Calling consults

[siliso]

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Why do people have to act offended that you asked them to do the thing that is their job as the consultant of their chosen profession?

Me: I'm calling from ICU regarding our patient Mr. X who developed a cold, weak pulsed, cyanotic, monophasic extremity overnight despite being normotensive and not on pressors...
Dr. Evil: Why are you calling me? This is a new consult. I don't know why the on call person you spoke to suggested Y and never saw the patient. You have to tell me all about the patient.
Me: Okay. Patient is an xx yo m admitted for x and y s/p procedure z who overnight developed the following findings....
Dr. Evil: No, I only want to know why you are consulting MY service.
Me: Okay, you asked to hear all about the patient, what would you like to know?
Dr. Evil: Why are you consulting My Service?? What do you want Me to do?
Me: I called you because I am concerned that his toes may fall off. Can you come see him please?

Yargh. Tell me you have nothing to offer, smarmy person, fine. That's what I need to know before I let the guy's feet fall off and someone asks "what did Service X say?" and I say "oh I never called them, I was sure they had nothing for us." You want I should tell you how to do your job? Come see the damn patient and tell me if your service can benefit the patient or not. Does the barber have to look at a person crosseyed and ask why they came to his place of business? No, they are there for a haircut like every gdamn body else. So do your thing. Assess and freaking recommend. Thank you.

 

[Dral]

What was your specific question? I was trained that whenever calling a consult, you start by giving quick demographics, reason for admission, short PERTINENT history, PERTINENT work up, then ask the specific question.

As a consultant, it's nice to see that a primary team has put in some work to figure something out first...even if that's just looking something up on medscape or something. Did you guys do an US or any imaging before calling?

I know I'm being devil's advocate, but I've been on both ends and it's frustrating from both those ends.

I think the person just wanted to know the specific question you wanted answered so they could come see the patient and work up that specific question. Symptoms aren't really a specific question. Listing those symptoms and asking 'what should we do?' Isn't specific either.

A not totally specific question (but appropriate imo) could be: Mr. X developed cold cyanotic extremity overnight. His CBC and diff are normal as was an US of the extremity. We'd like some advice on next steps in management and/or treatment.

You might not be able to say "We'd like you to rule out cryoglobulinemia" or something that specific in this case, but at least my example conveys you've done your work and exhausted your knowledge base...which is when a specialist comes in to advise. Basically, be a specialist consultant, not a triager (I don't know the whole situation, so I'm sorry if I'm assuming some things here...just trying to help in calling in consults more effectively).

I found that surgery services are especially very to the point: they want pt name, dob, MRN, specific question;
ok, we'll come see the pt. Done.

To use your barber metaphor:

#1
Customer: Please cut my hair.
Barber: Ok, how do you want it cut?
Customer: Hmm, I didn't really think of that. I guess I like flat tops, I dunno.
Barber: How about a bowl cut?
Customer: Ok, that sounds good.

#2
Customer: Hello, can you give me a bowl cut?
Barber: Yep. Sit down, let's get to work.

 

[hrandani]

As a medical student, you're going to get yelled at for things that aren't your fault. I'm a little surprised you haven't internalized this already. You gotta let this stuff slide.

You can't win. Every consultant is going to want something different from you, and is likely going to take the opportunity to rail at The System for their life choices. Smile, nod, move on with your life.

Within the same 18 hour shift I've consulted the same service multiple for identical presentations and the resident on call wanted an entirely different telephone presentation of the patient each time around and openly mocked me, my life choices, my ethnicity, my mother's skill at sexual congress with various animals, my likely sexual preferences, and my highly questionable chromosomal integrity.

You gotta laugh at this stuff, it's not personal. These people you're calling at 3 in the morning are very frequently under a lot of stress and generally not happy with their lives.

 

[siliso]

It didn't hurt my personal feelers, particularly. Good team room laughs were had by all. It's just kind of mystifying, and occasionally frustrating when it leads to bad patient care. Like if you don't want to be called (in midmorning no less) to evaluate people's peripheral vasculature for potential surgical intervention...why are you in a PV surgery residency? Someday soon you will need to learn how to say "thank you for the interesting consult" rather than "f*** you for requesting my expert assessment" if you want to make money and friends, so why not start practicing?

 

[QuizzicalApe]

A safe rule of consults is have a quick one sentence question that you are hoping the consult will answer. If the consult service is hectic, starting off on that sentence can be a way to grab their attention and help to focus the call.

That being said, sometimes jerks are just jerks.

 

[siliso]

Sometimes the question is, In your specialist consultant opinion, does this patient with finding X in the setting of conditions Y and Z have a condition that would be amenable to intervention by your service? Even though I don't particularly think so, the situation is one in which prudence slash ass-covering requires a call to you and so I must call and you must come and evaluate the situation and that is life, buddy. Being an ass about it will not resolve the situation - assessing the patient and saying yay or nay will. Who in this world or in the hospital at whatever hour is not busy and stressed? If all you are able to handle are specific requests for specific procedures under specific circumstances, you are a tech, not a physician. There's always McDonald's if this s**t doesn't suit you.

 

[Dral]

If all you are able to handle are specific requests for specific procedures under specific circumstances, you are a tech, not a physician.

...and if all you do is have a patient with some symptoms and go consult the service you feel appropriate before thinking the problem through intelligently and having a specific question to ask, you are a triage nurse, not a physician.


