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CHAPTER 49 Role of the Medical Consultant

Steven L. Cohn, MD, FACP, SFHM

INTRODUCTION Medical consultation has become an important component of Hospital Medicine. These consultations include preoperative evaluation, perioperative management, and medical care of patients on various nonmedical services. Previous surveys found that many primary care physicians and hospitalists felt inadequately trained in perioperative medicine, and as a result, this area received additional emphasis as part of the core competencies for Hospital Medicine. With the growth of the hospitalist movement, the role of the consultant has evolved from providing evaluation and advice to include comanagement of the patient in certain settings. The goal of this chapter is to review the role and responsibilities of the medical consultant, focusing on the principles of consultation and techniques to improve effectiveness.

GENERAL PRINCIPLES OF CONSULTATION

More than 25 years ago, Goldman and colleagues described the concepts for performing medical consultations. His “Ten Commandments” for effective consultation included the following:

1. Determine the question. 2. Establish urgency. 3. Look for yourself.

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4. Be as brief as appropriate. 5. Be specific and concise. 6. Provide contingency plans. 7. Honor thy turf. 8. Teach with tact. 9. Talk is cheap and effective.

10. Follow-up.

These concepts, which incorporated many of the ethical principles described by the American Medical Association (AMA), are important and remain valid for the traditional consultation. However, some modifications are necessary to cover the new role of hospitalists as comanagers.

TYPES OF CONSULTATION

The traditional or standard medical consultation consisted of a formal request from the requesting physician to evaluate a patient and answer a specific question (Table 49-1). The consultant was expected to address the question and to provide advice and recommendations, but not to write orders or bring in other consultants; the requesting physician remained in control and responsible for the patient’s overall care and treatment. The consultant also focused on the specific problem rather than looking for and addressing other issues. Consultations were requested only when necessary and not for routine management. The follow-up period was usually brief and did not involve daily visits for the duration of hospitalization.

TABLE 49-1 Roles and Responsibilities of Different Types on Consultations

  Traditional Comanagement Curbside MD in charge overall Requesting

physician Shared responsibility Requesting physician

Primary care of medical problems

Requesting physician

Medical consultant Surgical—requesting physician

Requesting physician

Question addressed Specific Broader issues— other medical problems

Should not address either but offer to do formal consult or give only general advice

Order writing No Yes No Follow-up Limited-as

needed Daily until discharge No—no formal

relationship

This traditional role of the consultant has been changing over the past 5 to 10 years. A survey by Salerno and colleagues revealed that many surgeons wanted the medical consultant to assume more of a comanagement role. Specifically, they wanted the consultant to address all medical issues as necessary as well as to write orders and

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continue to follow the patient. Comanagement arrangements have most often been with orthopedic surgeons and more recently with neurosurgeons. Comanagement has potential advantages of decreasing length of stay and reducing complications. Surgeons and nurses often prefer comanagement; however, one possible disadvantage is that the comanaging consultant may feel subservient to the surgeon and may be asked to assume responsibilities outside his area of training.

Yet another type of consultation is the so-called curbside or informal consult in which the consultant is asked to provide an opinion or advice without personally seeing the patient. Although these should be avoided from a medicolegal standpoint, they occur frequently. Ideally the consultant should offer to perform a formal consult but if any advice is given, it should be generic and simple. The requesting physician should not refer to the consultant in the medical record if he has not seen the patient, and if he has had any contact with the patient, the consultant should write a note in the chart.

PRACTICE POINT If the consultant is asked to provide an opinion or advice without personally seeing the patient (the “curbside consult”), the consultant should:

Offer to perform a formal consult. Provide only generic and simple advice. Document any patient encounter in the chart.

The requesting physician should not refer to the consultant in the medical record if the consultant has not seen the patient.

DETERMINING THE QUESTION

In view of the multiple types of consultations, it is imperative that the requesting physician specify exactly what is being requested, and if there is any uncertainty, the consultant should clarify this question by communicating directly with the requesting physician. In addition to specifying the role of the consultant, the requesting physician should be specific as to the question being asked of the consultant. For example, a request for preoperative consultation may be for surgical risk assessment, a “green light” to proceed with anesthesia and surgery, a diagnostic or management issue, reassurance, or documentation for medicolegal purposes. As obvious as this may be, disagreement regarding the primary purpose for the consult still occurs between the requesting physician and the consultant. Several studies noted that the consult requests were vague and nonspecific (eg, clearance or evaluation), or did not even ask a question. Without clarifying the reason for the consult, the consultant may respond in a manner that fails to answer the question being asked by the requesting physician.

PRACTICE POINT In view of the multiple types of consultations, it is imperative that the requesting physician specify:

The expected role of the consultant

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The question to be answered by the consultant

If there is any uncertainty, the consultant should clarify this question by communicating directly with the requesting physician. The consultant should avoid making recommendations about the type of anesthesia and other areas outside his or her area of expertise.

ANSWERING THE QUESTION

Traditionally, the consultant restricted his or her advice to the specific problem or question. However, more frequently the consultant is addressing other issues noted during the evaluations. Assuming these other findings and recommendations are relevant and important, most surgeons are in favor of this approach. What the requesting physician does not want is a laundry list of things to do for minor problems or issues that do not need to be addressed during the current hospitalization.

