When I open a newspaper, I expect to get depressed about the bad news that fills the paper. But when I open a medical journal, I don't expect to get...
Two days ago I got an urgent email from one of our case managers asking if I could see a patient with asthma in the office ASAP. She was in the hospital with her third asthma exacerbation in 2 months and the case manager was trying to keep her from being admitted yet again. Although my practice is primarily interstitial lung diseases, I do try to help out with other pulmonary diseases when I can. I pulled her up on our electronic medical record and found that she had never had an inpatient pulmonary consult with any of her previous asthma admissions.
So, why in the world would a patient with a disease that is this difficult NOT have a consult by a specialist? I think it is a reflection of how residents are often trained. Going back to my own internal medicine residency, the mantra of the senior residents was that “A consult is a sign of weakness”, meaning that if you ordered a consult to an internal medicine specialist, it meant that you weren’t smart enough to handle that problem yourself. It wasn’t just my own specialty of internal medicine – a senior surgery resident told me that he didn’t get medical specialty consults because “A surgeon can do anything an internist can do plus we can operate”.
Over the years, those attitudes have become embedded in the culture of American medicine. What we forget is that the practice of medicine is a skill and like any skill, if you want to be good, the practice of medicine takes practice. Let me give you the analogy I use with my medical students. If you want to learn to ski, you can’t just read a bunch of books about skiing. You can’t just watch a bunch of videos of experienced skiers. And you can’t just strap on skis, go to the top of the slope and then try to get to the bottom over and over again. Truly learning a skill takes all three: didactic education, observation of skilled practitioners, and practice on your own.
In some residencies, the didactic education will be awesome, for example, many academic medical centers. In some residencies, there will be extraordinarily experienced clinicians that you will observe, for example, many community hospitals. In some residencies, the interns and residents are often on their own and get a lot of “sink or swim” experience taking care of patients independently, for example, some VA hospitals. Each resident needs a different optimal mix of didactics, observation, and practice to reach his or her potential. But all residents need each of them in some combination.
The thing that sets a specialist apart is that he or she has had a lot more practice with a specific group of diseases. And that practice can translate into more nuanced care, particularly for those difficult-to-treat cases. Furthermore, the specialist that sees the patient in the hospital is often the one who will be seeing that patient in the outpatient clinic and that translates into better continuity of care.
The literature confirms that inpatient consultation improves outcomes in difficult cases. A study presented at the Society of Hospital Medicine showed that inpatient cardiology consultation reduced the 30-day readmission rate for heart failure from 26% to 15%. A study of inpatient geriatrics consults showed a reduction in 6 & 8 month mortality rates. A study of inpatient palliative medicine consults showed a reduction in readmissions from 15% to 10%.
As a specialist who sees both inpatient and outpatient consultation, I don’t believe that there is any question too small or medical problem too minor and so I will never criticize another physician for requesting an inpatient consult. However, I will criticize a physician for not getting an inpatient consult when they should have. A patient with a medical illness who is being repeatedly readmitted is more complex and takes a lot more of the consultant’s time than a patient with the same disease but more minor symptoms who never gets admitted to the hospital. Insurance companies recognize that, for example, a level III inpatient new/consult visit has 3.86 work RVUs whereas a level V outpatient new/consult visit has 3.17 work RVUs. The implication is that it takes more time and more complexity to take care of that problem if it is bad enough to result in a hospitalization than if the patient is in an ambulatory office setting. So, I don’t want to see that really sick patient in the office, I want to see them in the hospital where I will have more time to do the evaluation and more diagnostic and therapeutic resources immediately available.
An inpatient who is challenging enough that they need to be seen by a specialist immediately after discharge is challenging enough that they should be seen by that specialist while they are still in the hospital. Because a consult is not a sign of weakness.
October 8, 2016