Sorry consults are rough. The person may have had a bad day. You'll have bad days when you're on the other side too. Sometimes the surgery service consultants are called to the OR. They are juggling numerous things at once. I don't like to defend rude behavior, but you can't take it personally. I guess blowing off steam on the forum is actually a good thing to do.

I hated calling consults because you know half the time you get push back. My intern year hospital had a no consult refusal rule actually. However, it SUCKED when I knew I was calling in a consult just to cover butts. As a med student/intern, you're stuck in the middle. I hated when we had a pt with abd pain and I was told to call gen surg 'to get them on board'. It sucks to wrestle with the surg person on call, them come eval the pt, and them to say...'great, constipation, really?. Call us if you need us...or don't. signing off'.

It is correct that in the 'real world', the generalist is doing the consultant a favor by giving them a consult since the consultant is reimbursed for their effort. The consultant gives the generalist their help in return.

In the academic setting, the reimbursement for the consultant is not there. Thus, it changes the dynamic. Monetary reimbursement is replaced by educational value. Yes, there is something to be learned by every case, but sometimes the bread and butter consults get really old and a consult without specifics gets frustrating.

Again, it sucks...but in academics, ya just gotta stroke the consultants ego and make things easier since they are the ones helping you out.

 

[sakata8242]

Did you identify yourself as a student on the consult page? Consultants seem less irritated when an intern or resident is on the other end of the phone when they call back. Because nobody wants to talk to a clueless M3. The more memorable consults I've called as an M3:

1) My intern told me to page ID for a new consult. He neglected to tell me that all new consults are supposed to go to the ID fellow, not the resident. I get an irate ID fellow on the line who demands to know why I'm paging "his resident" with a consult. He lets me get about 5 seconds into the patient's history, then cuts me off, says he'll see the patient and promptly hangs up.

2) I page the cards fellow with a new consult to ask him to ablate a patient in refractory Afib/RVR. He starts pimping me over the phone about how we should be managing Afib before he finally asks, "So you want me to ablate him? Is that it?"
No, ass, I just wanted to pad your ego by allowing you the opportunity to hear your own voice...Jesus tap dancing christ in a chicken basket.

 

[siliso]

...and if all you do is have a patient with some symptoms and go consult the service you feel appropriate before thinking the problem through intelligently and having a specific question to ask, you are a triage nurse, not out.

Fair enough, but if I am managing their sepsis, ARDS, renal failure, CAD and CHF in accordance with the purview of my specialty, I think asking you to evaluate their half-dead foot with your professional expertise before I shrug and let it rot is not out of order.

I identify myself as "firstname in the ICU," (secret sub-I) as vague as possible without actively lying. Although this person in this specific instance acted a fool in person in front of the board certified attending, God, and everybody, so I don't think in the end it was my peon status that caused the *******ry. Maybe it was their own confusion and inexperience, to be charitably condescending, who knows. The academic attending was much more helpful...even at 3am.

 

[jdh71]

Fair enough, but if I am managing their sepsis, ARDS, renal failure, CAD and CHF in accordance with the purview of my specialty, I think asking you to evaluate their half-dead foot with your professional expertise before I shrug and let it rot is not out of order.

I identify myself as "firstname in the ICU," (secret sub-I) as vague as possible without actively lying. Although this person in this specific instance acted a fool in person in front of the board certified attending, God, and everybody, so I don't think in the end it was my peon status that caused the *******ry. Maybe it was their own confusion and inexperience, to be charitably condescending, who knows. The academic attending was much more helpful...even at 3am.

Well. You never did seem to get around to telling the surgical consultant what was the issue. I mean simply telling an consultant to "evaluate and treat" doesn't help the consultant help you, which I assume is what you're looking for, an expert opinion regarding a problem that is outside your personal comfort zone or area of expertise, right?

In this case start by telling them you are concerned about limb ischemia that you think/are concerned may be due to an arterial abnormality and think they may need a surgeon and the OR.

At this point surgical residents can still be difficult, but at least you're told them the issue and how they can help.

As the pulmonary consultant nothing is more annoying than the "eval and treat" consult. What is this thinking for idiots day? Eval and treat what? Secretions? Hypoxia? Deal with the underlying asthma? Recommend treatment for their pulmonary infection? Do you just want a bronch? What? It can be frustrating when we give recommendations on a vague consult regarding one thing to later find out the primary team is frustrated because they wanted opinion on something else.

Before calling a consult have the specific issue in mind, and don't be vague, it wastes a lot of the consultants time to try and figure out what you want and don't turn it into an thinking for idiots game.

 

[siliso]

I don't know how much more specific it gets than, there is a suddenly ischemic appearing extremity on my critically ill but normotensive, not on pressors patient who does not have DIC and I want you to take a look at it and confirm that surgery would or (just as likely and more than acceptable as an assessment) would not be helpful to preserve the said extremity? I get the sense that "WHAT is your QUESTION" means "I have no idea how to evaluate this condition." I told you what the question was: could this person benefit from your surgical services, or not?

 

[jdh71]

I don't know how much more specific it gets than, there is a suddenly ischemic appearing extremity on my critically ill but normotensive, not on pressors patient who does not have DIC and I want you to take a look at it and confirm that surgery would or (just as likely and more than acceptable as an assessment) would not be helpful to preserve the said extremity? I get the sense that "WHAT is your QUESTION" means "I have no idea how to evaluate this condition." I told you what the question was: could this person benefit from your surgical services, or not?

Ok.

You are clearly correct. The fact that the consultant and myself both seemed to have missed what you were stumbling around about means that we are the idiots.

That sounds legit.

Carry on.

