The Art and Science of Infectious Diseases Consultation

Abstract

Infectious diseases is a cognitive specialty that is procedurally represented by the consultation. Done correctly, a consultation is a powerful tool that can change physician behavior, strengthen critical relationships, and establish a consultant's reputation of excellence. The process of consultation requires multiple learnable skills that, when practiced and perfected, translate into a blueprint for professional success and satisfaction.

The field of infectious diseases (IDs), while lacking many procedures that define other disciplines of medicine, has as its most powerful tool, the consultation. Not only does it serve to demonstrate our skill and expertise, but when done correctly, an ID consultation serves as a lifeline. In contrast to many other procedures, performance of an ID consultation is complex, blending scientific, written, and verbal skills. These skills, combined with the ability to socially interact and the desire to educate, are major determinants of success. Thus, our ability to master and consistently perform this procedure is crucial to our professional sense of accomplishment and acceptance as valuable contributors to the delivery of optimal patient care. When successful, a consultation leaves both the referral source and patient, thankful that the ID consultant was invited to participate in the case.

Numerous authors have documented the value of an ID consultation. These studies have supported the concept that utilizing an ID specialist's skills can translate into improved antibiotic utilization^1,2 and avoidance of suboptimal regimens.³ Others have delineated improved overall patient outcomes when treating urinary tract infections,⁴ osteomyelitis,⁵ and bacterial endocarditis.⁶ The common thread in all of these studies is that the effector mechanism was a form of ID consultation. This article intended to serve as a framework for those ID specialists who affect patient care and practice their profession through the influence of consultation.

TYPES OF CONSULTATION

Consultations may be either formal or informal. Informal consultations take on many forms, including the "curbside" variety. Usually, this occurs spontaneously in an unpredictable forum with variable requests. The most common questions are those pertaining to therapeutic decisions,^2,7 but a large and varied number of questions may be posed. Formal consultations are requested, structured, reimbursable, and typically communicated in some fashion to the requesting entity. For purposes of this article, all comments will be referable to the formal variety of consultation.

CHARACTERISTICS OF SUCCESSFUL CONSULTANTS

Successful ID consultants possess certain qualities that identify them as exceptional. Although not all of these physicians share the exact same skill set, enough overlap exists to allow for generalizations (Table 1).

TABLE 1: Characteristics of a Successful ID Consultant

First, excellent consultants are excellent communicators. While the effectiveness of communication has been documented,⁸ it is the verbal aspect that appears most critical.⁷ Both the ability and desire to delineate issues to the patient, family, nurses, house staff, and attending physicians set these consultants apart. Frequently, these consultants write short notes but spend significant time verbally communicating. For years, we have received numerous consultations because of our communication skills with family members and other treating physicians. A talented ID consultant with excellent clinical skills may sometimes, however, aggravate a patient by virtue of their perceptually condescending demeanor. Despite making the correct diagnosis and delineating appropriate recommendations, the patient refuses to comply with the treatment plan and complains to the primary care physician. Subsequently, a second-opinion ID consult is called with the explicit purpose of reviewing the case and communicating the data in a professional and polite manner to the patient and family. Usually, the initial diagnosis is correct, and the only alteration made is the style with which the data are communicated. This frequently results in the generation of a positive relationship with both the referring physician as well as the initial consultant, who may appreciate the fact that his reputation was not tarnished by his competition.

Second, excellent consultants must have the desire to teach. This desire compels them to perfect and display the verbal communication skill. Early in an individual's career, a consultant must seek opportunities to educate. By doing so, they gain a reputation for availability, affability, and passion for the practice of ID. It is more the desire than the topic or teaching style that impresses the recipients of the educational activity.

Third, they keep abreast of the rapidly changing data base of ID. As subspecialty consultants, we are mandated to be knowledgeable, concerning developments in emerging diseases, diagnostic testing, and antimicrobial therapy. This should be made evident with every educational effort, as the consultants display their distinctive competency. This does not imply that all consultants have a data base that is replete with answers to any question. In contrast, a consultant should not hesitate to tell an inquiring physician that they will research the issue and call back in the near future with a cogent and articulate answer.

