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After the Match: Make Consultants Happy with an Elevator Pitch

Cook, Thomas MD

doi: 10.1097/01.EEM.0000481773.17568.b1
After the Match

Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him atwww.facebook.com/3rdRockUltrasound, follow him @3rdRockUS, and read his past columns athttp://emn.online/AfterMatchEMN.

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The elevator pitch is a ubiquitous business strategy, and a Google search for this term generates more than three million results. This is a short, concise, compelling speech to entice the listener to buy whatever it is that you are selling. The metaphorical elevator is the timed and controlled environment within which you have to work.

You didn't sign up to be a salesman when you applied for residency, however. You might even argue that it is the patients who are trying to sell you on the idea that they are sick.

Nonetheless, you will eventually have to admit some of them. This can be a source of great frustration for a resident. You are regularly confronted with the consultant's faceless voice over a phone line. He can be tired, overworked, and possibly passive-aggressive.

One of the most painful things for emergency medicine faculty is watching interns call consultants in their first few months of training. They are awful. It has been drilled into their heads since their first days of med school that they need to construct thorough patient presentations that will not miss the small details. When you start working regularly in the ED, though, this approach quickly drives a lot of consultants nuts.

What should you do? A few websites describe the traditional approach of chief complaint, history and physical, etc., etc., etc. Unfortunately, by the time you are a few minutes into this with your consultants, they want to scream, “Get to the point! What do you want?”

Consider the consultants' point of view. They are busy admitting patients and putting out fires. They get a call that shows up on their phone as the ED. Their minds and stomachs start churning; you know what this feels like. You experience it when you are off-service and getting ED consults from your classmates.

My advice is to start with the end. You can ask a consultant to do only three things: admit the patient, help arrange follow-up for the patient after discharge, or answer a question. Everything else is just a derivative of these three options.

Give them this information up front: “Hi. I have someone I would like you to evaluate for admission.” Or, “I do NOT need you to see anyone now, but I need help arranging follow-up for a patient.” Or, “I do NOT need you to see anyone. I just need some advice.”

Now, the consultant has the one piece of information he really wants, and it sets the tone for the remainder of the conversation.

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By contrast, do not start off with, “This guy came in with chest pain. He was at home, felt weak and dizzy after an argument with his wife, didn't take his meds this morning, blah, blah, blah.” This takes a lot of time and invites the consultant to negotiate when the case might have a clear-cut path toward admission.

The strategy I am advising is not an excuse for being unable to present all the relevant clinical data. You still need to know your stuff. But it often does allow you to be efficient. Many times just getting to the point is enough to complete the call in a minute or two.

Start your call with, “Hi. I have someone with chest pain I would like you to evaluate for admission. He has a history of heart failure, an unremarkable ECG, and negative troponins. On bedside ultrasound, he has a decreased ejection fraction, elevated central venous pressure, and a large left pleural effusion. What other information would you like to hear?”

This tells the consultant what you want, telling her the information relevant to the need for admission and giving her the option to hear more or accept the consult without further discussion over the phone.

The impact on your career can be enormous. If you average two and a half patients per hour and admit 20 percent of them, you will make about 12 calls for admission and a few others to arrange follow-up or to ask questions over a 10-hour shift. If each of these calls is eight minutes, you will spend roughly 20 percent of your shift just talking on the phone.

When you cut this by half, the results are huge. Full-time emergency physicians work approximately 1,800 hours per year. Ten percent of that time is 180 hours. Consult efficiency provides you with the opportunity to see another 400 patients each year. If you estimate the average ED patient charge at $500, the amount of potential revenue you will generate is $200,000 annually. Multiply this over a couple of decades' work, and the result can be millions of dollars.

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