 

[Dral]

Ok, take the next step...you're a med student...you know about surgery at least a little bit. What type of surgery do you expect the vascular person to do? Do you think there is a vessel blockage that needs to be bypassed? Is there some type of lymphatic blockage? If you ruled out medical reasons for the condition, did you do visualization studies? U/S at least?

I dunno, if I was calling this consult, I would have ordered a stat U/S before anything. Surgeons don't go cutting on people blindly. If you know the surgeon will need the study, get the study before you call...or at least as you care calling. Maybe an U/S was done. It's an academic center...get the study, learn from it...help the consultant out.

Let's say an U/S was negative. Let's say you went one step further and got an MRI. Both are negative studies. Do you still call the consult? What surgical intervention is the team going to do if there are no structural abnormalities?

Let's say the U/S was positive for a severe clot?

Either way, you thought for yourself, got studies...and you can ask a more specific question:

We have a pt with an ischemic limb, U/S is negative, he's at MRI now. Can you recommend any other studies to help us figure out what is going on and treat the patient if you can offer surgical intervention?

We have a pt with an ischemic limb...U/S was positive for a large clot in so and so vessel. The limbs looking pretty bad. Is there an acute surgical intervention you can offer?

Both of those would be great consult questions imo.

Yes you're managing sixty bazillion other things on the patient, but nobody ever said being the primary team was easy. I'm not accusing you or your team of this, but if a primary team just calls a bunch of consults and follows recs, all you end up being is a triager and social worker. No fun.

This is the primary team's patient, not vascular's patient. As soon a as generalized consult is sent out, there is an air of transfer of 'owerniship' of a problem. 'Hey vascular, this is this, we have no idea nor have we done much, what can you do?' That passes ownership of the problem to vascular to deal with. While they have responsibility as the consultant, it is not pleasant to feel you are being dumped on. A specific question gives the air of 'We have this problem with the patient...we are still taking ownership of the pt's problem, but we would like your help with this part of it.'

There may be times when one really needs a consult team to manage all of a problem. It happens. Maybe this truly was one of those cases. *shrug*

Sometimes a problem is severe enough for the patient to be transferred to another service, but ya can't dump pts, you have to facilitate. I had a patient with severe back pain. We did an MRI...she had a hairline fracture of vertebrae. The spine surg team was consulted with the question "We have a patient admitted for severe back pain, we imaged and there are hairline fractures in vertebrae, does this need surgical intervention?" The team looked at her, said 'this is an unstable situation that could get bad, we'll take the patient and take care of her'....but not until we asked them a question with specifics in it. We didn't say 'Oh, pt admitted for backpain, call neurosurg or spine surg...they'll know what to do'. See the difference?

Again, most of what I'm doing is devil's advocating. I've had my fair share of bad calls to consultants. I think not enough emphasis is put on teaching people how to call in a good consult though, so I think this is a worthwhile discussion for those who have followed along the thread. I'm not saying I'm the best at calling consults, but I think I've learned a thing or two about it from being on both ends.

 

[Doctor Bob]

I think not enough emphasis is put on teaching people how to call in a good consult though, so I think this is a worthwhile discussion for those who have followed along the thread.

This is a skill that takes a lot of people months/years to get right; I see a lot of interns (and PGY2s) that still fumble through this. We give our interns lectures on this topic throughout the year beause in the ED it's a critical skill to be able to quickly/succintly engage a consultant and get the desired outcome.

 

[GoSpursGo]

I don't know how much more specific it gets than, there is a suddenly ischemic appearing extremity on my critically ill but normotensive, not on pressors patient who does not have DIC and I want you to take a look at it and confirm that surgery would or (just as likely and more than acceptable as an assessment) would not be helpful to preserve the said extremity? I get the sense that "WHAT is your QUESTION" means "I have no idea how to evaluate this condition." I told you what the question was: could this person benefit from your surgical services, or not?

Honestly, while I agree that there was no need for them to be so snappy at you, you also could have presented your consult better. Yes, you were getting to your question, and yes, your question was totally reasonable, but you could have gotten there more succinctly. I'd go even further than some of the other posters here--offer it in your "one-liner."

"Hi, I'm siliso from the ICU and I'm calling a new consult. The patient is (identifying information and location). They are a xx year old M/F with (primary diagnosis), and we are calling because we would like for you to evaluate for surgical management of his new ischemic limb."

THEN you can launch into the story of what the exact findings are, the most important parts in the patient's hospital course, etc etc. This isn't a SOAP note where you have to present the objective info first--just jump to the point, and then give any other key bits of information. While you say "I told you what the question was," in the story you told you actually did not get to that point, and while you may be justifiably angry that you had your head bitten off before you could get to it, you can still take away a point that might save you from getting that response in the future.

A smaller point is that you should explicitly state in the first line that this is a formal consult (as opposed to a curbside). If you don't know if it's a consult when you call, you can say that too. It's all about making it abundantly clear exactly what you're asking for as quickly as possible when you call them.

 

[hrandani]

The "hidden curriculum" in medical school is outlined above.

Remember kids, whatever happens, it's always your fault. Especially when it isn't.

 

[GoSpursGo]

The "hidden curriculum" in medical school is outlined above.

Remember kids, whatever happens, it's always your fault. Especially when it isn't.

Actually not what anyone was saying--everyone agrees that the consulting resident was being a jerk. At the same time, just because the OP didn't do anything "wrong" doesn't mean he can't take the opportunity to learn to do "better" and maybe avoid having a jerk be a jerk to him in the future.

