Calling Consultants

[AlienHand]

As an EM intern, I find that one of the more frustrating aspects of the job is dealing with certain consultants. Things usually go okay, but in maybe 5-10% of cases, I find that after giving the consultant a brief synopsis of the case, the consultant just kind of scoffs at what I had to say or perhaps says something like, "and?". I end up saying, "Well, what more do you need to know?" and then they come back with a condescending statement or a question I can't answer, and things just degenerate from there. I really do try to get my ducks in a row before making the call, but too often things just don't go very well.

Does anyone have any pearls of wisdom on dealing with consultants?

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[edinOH]

Before calling the consultant, decide in your own mind what action/disposition you expect from the consultant. Work on getting quickly to the point of the call or consult. Specifically try to be able to tell them what you think the problem is and what your plan is or what you expect them to do about it.

Try to avoid a long winded presentation. They don't necessarily need or want to know every detail surrounding their presentation and work-up. Think about the information you would want to hear, especially at 2 a.m.

Example:

Hello, um..Dr. Jones,..um...this is Dr. Smith in the ED. I've got a patient in the ER here Ms. Woods. She's a 78 year old woman with a history of COPD, diabetes, coronary artery disease, and arthritis who presents with a three day history of cough, shortness of breath and fever. She says she called the office the other day but wasn't able to get an appointment until early next week. She reports a fever but hasn't really taken it herself. Her temp. here is 101. She complains of body aches though. Anyway she doesn't have any chest pain, no recent hospitalizations, no PE risk factors. She lives at home with her daughter. Her saturation is 92% on room air. Her white count is 15. Her sodium is 140, potassium is 3.6, her renal function is good. Glucose is kind of high at 200. Looks like on her chest xray she has a RML infiltrate. Should we admit her to the hospital? I gave her some antibiotics.
Vs:

Dr. Jones, this is Dr. Smith in the ED. I have one of your pts. here, Ms. Woods. Looks like she's got a community acquired pneumonia from her history and chest xray. She doesn't look too bad right now but I think we ought to hold on to her. My plan is to write some orders and get her a bed upstairs. I'll have them call you with a room number in the morning.

Of course by this point in your intern year, your presentations should rarely (if ever) sound like the first one, but I think you understand my point.

I think the key to the successful consultation is having your facts straight before you call, anticipate things the consultant will ask, and have a firm plan in mind of what you expect the consultant to do. If you can tell them early what is expected and sound like you know what you are talking about, things will go smoothly most of the time.

A closely related topic is how to politely and firmly stand your ground when you disagree with a consultant's recommendations.

I know many others on this board will have some useful insights, so I'll defer to them.

 

[The White Coat Investor]

Good tips above. There is a certain amount of salesmanship involved (which you will learn) but the key is definitely figuring out what you want the consultant to do and telling him up front. He may later disagree, but that is fine, at least he knows what you want. Another example:

Dr. Smith, this is Dr. Jones in the ED. I have a patient with pneumonia that I want you to admit for IV antibiotics. Mrs. Martinez is a 79 year old with CHF and CRF who came in mildly tachycardic, tachypneic, and slightly hypoxic with bilobar infiltrates. I gave her Rocephin and Azithromycin after drawing cultures. I think she'll be all right on the floor.

Or...

Dr. BoneHo, this is Dr. Jones in the ED. I have a patient that I would like to arrange follow-up for. He presents with a closed, minimally displaced, comminuted distal fibula fracture without joint involvement. Can I send him to see you in the clinic in the next day or two?

Or...

Dr. Heartman, this is Dr. Jones in the ED. I am seeing a patient that I would like you to consult on. Mr. Helman has a history of recent CABG and came in today complaining of chest pressure. He says it is quite different than the pain he had before the CABG, but it certainly sounds anginal to me. Would you mind coming in and seeing him?

Or....

Dr. Buttman, this is Dr. Jones in the ED. I have a patient down here that needs to go to the OR. Mrs. Jacobs has 2 days of RLQ pain with CT-proven appendicitis. Would you come see her?

Or...

Dr. Nuts, this is Dr. Jones in the ED. I have a patient I'd like you to see. He is expressing suicidal thoughts and I'm not sure if he's safe to send home.

Or...

