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What Are We Really Talking About? An Organizing Framework for Types of Consultation and Their Implications for Physician Communication

Hale, Andrew J. MD; Freed, Jason A. MD; Alston, W. Kemper MD, MPH; Ricotta, Daniel N. MD

Author Information
doi: 10.1097/ACM.0000000000002659
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Abstract

Consultation from one provider to another is a cornerstone of medical practice and is the most common reason for interdisciplinary communication between medical specialties.1 The focal point of a consult is often reduced to, “What’s the question?” Prior work has identified the clear question as the most important aspect of requesting a consult.1–3 In the ideal state, the provider requesting consultation asks a specific question that falls within the consultant’s purview, and the consultant then provides an efficient, detailed response that improves the patient’s outcome.4,5

Such simplicity, however, is often not the reality with many inpatient consultations.6–11 In the real world, increasingly complex patient care frequently necessitates consultation requests without straightforward questions. This may create a mismatch between expectations and reality. Imagine that a patient has eosinophilia of unclear etiology, and the primary team would like help. Is this a consultation for infectious diseases (ID), dermatology, hematology, or allergy–immunology? All four? Consultants from each of the services may feel that they are not ideally suited to solve the case, and may express dissatisfaction with the consultation request, resulting in frustration for both caller and consultant.8,12 However, the consultant’s expectation of receiving a clear question within his or her realm of expertise falls short of what the patient needs. Patient care often demands a “nonideal” consult. The fact that “real-world” consultation requests frequently fall short of the “ideal consult state” suggests that such a narrow definition of what a consult should be is erroneous and likely is not in patients’ best interests.

Furthermore, consultation-related interaction between providers has been clearly identified as a potentially rich educational encounter. One recent survey found that 99% of providers recognized consultation as a potential learning experience.13 However, the educational value of consultation is threatened by various factors including poor communication, “pushback” from consultants, incivility, and an overloaded clinical environment.13–17 Studies suggest that consultation-related learning is more effective when consultations take place in person.5,9,12 Optimizing consultation-related communication between providers thus holds the promise of improving interdisciplinary education.

The current state of consultation has been decades in the making.18 The American Board of Internal Medicine (ABIM) was established in 1936 and initially had no formal training requirements other than a five-year postgraduate training period followed by examination. The ABIM did not initially include specialists, but in 1940 they created unique oral examinations for cardiology, gastroenterology, allergy, and tuberculosis (the precursor to pulmonology). In 1970, the trend toward specialization was formalized with requirements for two additional years of fellowship training and examinations in endocrinology, hematology, ID, nephrology, oncology, and rheumatology. Medicine became increasingly specialized and then subspecialized; whereas in the 1940s, 76% of physicians were general practitioners, by 2015 the proportion had decreased to 33%.19 With increasing specialization and compartmentalization of care, the need for consultation from one provider to another has increased. In the current era, at least 50% of patients admitted to the hospital will receive a consultation during their stay.1 The modern care environment allows access to specialty expertise but also puts patients at risk of increasingly fractionalized care.

In this context, the need for clear, efficient communication between providers across disciplines has never been more apparent. To improve communication between providers, we therefore propose an organizing framework of seven consult types and outline the benefits and pitfalls of each. The categories were developed by a group of medical providers from diverse specialties through an iterative process, informed by the literature and expert opinion, until consensus was achieved. Although significant literature exists regarding how consultations can ideally be requested and provided,1–6,8,12,20,21 we are not aware of a prior work categorizing specific types of consultation. Such a cohesive framework may help providers have more productive, efficient, and collegial conversations about patient care.

Type 1: Ideal Consults

“Ideal” consults concern a clinically significant illness that undoubtedly falls within the expertise of the consultant.2,4,12 An example would be calling rheumatology and saying, “I have a patient with suspected lupus cerebritis; would you please recommend appropriate management?” A nonrheumatologist is unlikely to have the expertise to manage the patient alone, and the pathology is clearly important and within the scope of the consulting team. Physicians prefer “ideal” consults, and such interdisciplinary care is critical for good patient outcomes.8 However, it is important to recognize that many consults will fall outside this category yet remain essential for patient care.

Type 2: Obligatory Consults

In an effort to improve patient care, some hospitals have policies which require consultation for certain conditions. One example is required ID consultation for Staphylococcus aureus bloodstream infection, based on evidence showing a mortality benefit.22–24 There may not be a clinical question in such a scenario—a generalist may feel entirely adept at appropriately managing such patients—yet hospital policies mandate the consultant’s involvement. The benefit of labeling a consult “obligatory” is that such framing may increase efficiency; the consult can often be quite focused. A potential pitfall is indication creep; although S. aureus bloodstream infection consults may be mandatory, this could lead to confusion that any gram-positive cocci in blood cultures require ID consultation. Providers should be clear on what scenarios mandate consultation to avoid friction about “obligatory” consults.