Again, properly calling a consult is not as easy of a skill as one might think; there is a reason that many (most?) residencies have a workshop in orientation to help the new interns figure out how to do it right, and so it's not surprising that a sub-I might stumble through a consult call. You might be somewhat morally justified in decrying how mean people can be in academic medicine, but it doesn't actually help you.

 

[JJMrK]

Why do people have to act offended that you asked them to do the thing that is their job as the consultant of their chosen profession?

Yargh. Tell me you have nothing to offer, smarmy person, fine. That's what I need to know before I let the guy's feet fall off and someone asks "what did Service X say?" and I say "oh I never called them, I was sure they had nothing for us." You want I should tell you how to do your job? Come see the damn patient and tell me if your service can benefit the patient or not. Does the barber have to look at a person crosseyed and ask why they came to his place of business? No, they are there for a haircut like every gdamn body else. So do your thing. Assess and freaking recommend. Thank you.

That's not really how it works, though. As others have said, there has to be a specific question you want the consulting team to answer. We were drilled with this over and over and over again during MS3. Think about the information you're after. "Does this condition require surgical intervention?" probably would have been a good place to start in this case.

 

[Bacchus]

That's not really how it works, though. As others have said, there has to be a specific question you want the consulting team to answer. We were drilled with this over and over and over again during MS3. Think about the information you're after. "Does this condition require surgical intervention?" probably would have been a good place to start in this case.

When you're a resident I might consult you because my patient's belly hurts.

-Please tell me why my patient's belly hurts. Thx.

😛

 

[michaelrack]

...
It is correct that in the 'real world', the generalist is doing the consultant a favor by giving them a consult since the consultant is reimbursed for their effort. .

Sometimes true, sometimes not. For example, some insurance policies require a doc to have hospital privileges to be in network. If a doc obtains hospital privileges primarily for that reason, he will probably lose $ on most inpatient consults (due to time spent away from office), even if the patient has good insurance.

What you are saying was once true in most situations but things have changed

 

[JJMrK]

When you're a resident I might consult you because my patient's belly hurts.

-Why does my patient's belly hurt?

😛

Fixed for you dude.

 

[Bacchus]

Fixed for you dude.

mybad.

 

[SouthernSurgeon]

Surgery resident's opinion here for what it's worth:

There a couple of issues at play:

1) The academic medical system allows consulting services staffed with residents and fellows to have an adversarial/confrontational role. An "us versus them" mentality in which it is acceptable to be rude and unprofessional when another physician is simply calling and asking for help. This is a model that exists only in academia. At my hospital, while the surgeons are by no means totally innocent, it is actually the medical subspecialists that have the worst reputation. Woe be to the poor M3 who has to call GI for a consult...


2) You're an M3 or M4. Whether it's fair or not, when we are taking consults and get a page from a med student, we sigh and take a deep breath before calling back. The reason for this is that 9 out of 10 times, the student is totally unprepared to discuss the patient and provide relevant information. This is not your fault. It is the fault of the residents who make students call consults without providing them appropriate education on how to do so. The reason residents do this? Item (1) above. They just don't want to deal with it.

 

[jdh71]

At my hospital, while the surgeons are by no means totally innocent, it is actually the medical subspecialists that have the worst reputation. Woe be to the poor M3 who has to call GI for a consult...

This is an interesting point. I think part of the annoying problem with consults on the medical sub-specialist side of things is that there is this attitude that seems to come from the primary medical team that they want to make their problem your problem, and you are no longer allowed to simply give recommendations, but that it is expected you handle all the little details around the problem as well. It's not enough to simply tell people to sample an effusion, and further rec's pending reuslts, but rather it is expected you do the thoracentesis, arrange for IR to do it, and/or order all of the pertinent labs. For every reasonable consult, we get asked to do three or four that end up being a lot of unnecessary busy work from people who should know better. I keep being told when I get paid for every consult, I'll be very happy to get them - every single one. I'm still skeptical, especially about those 4:30 pm gems.

This is what is nice about when surgery consults. We leave rec's and they handle the business.

 

[siliso]

Surgery resident's opinion here for what it's worth:

There a couple of issues at play:

1) The academic medical system allows consulting services staffed with residents and fellows to have an adversarial/confrontational role. An "us versus them" mentality in which it is acceptable to be rude and unprofessional when another physician is simply calling and asking for help. This is a model that exists only in academia. At my hospital, while the surgeons are by no means totally innocent, it is actually the medical subspecialists that have the worst reputation. Woe be to the poor M3 who has to call GI for a consult...

It was the cardiologists who were worst, at this particular place. Which was not academic but had similar (lack of) incentives to act like a professional human. We're on the same team. Nurses, RTs, students, janitors, attendings, lab techs, fellows, scrub techs, consultants, primary teams. I'm on Team Patient. It's not my STEMI or bleeding varix or my toes that will fall off, if you blow it off or think I wasn't worthy of speaking to you, it's the patient's. Is it ingrained culture? Seems to be, between many of the above. One fellow of Service X wouldn't come in at night for crashing patient until they were assured that fellow of Service Y was already in the building. Nurse doesn't want to draw off-schedule stat labs even though they are ordered and it's the ICU. And many other assholisms day after day. .

I'm sure there is some hierarchical "how dare this student call me" bs going on despite that I am neither an idiot nor an *******, but the behavior seems quite the same to the interns and residents and in this case, the fellow and the attending, openly to their faces in the middle of a public space. Yes it is frequent. No it doesnt wound my personal soul. Still not okay. Not good for patients, or professional relations, or anyone, like ever.

