled these as “bless the patient” consultations where specialists essentially endorse the care plan that a hospitalist has set in motion.

● And lastly, the “demanding family/patient” consult. This can also fall within the last two categories but deserves a separate mention. It’s certainly the trickiest consult request to handle.

The worst thing to do in this situation is to question the right of the patient/family to ask for another opinion. As an attending, if you think such a request is unnecessary, I’d suggest liberally sharing solid, evidence-based literature to support that view. Otherwise, go ahead and get the consult, without making it a point of contention.

When and how should you make those requests? Here are some basics, which seasoned hospitalists have probably already figured out:

● Ask for consults early in the course of treatment, preferably right when you’re formulating your assessment and plan. If you’re picking up an overnight admit, ask for a consult that same morning.

● Make requests yourself. There is no substitute for provider-to-provider conversation. I realize that on a busy day, it is a pain in the neck to interrupt your work flow and call umpteen specialists. But trust me, there is no other way. Relying on nurses or another third party just increases the chance that the information conveyed will either be delayed or inaccurate.

● Frame requests succinctly. And be honest; don’t be afraid or shy about admitting your gaps in knowledge. Most specialists are busy and appreciate a pithy, well-formulated request.

Part of that is explicitly stating how soon you’d like the consult to happen: stat, ASAP or non-urgent. One of the biggest pitfalls in getting consults is not having a clear discussion about your underlying concerns and possible complications if the consult is delayed. It’s not a good sign when a post-consult conversation goes something like this:

Consultant: “You should have called earlier!”

You: “I told you over the phone that the patient was sick.” The moral of the story: Do not hesitate to state, “I want you to see this patient NOW.” Better to have egg on your face if it turns out that you cried wolf than to have a bad outcome from waiting too long to ask for help.

So what’s my breakdown on consultants? Here are the types I see:

The full-service consultant. These are the names that light your face up when you find out that they’re on call. Your patient is not only seen promptly, but the specialists enter appropriate orders (extra brownie points if your hospital has just transitioned to EMR/CPOE!) and call you back, thanking you for the consult and explaining their opinions and recommendations, educating you in the process.

And get this: Full-service consultants even call a patient’s extra-attentive daughter and talk to her about the case! They provide follow-up visits with a similar level of service and closer to discharge, give patients separate discharge and follow-up instructions. Consultative nirvana indeed.

The drive-by (or assembly-line) consultant. Typically, you have just a brief phone conversation when you’re making the request. These consultants will come and see the patient, typically after you’ve already posted the H and P.

They put in their recommendations, give verbal orders to an RN, and poof! They’re gone! You end up being their surrogate, trying your level best to explain to patients (who barely remember them popping in right after they were given the Ativan or Haldol) what their opinions and recommendations are.

You end up leaving a few messages with the specialists’ office staff when you realize patients have not been seen subsequently. Those messages have an edge of panic when patients’ overly attentive daughters or sons are demanding better explanations, especially when discharge is looming.

The reluctant consultant. This is the one you know you will spend an ungodly amount of time on the phone with, not only giving the medical context for the consult, but explaining repeatedly why you need a consult while the patient is in the hospital as opposed to seeing the specialist post-discharge. These conversations can be frustrating, to say the least.

Reluctant consultants can be friendly, wiggling out amicably or punting your request to someone else. Or they can be hostile, which makes you feel like an incompetent doc who should know better. Thankfully, the latter is rare.

The hungry consultant. Typically, these specialists are just out of residency, are in a procedure-oriented specialty and are aggressively marketing themselves. They’re enthusiastic, respond quickly and bend over backwards to accommodate the hospitalist team.

The downside? You may be tempted to ask for a consult without having a clear reason for one, increasing the risk that patients will be exposed to an unwarranted procedure. It’s also not uncommon to see these overly enthusiastic, freshly minted specialists lose steam and transition to the reluctant-consultant mode, once their appointment books are a little more full.

And finally, here are strategies that I’ve found make the consultative process go more smoothly:

● Have separate service agreements that work in tandem with medical staff bylaws. These are agreements reached independently (with the blessing of the hospital administration) between large service groups–say, the hospitalist team and a group of neurologists–on how best to take care of stroke patients.

Service agreements outline succinctly the responsibilities of the parties involved, such as response times, metrics to monitor the care process, and ways to detect and mitigate problems quickly. These agreements work well only if there is a collective will, a sense of direction and a mechanism to help track the process.

● Develop an effective escalation policy to deal with the “missing” or “hostile” consultants. Any policy should involve the hospital administration, typically the chief medical officer or his/her designee.

● And finally, consultation is all about teamwork and communication. Getting to know the consultants on a personal basis, meeting them outside the confines of the ward, sharing a lunch with them and talking about their favorite hobby or sports team–these are all well worth your time.