Consult with confidence

Consulting on patients admitted to other specialties has become routine for many hospitalists, but most have had little if any training in this area.

Consulting on the care of patients admitted to other specialties has become a routine task for many hospitalists. Yet most physicians have had little training, if any, on how to be a consultant, according to Geno J. Merli, FACP, who led a session on medical consultation during the Society of Hospital Medicine's annual meeting in April.

“It's just assumed that we're all good at this, and you know what, we're not all good at it,” said Dr. Merli, who is a professor of medicine and chief medical officer (CMO) at Thomas Jefferson University Hospital in Philadelphia.

Attendees listen to a panel discussion on health care reform at Hospital Medicine 2010
Attendees listen to a panel discussion on health care reform at Hospital Medicine 2010.

To improve hospitalists' consultative skills, Dr. Merli offered a list of tips, or “commandments,” during the session.

Be prompt and communicate

His first priority for consultants is timeliness in responding to a request. At Jefferson, this advice is actually a requirement in the hospital bylaws. “They have to be done within 24 hours, or if they're emergent, they need to be done immediately,” said Dr. Merli.

Rapid response may sometimes be inconvenient for a consultant, but a delay could extend length of stay and negatively impact patient care, Dr. Merli said. “If the consult comes at 5 o’clock—the resident is leaving and it's only you—you need to stay and do that consult, so that that patient can move on in the process of care. If you wait until the next day, and the resident does the consult at 8 o’clock, and you round a little later, now a whole day has gone by.”

Effective communication is another key to good consulting, beginning with a clear understanding of the reason for the consult. “If you're not sure what the consult was called for, then you need to talk to the person to find out what they need,” Dr. Merli said. He recommends communicating with the attending, but acknowledged that sometimes it's necessary to work through residents.

“That's OK, as long as that communication is good. I can't stress enough: If you communicate, things won't fall through the cracks,” he said. (Dr. Merli offered an additional note on communicating with residents on the subspecialties: “You can teach, but teach in a tactful way.”)

Be consistent

Communication among hospitalists is also necessary to fulfill Dr. Merli's requirement for consistency among consultants on a service. “Everyone has to have consistent management recommendations. You can't have Hospitalist A using aspirin as DVT [deep venous thrombosis] prophylaxis and Hospitalist B using Coumadin and Hospitalist C using low-molecular-weight heparin,” he said.

A consistent style for reporting the results of a consultation will also make the process run more smoothly. At Jefferson, a basic form listing the reason for the consultation, a few impressions and a few recommendations is the norm. One should never say a patient is “cleared for surgery,” but it's acceptable to include percentages assessing the patient's risk for complications, or to describe him or her as “optimized for surgery,” Dr. Merli said.

“Simple is best,” he said. “I don't want to see the long history and physical. When I review a chart, I like to see the recommendations; then I look at the H&P in the back.”

Be thorough

Although the report should be simple, the evaluation should be thorough, including a good history, physical and review of pertinent medical records, Dr. Merli advised. “Doing this thorough assessment is your responsibility,” he said. The medical consult should be designed to prevent not only an avoidable bad outcome (and possible resulting lawsuit), but also the necessity of rescheduling surgery at the last minute because a medication wasn't stopped or a patient's blood sugar was too high, for example.

“We cannot have surgery canceled the day of the procedure because we didn't do a thorough history and physical and get the data. This is a ‘never event’ for me as the CMO,” said Dr. Merli.

In making recommendations, consultants should consider not only pre-surgical issues, such as stopping medications, but also potential post-op issues, such as blood sugar control and DVT prophylaxis. Dr. Merli reviews all of the morbidity and mortality reports from his hospital to assess whether these issues were covered. “My first look is what did the medical consultant recommend,” he said.

Follow up

Sometimes effective consulting will require additional involvement after surgery. This possibility can be addressed in the consultant's report, with a note like “I will reassess the status with you.” Of course, once you write that, then you're obligated to keep on top of the case. “When you've built a big consult service, it could be as big as your medical service. The weekends could become brutal managing the follow-up,” warned Dr. Merli.

A hospitalist's responsibility for follow-up may depend on his or her role with the subspecialty patients. “Are you a pure consultant or a comanager? This is very important,” said Dr. Merli. Unappealing as it may sound to some, consultants should think of themselves as “servants” providing good service to their customers, Dr. Merli advised. “If you think of yourself as a servant, your mindset is that you're going to be very flexible.”

Unlike consultants, comanaging hospitalists are typically expected to see the patient every day until discharge, said Dr. Merli. Either way, the chart should clearly indicate your current status with the patient. “If you're not coming back, you need to write in the chart that you're no longer following the patient,” he said. “But if they need anything else, leave your number.” He also recommends a phone call to the attending or resident subspecialist, as an extra courtesy to make it totally clear that you are signing off.

The benefits of following these steps and providing good consults include better patient care and fruitful relationships with subspecialists, said Dr. Merli: “If you do this well, you'll get a lot of business.”

And soon sticks as well as carrots may be employed in the evaluation of consultation, Dr. Merli added. “Probably in a year at our place, we're going to actually measure: Did you answer that consult in a timely manner? Did you communicate with the clinician requesting the consult? The harder thing to get at is the actual consult recommendation, but we're going to have to do that in a systematic way,” he said.

The Joint Commission may also start to take an interest in the subject. “No one has scrutinized medical consultation,” Dr. Merli noted. “I think they're going to start looking at medical consultation as part of the medical care delivered, because medical consultants are an important part of the delivery of care.”