Reaching out to your referring physicians Part II – Consultation Etiquette

1. Reaching out to your referring physiciansPart II – Consultation Etiquette David E. Weissman, MD End-of-Life Palliative Education Resource Center (EPERC) Palliative Care Leadership Center (PCLC) Froedtert Hospital Medical College of Wisconsin

2. Learning Objectives • Review ten steps of effective palliative care consultations. • Learn five predictors of successful consultations. • Discuss two different approaches that will maximize your ability to be a patient/family advocate.

3. What is a successful consultation? • You have met the needs of your stakeholders: • Referring MD • Answered a question • Provided leadership in decision making and disposition planning • Guided improved symptom control • Provided psychological support • Patient/Family • Same

4. What is the same about PC? • Physician order driven. • Use of standard medical format: Hx/PE/Imp/Recommendation. • We serve at the pleasure of the primary MD. • Note: sometimes we forget this in our zeal to be patient advocates.

5. What is different about PC? • Referral questions are often “fuzzy”. • Patient-family unit poses unique challenges. • Greater emphasis on communication to achieve outcomes, rather than testing/procedures.

6. What is different about PC? • PC consultants feel a strong obligation (zeal) to provide leadership/advocacy in patient management decisions. • There is a correlation between the degree to which PC recommendations are followed, and hospital cost savings.

7. day of palliative care intervention mean reimbursement per day

8. Principles of Consultation Etiquette • Determine the question • Triage urgency • Gather your own data • Brevity • Specificity • Plan ahead • Honor turf • Teach with tact • Personal contact • Follow-up Goldman and Lee. Arch Intern Med. 1983

9. 1. Determine the question • Symptom issue • Decision making issue • Disposition issue • Support/Coping issue • All or some of the above Dr. Jones, how can we help you in the care of Ms. Smith?

10. 2. Triage urgency • Emergent • Pain out of control. • Urgent • Death likely within days, needs goal setting discussion. • Elective • Cancer progression on chemotherapy, starting “salvage” treatment; patient not coping well. Tip: Do the triage assessment yourself.

11. 3. Gather your own data • History and Physical examination • Lab and x-rays • Obtain outside info when needed • Correlate symptoms/signs to H and P • Make your own independent medical judgment

12. Example • 56 y/o with prostate CA; consult for back pain management. • Lumbar CT pre-consult shows bone mets; XRT called and planned. • PC consultant finds ankle clonus, suspects cord compression above L1, recommends MRI. • MRI finds large compression at T3 and T10; XRT fields changed.

13. 4. Brevity • Referral MDs typically read the Assessment/Recommendations; keep the other sections of your notes brief.

14. 5. Specificity • Consultants can increase hospital costs unnecessarily. • Fewer recommendations increase likelihood of compliance. • Recommendations should be Goal-Oriented; • focused solely on the issue or question; avoid temptation to expand outside the question.

15. Example • Impression: Patient is dying; prognosis 4-8 weeks. • Recommendations: • Family meeting for goal setting • Morphine 10 mg q2h prn dyspnea • Hospice referral

16. 6. Plan Ahead • Anticipate the next set of problems-- due to disease progression or side effects of recommended treatments. • Document suggestions for management.

17. Example • Impression: back pain from bone metastases • Recommendation: SR morphine 30 q12h. • Anticipate constipation: start MOM 1-2 tbsp q day.

18. 7. Honor turf • Remember you are only a consultant, and may be one of many. • Clarify your role early • Order writing for symptom control • Leadership for sensitive communication • Disposition planning

19. 8. Teach with tact • Every consult can be viewed as a teaching (and marketing) opportunity. • Clarity and brevity without condescension • Single reference when appropriate

20. 9. Personal Contact • Direct personal contact with referring MD before and after encounter. • Empathic support (Wow, this sounds like a tough problem) • Recommendations are more likely to be followed • Risk of misunderstanding reduced • Opportunity to teach • Do not use chart for arguments about care decisions.

21. 10. Follow-Up • Clarify your on-going role after initial assessment. • Follow-through on recommendations. • Monitor new lab/x-rays. • Sign-off when appropriate-talk first.

22. Improving Compliance with Recommendations • Prompt response (< 24 hrs) • Make specific and relevant recommendations • Limit number of recommendations (<5) • Identify critical recommendations • Use definitive language • Patient is dying not prognosis is poor Cohn, SL. Med Clin N Am. 2003

23. Improving Compliance • Specific drug dosage, route, frequency • Frequent follow-up • Direct verbal contact • Therapeutic (versus diagnostic) recommendations Cohn, SL. Med Clin N Am. 2003

24. Service StandardsFroedtert Hospital/MCW • Consult seen same day, or contact referring MD. • Daily contact with referring MD. • Invitation to MD/team to attend significant communication encounters. • Contact MD with significant changes in meds or disposition planning.

25. Finding the right balance • Tension between honoring the consultant role and serving as patient/family advocate. • Common situations where tension is highest • Need for emergent symptom control • You feel the need to broach sensitive topic to help patient/family move forward. • Patient/family broaches sensitive communication topic and referring MD is not present. • Prognosis • Role of future treatments

26. Plan Ahead—Option #1 • Passive • Would you like me to write orders for pain management? • Do you wish to be present for a family meeting? • If the patient asks about time, is it alright if I give my opinion?

27. Option #2 • Active • It may be more efficient if I write the analgesic orders, is that OK? • If the family asks me about time, I plan to give them my opinion; is that OK?

28. Option #3 • Aggressive • Don’t ask permission, only forgiveness. • When is this appropriate?? • Acute symptom control • Patient needs trump MD feelings • Patient/Family press for answers/discussion • Don’t ignore opportunities for meaningful discussion

29. Building Trust Remember; successful consultations are most likely to occur when the referring physician trusts the consultant to: a) make decisions/interventions that help the patient and family b) maintain the authority of the referring MD

30. Palliative Care Leadership Centers SM (PCLC) Medical College of Wisconsin Milwaukee, WI Fairview Health Services Minneapolis, MN Massey Cancer Center of the VCU Medical Center Richmond, VA Mount Carmel Health System Palliative Care Service Columbus, OH Palliative Care Center of the Bluegrass Lexington, KY University of California San Francisco, CA

31. New PCLC Curriculum for Academic Medical Centers • Regular PCLC Training + • Academic mentoring • Academic education planning • Content specific to the AMC • MCW • UCSF • VCU Medical Center To register, go to www.capc.org/pclc