If the consultation is for preoperative evaluation, the consultant needs to:

1. Assess the severity and degree of control of the patient’s medical problems. 2. Estimate surgical risk. 3. Determine if the patient is in his or her optimal medical condition for surgery. 4. Decide whether further tests or interventions are indicated. 5. Make recommendations regarding the patient’s medications and any necessary

prophylaxis.

The consultant should avoid making recommendations about the type of anesthesia and other areas outside his or her area of expertise. Also, the consultant should refrain from using the term “cleared for surgery,” even if consulted for that reason, as this implies a guarantee that the patient will not have a complication.

OPTIMIZING EFFECTIVENESS

Factors influencing or improving compliance

Various studies found a number of factors that have been associated with improved compliance with the consultant’s recommendations (Table 49-2). In general, following Goldman’s Ten Commandments or Salerno’s modification (see Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st- century consultant. Arch Intern Med. 2007;167(3):271-275) will result in effective consultation.

TABLE 49-2 Factors that Influence or Improve Compliance with Consultant Recommendations

Prompt response (within 24 h) Limit number of recommendations (≤ 5) Identify crucial or critical recommendations (vs routine) Focus on central issues Make specific relevant recommendations

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Use definitive language Specify drug dosage, route, frequency, duration Frequent follow-up including progress notes Direct verbal contact Therapeutic (vs diagnostic) recommendations Severity of illness

From Cohn SL, Macpherson DS. Overview of the principles of medical consultation. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2009; with permission.

Determine and clarify the question: As noted, the reason for the consultation needs to be clearly defined by the requesting physician and understood and addressed by the consultant.

Punctual response: The consultant should be available to respond in a timely fashion, depending on the urgency of the consultation. Truly “stat” consults should be answered in less than 30 minutes, and in general, elective consults should be answered within 24 hours, preferably the same day they were requested.

Recommendations:

1. Prioritize and limit: The consultant should make specific, precise recommendations that should be listed in order of importance. Crucial or critical recommendations are more likely to be followed, as are those at the top of the list. For this reason, it was previously felt that the number of recommendations should be limited to no more than five, but more recently the feeling is to leave as many recommendations as needed to answer the consult and offer to help with writing and implementing them (comanagement). Therapeutic recommendations are more likely to be followed than diagnostic ones.

2. Language: The consultant should use definitive language, be specific with his recommendations, and provide contingency plans. For example, recommendations for medications should specify the drug name, dose, frequency, route of administration, and duration of therapy. The requesting physician should be told what response to expect, how long it will take, as well as how and when to adjust the medication dose if necessary.

3. Communication: Direct verbal communication with the requesting physician is crucial and preferable to just leaving a note in the chart. A quick call to the requesting physician will let him know that the consult has been answered, what the recommendations are, and what needs to be done so the orders can be written and the process expedited. It is also important to communicate with other members of the health care team to coordinate care.

4. Follow-up: Appropriate follow-up visits will reassess the patient’s condition and ensure that recommendations were followed. The consultant should clearly document his findings and update recommendations in the medical record. There is no standard regarding how often the consultant needs to see the patient, but this should be determined by the patient’s medical condition, type of surgery, and whether the requesting physician wants comanagement or not. When the patient is medically stable and there is no longer a need for the medical consultant, he should

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sign off and document this in the chart. Recommendations and arrangements for long-term follow-up can also be noted at this time.

PRACTICE POINT The consultant should document:

Specific and precise recommendations listed in order of importance Name, initial dose, frequency, route of administration, titration, and duration of recommended therapy

The consultant should provide: Prompt service Direct verbal communication with the requesting physician upon completion of the initial consult Updates and follow-up as appropriate depending on requested role

CONCLUSION The ideal medical consultant will “render a report that informs without patronizing, educates without lecturing, directs without ordering, and solves the problem without making the referring physician appear to be stupid.” It is hoped that by following these principles, the medical consultant will be effective in providing useful information and recommendations to the requesting physician who will then implement them in an attempt to improve patient outcome.

SUGGESTED READINGS Choi JJ. An anesthesiologist’s philosophy on “medical clearance” for surgical patients.

Arch Intern Med. 1987;147(12):2090-2092. Cohn SL, Macpherson D. Overview of the principles of medical consultation. In: Basow D,

ed. UpToDate. Waltham, MA: UpToDate; 2015. Devor M, Renvall M, Ramsdell J. Practice patterns and the adequacy of residency training

in consultation medicine. J Gen Intern Med. 1993;8(10):554-560. Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern

Med. 1983;143(9):1753-1755. Kleinman B, Czinn E, Shah K, Sobotka PA, Rao TK. The value to the anesthesia-surgical

care team of the preoperative cardiac consultation. J Cardiothorac Anesth. 1989;3(6):682-687.

Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280(10):905-909.

Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74(1):106-112.

Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247-254.

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Rudd P, Siegler M, Byyny RL. Perioperative diabetic consultation: a plead for improved training. J Med Educ. 1978;53(7):590-596.

Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med. 2007;167(3):271-275.