Better Consultations

A while back a reader asked the following question:

"How do you get them to buy in? as a resident in a surgical specialty, I'd love the EM residents to give better referrals, but often they want nothing more than to sell the patient and move the meat."

This immediately made me think of a lecture given by Emergency Medicine Superstar Chad Kessler.  He actually has a research paper on the way studying the effect of his approach that I'm looking forward to reading.  In the mean time, I'll settle for listening to him lecture, repeatedly, again and again, on consultation skills.  In his lecture, he offers up some consultation pearls that we would all benefit from learning:

The Five "C's" of Consultation

1. Contact: This is where you call your consultant.  Before picking up the phone, make sure you need the consultation.  I'm currently a dedicated night doc.  When admitting a patient to a medical service, the accepting physician will often ask me to "consult" service x,y, or z.  Knowing when to simply write an order for a "routine" consultation versus calling each service in the middle of the night goes a long way towards improving your relationship with each service.  When you call appropriately, they begin to recognize that when you call, you need them.

When first making contact, make sure to identify yourself and get their identity as well.

2. Communicate: Once you've made contact, tell them about the patient.  The level of detail will vary by specialty.  Surgery often needs a one liner while medicine wants a thorough review of the patient.

3. Core Question: Here's the money issue: What do you need?  Be as specific as possible.  "I need you to admit this patient for fluids and antibiotics," or "I need you to take the patient for emergent cardiac catheterization."

4. Collaborate: Let your consultant digest the information presented and respond with their needs.  They may need you to order additional tests, call in the cath team, etc.  I've found that this are is where the consultation can quickly break down, especially with the uber-specialists.  Their plan may deviate from what you believe the patient needs.  You may need to take a quick time out and engage in some shared problem solving.  I find this to be most true when they're asking for a test to "stall" the need to see the patient.

For example:
"I have a patient with a fever, back pain, and loss of sensation in the L4 distribution who I think has an epidural abscess.  I need you to come and evaluate him for operative drainage."

"Order the MRI and call me back after the results."

Unfortunately, this behavior delays the needed evaluation.

Shared problem solving allows you to advocate for the patient and get them to the person they need to see.  For example: "How about you send your resident or PA down to get a quick baseline neurologic exam while I order the bed, the MRI, and antibiotics after a set of cultures."

5. Close the loop:  Take the time to repeat the plan back.  Letting them hear it allows for correction of errors or the addition of something that they may have forgotten.  Make sure to take the time to document the date, time, name, and nature of your conversation.

Another important point that Dr. Kessler makes is the need to practice.  Just like intubation or suturing, consultation is a skill.  To improve this skill, we need to take the time to practice.  As teachers, we can help our residents with a "practice run" so that they don't end up frustrated on the phone.  With luck, this short list will help to ease the frustration felt with difficult consultations.