I can understand frustrations on all sides. It's frustrating work some days. Sometimes the consult is one where everyone knows you've got nothing to offer and we just need to document it (as in this case of blue toe syndrome). Sometimes it's something that the primary team should have figured out - but if they couldn't, isn't it better they called for your input rather than letting the patient suffer? I mean the ones where I most understand taking offense is when someone outside your field calls to say "you have to come put a chest tube in my patient" or "I need you to take out this gallbladder." Respect for the consultant's field of expertise would seem to call for asking them to evaluate the patient in re the need for procedural/surgical intervention, not ordering it be done like a lab test. In any case I believe in the ability of smart capable people to manage their frustration and roll their eyes privately if they need to rather than acting a fool out loud to their colleagues, juniors and elders. I'm INTP that way.

 

[siliso]

Sometimes I wonder if surgeons in general think that just because someone called them, they want and expect surgery to be done. From my time on surgery, I think yes. From my time on any other service, I think no: most of the time I am perfectly happy to hear that no surgery is planned and would have grave misgivings if it were.

 

[Gastrapathy]

Sometimes I wonder if surgeons in general think that just because someone called them, they want and expect surgery to be done. From my time on surgery, I think yes. From my time on any other service, I think no: most of the time I am perfectly happy to hear that no surgery is planned and would have grave misgivings if it were.

This is why they hate us. If we don't think there is any chance that the patient needs a surgery, why are we calling a surgeon? The answer is so that when there is a complication, we can throw up our hands and say "well, I called surgery." Its weak sauce and really should only be necessary in rare occasions. If I call a surgeon, they won't always operate but they will at least have a decision to make that I don't already know the answer to.

For the original topic, residents need to actively manage students calling consults. I tell our residents that they had better be sitting next to the student when he makes the call. And God help the resident who says "sorry but my attending wants this." Get on board. On the other hand, when I get a consult, I just want to know the bed number and maybe the question.

 

[Doctor Bob]

For the original topic, residents need to actively manage students calling consults. I tell our residents that they had better be sitting next to the student when he makes the call.

Indeed. When I want a student to make a consult call sometimes I'll take the phone first and ask the consultant if they're especially busy at the moment; if they say no then I have the student go ahead with the consult. If the consultant is being swamped I'll defer the learning moment for a better time.

And God help the resident who says "sorry but my attending wants this." Get on board.

Well... this may depend. There are times when, as a resident your relationship with the consulting resident needs to be maintained in order to facilitate ease of consults down the road If your attending directs you to make a weak consult I don't think it's a bad thing to say "sorry about this... but the attending wants this". Now that's not something a resident should ever say to a consulting attending though.

I've had patients that I've admitted based on "attending gestalt" so on the surface it seems like a weak admission... residents hate making those admission calls because they know they'll get push back from the admitting service residents. It's difficult to make a good sales call when you don't believe in the necessity of the admission. So I tell my residents it's ok to throw me under the bus and say "look I'm really just calling you because my attending says he wants this patient admitted". But that's after the resident and I have a talk about how they would be managing this patient if they were on their own.

And then a day or two later I get to say "neener neener" when the patient clinically deteriorates.

 

[SouthernSurgeon]

And God help the resident who says "sorry but my attending wants this."

There is one circumstance where I am often forced to use this line, and I do so pretty unapologetically.

Our cards fellows DESPISE seeing a consult for "preop cardiac evaluation/clearance". They will argue with you til they are blue in the face about it.

Consequently our medicine residents hate calling these consults too.

I will often pull the attending line in these cases. Specifically, what I say is - "look, my attending is the one taking on all the liability by operating on this patient. He's not going to touch the patient until there is a documented note in the chart from cardiology. If this is a problem for you he will be happy to call your staff."

I know these consults are BS, and I usually have to remind the fellows that I actually know the data on periop risk assessment and optimization better than they do. But it's all about liability and documentation. CYA medicine at its best, but that's the world we live in.

 

[sacrament]

A couple of people have alluded to it, but I will reiterate that this dynamic completely changes if you leave academia for the "real world." I moonlit as a hospitalist at three different private systems while I was in residency/fellowship, and called dozens of consultants combined over the years. I can't remember a single instance of any of them ever being rude to me. The response was almost always something along the lines of "I would absolutely like to help you out!"
That being said, having served in a cardiology consulting role in academia for four years I absolutely understand how frustrating it can be when the vast bulk of what you do serves no discernible purpose, benefits nobody, and yet still costs the system money. I often pondered how ludicrous a consult needs to be before billing for it constitutes insurance fraud.

 

[sacrament]

On the other hand, when I get a consult, I just want to know the bed number and maybe the question.

At a certain point, I stopped even asking for a question because either they don't really have a specific question and asking for one just leads to bad feelings, or the question they have isn't the real question they should be asking.

 

[Instatewaiter]

It was the cardiologists who were worst

That is because cardiology gets consulted for EVERYTHING heart related, including sinus tach... womp womp...

The other day our cards consult service got 31 consults- 1 fellow. When your internal medicine attending is asking you to consult cards for A-fib you are getting pushback from me unless there are some really extenuating circumstances. You are capable of treating that, don't waste my time.

Remember those 31 consults require a chart biopsy, looking at the tele, all EKGs, echos etc and they all require notes and seeing the patient and staffing with the attending. You can't really do a consult in under 30-45 minutes. You do the math. Don't consult me for bull****; I don't have time for it.

