Interdepartmental Interactions and Dealing with Consultants

1. Interdepartmental Interactions and Dealing with Consultants Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.

2. Published Reference Citation Holliman, C.J. : The Art of Dealing With Consultants. J. Emer. Med. 1993; 11 : 633-640. First presented at Pa. ACEP "High Anxiety" Seminars Dec. 1991 & Jan. 1993, and as EM Grand Rounds at Johns Hopkins, Einstein, Pittsburgh, etc., and as part of the new EM resident orientation at Penn State University.

3. Definition of "Consultant" • Any fellow physician whom an emergency physician would call by telephone or otherwise contact regarding patient care or patient information.

4. Why talk about this topic ? • Is applicable to the “Professionalism” and “Communications and Interpersonal Issues” components of Emergency Medicine (EM) curricula. • Not discussed at length in most standard EM texts. • Avoid the "error" part of "trial & error" learning. • Makes work interactions less stressful. • ? results in better patient care

5. Avoidable Events That Irritate Consultants • Insufficient workup completed before phone call made. • Being called when not on call. • The patient "belongs" to another physician. • Receiving calls at inappropriate times. • Calling other consultants or "sub-consultants" first on the same case.

6. Avoiding Calling Consults After Insufficient Workup • Example : Chest Pain : • History : most important admission criteria ; note major contraindications to thrombolysis. • Physical exam : check for chest wall tenderness ; consider awaiting lab (lipase) if abdomen tender. • EKG : Compare to old EKG ; Consider requesting FAX of old EKG. • Chest X-ray (CXR) : Await if may change diagnosis ( ? pneumothorax or aortic dissection) ; compare to old CXR. • Lab : usually NOT critical before call ; CBC almost always not relevant.

7. Avoiding Calling Consults After Insufficient Workup (cont.) • Example : Abdominal Pain : • History : be sure to determine prior surgeries & what time the patient last took anything by mouth (PO). • Physical Exam : Early call prior to other data being available may be appropriate if marked findings ; be sure to include pelvic exam findings. • Lab : often should await urinalysis, lipase, or pregnancy test before call ; WBC value typically useless ; Hematocrit may be important. • X-ray : await if chance of free air or SBO.

8. Avoiding Calling Consultants After Insufficient Workup (cont.) • Example : Trauma : • Per protocol may be OK to call early if patient potentially unstable. • If stable : • Check neurovascular exam all limbs. • Get all X-rays done. • When X-rays done & interpreted, consult specialties per department protocol.

9. Avoiding Calling Consultants After Insufficient Workup (cont.) • Old chart availability : • If patient is stable & history is unclear, await obtaining old chart for review. • May call private practice office & request limited data from office staff. • May call pharmacy for medication identification. • Notify consultant at time of call if old chart truly not available.

10. If Potentially Multiple Consultants On Same Case Are Needed • Identify primary consultant & call first. • If Emergency Department (ED) protocol requires concurrent different consultants, notify each one that protocol was used. • Examples : • GI bleed : surgery & gastroenterology • SAH : neurology & neurosurgery • Renal transplant complication : nephrology & transplant surgery • Spine fracture : orthopedics & neurosurgery

11. Avoiding Calling Consultants Who Are Not Currently On Call • Make all calls through secretary or phone operator. • Deflects blame if wrong consultant called • Double - check on-call list first. • Verify daily that the on-call list is updated. • Have mechanism to ensure changes in the on-call list are recorded.

12. What to Do if Consultant Denies Being On-Call & Refuses to Deal With the Case • Should have back-up mechanism available thru ED policy or hospital by-laws : • Call another consultant of same specialty • Call department chairman • Call Chief of Medical Staff • Call hospital administrator • Admit the patient yourself • Transfer the patient to another facility

13. Avoiding Calling Consultants When the Patient "Belongs" to Another Physician • Ask patient directly if under care already. • Don't "cross patients over" between competing groups. • Know which doctors are in which groups. • Document if patient himself requests a new referral.

14. Avoiding Calling Consultants at "Inconvenient" Times • May need to call earlier than usual (before workup is complete). • Call before they go home from hospital or office. • Know or check their usual hospital or office hours. • Avoid call in normal sleep time (? 0130 to 0500) : • Call earlier (i.e., 2300 vs. 0200) • Delay 0400 calls until 0600 to 0630 • Only if patient is stable, ED patient flow not compromised, & patient OK to wait.

15. Avoid "Irritating" Multiple Calls to Consultants • If consultant already called & is coming in to ED, hold second call. • Unless new info is truly emergent, or consultant has 3 or more patients to see. • Avoid multiple "single-topic" calls in quick succession to same consultant. • Multiple calls may greatly disrupt his office schedule.

