Consultants role?

[opr8n]

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For those residents out there and attendings who have residents, how much of a role are you told to take in writing orders on a consult?

I mean obviously anything that directly pertains to the workup you need to perform would be fair game, and any complicated or advanced treatment plan as well

But what about dump consults?
Dr X who is a (fill in the blank) subspecialist surgeon does not want to deal with any problem but his own speciality despite the fact that a patient is admitted to him, so when his pt has unexplained abdominal pain, he consults gen surg. Is it the gen surg's responsibility manage the evryday care of that patient? Manage reflux? Manage UTI? Manage muscle spasm? Manage constipation? Or can Surgeon Dr X mange those things himself?

 

[Ronin2258]

When asking for a consult, the home team needs to know what they are asking. Experience with consults from my perspective is that the "dumps" from residents try to blather about it. One of ways to keep this in check is to stop said resident in their med-student presentation ("this is a XX-year-old COPDer, etc, etc...") and ask, "what is the surgical problem?" I want to know what they need me to do for this patient, then give me the specifics.

Good example of how a consult should be phrased:
-Resident or attending: I need an surgical consult regarding a pancreatic mass.
-Me: Sure. Give me some of the details.
-Resident or attending: I have a xx-year-old patient who is yellow from across the room, admitted for malaise and jaundice, found to have a 5cm mass in the pancreatic head on CT, with what appears to be lympadenopathy in the region. We would like to get your opinion on it, and see if immediate surgical intervention is required.

Someone who asks for a consult should give a simple, one sentence bullet of why you are needed, *then* give the details. I do this when I call for a consult.

When I ask for a consult on my patients, I want specific answers or treatments that are beyond my scope as (at the time,) a surgical resident. For example: Someone with acute MI post-op on a lap chole. Yes, the basics to treat, basic labs to start on, all of us should know what to do and when to start. Will a PCA, CABG, or medical management be the best route? My consult to cards on the phone would sound like, "I have an MI in progress in a post-op that we could use your advice on (the bullet question.) xx-year old male status post lap chole that has ongoing chest pain over the last few minutes. Enzymes and labs are running. There are definite EKG changes in the anterior leads from the pre-op EKG. We started the acute MI protocol (one was in place at my hospital,) and would like to know if there is an indication for PCA vs. medical management or other options."

The thing is, and I teach every intern that calls, is that a consult answers questions or recommends things that are specific to the field you are asking. As surgeons, are we going to rush to that patient to the OR tonight for a perforated bowel? Are we going to wait until the acute condition that brought them to your service has resolved before we do something invasive that would aggravate that condition? Or will what we have to offer as surgeons give your patient a better chance of getting out of the hospital? Or is there anything we can do at all (there have been some futile consults in terminal stages.)

Things that would feel like dumps:
-First episode of diverticulitis, with no free air (a resident or intern would call the consult.) Our medicine residents would try and make us take them to the OR, and thereby transfer the patient to our service, or at least take them on our service. This was without even trying antibiotic management for the first episode. Medicine attendings were comfortable treating a first episode, and would ask us to arrange surgery follow-up at discharge to keep the patient in the loop.
-Central lines. PICCs were placed by IR, portacaths, et al, were placed by vascular. Subclavians, IJs, and femorals, surgery consults got called. Our medicine residents were academically good, but were scared witless with the idea of placing a central line. Tied up the consult surgical resident for a bit, considering we had the full gown and glove by the bedside protocol. As a consultant, and as a higher ranking resident who was qualified for central lines, I would take the intern that called me into it and have them place it with me gowned and gloved mentoring them. Mean? Perhaps. But the medicine attendings would back us on doing this, because all residents in the hospital had to be certified to do central lines. A second year medicine resident or higher, well, I was SOL. But the procedure note was made in the chart for attending review in the morning.

