# 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