Dr. Lungpus, this is Dr. Jones in the ED. I just intubated a patient I would like to send up to your unit. He is a 79 year old COPDer with altered mental status and respiratory failure. His x-ray shows no infiltrates but his pre-intubation gas was remarkable for a CO2 of 122. Would you come take a look at him?

Or...

Dr. Cutekids, this is Dr. Jones in the ED. I am working up a patient and I would like your advice. Johnny is a previously healthy 15 month old male who the mother noticed wouldn't walk on his left leg after he woke up this morning. He has had no trauma, fever, or vomiting. His vitals are normal and he has no tenderness on palpation of the entire lower extremity or pain with range of motion of the joints. There is no skin breakage, redness, or swelling, but he clearly limps when set down on his feet. I x-rayed the entire lower extremity but didn't see anything. I'm not really sure what's going on. Do you have any other recommendations for working this kid up?

I find that some consultants want a lot of detail (what is his white count....what is his PMH.....is the fracture displaced etc etc etc) but some are just calling in to let you know they're on their way and actually plan on interviewing and examining the patient when they get there anyway.

 

[beyond all hope]

Agree with prev poster.

Three reasons to call consults
1) Admit
2) Procedure I can't do myself (cath, scope, bronch, etc)
3) Potentially dangerous Dx that I can't figure out myself (usually Neuro): weakest of all ED consults

The way to get the best results from consults is to make it clear that you've already done the workup and you need your consultant to do what only they do best.

Also you have to present to the consultant in a manner that suggests you know what you're talking about. Use the proper medical terminology. I used to work at a burn unit and I got calls from ED attendings who couldn't even describe to me 2nd degree vs 3rd degree burn. "It looks real bad," doesn't come off as knowledgable.

Just realize that consultants at academic centers are overworked residents so it's in their best interests to try to talk you out of a consult over the phone. The worst are fellows.

Stick to your guns. Don't call unnecessary consults, and when you do call a consult, make sure they come.

 

[roja]

All great advice. Also, always keep in the back of your mind a few things:

1. some people are just jerks. don't let them make you loose your cool. keep in mind that you are working for your patient, not your ego. (sometimes hard to remember when a consult is being a condescending jerk-off)

2. You are making work for them, and they might be overly worked, tired, thier spouse could have left them, or any number of *other* reasons. Again, be straightforward and don't invest your ego in it.

3. Realize that as an intern, you are building relationships with these people. when you see them in your hospital, cafeteria, whatever, be nice, genuine. Its easier to get consults and have good interactions if you know who they are and they don't think you are just there to dump on them. sometimes schmoozing is a good thing adn it can make your life infinately easier. it doesn't mean to bury your nose in unattractive places, just recognize that finessing consults is part of your life.

4. When dealing with particular fields, that are often more notorious than others, realize that they are often angry, frustrated and bitter because they are getting thier tails pounded on a regular basis and no one ever acknowledges thier hard work. it doesn't hurt to off set that some by saying "I know you are really busy but..." Also, don't approach consults with an attitutude of superiority (notorious among many EM people). you are consulting them because you cant do something or don't know something. If you act arrogant, they will immediately respond in kind.

Just a few hints/tips to think about. 🙂

 

[ERMudPhud]

First of all, this is much more of a problem in the academic world where the residents, fellows, and often even the attendings aren't getting paid per patient. In the non-academic(almost wrote "real) world you do consult much less and you learn what can be left to be seen in the office the next morning ( a surprising variety of fractures) and what can be admitted to the hospitalist overnight and seen by the specialist the next day.

Two other tips.

1. After they see the patient if it turns out they did need to be involved ask them how you could have better presented the case next time. That way you can improve your presentation and learn the "magic words" for next time. If they didn't need to be involved then apologise sincerely and ask how you can distinguish the patients less serious condition from whatever it was you were worried about so that you won't have to call them next time.
This assumes you had a differential when you called and you didn't just call to say, "Yeah, I got an old lady with belly pain I can't figure out. Can you come lay some hands on her and see what you think" Much of my diagnostic skill in neuro, surgery, cardio etc... comes from having paid attention and questioning consultants during residency.

2. If they are doing a procedure ask them to teach you everything they are doing as they are doing it even if it goes beyond the usual scope of EM at your institution. You will learn something and maybe not have to call them next time. Certainly I do many things now that I didn't do much of in training, oversewing spurting AV fistulas, rongeuring down bone stumps on traumatic finger amputations so I can close the soft tissue, cauterizing tonsilar bleeds, burring out rust rings, the list goes on. I'm always greatful that I paid attention to what the consultants where doing during residency and didn't just leave and move on to the next case.

