01 - 490 Approach to Medical Consultation

490 Approach to Medical Consultation

Jeffrey S. Berns, Jack Ende

Approach to Medical Consultation Effective health care requires teams of generalists and specialists with complementary expertise. Many clinical conditions require the input of more than one clinical provider, either because the diagnosis and recommended treatment is uncertain or because the required diagnos­ tic procedure or management lie outside the principal provider’s area of expertise. To consult is to seek advice from someone with expertise in a par­ ticular area, whereas consultation refers to the meeting or comparable outcome arising from that request. Medical consultation takes several forms. Its most traditional forms include in-hospital consultation, in which physicians provide recommendations, typically recorded in the medical record, or perform procedures for a hospitalized patient, and outpatient consultations, in which patients are seen in the office setting. More contemporary forms of consultation include e-consultations, telemedicine evaluations (see “Consultation Involving Telemedicine,” below), and remote medical second opinions. In these forms, the consultant may not actually see the patient but, nonetheless, assumes the responsibility of evaluating the patient’s clinical condition, assessing and analyzing pertinent clinical data, and offering a synthesis and appropriate recommendations. While forms of medical consultation evolve, basic responsibilities associated with medical consultation endure. These responsibilities can be divided into those that fall to the requesting physician or non­ physician practitioner; the consultant, who provides the consultation; and the health system, hospital, or organization that must support this important medical encounter (Table 490-1). ■ ■RESPONSIBILITIES OF THE REQUESTING CLINICIAN Before requesting a consultation, the physician or other provider should ensure that the patient endorses the purpose of the consulta­ tion, understands the role of the consultant, and anticipates the likely outcomes of the encounter. Further responsibilities of the requesting physician include being specific and communicating clearly the reason for the consultation. Vague messages such as “Please evaluate” are not TABLE 490-1  Stakeholder Responsibilities in the Medical Consultation Process REFERRING PHYSICIAN OR PROVIDER CONSULTANT PHYSICIAN HEALTH SYSTEM, HOSPITAL, OR CARE ORGANIZATION • Ensure patient • Maintain standards of • Maintain adequate participation and engagement • Be specific professionalism, including those pertaining to availability, communication, respect, and collegiality • Appreciate levels of urgency specialty workforce to enable appropriate access • Support systems regarding clinical question and desired outcome • Communicate level and respond appropriately • Assemble and develop one’s for efficient exchange of clinical information • Develop culture of urgency • Avoid consulting own database • Be specific in synthesis and of collegiality and team-based care for nonclinical purposes recommendations • Understand desired outcomes, including arrangements for follow-up • Communicate with referring provider in whatever manner is mutually desirable

Consultative Medicine PART 19 as helpful as more specific inquiries such as “What is the cause of the declining kidney function?” or “How should this asymptomatic pulmo­ nary nodule be evaluated?” To the extent possible, the requesting phy­ sician should provide the relevant clinical information, summarized as succinctly as possible. Urgency should be clearly conveyed, typically with a phone call or other direct communication. The requesting physician should be explicit regarding the intended outcome of the consultation, i.e., is this for a single evaluation or ongoing co-management? Communication between the requesting and the consulting physicians is paramount. Whether this communi­ cation includes direct contact is less important than that the relevant information and desired outcome be explicit and clear, regardless of communication medium. Consultations should be requested for clini­ cal purposes and always directed to qualified consultants; they should not be driven by entrepreneurial or relationship-building purposes. Another responsibility of the referring physician is not to “overconsult.” Medical care should be focused on value, not volume. ■ ■RESPONSIBILITIES OF THE CONSULTANT Just as the referring physician should attend to clear and explicit com­ munication, so too should the consultant follow the precepts of effective interactions between professionals, which include courtesy, availability, and clarity. Particularly on the inpatient service, where consultants may receive several requests each day, it is important that the incom­ ing consultations are triaged and dispatched as clinically appropriate. Consultants also need to determine the requested level of involvement going forward and not assume that long-term co-management is being sought. While consultants can and should make use of available clini­ cal data, they should also assemble independently their own database, including taking a history, performing a physical exam, and reviewing pertinent laboratory, imaging, and pathology studies. Absent that, they may be unable to provide an independent and actionable synthesis. Just as the referring physician needs to be clear and concise, so too should the consultant be specific and focused in the recommendations pro­ vided. “Possible malignant ascites” is less helpful than, “I will arrange for paracentesis to exclude the possibility of malignant ascites.” For the most part, recommendations to “consider” some diagnosis or test are less helpful than more specific and concrete advice. Some referring physicians wish to be called after a patient is seen; others prefer that communication be handled as part of the medical record. How this communication is handled must also align with the complexity and urgency of the consultation and clinical circumstances. ■ ■RESPONSIBILITIES OF HEALTH SYSTEMS, HOSPITALS, AND MEDICAL ORGANIZATIONS Health systems, hospitals, and medical organizations also have respon­ sibilities in the consultation process. This responsibility includes ensuring that qualified consultants are accessible and available on the medical staff. Consultations within a single system are aided by common shared electronic medical records, particularly when con­ sultations originate in the hospital, but then also involve care in the outpatient setting. Finally, health care entities should strive to foster a culture of team-based care and collegiality. Reimbursement for con­ sultations varies among payors and may have implications for self-pay or unreimbursed expenses for providers or health systems. While it is important to understand reimbursement models, the clinical needs of the patient should be prioritized. ■ ■SPECIAL ISSUES IN MEDICAL CONSULTATION Curbside Consults  Curbside consults are requests from one physician to another for an informal and unwritten opinion about a specific patient care matter. They are typically limited in scope, mostly regarding management or questions regarding procedures, and devel­ oped from information provided by the consulting physician and per­ haps the medical record (such as labs and imaging studies). Although