Fourth, successful consultants have an even and unwavering professional demeanor, even under stress. While others slam charts, throw various objects, and complain to ward secretaries about "simple" consults, the successful consultant remains gracious and pleasant. Venting frustrations should remain a private activity, and with trusted colleagues only. We have found that complaining to one of our partners in a safe and secluded area is healthy and cleansing, but has no place at the bedside, nursing unit, or within earshot of patients, family members, or other health care professionals.

Fifth, successful consultants display passion for their profession and specifically the practice of ID. This serves as a professional pheromone, attracting a wide and diverse circle of referring physicians, and generating for the consultant a reputation of energy and excellence. As an example of this passion, successful consultants remain available and grateful for consultations, even at inconvenient times of the day.

Sixth, successful consultants have the ability, desire, and fortitude to direct a patient's care. As discussed below, this is an extremely valuable and difficult skill. A consultant who can review a difficult case, rapidly survey the literature, discuss the case with other colleagues, and concisely convey specific recommendations to members of the patient care team will be touted as an asset in any clinical arena. This is frequently manifested by an ID consultant who takes charge of a critical case, moving it toward an optimal patient outcome, while remaining respectful of diplomatic and political boundaries.

Lastly, successful consultants, through mastery of the above, are respected by multiple sectors of the hospital including nurses, physicians, clerks, administrators, and students. This respect is earned, not awarded, and manifested in multiple ways. Respected ID consultants receive multiple teaching awards, deal with politically sensitive issues, and are frequently asked to care for hospital employees or physician family members-all acknowledgements of respect.

COMPONENTS OF CONSULTATION

Infectious disease clinicians incorporate numerous components into successful consultations. When presented correctly, these components have the ability to change physician behavior and maximize outcomes for patients, while minimizing lengths of hospitalization and unnecessary expenditures.

Historical Elaboration

Infectious disease consultants should be experts at uncovering historical clues that were suppressed by the patient on previous evaluations. For example, knowing that a patient who presents with a fever of unknown origin and negative blood cultures had recently taken erythromycin for a week is critical to the recommendations for evaluation and therapy. To attain this data, consultants should query historical facts pertinent to the case and refocus questions to the patient that have been previously asked. Issues concerning pets, travel, over-the-counter or illicit medications, sexual encounters, and sick contacts are several areas in which the insightful ID consultant dwells to obtain suppressed or embarrassing data. Frequently, an environment of caring needs to be established so that the patient will "spill the beans" and shed light on the diagnosis. One strategy that we have been used is to simply ask the patient, "What do you think is causing your problem?" Historical facts such as previous evaluations or recurrent symptoms are sometimes brought forth, giving a new focus to the interview. This may be difficult during the initial evaluation, and therefore, follow-up and sequential evaluations are critical to accomplish this goal.

Transmission of Information

To accurately transmit information, the consultant must know what question or problem is being posed. After identifying the question, the answer can and should be comprehensive in nature. Too often, the answer to the above question is quickly apparent to the consultant. This can lead to a brief response or recommendation that, although accurate, does not allow for the delineation of the consultant's thought process. Thus, the clinician misses an opportunity to both educate the referring physician and display his or her expertise. An excellent but inadequately utilized technique is the generation and discussion of a differential diagnosis (DDx). Although many diagnoses can be considered, only the most likely or potentially dangerous ones should be evaluated. By using this technique, consultants are more likely to avoid cognitive shortcuts (see below) that may result in a less-than-optimal outcome.

Direction of Care

To optimally direct a patient's care, an ID consultant must complete the following steps: (1) make recommendations, (2) generate a contingency plan, and (3) communicate actively (verbally). Follow the patient sequentially, and restructure recommendations as necessary.

Directing care is an active process that is best accomplished through articulating recommendations and active communication with the referring group or physician.⁹ Depending on the question being asked, the care direction may take on several orientations. Usually, however, we are asked to help direct care along the lines of a specific diagnosis or therapy. To direct a patient's care, the consultant must ensure that the recommendations offered in the initial consult are communicated to the pertinent medical effector. This may be nursing, the referring physician, the house staff caring for the patient, the surgical consultant, an interventional radiologist, and so on. Leaving an exemplary written evaluation in a patient's chart is, unfortunately, passive. For action to occur, someone would have to read, understand, and take the initiative for activating the process. Thus, brief verbal communication is key to expediently moving a case toward successful resolution.