 

[Joejitsu]

Does anyone have any pearls of wisdom on dealing with consultants?

Some tips as some ppl have already mentioned, just give the pertinent info and what you expect from them. Don't get into a huge debate on why they need to come and see the patient. Most consultants are great and don't give you trouble, but there are a lot that under no circumstance give a crap about taking care of people...their sole goal is to minimize their patient list and maximize their sleep. With those guys, my usual conversation goes something like this.

Me: Is this neurosurg? I have a 73 yo with what appears to be a chronic SDH after falling 2 weeks ago. She's not altered, but it's a fairly sizeable SDH, can you come evaluate her for admission or drainage or whatever please?

Him: We're not going to do anything for that.

Me: Okay, that's fine, come and evaluate the patient, put your consult in writing and we'll take it from there.

Him: Just call medicine and we can consult on the side.

Me: come evaluate the patient

Him: If they admit the patient we're happy to see them

Me: come evaluate the patient

Him: But I don't...

Me: come evaluate the patient

Him: B....

Me: come evaluate the patient.

Him: ....

Me: ... bed 2, thanks (click)

Now, I guess it takes a little while in the ED to feel comfortable handling stuff like that, but if a consultant is a dick I am not going to bend over backwards to do his job for him. I have my own stuff to do.

Joe

 

[roja]

First of all, this is much more of a problem in the academic world where the residents, fellows, and often even the attendings aren't getting paid per patient. In the non-academic(almost wrote "real) world you do consult much less and you learn what can be left to be seen in the office the next morning ( a surprising variety of fractures) and what can be admitted to the hospitalist overnight and seen by the specialist the next day.

Two other tips.

1. After they see the patient if it turns out they did need to be involved ask them how you could have better presented the case next time. That way you can improve your presentation and learn the "magic words" for next time. If they didn't need to be involved then apologise sincerely and ask how you can distinguish the patients less serious condition from whatever it was you were worried about so that you won't have to call them next time.
This assumes you had a differential when you called and you didn't just call to say, "Yeah, I got an old lady with belly pain I can't figure out. Can you come lay some hands on her and see what you think" Much of my diagnostic skill in neuro, surgery, cardio etc... comes from having paid attention and questioning consultants during residency.

2. If they are doing a procedure ask them to teach you everything they are doing as they are doing it even if it goes beyond the usual scope of EM at your institution. You will learn something and maybe not have to call them next time. Certainly I do many things now that I didn't do much of in training, oversewing spurting AV fistulas, rongeuring down bone stumps on traumatic finger amputations so I can close the soft tissue, cauterizing tonsilar bleeds, burring out rust rings, the list goes on. I'm always greatful that I paid attention to what the consultants where doing during residency and didn't just leave and move on to the next case.

😍 😍

Outstanding points!

Particular with regards to procedures. Education in general is all about compartmentalization. In EM, we are especially vulnerable to this given our severe time constraints, volume, etc. Residency is an excellent chance to battle this. And actually learn things that will help you understand your patients pathology and management.

While I was on trauma surgery, I actually spent a good deal of time (for an EM person) in the OR scrubbed in to watch cases that I had managed in the bays. while I didn't need to know how to remove a shattered spleen, getting in adn seeing the injuries, the anatomy in real life made alot of sense as to the hows and whys of what was going on in the trauma bay.

So, residency you have a prime time to really get in and learn, take advantage of your consults... Your habits are developing now, so this is great advice to start to encorporate

 

[roja]

Some tips as some ppl have already mentioned, just give the pertinent info and what you expect from them. Don't get into a huge debate on why they need to come and see the patient. Most consultants are great and don't give you trouble, but there are a lot that under no circumstance give a crap about taking care of people...their sole goal is to minimize their patient list and maximize their sleep. With those guys, my usual conversation goes something like this.

Me: Is this neurosurg? I have a 73 yo with what appears to be a chronic SDH after falling 2 weeks ago. She's not altered, but it's a fairly sizeable SDH, can you come evaluate her for admission or drainage or whatever please?

Him: We're not going to do anything for that.