Type 3: Procedural Consults

Specialists are often consulted specifically to perform a procedure, with one recent analysis showing that 18% of consultations were specifically to request a procedure.13 In the appropriate setting, this is an efficient consultation; the consultant focuses on his or her procedure and leaves larger management decisions to the primary team. However, there are pitfalls to such an approach. Imagine an immunocompromised patient with diffuse pulmonary infiltrates; the primary team calls the pulmonologist to perform a bronchoscopy to rule out Pneumocystis jirovecii. The pulmonologist may narrowly focus on performing the procedure and not address the broader clinical scenario. The primary team may be expecting more than what the pulmonologist believes was asked of her. The benefit of labeling a consult “procedural”—“Can you perform a bronchoscopy?”—is that it clarifies for the consultant what is being asked of him or her: a procedure alone, rather than a thorough assessment regarding the patient’s condition and management. In contrast, a type 1 ideal consult—“What is your diagnosis for this patient’s lung disease?”—may or may not result in the procedure. When used appropriately, procedural consults are efficient. However, when a different consult type is mistakenly interpreted by the consultant as simply procedural, there is risk of both inappropriate intervention (error of commission) and cognitive errors of omission.25

Type 4: S.O.S. Consults

Frequently, patients are admitted with many comorbidities and undifferentiated acute medical illnesses. In such scenarios, it may not be possible to ask a narrowly defined question. Instead, the primary team requests that the consultant essentially comanage the patient. Such “S.O.S. consults” are the most dangerous for interdisciplinary communication. The consultant is unclear of his or her role and may push the requesting provider to clearly state, “What’s the question?” though for some patients this is the wrong approach. By pressuring the caller to provide a single clear question, the consultant may miss important, broader issues. For instance, imagine an intern calling ID for treatment recommendations for Candida pneumonia in a patient with respiratory failure and Candida on sputum culture. The ID consultant recommends no treatment and signs off. Although the consult question has been answered, there has been a serious error of omission; the consultant ignored the fact that the patient is doing poorly and there may be other ways in which the ID consultant could have helped, beyond the narrow scope of the question. By forcing an S.O.S. consult into an “ideal” consult, the risk of an error of omission has increased. Simply asking, “What’s the question?” falls short. If the consultant were to recognize this as an S.O.S. consult in disguise, or if the intern had said, “This patient is ill; we are not sure what to do and need an S.O.S. consult,” this error may have been avoided. Such framing signals to the consultant that a more thoughtful, comanagement approach is needed.

There may be a particularly high risk for poor communication and associated medical error in clinical scenarios in which patients require S.O.S. consults. Carrying out these consults through verbal correspondence instead of electronic methods such as e-mail or pagers may decrease this risk in addition to having potential educational benefits.3 Clear, closed-loop communication regarding who is ultimately in charge of each aspect of a patient’s care is essential so that comanagement does not result in erroneous assumptions of which team is completing a particular task.26,27

Type 5: Confirmatory Consults

Confirmatory consults are those in which the caller seeks to confirm the existing clinical plan. Such consults may create friction between the two providers if the consultant feels the request is not an effective use of time. Imagine a patient with a long history of smoking and a large lung mass. The primary provider may have a high suspicion for lung cancer, but requests ID consultation just in case it could be infectious. “Confirmatory” consults are potentially helpful but frequently inefficient. On the one hand, there is the “never worry alone” approach, where expert consultation is sought whenever uncertainty exists. On the other hand, there are potential downsides. Consider the “Chevy Dealer” phenomenon: If you go to a Chevrolet truck dealer, you tend to get a Chevy truck, whether you needed one or not. Likewise, if a subspecialty consult is called, there is an increased chance of obtaining workup specific to that subspecialty, which may not have much overall benefit for the patient and may even carry associated risks and costs.28,29

Type 6: Inappropriate Consults

Although consultants should always be of service to the requesting provider, they must also be wary of requests that would unfavorably affect the patient.30 For instance, a gastroenterologist may be asked to perform a colonoscopy for a patient admitted with chronic anemia, yet the patient had a normal colonoscopy two weeks prior. A repeat procedure is unlikely to be helpful and entails risks and costs to the patient. Consultants must be the guardians of the procedures, tests, and medications that fall within their domain. If a consultant truly feels a consult request is inappropriate, a collegial discussion of why, done with professionalism and the patient’s best interests in mind, is critical. With recent research noting the tolls of incivility in medicine, a collaborative spirit is essential.17 Consultants should be mindful that a so-called “inappropriate” consult might be an S.O.S. consult in disguise, and should explore ways in which they might be helpful.