Directing care does not usually stop with the initial consultation. A patient's clinical course may change unexpectedly and frequently. Thus, recommendations relating to diagnostic evaluations, therapeutic interventions, and prognoses for a successful outcome may also change from the initial impression. A consultant who makes initial recommendations and then fails to follow the case aggressively, misses another opportunity to demonstrate their inherent value. This may also strain relationships with the referring physician or patient, who are left to either request a reevaluation or make decisions with the ID consultant in absentia. Neither of these scenarios is optimal for patient care, cost containment, or relationship building.

Often it is useful to delineate a contingency plan. While brief, this plan delineates the next maneuvers to be made should the diagnosis be elusive or the patient fail to respond to the initial recommendations. This is one of many reasons why the development of an extensive DDx is critical to the successful completion of an ID consult. By rapidly reviewing the DDx, a consultant can review other possibilities for the patient's problem and make recommendations accordingly.

Directing care does not always mandate additional testing, multiantibiotic regimens, or prolonged lengths of stay. In reality, successful consultants, seasoned in their specialty and confident in their skills, leave many recommendations to the contrary. Differentiating colonizing organisms from pathogens in need of therapy is a valuable distinction that frequently falls under the purview of an ID specialist. As cogently summarized by Sexton et al,¹⁰ an ID consultant should be able to master the art of MICO-masterful inactivity and catlike observation. With purposeful impatience, a skilled clinician must learn to actively observe and identify when further intervention is warranted.

Direction of a patient's care may also be difficult. In our present medical climate, where minimizing length of hospital stay is crucial to the success of an acute care facility, the pattern of care frequently becomes strained. We are sometimes asked to discharge a patient who does not have a diagnosis, only to complete the evaluation in the outpatient arena, where efficiency and coordination are much more difficult to attain. The successful consultant must embrace this as an opportunity and accept the challenge of outpatient management with the hope of optimizing patient outcomes.

Educational

An ID consult is at its very core, an educational event with all participants as potentially active learners. Adult educational theory suggests that adults learn more effectively through concurrent, problem-oriented, multisensory modalities.^11,12 The authors suggest that an ID consult that is written, verbally discussed, supported by the literature, and restructured concurrently is a perfect model with which to educate adults.

Concurrent antibiotic utilization programs are an example of an educational venue that can change physician behavior. In many hospitals, certain antibiotics are monitored in an effort to optimize their usage, minimize the likelihood of developing microbial resistance, and hold costs in check. Multiple programs have utilized an ID physician who calls the prescribing physician to discuss alternative options for therapy. Done concurrently at the time decisions are being made, and in the context of a clinical scenario, a physician learner will be able to incorporate valuable tenets of antimicrobial prescribing into their data base for future reference.

Above all, the successful ID consultant embraces the opportunity to educate. Any subspecialist could easily impart his or her message in a condescending fashion to a different physician who does not possess the same depth of knowledge. Although this may satisfy an insecure ego or engender a sense of false bravado, it has no usefulness in negotiations, personal interactions, and certainly not in an ID consultation. Diplomacy should rule, and our adopted motto should be: "EDUCATE-DON'T INTIMIDATE!"

Education, regardless of how well it is done, has the ability to engender good will that in time may translate into more clinical opportunities. Condescension and intimidation will, unequivocally, produce the opposite and should be reserved for those planning to leave the practice of medicine.

A consultant's ability to demonstrate expertise and transmit information in an educational framework allows him or her the opportunity to direct care. Directing care translates into value. Value translates into longevity, and longevity into professional satisfaction.

Medical/Legal Documentation

With all positive attributes come unwanted and potentially negative consequences. Any ID consultant who has been forced to read, word for word, his documentation or that of his associate into the legal record of a medical malpractice case understands this sensitive and flammable aspect. Too often, less sophisticated or insecure physicians will wage a confrontation in the chart rather than verbally discussing the issue in question. The result is the framework for a plaintiff's attorney looking for disagreement among the experts in a case with an unfortunate outcome.