Me: Okay, that's fine, come and evaluate the patient, put your consult in writing and we'll take it from there.

Him: Just call medicine and we can consult on the side.

Me: come evaluate the patient

Him: If they admit the patient we're happy to see them

Me: come evaluate the patient

Him: But I don't...

Me: come evaluate the patient

Him: B....

Me: come evaluate the patient.

Him: ....

Me: ... bed 2, thanks (click)

Now, I guess it takes a little while in the ED to feel comfortable handling stuff like that, but if a consultant is a dick I am not going to bend over backwards to do his job for him. I have my own stuff to do.

Joe

In a case like this, I find that I don't even get this hostile... I simply say: I understand completely. But I am requesting a consult. However, if you are refusing to see the patient and take the consult, I'll just drop that in the chart and let the admitting staff know. thank you so much for calling me back.



Or some variation there-in. always in a very nice, sweet polite voice.

On the rare occasion that an attending tries to refuse an admission (we have direct admitting privilages here): "Well, I certainly understand. However, you will need to come down here and right up a note, discharging the patient and I'll take care of that right away for you."

Both seem to be incredibly effective

 

[ERMudPhud]

Me: Is this neurosurg? I have a 73 yo with what appears to be a chronic SDH after falling 2 weeks ago. She's not altered, but it's a fairly sizeable SDH, can you come evaluate her for admission or drainage or whatever please?

This is exactly the sort of case that in the private world would get admitted to the hospitalist with neurosurg consulted on the floor sometime during the next 12-24 hours. The SDH happened 2 week ago, he's not altered, he's not herniating. In cases like these I find two things are very important get a very accurate description of the CT finding, size (in cm), apparent age, degree of brain crowding, other complications from radiology to pass on to neurosurg and get the radiologists phone number for the neurosurgeon. That way he can directly discuss the findings if necessary. Now with teleradiology some of the surgeons can pull up the scans on their home computer and directly evaluate the images. My neurosurgeons don't come in unless the patient needs to go to the OR.

 

[DrQuinn]

What a great forum we have here... look how many new (and "old" attendings) have responded with such excellent advice!

My two cents.

It really is an art. You'll get better at it. But as an intern, it is so important that you get some face time with these residents. They'll be grumpy as hell when they come down. Greet them with a smile.
"Hey, its me, Dr. Quinn, I told you about the patient. Do you mind if I hang out while you do the detorsion/enucleation/bone biopsy/heart transplant/neuro exam/bronch?" Then you'll see how they evaluate the patient. They may even teach you a thing or two. Always thank them for coming down to see the patient.

One thing that I have noticed at my institution now where I work (level 1, academic 960 bed), we have an ophtho resident almost 24 hours a day. A lot of my attendings abuse them. Seriously. For any eye complaint, they basically send them to the ophtho resident. I was aghast when I came here. Regardless, my first eye patient, I dusted off the tonoPen, which had condoms that were from about 1960. I called the ophtho resident and apologized (I thought the patient did have acute angle...). They said to me "HOLY CRAP you actually attempted to check pressures yourself?"

Regardless, this made me an instant fan of the ophto people. Now, when I consult them, they are super nice. Even thanked me for the HSV keratitis I sent them three days ago.

Just be nice to your consultants, schmooze a little bit, try to make them laugh here and there (that's my solution to anyone grumpy), and LEARN from them. Shoot. I'm STILL learning from my consultants now, as a 6 month old attending (except for the neurosurgeon who wrote "moves all extremities x 4 5/5" in a T4 paraplegic).

Quinn

 

[ERMudPhud]

Regardless, my first eye patient, I dusted off the tonoPen, which had condoms that were from about 1960.
Quinn

Don't you hate when every condom in the box crumbles as you struggle to put them on the pen.

This is a perfect example of the difference between academic and private practice. I think the only time in the last 5 years I've seen ophtho in the ED was for open globes. Everything else is handled by phone with next day follow up. I mean everything: hyphemas, hsv keratitis, corneal ulcers, detached retinas. Thats why if you get too used to having the optho resident, who might be only a pgy2, seeing everything you will be hurting when you leave residency

 

[basementbeastie]

Don't you hate when every condom in the box crumbles as you struggle to put them on the pen.

hate that!!😀

 

[edinOH]

If by pen you mean...

Never mind.

 

[basementbeastie]

the pen is what the pen is.....😎