How to be a good consultant

Deborah J. DeWaay, MD, FACPMedical University of South Carolina

April 16, 2013

Objectives• Knowledge

– Define the role of a consultant– Describe the components of an effective

consultation• Skills

– Assess the urgency of the consultation– Obtain a thorough and relevant history and review

of the medical record– Perform a relevant physical exam– Synthesize a treatment plan based upon patient

data.– Effectively communicate with the primary team

Objectives

• Attitudes– Understand the importance of establishing the

exact question the consulting team is asking and the urgency of the consult.

– Understand the importance of augmenting the medical record, not repeating it.

– Understand the importance of direct, verbal communication with the primary team

– Understand the importance of follow-up communication, both written and verbal

Key Messages

1.Determine the question the primary team is asking and establish the urgency for the consult.

2.Gather all necessary data yourself.

3.Provide the primary team contingency plans for what may happen with the patient.

4.Communicate with primary team verbally and via medical record.

5.Respect the primary teams ownership of the patient.

6.Follow-up regularly.

Determine the question

• Background – multiple studies have shown that a large portion of the time the consultant doesn’t know the question that is being asked.

• Practical tip – when you are doing a consult, write the question being asked in your note. If you don’t know the question, contact the primary team for clarification.

Establish urgency: emergent, urgent, elective

• There are three parts to this:• How urgent does the primary team believe the

consult is? – Remember if someone is asking for help – they

probably need it

• How urgent does the consulting team believe the consult is?

• Practical tip: Ask yourself: “how urgent would I think the consult is if my mother was the patient?

Gather your own data independently

• Apply everything you already know to obtaining a good history and physical

• Review all labs and radiology yourself • Don’t depend on the primary teams

documentation for your information• Most of the time the primary team is not calling

to interpret data already present

Be concise

• Technically speaking you do not have to rehash everything that is already in the chart

• For billing purposes, there needs to be rehashing• Be concise in your assessment and plan

Be specific

• Case: you are on the General Medicine Consult service. You are called to help evaluate and manage a 55 yo white male who developed acute kidney injury after a hip replacement.

• What would a non-specific consult assessment and plan sound like?

• What would a specific consult assessment and plan sound like?

Give contingency plans

• Try to anticipate what problems may occur and give the primary team a plan– If the blood pressure exceeds 180/90 give lopressor

50mg PO every 6 hours– If the blood pressure drops below 100/60 give a 1L

bolus of normal saline

Respect the primary teams responsibility for the patient

• Ultimately the primary team is in charge and gets to make the decisions.

• Practical tip: don’t say negative things about the primary team because they didn’t listen to you (especially if you haven’t spoken to them in person.)

Share your expertise

• Explain why you are making the recommendations that you are making

• Practical tip: leave articles that relevant• (When you are primary: read articles that are left)

Verbally communicate with the primary team

• Despite a physicians best efforts, the thought process behind the decision making is not always documented

• Verbal discussion allows for physicians to understand how the decision is being made and to “bounce ideas”off of each other

• Having said that – written communication about the thought process behind the decision making is crucial

• Different subspecialties have different expectations from the consult. Verbal communication helps bridge that gap

Provide follow-up

• A consultants suggestions are followed more accurately if the consultant follows up with the primary team

References• Goldman L, Lee T, Rudd P. Ten Commandments for Effective Consu

ltations. Arch Intern Med Vol Sept 1983; 183: 1753-1755

• Pupa L, Coventry J, Hanley J, Carpenter J. Factor affecting compliance for general medicine consultations to non-internists. AM J Med 1986; 81: 508-514

• Devor M, Renvall M, Ramsdell J. Practice patterns and the adequacy of residency training in consultation medicine. J Gen Intern Med. 1993;8(10):554

• Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med. 2007; 167(3):271