Alternatively, documentation in a medical/legal document such as the medical record serves as a buffer when a physician is accused of wrongdoing or negligence. A concisely written note or a list of DDx's can delineate the thought processes of the consultant and rebuke or defer litigation. When physicians differ on the appropriate course of action, these issues should be decided before documentation is completed in an effort to present as close to a consensus as possible.

Many lawsuits are generated from "innocent" comments made by unassuming consultants. For example, a statement such as "…no indication for aminoglycoside therapy…" is potentially an invitation for problems and probably offensive to the medical entity who wrote the orders. In contrast, a comment such as "…excellent empiric antibiotic therapy ordered by primary care physician…" is both complimentary and defensive in nature.

In general, we cannot allow medical/legal concerns to dominate our consultation style. Helpful guidelines include the following:

• (a) Compliment the medical care provided as often as reasonably possible both in the chart and verbally to the family and patient.
• (b) Be honest, but do not represent your opinion as edict unless you feel the alternative plan would be potentially harmful to the patient.
• (c) Hold no debates concerning patient care in the medical record.
• (d) Building the relationship bridge-Life revolves around relationship building. We work diligently to nurture relationships that help us in our daily lives with our spouses or significant others, children, coworkers, and so on. As an ID consultant, one of our most precious assets is our physician referral network. Without an extensive network to generate consult requests, we may indeed be looking for alternative means of professional satisfaction. Optimally, at the conclusion of the consult, the referring physician should be gratified that they consulted you.

An ID consult can strengthen or weaken relationships with potentially referring physicians in a number of ways. Initially, a patient needs to understand that you are being asked to consult because the issue or diagnosis is difficult or unusual. A casual conversation with the patient inferring that the answer to the question being posed is medically simple or basic may damage a consultant's relationship with the referring doctor. In contrast, any complimentary statement to the patient or family about the previous medical care and the need to obtain a specialist's viewpoint works to the betterment of that relationship. It also helps to cement the relationship between the primary care physician and the patient, as they become comfortable that their primary doctor has been managing the case with expertise.

Lastly, many an ID consultant will reflect on cases in which they were called to deal with a difficult or angry family. Usually, the majority of time is spent explaining why the patient's course has been fraught with unpredictable or unwanted outcomes and defining a new plan of care. While sometimes a nuisance, these consultations serve to underscore the value of a given consultant and display the versatility they possess to deal with various personalities in difficult situations. Willingness to deal with these predicaments strengthens not only the consultant-physician but also the consultant-administrator relationship, as they attempt to manage risk in the acute care setting.

COGNITIVE SHORTCUTS

For ID consultants, our procedure is not manual, but rather cognitive, and resides in the body of consultation. As with other procedures, it must be studied, broken into its component parts, and practiced so that it can be consistently executed. Achieving excellence mandates that we also analyze the potential pitfalls of the procedure in an effort to avoid or marginalize downside risk to the patient. Unfortunately, cognitive errors are complex and more common than initially perceived.^13,14

Cognitive psychologists study the mechanism by which people reach conclusions and make decisions. Termed heuristics, cognitive shortcuts are streamlined and seemingly less sophisticated thought processes used to make decisions. In reality, these shortcuts have been firmly established over many years of clinical decision making because they typically lead to the correct answers. For example, epigastric pain typically predicts peptic ulcer disease or pancreatitis. Unfortunately, this can be the presenting symptom of cholecystitis, lower lobe pneumonia, or inferior wall myocardial infarction. Because of the efficiency inherent in utilizing shortcuts, it is impractical to eliminate them. It is more logical to understand the pitfalls and structure a procedural approach to minimize their potential damage.

As delineated by Redelmeier,¹⁵ the following are the most commonly encountered cognitive shortcuts:

1. Availability. A clinician makes decisions based on recall of recent cases. An example of this pitfall is exemplified by the following case. A 45-year-old woman presents to the ID physician complaining of back pain, fever to 101°F, and a urine analysis consistent with a bacterial infection. The patient is treated for pyelonephritis as the most likely diagnosis, but shows no evidence of clinical improvement. Further evaluation reveals that the patient has extensive exposure to tuberculosis and eventually is diagnosed with renal tuberculosis.
2. Anchoring. A clinician relies on initial impressions. A patient admitted with community-acquired pneumonia is found to have bibasilar infiltrates. Ceftriaxone is begun without clinical response. When cultures are negative, the clinician administered vancomycin for enhanced coverage of presumed pneumococcal pneumonia instead of broadening the DDx. The patient eventually is found to have psittacosis after a medical student uncovers the historical fact that she raises parrots for a living.
3. Framing. A clinician is swayed by subtle wording. A consultant is told over the phone that the patient presented with headache and fever. Immediately, the concern is raised about bacterial meningitis, and ceftriaxone and ampicillin are begun. Unfortunately, the fact that the headache disappears when the fever dissipates and that the patient has had right upper quadrant pain in the last several days is unavailable. The acute cholecystitis therefore goes undiagnosed.
4. Blind obedience. A clinician is unduly influenced by perceived superior clinical insight or technology. A patient is admitted and found to have 2 blood cultures positive for Staphylococcus aureus. A transesophageal echocardiogram is unremarkable, and despite the fact that the patient eventually has 4 blood cultures positive for the same organism, the diagnosis of endocarditis is dismissed on the assumption that a negative transesophageal echocardiography effectively eliminates this as a possibility. The patient is given a short course of appropriate antibiotics but is readmitted 2 weeks later with a new fever and splenic infarcts.

This pitfall is also frequently encountered when a physician who is perceived to be superior by virtue of expertise or experience represents a contrary opinion. A less seasoned clinician may be swayed away from their clinical conviction despite a lack of objective data supporting this decision.

1. Premature closure. A clinician makes a diagnosis based on a single idea. Although this may be clinically sound and even the most likely diagnosis to be considered, it is not universally correct. For example, a liver abscess that fails to respond to piperacillin/tazobactam therapy is not always a function of improved drainage or multiple resistant anaerobes. Restructuring antibiotic therapy and attempting to improve the drainage of the abscess rather than considering that the patient may have another diagnosis such as Entamoeba histolytica are an example of premature closure. This can be assuaged by reevaluating the working diagnosis every time that the initial intervention appears suboptimal. Reviewing the DDx which you initially delineated is a very effective and rapid maneuver to remediate this problem. This assumes, however, that the list of initial DDx's represents both likely and less likely disease entities to be considered. Verbally discussing a case with a house staff or a referring physician obviates this shortcut. It is frequently difficult and somewhat pretentious to consider that the patient may have only a single diagnosis. Discussion allows a consultant to reevaluate for other potential options, thereby expanding the DDx.

We suggest that placing ID consultation into an educational framework obviates cognitive shortcuts. A consultant cannot engage in an educational activity without being prepared for subsequent questions. Would any physician discuss a case with a family member without reviewing the clinical data, examining the patient, and structuring a clinical impression and plan?

Thus, by thinking through an issue with data verification, identifying the most dangerous diagnosis by playing "devil's advocate," discussing the limitations of technology, and reevaluating in light of new information, these problems can be largely avoided.

FAUX PAS

Defined as a "socially awkward or tactless task," the following represent common miscues that may be devastating to an individual consult or the reputation of a well-intentioned consultant.