We're on the same team. Nurses, RTs, students, janitors, attendings, lab techs, fellows, scrub techs, consultants, primary teams. I'm on Team Patient. It's not my STEMI or bleeding varix or my toes that will fall off, if you blow it off or think I wasn't worthy of speaking to you, it's the patient's.

.

We are obviously not on the same team because your BS consult is keeping me from my family. If we were on the same team you wouldn't consult me for sinus tach. You instead would use your brain. Furthermore, you would know the patient.

Also, no GI doc is giving you flack for a bleeding varix. Those patients are quite unstable. No Cardiologist is giving your flack for calling about a STEMI. Stop being hyperbolic.

 

[sacrament]

That is because cardiology gets consulted for EVERYTHING heart related, including sinus tach... womp womp...

Sinus tach was one of my more frequent consults, typically a heart rate that is just north of 100 in a patient who has several solid reasons to be a little tachycardic.
Sinus brady was also common (HR ~50 while asleep, usually).
Artifact on EKG or telemetry, constantly. Was once consulted for multiple prolonged episodes of VT at >200bpm, and they wanted a CCU bed. Pt was completely asymptomatic and walking around during these. I said over the phone that, given this story, there was a 99% chance it was artifact but I would come look anyway. QRS complexes were clearly marching through all of the artifact. I pointed this out. They asked for a CCU bed anyway, "just in case."
All-time favorite: "The computer interpretation of the ECG said several lines of stuff." Me: "What stuff exactly?" Them: "I don't remember, and I lost the ECG." Me: "Did you get another one?" Them: "Yeah, and now it says it is normal." Me: "I have no idea how I can help you." Them: "Could you just put in a note anyway?"
These are the blatant ones that leap immediately to mind, but the usual day-to-day stuff wasn't much different. 15-20, sometimes 30 a day, at least 90% of which are some flavor of the above. Some days, 100%. From a psychological standpoint, it is challenging to keep it together. Especially when you actually do get a couple of legitimate consults on sick, complicated people, and you're still getting hammered with requests to look at some PVCs on telemetry. It's still no excuse to harass people on the phone, and I always tried to be polite no matter what, but it's a struggle.

 

[sacrament]

Furthermore, you would know the patient.

The ED residents where I just finished fellowship would routinely consult cards for chest pain patients before they had ever even laid eyes on the person, and sometimes before an ECG had been obtained. It was typical that I would have seen, examined and written a note on the patient before any physician in the ED had ever met them. I hope this is an atypical scenario, but it happened daily at my hospital.

 

[Doctor Bob]

The ED residents where I just finished fellowship would routinely consult cards for chest pain patients before they had ever even laid eyes on the person, and sometimes before an ECG had been obtained. It was typical that I would have seen, examined and written a note on the patient before any physician in the ED had ever met them. I hope this is an atypical scenario, but it happened daily at my hospital.

Eh, then you've just got some weak ED residents... All the places I've worked we've never called a consultant without finishing the appropriate ED workup.

 

[FutureInternist]

That is because cardiology gets consulted for EVERYTHING heart related, including sinus tach... womp womp...

The other day our cards consult service got 31 consults- 1 fellow. When your internal medicine attending is asking you to consult cards for A-fib you are getting pushback from me unless there are some really extenuating circumstances. You are capable of treating that, don't waste my time.

Remember those 31 consults require a chart biopsy, looking at the tele, all EKGs, echos etc and they all require notes and seeing the patient and staffing with the attending. You can't really do a consult in under 30-45 minutes. You do the math. Don't consult me for bull****; I don't have time for it.

My philosophy for consults is as follows
In patient - Work up the pt to the end of your ability & then call saying exactly what you have done, what it showed & why you need to know what the nest step is. This is not only helpful for you to learn, it prevents future pts getting consults they do not need. As a bonus you help the other fellows get home on time 🙂

Out patient - Devise a plan the first time you see a patient & then consult the appropriate service & basically ask "Is my plan correct & if not please make changes". This prevents me from wrongly treating a patient for x months thinking I am on the right track

Once on Cardio service I got a consult for "Abnormal EKG"
Looked at the EKG, called the primary team & said "You may want to do the EKG again with all the leads properly attached" 😀
Got in trouble for calling the 2nd year resident a dumb-ass for that one !!

 

[DrBodacious]

Typical private practice hospitals are much different than what people are describing here. One hospital where I spent a lot of time at in residency was 80% private 20% academic. Consults are usually called in by the clerk on the unit. You get call saying "there is a consult for you in bed so and so." You can ask the nurse a lot of questions, but he/she probably will not know the answers. Consults are supposed to be seen within 24 hours. As part of an academic program, we would act quickly out of respect for our attending's schedules, but private practice physicians would usually see consults either that evening or the next morning depending on their preference and schedule. Of course, there are some services that were in house, such as critical care and trauma. But this is hit or miss depending on your hospital. If someone is calling directly for a consult, there is usually a very serious issue that is going on. In private practice, if you are directly calling a consult, you are pretty much implying that the patient you are calling about is more important than whoever the consultant is seeing, or whatever the consultant is doing. Not everyone will take offense to being interrupted, but some people definately did. Once you know what you are doing, you can usually get the necessary information to see a patient from the chart and the patient, so all the phone calling and bickering is pretty meaningless.

 

[neusu]

As a surgical sub-specialist, I agree with the sense that a well thought out one-liner is indispensable. If your hospital has text-paging, send it as the consult request.

