On Consulting and Being Consulted

I remember it vividly, being a 3rd year medical student and my senior resident giving me the daunting task of consulting cardiology for one of my patients. My heart dropped in my chest with fear, to do a seemingly simple task of calling a doctor to ask for their opinion. But I had already spent some time listening to passive aggressive conversations, interns getting yelled at for calling in “lame consults” and specialties trying to block consults despite our attending’s request. It seemed unnecessarily uncomfortable, and me being my typical overthinking, strive-for-perfection self, worked it up to be something so much more than what it was: an exchange of information in order to care for a patient.

Though it’s only been a little over a year’s experience working primarily as a consultant, I spent three years on the other side and want to graciously discuss how we can make this experience better for everyone.

Firstly, let’s remember how this relationship works. The primary team ultimately makes the decision for what specific care a patient receives. A consultant is simply an expert offering their specific recommendations for how to provide that care. If a consultant makes a recommendation, but the primary team feels it may not be in the patient’s best interest (i.e., an invasive procedure, noting a specific medication interaction that may occur, etc.) that is ultimately up to the primary doctor and patient to discuss and decide. The lines blur here, with the assumption that by asking for the consult, the primary team will follow through with any recommendations made. Like the very wise quote by Abraham Maslow: “If all you have is a hammer, everything looks like a nail.” While I hope that most consultants will approach their patients with a global approach, it’s easy to become narrow minded with one solution in mind. If you’re going to call a consultant, make sure you are prepared to have the “hammer” be brought to your patient’s “nails” (figuratively, or maybe not?) For both primary team doctors and consultants, if we always keep the patient’s best interest in mind, we can work together for the best decision.

The Do’s & Don’ts of Consulting:

  • DO have a specific question for which you would like help in answering or managing. For example, calling infectious disease and telling them “the patient is here for pneumonia, please help” or “my attending told us to consult” is not a question. Rather, “We have treated our patient with antibiotics for community acquired pneumonia, yet he is still febrile with significant sputum production 2 days later. Given that the patient is on immunosuppression medications and at risk for more rare infections, can you help guide us in the decision to broaden antibiotic coverage?”

  • DO have all relevant information available to the consultant when calling. We are all busy, and a quick, efficient conversation is best for everyone. Patient’s name, medical record number, room number, past medical history, and brief history of present illness should be easily provided.

  • DO perform an adequate and appropriate workup for a particular diagnosis or complaint prior to consulting. If you’re consulting hematology for macrocytic anemia, an appropriate history/exam along with adequate blood tests for ruling out basic causes should already be available. Don’t wait for the consultant to tell you what you already know!

  • DON’T consult to pass on the responsibility of a task that is within your practice. If you practice internal medicine, you should sufficiently be able to assess someone’s cardiac risk assessment pre-operatively. Consulting cardiology is typically not necessary and a waste or resources. Of course, if you are concerned based on a patient’s extensive heart history, by all means call cardiology! But if it is within your comfort level (or it should be) don’t pass the buck. This also goes for physical exams. I’ve been consulted a few times simply to perform a rectal exam (that no one had done yet) to see if a patient was bleeding. ANY doctor should have the basic skills to do this. If there is concerns regarding your findings, of course a consult is appropriate. ALSO- DO. YOUR. OWN. DISIMPACTIONS. xoxo

  • DO have follow up questions simply for the sake of learning. At any given time, an interaction between two specialties should be an opportunity to grow. If you have a question as to WHY certain recommendations are made, ASK.

  • DON’T call a consult urgent if it is indeed, not urgent. Emergent or urgent consults should be apparent to you, and if they aren’t yet, ask a senior or attending how quickly the patient should be seen. Usually this is apparent to the consultant after your exchange of information (for gastroenterology, as an example, clinical history, vital signs, and blood work tell me if I need to see a patient now for a possible same-day urgent procedure) but sometimes that information is missed if we are busy and multi-tasking. Advocate for your patient for urgent concerns, but know when certain issues are routine that can be addressed in a timely manner.

  • DO be judicious in your consulting. As you grow into a stronger doctor, routine medical issues will not require an expert consult because you, in fact, have the expert skills to manage it on your own. It’s powerful to grow confident in your skills. If there is any hesitation, consultants are always available to help! But often times, you’ve got what it takes.

The Do’s and Don’ts of being a Consultant

  • DON’T be mean.

  • DON’T be rude.

  • DON’T be condescending.

  • DO recognize that primary teams are working really really hard to take care of patients, buried in paperwork, orders, discharge summaries, and everything in between. Do what you can to help them out when appropriate, as it pertains to your expertise.

  • DO be extremely clear in your recommendations. Write it out clearly in your notes. Call or text back the provider that consulted you to clearly communicate your assessment.

  • DO be aware of the patient’s multiple medical diagnoses, coinciding problem list being addressed while in the hospital, medication interactions, and timing of planned procedures. The more complex the patient results in “more cooks in the kitchen” results in potential for more medical errors.

  • DO be willing to teach, no matter what. Regardless of working in an academic center or a small community hospital, there is always opportunity to educate other providers in a non-condescending matter (and also, to receive education back from their point of view/expertise) on why certain recommendations are made. If there is any notion of curiosity, follow up with an evidence based answer. Go so far as to send a review paper their way. This is a huge step in providing long-lasting relationships amongst a group of people showing up to take care of patients every day.

  • DO thank the primary team for the consult. When it comes down to it, your job probably wouldn’t exist without their outpatient or inpatient referrals. That’s not to be taken lightly- even if you’re a critical part of a hospital system, your work flow is dependent on others. Thank them!

  • DO be nice. It’s not that hard.

To all my med students and interns, I know it takes some getting used to, but as your confidence grows your ability to communicate information will grow too. If a consultant is making you feel bad for not yet having certain aspects of medical knowledge, that’s on them. Just remember if someone makes you feel bad, don’t take it personally. But one day when you’re in the role of consultant, you can play your small role in keeping the culture of hospital communication both kind and productive. It’s all love out here :-)

Sincerely,

Shanny DO

PS- yes, I’m serious about the disimpactions. I believe in you and I’m confident in your skills ;-)