16. Know Your Consultants • Have list available in ED : • Members denoted by group & specialty • Office telephone #'s • Home telephone #'s • Beeper #'s • Find out which groups are competing or do not share patients. • Find out if consultant prefers ED call his answering service, or direct call to office or home, etc.

17. Know Your Consultants (cont.) • Generate a consultant preference list (denoting which other physicians your consultants utilize as their own consultants). • Obtain this information by phone. • Keep this list in secure place not accessible to rest of ED staff. • Update list as required. • Note if consultant will keep new patient or refer back. • If consultant does not want to commit to a written preference, then call him for each referral situation.

18. Know Your Consultants (cont.) • "Geographic" consultant data to have available in the ED : • Usual office hours • Office addresses • Days of week patients are seen in different offices by the same group • Distribution or types of patient problems seen in separate offices or clinics • Special equipment available in different offices

19. Know Your Consultants (cont.) • Determine each consultant's scope of practice : • Primary Care physicians • ? remove sutures or do wound checks • ? followup orthopedic injuries • ? followup gyn or ophthalmic cases • ? have admission privileges • ? have ICU privileges • Subspecialists • ? manage patients solo or act as secondary consultant • ? follow patients post - discharge • ? manage all age groups or just adults

20. Know Your Consultants (cont.) • Determine the capabilities of the hospital : • If hospital not properly equipped, certain cases may need to be transferred from ED rather than admitted (despite capability of the consultant) ; examples : • Neonates to neonatal ICU • Complicated Ob cases ( watch out for COBRA) • Need for CPB backup capability • Major trauma • If case meets referral criteria & stabilizing procedure by consultant not needed prior to transfer, usually OK to transfer without calling consultant.

21. Summary of Items to Record on the "Consultant Preference Form" • Name / group or cross-coverage members • Hospital / HMO affiliations • Office address(es) / office hours • Office & home phone #'s, beeper #'s • Preferred method of call (service vs. home) • "Secondary" consultant preference list • Specify each specialty & rank # preference • Scope of practice / Followup practices • Problem-specific followup times

23. What To Say On The Phone • Brief report usually best if consultant knows & trusts the ED physician. • Emphasize early the reason for the call (especially if not for admission) : • Advice only • Perform specific procedure • Additional opinion • Proper disposition unclear • Obvious admission

24. Phone Consults : Additional Considerations • Warn consultant if report needs to be long. • For orthopedic cases : • Have X-rays on viewbox or screen ready • Have ruler, +/- goniometer available • Know fracture description terminology • For other cases : • Have EKG & lab reports in hand. • If admission : focus early on reasons to admit. • If you are uncertain as to proper disposition (admit versus discharge) then emphasize the aspects of the case that make this decision difficult.

25. Types (Classification) of Consults • Consults for advice • Consults for admission • Consults to verify that the patient can be discharged • Consults for management (or for performance of specific procedures) • Consults to arrange followup • Consults for "information relay"

26. Consults for Advice • Need for these should decrease with experience. • Determine "practice style" features for individual consultants : • Standard workup components ( examples : pediatric fevers, renal stones, etc.) • Admission criteria or "thresholds" (high vs. low, as for pyelonephritis, PID, pneumonia, etc.) • Followup visit timing • Avoid asking advice easily available from PDR or standard texts.

27. Consults for Admission • Probably most common reason to call consultant. • Emphasize “the patient needs to be admitted" early in the call. • If need for admission is unclear, don't be adamant regarding admission, but have consultant see the patient (pt.) in ED & decide on admission. • If disposition of the patient is disputed, consultant must come in & see pt. in ED.

28. Consults for "Verification of Suitability of Discharge" • Consider this type of consult on any patient whose disposition "makes you nervous" and on whom you wish to share disposition liability : • Atypical chest pain • RLQ abdominal pain • LOC / persistent headache from trauma • New onset seizure • TIA • Croup • Decide with consultant if only "phone blessing" or instead exam by consultant in ED needed.

29. Consults for Management or Procedures • State if patient directly requested subspecialist referral for procedure. • If "wallet biopsy" determines if consultant does procedure, then check source of payment before call. • If pt. to be transferred, may still need consultant for stabilization procedures. • Decide with consultant if pt. is to return to ED for followup of procedure or to consultant.

30. Consults for Followup (F/U) • Routinely call consultant if followup needed in < 3 days (? unless can FAX ED chart to office). • Delay call till convenient hour if is at night and followup is nonemergent . • Record pt's phone # in case consultant wants earlier F/U than you told pt. prior to D/C from ED. • Know your consultant's F/U preferences : • ? notify about cases only needing prn F/U • ? time intervals for F/U for specific problems

31. Other Aspects of Followup • Don't make scheduled F/U visits for problems that should fully resolve & not need specific F/U ("not everybody in the ED needs scheduled followup"). • Consider giving pt. info on his ED visit : • Xerox of ED chart • Xerox of EKG, lab, +/- X-ray findings • Computerized detailed D/C instructions • Consider FAXing copy of ED chart to consultant's office.