(call back number, name/service/pager) Pt Lastname, Firstname Age/Sex, admitting Dx, reason for consult, pertinent exam findings, pertinent imaging/diagnostics.

We're (typically) not arguing that we aren't going to see the patient. If anything, we ask for further relevant information to allow subsequent tests/exam findings to be relayed prior to our arrival. In the rare scenario are we asking for the relevance for the consult.

Also, to the OP: Identifying yourself and being personable on the phone goes a long ways. Certainly, if an average MS3 is on the phone the discussion is different than an average medicine chief. Similarly, asking leading or condescending questions may feel good, but inevitably reinforce the disconnect you experienced.

 

[jdh71]

That is because cardiology gets consulted for EVERYTHING heart related, including sinus tach... womp womp...

The other day our cards consult service got 31 consults- 1 fellow. When your internal medicine attending is asking you to consult cards for A-fib you are getting pushback from me unless there are some really extenuating circumstances. You are capable of treating that, don't waste my time.

Remember those 31 consults require a chart biopsy, looking at the tele, all EKGs, echos etc and they all require notes and seeing the patient and staffing with the attending. You can't really do a consult in under 30-45 minutes. You do the math. Don't consult me for bull****; I don't have time for it.


We are obviously not on the same team because your BS consult is keeping me from my family. If we were on the same team you wouldn't consult me for sinus tach. You instead would use your brain. Furthermore, you would know the patient.

Also, no GI doc is giving you flack for a bleeding varix. Those patients are quite unstable. No Cardiologist is giving your flack for calling about a STEMI. Stop being hyperbolic.

Heh.

Couldn't stop giggling.

Welcome to fellowship.

 

[Bacchus]

Not a consult, but just called my first admission to an attending. I was sweating by the end of it. I'm going to have to call a 2nd admit in a bit, ugh.

 

[PTPoeny]

Residents also have to maintain good relationships with consulting services for future rotations and possible letters and fellowship applications in addition to future consults. When I was on my sub-i one of my interns bought me a bottle of wine for calling in her cards consult. She was doing a cards rotation the following month and didn't want to go in with a reputation as the intern that was calling with stupid consults.

 

[sacrament]

In private practice, if you are directly calling a consult, you are pretty much implying that the patient you are calling about is more important than whoever the consultant is seeing, or whatever the consultant is doing. Not everyone will take offense to being interrupted, but some people definately did.

I've seen a variety of different ways this is practiced in different systems. At two places where I did some hospitalist work, what you describe was indeed the common practice. At a third place, the nurses would call a consult if you asked but it definitely wasn't the norm. But where I am currently working, it is actually in the bylaws that all consults will be called physician-to-physician unless there are extenuating circumstances.

 

[Dwindlin]

I love being in a community hospital. My consultants are always extremely nice, polite, and literately the only thing they ever ask is "What's the patients name and where are they?" Followed immediately by, "Thanks for the consult, we'll see them right away." It's fantastic.

 

[e30ftw]

notice that this thread was about calling consults as a med student and the last 20 or so posts are all from residents and attendings?

as a med student you shouldn't routinely be calling consults.

I did it a couple of times, always saying "this is *first name* with internal medicine" or whatever to try to hide the fact that I was a student..

interns/residents should be calling those consults. I have never made a student call a consult nor would I think it appropriate for a student to wake up an attending subspecialist.. it's just fighting a losing battle.

as a resident you learn the game, the long list of short 10 second phrases that will make specialists of every variety sigh and reluctantly realize that now they will have to do work, but if you deliver the news in a certain way, there is no push back, only acceptance.. students haven't picked up this jedi mind trick skill and therefore are totally disadvantaged, which really just puts patients at risk.

and yada yada to the cards guy who said they would routinely get ED c/s w/o the EM physician seeing the pt. You probably called at shift change and the on coming doc had sign out and didn't know the story. That or it's the worst ED in the country. More likely just plain ED hate, every floor/specialist resident at every hospital knows the ED call back number and likes nothing more to talk for years about every inappropriate cs they have ever received.. some sort of cathartic bitching. At my shop our cardiologists are salaried and therefore every non-insured pt w/ elevated troponin x 2 and CP has "troponin leak" and will refuse to even admit these pts with obvious NSTEMI. I basically have to beg to get them admitted.. guess what, 3x this year pts who cards tried to block admission i used my ninja consult skillz to put them up and they were cathed within 24 hrs..

 

[punkedoutriffs]

notice that this thread was about calling consults as a med student and the last 20 or so posts are all from residents and attendings?

as a med student you shouldn't routinely be calling consults.

I did it a couple of times, always saying "this is *first name* with internal medicine" or whatever to try to hide the fact that I was a student..

interns/residents should be calling those consults. I have never made a student call a consult nor would I think it appropriate for a student to wake up an attending subspecialist.. it's just fighting a losing battle.

as a resident you learn the game, the long list of short 10 second phrases that will make specialists of every variety sigh and reluctantly realize that now they will have to do work, but if you deliver the news in a certain way, there is no push back, only acceptance.. students haven't picked up this jedi mind trick skill and therefore are totally disadvantaged, which really just puts patients at risk.

and yada yada to the cards guy who said they would routinely get ED c/s w/o the EM physician seeing the pt. You probably called at shift change and the on coming doc had sign out and didn't know the story. That or it's the worst ED in the country. More likely just plain ED hate, every floor/specialist resident at every hospital knows the ED call back number and likes nothing more to talk for years about every inappropriate cs they have ever received.. some sort of cathartic bitching. At my shop our cardiologists are salaried and therefore every non-insured pt w/ elevated troponin x 2 and CP has "troponin leak" and will refuse to even admit these pts with obvious NSTEMI. I basically have to beg to get them admitted.. guess what, 3x this year pts who cards tried to block admission i used my ninja consult skillz to put them up and they were cathed within 24 hrs..

