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Letters to the Editor

Important Consults Are Not Always “Perfect”

Hale, Andrew J. MD; Ricotta, Daniel N. MD; Freed, Jason MD

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doi: 10.1097/ACM.0000000000003871
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To the Editor:

We read with interest Pavitt and colleagues’ article 1 in which the authors evaluated resident and fellow perceptions on ideal communication for inpatient consultations. They identified that “the way residents frame the initial consult affects the resident–fellow relationship, teaching, learning, and patient care.” Additionally, “fellows emphasized that if a resident can articulate a well-formulated, specific consult question and include the pertinent patient information, it can positively affect the interaction,” while “residents commented that when consult questions were vague, they felt uncomfortable calling the consult and often received pushback.” We would like to comment on these findings from within the context of our Academic Medicine article outlining a framework on consultation types. 2

We defined 7 consult types as ideal, obligatory, procedural, S.O.S, confirmatory, inappropriate, and curbside. The value of categorization is that framing a consult type may positively impact provider communication and patient care. Pavitt and colleagues have now provided evidence for our theoretical perspective, identifying that residents and fellows do prefer when consults are “ideal”—when there is a clear question that undoubtedly falls within the expertise of the consultant. This is not surprising as “ideal” consults are the cleanest type for both caller and consultant. It is easy for each party to see the consult as important and that helps to avoid friction and positively impact the learning environment. Residents and fellows would prefer all consults be “ideal.”

However, not all consults valuable to patient care and teaching fall into the “ideal” category. The best example of this is what we labeled “S.O.S. consults,” in which the calling team is unable to formulate a clear question, but they believe that the consultant taking an overall look and providing advice would nonetheless be valuable. Although learning how to ask the right question of a consultant is a valuable skill, residents and fellows should recognize that S.O.S. consults are common, important for patient care, and often a valuable teaching opportunity. Forcing an S.O.S consult into a “clear question” can be detrimental if the question is off-mark. As Pavitt and colleagues have clarified, 1 these types of consults may be higher risk for interteam friction. However, we believe the described pushback from consultants could be largely mitigated with an improved lexicon by using the consult-type framework. If the confused practitioner were to highlight they were calling with an S.O.S consult, that framing could help the consultant focus on the need, rather than the frustration of receiving a vague question.

References

1. Pavitt S, Bogetz A, Blankenburg R. What makes the “perfect” inpatient consultation? A qualitative analysis of resident and fellow perspectives. Acad Med. 2020;95:104–110
2. Hale AJ, Freed JA, Alston WK, Ricotta DN. What are we really talking about? An organizing framework for types of consultation and their implications for physician communication. Acad Med. 2019;94:809–812
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