A medical consult is an amazing way to learn. Consultation challenges us to practice our best medicine while also exposing us to innovations in other specialties. It can forge new and productive relationships with physicians from all specialties. At its best, it is the purest of medicine or, as some put it, “medicine without the drama.”
As hospitalists, we are increasingly asked to be medical consultants and co-managers. Yet most training programs spend very little time educating residents on what makes a high-quality consultation. One of the first articles written on this subject was by Lee Goldman and colleagues in 1983. In this article, Goldman sets out 10 commandments for effective consultation.1
Many of the lessons in these 10 commandments continue to ring true today. As primary providers, we know that consulting another service can run the gamut from being pleasant, helpful, and enlightening to being the most frustrating, slam-the-phone-down experience of the day. In this article, we update these commandments to create five golden rules for medical consultations that ensure that your referring providers’ experiences are purely positive.
One warning about communication: If you do not agree with the primary team’s plan of care, make sure you discuss these concerns instead of just writing them in the chart. Any teaching moments should be reserved for those who are open to that discussion, not forced on providers who are not receptive to it at that time.
Five Golden Rules
1 Listen and determine the needs of your customer.
Understanding the needs of your requesting physician is paramount to being an effective consultant, and the first step is to determine the physician’s question. Some referring providers want the bird’s eye view of a general medicine consult, whereas others have just one specific question. In one study stratified by specialty, 59% of surgeons preferred a general medicine consult, while most non-surgeons preferred a focused consult.2
Next, establish the timeframe: Is it emergent, urgent, or routine? One rule of thumb is that all consults should be seen within 24 hours. But many consults need to be seen more quickly, or even immediately. For example, you may be correct to assume that a patient is stable enough to wait for your consult, but perhaps the lack of pre-operative medical assessment will cause her to lose her spot on the OR schedule. The orthopedic surgeon now operates late into the night. Truly understanding the needs of your referring provider might have avoided that scenario.
There are of course times when you really can’t get to a consult expeditiously, but you must let the referring provider know. Ultimately, once you agree upon the urgency, all parties, including the patient, will know when to expect the consultant at the bedside.
2 Look for yourself, and do it yourself.
We practice in an age in which we spend more time in front of computers than in front of patients. As Lee and colleagues write, “A consultant should not expect to make brilliant diagnostic conclusions based on an assessment of data that are already in the chart. Usually, if the answer could be deduced from this information, the consultations would not have been called.”1 Effective consultants always obtain their own history and physical—your special expertise may allow you to extract overlooked information.
In addition, simply leaving recommendations to repeat tests or obtain records often delays care. If you feel the information is vital, take it upon yourself to obtain it. This may include contacting outside primary care providers or medicine subspecialists, or getting outside records.