32. Consults for "Information Relay" • These are not really consults but just are notification that a patient was seen in the ED. • Should make calls to consultant for : • Pt. needs scheduled but nonemergent F/U • Pt. admitted to another service (if consultant doesn't have admission privileges) • Pt. dies or has life-threatening problem • Pt. unhappy with care by consultant • Pt. insisted on referral to subspecialist • ? for any of consultant's pts. seen in ED (even if discharged or only need prn F/U) ; find out consultant's preference about calls for night visits.

33. "Trade-Offs" with Consultants • Consultants should accept ED consults and admissions. • ED physicians should accept all referrals to ED from consultants. • Even if problem turns out to be minor. • Remember pts. may describe symptoms differently on phone to consultant than they do in the ED. • Consultants can't be expected to see every pt. that calls them (especially at night). • Avoid writing admission orders (per ACEP policy) : have consultant leave phone orders with ED nurse.

34. "Assistive Trade-Offs" with Consultants • Go ahead in ED with simple facilitating procedures : • Cultures • Blood draws • X-rays prior to going to inpatient bed • First dose of IV meds • If patient is clearly stable, then don't insist on emergent exam by consultant.

35. Don't Get Taken Advantage Of ! • If consultant requests you to see a patient he is also coming to see, then bill for your exam. • If pt. is direct admit, then don't stop in ED unless unstable (less liability if direct admits don't even come into the hospital via the ED). • If no other in-house physicians, is OK for ED physician to do death pronunciations on inpatients (the inpatient doctor should call the family though). • But avoid time-consuming care for inpatients. • Establish policy for ED coverage of "uncovered" deliveries in the obstetrics ward.

36. Considerations for Consults in Academic Medical Centers • Choice of who to call for consults : • 4th year student or intern as " on first call" • Specialty resident • Specialty fellow • Specialty attending • If call from ED made by a person in training, they should emphasize that the case was already discussed with the ED attending. • ED attending should make consult call himself if person in training does not have a good grasp of the case.

37. Consults in Academic Centers (cont.) • Consults for "information relay" to residents (regarding clinic F/U) are usually useless. • Determine case distribution to subspecialty services versus (vs.) general services. • Be honest with pt. re training level of consultant. • Generally, avoid referring pt. to subspecialty clinic without checking with pt's primary care physician first. • Determine if referral attendings follow individual pts. or refer cases to whichever attending is "on-service" for the month.

38. Consults in Academic Centers (cont.) • Develop referral system for cases "overlapping" two specialties : • Facial lacerations : Plastics vs. ENT • Hand trauma : Plastics vs. Orthopedics • Spine trauma : Orthopedics vs. Neurosurgery • Nonemergent chest tubes : General vs. Thoracic Surgery • Burns : Plastics vs. General Surgery • Oral trauma : Oral Surgery vs. ENT

39. "Helpful Politics" With Consultants • Don't criticize the consultant in front of the patient. • Generally should have phone conversations with consultants out of earshot of the pt. • Don't point out consultant mistakes "in public“. • Notify consultant if any event with his pt. requires notification of hospital risk management. • Preface calls with mild apology if late at night • Can deflect blame for timing on the pt.

40. More "Helpful Politics" with Consultants • Avoid making multiple phone calls to same consultant in short period of time (may disrupt his office schedule). • If consultant already coming in to ED to see one pt., usually do not need to call regarding 2nd pt. (unless need to speed up consultant response). • Time calls around conferences & meetings that the consultant attends.

41. Other Political Considerations With Consultants • Goals : • Increase your visibility • Develop friendships with consultants • Means : • Serve on hospital committees (initially avoid potentially controversial committees like Credentials) • Have lunch in hospital cafeteria • Attend staff social functions • Participate in staff conferences • Donate to hospital charities • Consult the consultants about ED protocols that affect their specialty

42. Instructional Module on Consultant Communications • Reported as abstract # 315 at 1994 SAEM meeting. • Frohna WJ: "Effectively communicating with consultants : an instructional module", Academic Emer Med 1994; 1(2): A105. • From Madigan Army Medical Center, Tacoma, Washington. • Is a 2 to 3 hour program for EM-1's involving lecture, role playing, & listening to tapes of recorded interactions.

43. The Art of Dealing With Consultants : Summary • First priority in dealing with consultants is quality patient care ("do what is right"). • Know your consultants' practice patterns and philosophies. • Make clear the reason for the consultation. • Be concise. • Interact in a "give and take" fashion.