Type 7: Curbside Consults

A “curbside” consult entails asking a consultant a clinical question without expectation that he or she will see the patient, document recommendations, or submit a bill. Curbside consults are frequent, and their appropriate use and costs have been discussed previously.31–33 Curbside consults are risky as data suggest a discrepancy rate as high as 60% with regard to recommendations provided in curbside versus formal consultation.34 Curbside consultations should be limited to general questions and not patient-specific information. There should be no documentation of the consultant’s involvement because the consultant’s participation was informal, and this entails medicolegal risk.35 If the situation requires discussing patient-specific information, the curbside consult should be “upgraded” to another consult type. A useful response can be, “If my opinion on this particular patient would be helpful, please request a formal consult.”

Modifying Factors

Specific scenarios surrounding consultation may arise that pose a threat to communication, patient care, or collegiality and, thus, require particular attention. Providers who request or provide consultation should be aware of these three modifying factors, which can affect any of the consult types outlined above.

Medicolegal handoff

Imagine the case of a healthy young woman with chest pain after a spicy meal. Although the probability of acute coronary syndrome is low, the initial provider may feel hesitation in “clearing” the patient without first consulting cardiology. Although nominally a type 1 ideal consult—“Does this patient have a serious cardiac issue?”— the caller has essentially asked cardiology to accept medicolegal responsibility for the case. Consultation for medicolegal purposes can be a manifestation of what has been described as “litigaphobia”: the exaggerated fear of lawsuits that can cripple practitioners and harm patients.36 Such calls can lead to frustration for the consultant if the consult is not likely to be very helpful yet entails assumption of risk.37 Specifically identifying medicolegal handoff issues may help providers have a collegial discussion about what is in the best interest of the patient and, secondarily, the best use of providers’ time. National society or institutional guidelines may reduce the number of medicolegal handoff-related consults by giving physicians recommendations to support their clinical decisions.

The very important person

Caring for very important persons (VIPs), who may include celebrities, politicians, colleagues, or trustees, presents unique challenges. Providers may feel unnecessarily fearful, resulting in overtesting and overtreatment—a situation called “VIP syndrome.”38 In such situations, providers should resist succumbing to “chairperson syndrome,” whereby only division chiefs are consulted in the care of the VIP patient.39 Chairperson-only consultation is appropriate only if the chairperson is most qualified to treat the VIP patient’s condition. When caring for VIP patients, normal rules and protocols for requesting and providing consultation should be followed.

Patient-requested consults

Imagine a patient is admitted with suspected cancer, biopsy results are pending, and the patient has an outpatient oncology follow-up visit scheduled. Then, the inpatient oncologist receives a call: “Patient requesting to speak to an oncologist now; would you see him today?” Patient-requested consults can be problematic because the caller is not requesting help with management, and the consultant may feel that the consult will take significant time without concurrent benefit. Such consults involve providing a courtesy instead of direct medical intervention and have been shown to account for over 3% of consultations.13 On the one hand, the patient may receive significant comfort by seeing the oncologist early. On the other hand, consultation may result in additional, perhaps unnecessary testing, or may take the consultant away from patients in more acute need of his or her services. The caller and consultant should collaboratively discuss how to proceed, understanding that, although generally the courtesy should be fulfilled, there may be situations in which it cannot be.

Conclusions

Clear, efficient communication between providers across medical specialties during consultation is essential to patient care and a collegial work environment. The framework of consult types outlined here may help providers better align expectations, advance collaboration and effective communication, allow constructive educational encounters, and ultimately improve patient care. Future work in this area might include quantifying the distribution of consult types within each specialty, and could explore connections between specific consult types and provider work satisfaction as a means to understand drivers of burnout. Additionally, descriptions of which specific consult types tend to result in the best educational interactions may provide guidance about distribution of consults to students, residents, and fellows on consultative services.

There are several limitations to our framework. There is currently a lack of supportive empirical data regarding the risks and benefits of specific consult categories. There may be consultation types particular to certain specialties that we have not included, as we have aimed to make the framework broadly applicable across disciplines. There may be overlap between consult types in certain scenarios. Regardless, we believe that clearer terminology and appropriate framing will remain beneficial for interdisciplinary communication.

Although providers would like all consults to be “ideal,” the reality of patient care mandates flexibility, and it is essential that both caller and consultant appreciate the benefits and pitfalls of each consult type. It is important to recognize that perhaps the fundamental communication piece is not “What’s the question?” but “What’s the consult type?”

Acknowledgments: The authors wish to thank C. Christopher Smith, MD, and Grace Huang, MD, for their invaluable insights and reviews.

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