Things that attract my attention as a surgical consultant (and these have been ones I have been called on):
-"I have a patient with no surgical scars with free air under the diaphragm in an upright and hypotensive." Run. (had two of these at once; one a perforated ulcer, one a complication of a colon rupture from air from a colonoscopy.)
-"I have a ruptured AAA with complaints of ripping belly pain." Bolt. Do not stop to the bathroom en route. Check the scan, briefly see and examine the patient. Spin up the attending on-call and OR/Anesthesia. Dictate the H&P if available. Wait patiently for the attending then rush to OR. (The senior on-call with me was in a case, and if wasn't for his (un)timely* finishing of his case, I would have been assisting or actually REPAIRING this rupture with the on-call vascular surgeon (the PD at the time.))
-Satellite hospital ED: "We have a XX-year-old healthy young man who was a victim of a stabbing assault. Patient is unconscious, intubated, being packed, coded once, brought back, still unresponsive, but stable to make a transport attempt. What would you like on-board the ambulance?" Answer: "Make sure you send at least 4 units of o-neg blood for the 20 minute trip, please."

A lot of the people calling for consults will get better at framing things as the year goes on.

*Grant me some cockiness here. I was both thrilled and terrified I would be the only one available to do a AAA repair as a PGY-2. I knew the boss would be doing most of it if it was just me, and in hindsight, as much as I would have been the envy of the other PGY-2s for landing such a sexy case, I was glad my senior was available. 🙂

 

[SLUser11]

For those residents out there and attendings who have residents, how much of a role are you told to take in writing orders on a consult?

I mean obviously anything that directly pertains to the workup you need to perform would be fair game, and any complicated or advanced treatment plan as well

But what about dump consults?
Dr X who is a (fill in the blank) subspecialist surgeon does not want to deal with any problem but his own speciality despite the fact that a patient is admitted to him, so when his pt has unexplained abdominal pain, he consults gen surg. Is it the gen surg's responsibility manage the evryday care of that patient? Manage reflux? Manage UTI? Manage muscle spasm? Manage constipation? Or can Surgeon Dr X mange those things himself?

I think this is different everywhere. I've worked some places where the consultants could only leave recommendations, and the orders were all left to the primary team, etc. However, in private practice, I've experienced that it's sort of a free-for-all, and chart wars can definitely occur.

I like the way we do it here, which is simply that surgery is in charge, consulted or primary. It eliminates confusion. Is it practical for a private practice surgeon? No, but it's beneficial to the residency program....

 

[njbmd]

For those residents out there and attendings who have residents, how much of a role are you told to take in writing orders on a consult?

I mean obviously anything that directly pertains to the workup you need to perform would be fair game, and any complicated or advanced treatment plan as well

But what about dump consults?
Dr X who is a (fill in the blank) subspecialist surgeon does not want to deal with any problem but his own speciality despite the fact that a patient is admitted to him, so when his pt has unexplained abdominal pain, he consults gen surg. Is it the gen surg's responsibility manage the evryday care of that patient? Manage reflux? Manage UTI? Manage muscle spasm? Manage constipation? Or can Surgeon Dr X mange those things himself?

When asking for a consult, the home team needs to know what they are asking. Experience with consults from my perspective is that the "dumps" from residents try to blather about it. One of ways to keep this in check is to stop said resident in their med-student presentation ("this is a XX-year-old COPDer, etc, etc...") and ask, "what is the surgical problem?" I want to know what they need me to do for this patient, then give me the specifics.

As Ronin said above, the physician that consulted you should be able to explain why they need your input. There are folks who consult for "management" because they don't want to be bothered but in my experience, they are in the minority. If this is what they want, then I can oblige if it's within my scope of practice. In short, you shouldn't have to guess your role in the care of the patient.

If I consult another service, I personally speak with the consultant (as early as possible) and discuss what I need from them. If they offer to "follow" the patient with me, they generally discuss (with me or the senior resident on my service)any orders that they want to write if I am the attending of record, before they write them. We strive to keep good communications face to face rather than "chart wars" which do not look good from a legal standpoint.