• Wrong question. The first mistake in ID consultation is not answering the question being posed to you. Expounding on the need to rule out endocarditis in a patient with Staphylococcus aureus bacteremia, when the question is the indication for synergistic therapy, does not fulfill the primary consultation goal.
• Writing without talking. Leaving a note in the medical record is an excellent means to document thought processes, conversations with the patient and family, and so on. It is a suboptimal mechanism to actively communicate recommendations and direct a patient's care. Many a primary physician has been provoked by a consultant's recommendations that sat idly in the chart waiting to be read and evaluated by another member of the medical team.
• Idiot savantism. The term idiot typically refers to someone simple, whereas savant is a French word meaning "alearned one." Too often, we conduct ourselves in a similar fashion. We achieve a great level of insight into the clinical problem, but ramble aimlessly in both writing and verbal structure, to no observable end. Pontificating verbosely is a misguided activity and usually intimidates or aggravates a referring physician. Writing cogently and speaking articulately would serve the consultant well.
• Alexander Haag approach. Alexander Haag was the vice president of the United States, who, when told that the president would be under anesthesia for a surgical procedure, declared that he was in charge. In fact, he was not, and neither is an ID consultant. We are given authority by the primary care physician or whoever consults us. Unless specifically asked to do so, we should not assume responsibility for all aspects of a patient's care. Many primary care physicians feel competent to manage the vast majority of a patient's care. Reorganizing intravenous fluids, oral hypoglycemics, or diuretics may be viewed as obtrusive. This is neither healthy from a political or professional liability standpoint.
• Rigidity. A hallmark of tetanus and Parkinson disease, this has no role in ID consultation. Life is a negotiation, and differences need to be resolved by the medical team to achieve the best outcome for the patient. Criticizing other health care providers, complaining about consults because of inopportune timing, or an easy diagnosis are forms of rigidity.
• Hit and run. Some consultants feel that an initial ID opinion is adequate service to both the patient and attending physician. Frequently, this is done under the guise of minimizing expenditures to the patient, not interfering with the attending physician's plan of care, or prioritizing only the sickest patients for follow-up evaluation. In reality, the "hit and run" phenomenon may lead to increasing costs by delaying critical decisions, thereby lengthening the patient's hospital stay. This may also aggravate an attending physician or family who is anticipating concurrent evaluations. Follow-up evaluation also serves as a mechanism to further delineate historical facts, adjust recommendations, and restructure contingency plans and may help avoid some of the cognitive errors discussed above.¹⁵ Regrettably, there are times that all patients on a busy consultation practice cannot be seen. This is typically the case on weekends or holidays when optimal physician staffing is not available. In these situations, it should be made known that the consultant is available by phone and will see any patient if requested or if the patient's condition warrants.

EIGHT STEPS TO SUCCESSFUL CONSULTATION

The following is a blueprint that can be utilized as such or incorporated into an already successful consultation scheme. Table 2 summarizes these steps with associated benefits.

TABLE 2: Eight Steps of Consultation With Avoided Shortcuts and Benefits

1. Identify the question to be answered. Although this sounds simplistic, a consultant may need to ask the attending physician, house staff, and so on, for guidance to make sure he or she accurately completes the task. If you fail to complete this step, the shortcut avoided may be unemployment.
2. Gather data. We are extensively trained to gather useful information through history, examination, and the use of laboratory and radiological procedures. By gathering data compulsively, we avoid the heuristics of availability and anchoring, 2 of the most common cognitive shortcuts.
3. Analyze data. By analyzing data and playing "devil's advocate" before generating a DDx, we avoid the pitfalls of framing and premature closure.
4. Generate DDx. This allows us to consolidate our impressions from the above into a list of most likely diagnoses. The simple generation of this list allows us to display our distinctive competency and avoid the anchoring and premature closure problems. This is obviously the first step toward making definitive recommendations and generating a contingency plan.
5. Make recommendations. These must be written and also verbally communicated. This provides the consultant an opportunity to direct the patient's care. This very specific act is the principal way a successful consultant differentiates himself or herself among a plethora of highly intelligent colleagues. While a DDx should be elaborate, recommendations are better when focused and definitive.
6. Generate a contingency plan. Regardless of how comfortable an individual consultant may be in a given clinical scenario, a contingency plan should be included in every consult. While brief, this delineates the next maneuvers to be made should the diagnosis be elusive or the patient fail to respond to the initial recommendations.
7. Communicate!!
8. Follow up patient to case conclusion. This is the anchor tenant to consolidating your reputation as an active member of the health care team and a pivotal step in helping to direct a patient's care.

CONCLUSION

Despite the multiple ways in which an ID physician can demonstrate his or her value, the consultation remains the most demonstrative and active process by which to accomplish this goal. Rooted in a framework of education, the consultation balances art and science and incorporates numerous defined and learnable skills. The dedicated ID clinician should work diligently to perfect this "lifeline," studying the patterns of success and cognitively mechanistic pitfalls. While this article serves as a blueprint for ID consultation, many avenues for future study remain untraveled. Optimal communication styles, alternative consultation formats, the impact of physician extenders, and curriculum for fellows in training must be further evaluated. As we learn to modify and perfect our individual styles of consultation, it will be critical to both the individual and the specialty of IDs to continue to share these experiences.

ACKNOWLEDGMENT

The authors thank Joanne Tagtmeier for her administrative assistance in the preparation of this article.