In the emergency room, boarders are patients who need to be admitted to the hospital but there are either no hospital beds to put them in or no doctors to...
Thirty years ago, Dr. Lee Goldman wrote an article titled “Ten Commandments for Effective Consultation”. I’ve taken some liberties with his recommendations in the context of practice in an era of the electronic medical record.
- No consult question is too small. If a physician requests a consultation, it is usually because he or she believes that they and their patient will benefit from your expertise.
- Weekends are the same as weekdays. Patients should expect the same level of physician care no matter what day of the week they happen to be in the hospital. New consults on Saturdays and Sundays should be seen promptly.
- Follow up your test results. Advising what test to order is one half of your responsibility as a consultant. Interpreting that test result in the context of the patient’s illness is the other half. As a consultant, you share responsibility for the tests that you recommend to the primary service.
- A consult is a gift. In the business of medicine, consultants survive by providing consultation. Refusing a consult is like refusing a birthday present.
- It’s not a request for consultation, it’s a request for collaboration. The admitting physician may not see your note until the next day and so tests or important medication changes may not be ordered for >24 hours unless you ensure that they happen promptly. On teaching services (with residents), call the resident to let him/her know what you want done. On non-teaching services, enter your own orders for tests or medication changes for the problem that you were asked to assist with or call the attending physician with your recommendations. Inpatient medicine has become a team sport and the patient who wins is the one who has the strongest team of physicians, not just a single strong player.
- Availability trumps ability. A consultant succeeds by providing the best customer service and the physician requesting consultation is the customer. Consults requested before 10:00 AM should be seen that day. Seeing patients promptly and being available by phone/pager to the primary service is best practice. If you need your car’s oil changed, would you give your business to the garage that is only open from 9 AM to noon or would you go to the garage that is open from 7 AM to 7 PM?
- The discharge is the most dangerous procedure in medicine. As a specialist, you are in the best position to know what is needed in follow up. Assist by scheduling outpatient testing or clinic appointments. Give specific recommendations for medication doses and duration after discharge (especially antibiotics). If monitoring labs are necessary for the treatment that you have recommended, either have those labs sent to you for action/review or make sure that there is a clear hand off to another physician who will take responsibility for those lab test results.
- Answer the question that you are asked. You may find additional medical problems that need to be addressed but never forget to respond to the initial question.
- Distillation is more important than regurgitation. With electronic medical records, it is easy to import pages and pages of test results. The physician requesting your consultation is not requesting you to restate all of the data retrievable from the computer, that physician is requesting your analysis of all of the data. Make your assessment and analysis easy to locate in your note. When it comes to background data in your consultation note, in general, less is more.
- Don’t be a one and done. Your initial impression and recommendation are valuable but your follow up of those recommendations is often even more valuable. See your consults daily until the problem that you were asked to address is resolved or stabilized. Consult follow ups should be seen daily, whether that day is a weekday or a weekend.
- And the Golden Rule of consultation: Consult unto your neighbor as you would want your neighbor to consult unto you. Enough said.
July 22, 2016