I know that the residents on the team hate what appears to be " a dump" but once you get into practice, you will often see other perspectives. Still, sometimes, patients are "dumped" and there is no other perspective. I certainly remember residency quite well in this respect. If I generally take over the management of a pateint, it usually because we have performed a case and will manage from there on out. We don't usually get to many objections from the team that consulted us if that happens.

 

[Ronin2258]

Orders on consults: depends on the rules of the hospital/interservice agreements. I would ask permission if I needed something. Either the home team would write it, or I would be given the green light to write it myself. When it was my patient they were consulted on, the same courtesy was given. One caveat: Some orders can only be processed if written by the consulting team (for my hospital, GI attendings had to order an IBD panel.) They were nice enough to let us know beforehand.

I know that the residents on the team hate what appears to be " a dump" but once you get into practice, you will often see other perspectives. Still, sometimes, patients are "dumped" and there is no other perspective. I certainly remember residency quite well in this respect. If I generally take over the management of a pateint, it usually because we have performed a case and will manage from there on out. We don't usually get to many objections from the team that consulted us if that happens.

When we got the word from attendings of accepting a "dump," it was a great teaching point of the why it was accepted. Definitely gave a perspective of things, and defused the potential frustration. Both made things run quite a bit smoother.

Taking the primary team role after a case is a definite. There are times the primary team is so frustrated with the patient progress, they would gladly resume primary team status, usually because the procedure would eliminate some of the problems they were having to begin with.

The ones that always got to me were the futile consults. The pleasant, languishing, brittle patients that had a 90% chance of dying en route to the OR to fix, and an even slimmer chance of making it back to the ICU alive. There are times that both the attending and I would look at a consult and look at each other going, "there isn't jack s*** we can do for this poor guy/gal aside from watch them pass." We were just there for the completeness of care.

 

[maxheadroom]

Orders on consults: depends on the rules of the hospital/interservice agreements. I would ask permission if I needed something. Either the home team would write it, or I would be given the green light to write it myself. When it was my patient they were consulted on, the same courtesy was given. One caveat: Some orders can only be processed if written by the consulting team (for my hospital, GI attendings had to order an IBD panel.) They were nice enough to let us know beforehand.

Orders on consults vary widely among institutions. I've been at places where only the primary team wrote orders and places where it was a free-for-all. My current place has a consult sheet that the primary team fills out. It has three boxes:

1. Make recommendations
2. Evaluate and Treat
3. Assume care

It's really nice to have the primary tell me what they want from me regarding my level of participation. Similarly, I like to tell my consultants exactly what problems I want them to address and if I need to clear any particular orders (anti-coagulation is a frequent argument).

 

[Dr.LeoSpaceman]

After a measely 2 weeks of covering consults, I can say that at my institution, it seems to be that as a consulting service we will handle anything that might relate to the reason for consult. For a legitimate consult, that can mean doing things on a day-to-day basis (including entering the orders for more complex patients). For the dump consult, they're going to get an initial workup and some recommendations, with a follow-up stop on rounds the next day. Then they're on their own. If the primary team has further questions, they can call.

On a side note, relating to people knowing what they're calling for, I really wish people woudn't throw around terms like "peritonitis" and "toxic megacolon" like they are just another thing on some unexhaustable list of possibilities.

 

[opr8n]

Dr X who is a (fill in the blank) subspecialist surgeon does not want to deal with any problem but his own speciality despite the fact that a patient is admitted to him, so when his pt has unexplained abdominal pain, he consults gen surg. Is it the gen surg's responsibility manage the everyday care of that patient? Manage reflux? Manage UTI? Manage muscle spasm? Manage constipation? Or can Surgeon Dr X mange those things himself?

So my question really focuses on this particular scenario .. any comments on this situation (i know ive kind of generalized it a little). Keep in mind Dr X did not call the consult to the attending surgeon or resident, the floor HUC did, and no specific instructions were left regarding when level of participation that was expected.