What is the form and nature of this eclectic power, exactly? (i.e. what do you say?)

 

[Stellar Clouds]

as a med student you shouldn't routinely be calling consults.

Couldn't agree with you more. As a resident, I know my patients 8 million times better than I ever did as a medical student, yet I still have a tough time calling a consult and articulating reasonably as to why they should come see my patient (granted I have only been a resident for 2 weeks--I imagine this will improve dramatically over the next few months...and of course for the few I have called I didn't think a consult was necessary). If a medical student asks to call a consult, I'll be happy to let them give it a shot, but I don't think I will ever scut it off on them.

 

[e30ftw]

What is the form and nature of this eclectic power, exactly? (i.e. what do you say?)

to know this you must get inside the mind of the consultant.

there are several types of consults. Some are emergent like cath lab for intervention cards or massive upper GI bleed for GI. some are urgent, like an obstructing kidney stone for urology. Some are non-urgent, like "hey Gyn MD i have an uninsured pt w/ a 10cm ovarian cyst that i'm sending to your office in 1 wk".

Every type of consult has its own game plan and sequence of events that the average consultant likes to hear, you just have to know your consultants and what they want to hear then just give them that. You need to have a different level of intensity in your voice for each type of consult and let them know up front what you are expecting them to do.. like if I have a STEMI I say in slightly-excited-but-firm-and-calm-tone.. "this is Dr. badass in the ED I have Mr. my-heart-is-fckxed who has CP and 5mm concordant st elevation in anterior and lateral contiguous leads, he is a pt of Dr. cardiologist and needs to go to the cath lab asap. vss at this time" which is basically all that needs to be said.

for soft consults use phrases like, "the patient's ekg and cardiac markers are currently non-diagnostic however because of his history of X and clinical presentation he needs to be evaluated with provocative testing.." or "the 90 y/o female's current (normal) labs do not reflect their clinical presentation and due to family concern for recent gait disturbance they need to be admitted".

sometimes a little Socratic questioning is in order, like if Dr. my-yatch-is-only-30-ft-long-cardiology asks, "What makes you think this patients pain is cardiac related?" you can ask, "What makes you think it isn't cardiac?". This is an advanced technique and is only recommended for upper lvl residents/attendings as it may invoke anger.. lol.

like i said man there's a million different reasons to call consults and each has their own strategy.. you need to open with a short declarative sentence that lets the consultant know what they're going to have to do (ie, come see the pt emergently, admit them, see them 2 wks later in clinic, etc) and once you have that expectation set, then back it up with your clinical evidence.

 

[Kaustikos]

Well,
I just consulted a cardiologists/ordered a cardiology consult because of a patient with bigeminal/trigeminal PVC's, QT prolongation and even absent T waves. So... I don't think I'd need anything else to warrant their services.

 

[sacrament]

and yada yada to the cards guy who said they would routinely get ED c/s w/o the EM physician seeing the pt. You probably called at shift change and the on coming doc had sign out and didn't know the story. That or it's the worst ED in the country.

I'm the cards guy in question. This didn't just happen at shift change, it happened through out the day, almost every day. If you want to proclaim it to be the worst ED in the country, I for one would not argue with you. Of the ~10 EDs that I've had experience with, this was the worst. But these places exist, they are out there, and they will make you unhappy.

 

[punkedoutriffs]

to know this you must get inside the mind of the consultant.

there are several types of consults. Some are emergent like cath lab for intervention cards or massive upper GI bleed for GI. some are urgent, like an obstructing kidney stone for urology. Some are non-urgent, like "hey Gyn MD i have an uninsured pt w/ a 10cm ovarian cyst that i'm sending to your office in 1 wk".

Every type of consult has its own game plan and sequence of events that the average consultant likes to hear, you just have to know your consultants and what they want to hear then just give them that. You need to have a different level of intensity in your voice for each type of consult and let them know up front what you are expecting them to do.. like if I have a STEMI I say in slightly-excited-but-firm-and-calm-tone.. "this is Dr. badass in the ED I have Mr. my-heart-is-fckxed who has CP and 5mm concordant st elevation in anterior and lateral contiguous leads, he is a pt of Dr. cardiologist and needs to go to the cath lab asap. vss at this time" which is basically all that needs to be said.

for soft consults use phrases like, "the patient's ekg and cardiac markers are currently non-diagnostic however because of his history of X and clinical presentation he needs to be evaluated with provocative testing.." or "the 90 y/o female's current (normal) labs do not reflect their clinical presentation and due to family concern for recent gait disturbance they need to be admitted".

sometimes a little Socratic questioning is in order, like if Dr. my-yatch-is-only-30-ft-long-cardiology asks, "What makes you think this patients pain is cardiac related?" you can ask, "What makes you think it isn't cardiac?". This is an advanced technique and is only recommended for upper lvl residents/attendings as it may invoke anger.. lol.

like i said man there's a million different reasons to call consults and each has their own strategy.. you need to open with a short declarative sentence that lets the consultant know what they're going to have to do (ie, come see the pt emergently, admit them, see them 2 wks later in clinic, etc) and once you have that expectation set, then back it up with your clinical evidence.

I see. Thanks.