consults

[cosine]

I just started my internal medicine residency and had a quick question for you guys. I'm having some difficulty calling in consults without being scolded by the person i'm talking to. I usually try and be as direct as possible but half the time I get the response, " are you seriously consulting this?" I dont really like to respond by stating my attending told me to but half the time I feel like I need to.

You guys got any tips on how to call in consults without being yelled at by the other person?

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[IMdocT]

yeah happens to me once in a while, especially when there really wasn't a reason to consult them. i try my best to explain the consult question, and then if they keep going on about it i just said my attending wanted it. they can't really say no if you keep saying you're still requesting the consult, or at least i don't think they can say no. you might run into that problem more often, if your teaching attending basically consults everyone

 

[WholeLottaGame7]

I just started my internal medicine residency and had a quick question for you guys. I'm having some difficulty calling in consults without being scolded by the person i'm talking to. I usually try and be as direct as possible but half the time I get the response, " are you seriously consulting this?" I dont really like to respond by stating my attending told me to but half the time I feel like I need to.

You guys got any tips on how to call in consults without being yelled at by the other person?

I started out intern year trying to be a "team player" and not throw anybody under the bus when calling bogus consults, but I relatively quickly learned to drop the Attending Bomb early on, because it makes life so much easier for everyone. You don't have to explain yourself and you don't give the resident/fellow an opportunity to evade. Because you both know how it's going to play out anyway, so why fight it?

I will say that in my admittedly limited experience there is a drastic difference between private practice and academia. In academia, a consult just means more work for an already slammed resident/fellow who is already working on a fixed income. It's not hard to understand the push back. In private practice, you're consulting an attending who makes their dinero off of just such consults, and they will jump all over it. That conversation usually goes like this:
YOU: Hi, this is X with the Y team. We'd like to consult you on a patient of ours.
CONSULTANT: What's their name, MRN, room number?
YOU: (Provide info)
CONSULTANT: What's the question?
YOU: We were wond...
CONSULTANT: We'll get back to you later today.
YOU: But you don't know the question...
CONSULTANT: It doesn't matter, we'll figure it out and let you know.

 

[reno911]

1. I think one of the key skills you pick up as an intern is the ability to legitimize even the most inane consult request (without playing the attending told me card). It's actually a pretty useful skill for a physician to have.

2. Don't take the "scoldings" personally. It's just a natural consult fellow reflex.
Last poster hit the nail on the head. In academia, a consult (especially for the fellow) is just more work, which unless it's super-interesting, no one really wants to do. On the other hand, in private practice, a consult is more work + more money. So, in many settings (not all), consultants are often more than happy to take your consult requests. In fact, the sillier and easier the question, the happier they are, because it's essentially the same amount of money for even less work.

 

[Law2Doc]

yeah happens to me once in a while, especially when there really wasn't a reason to consult them. i try my best to explain the consult question, and then if they keep going on about it i just said my attending wanted it. they can't really say no if you keep saying you're still requesting the consult, or at least i don't think they can say no. you might run into that problem more often, if your teaching attending basically consults everyone

Agree with what's been said. There are a few attendings out there who love the practice of "loading the boat"-- ie if the patient has a heart, he should have a cardiology consult during this admission, and if he has a brain, a neuro consult would be nice. That way, if something gets missed and it involves one of these vast territories, the attending can shrug and say the specialist missed it. It's called defensive medicine at it's worst, and allows bad doctors not to get sued. There are others who subscribe to the one stop shopping methodology. If a patient is in the ICU with a CVA but also has a patch of dermatitis, might as well get a dermatologist to look at it while the guy is here. As mentioned, in both cases the private practice consult loves this because it's easy money, but the resident in the academic setting gets killed writing up and calling attendings about these non-pressing consults. If your attending wants it, there's not much you can do, but I agree that after asking, you can drop your attendings name and if you still get resistance an attending to attending conversation is the way to go because that way both residents can get out of the messy loop and both attendings go away thinking the other attending is the jerk, not that his own resident didn't do his job.

A few suggestions on consults though. Know your patient. If you consult me and I ask you if the patient is stable, or what his history is, or for some recent lab values, you need to know, or I will feel like you are wasting my time. Be prepared when you make the call. Saying " I don't know I'm just cross covering and they asked me to call you" will get you abused. Saying I don't know why we are calling you, the attending just wants it gets you abused. Having your med student make the call and wasting my time before he sheepishly has to hand the call back to you because he cant answer my questions gets you abused. In general, it's a do unto others kind of thing. Pretend that you are going to be on the other side of the calls. This is often a busier resident or fellow than you are, and writing up a consult is often the least enjoyable part of his day. So make it easy on him. Have a short detailed history ready to go. Have the labs and vitals on hand when you make the call. Be clear on the question you want answered. If you are prepared, the calls usually go well. It's the ones who get on the phone, don't know the patient, and don't know why they are asking for the consult beyond "the attending wants it" that get abused.

 

[Tone2002]

In all fairness to the intern, a lot of these consultant residents believe that you're going to give them a full H&P over the phone. At least from my end, its not happening, go see the patient and get your own information. Reason for consult and any pertinent labs/imaging should suffice.

 

[core0]

My favorites are the ones that everyone wants. For example everyone with fungemia needs an eye exam. So I call Ophthalmology
Me: I need an eye exam on a fungemia patient in the ICU.
Optho tech: Takes down the information. In the background "who wants to go to the ICU for an eye exam?"
Resident 1: I'll do it
Resident 2: No I'll do it
Resident 1: Really I don't mind
Sound of scuffling in the background
Slightly out of breath resident 1: I'll be right over.

Comes over 10 minutes later. Looks at the chart for a while. Asks if its OK to dilate the eyes.
Resident 1: I'll be back in half an hour or so to do the exam.
Me: Sure
Comes back in half an hour does the worlds most thorough eye exam. Negative thanks.

Not sure but I would bet it has something to do with getting out of clinic.

 

[jdh71]

A few suggestions on consults though. Know your patient. If you consult me and I ask you if the patient is stable, or what his history is, or for some recent lab values, you need to know, or I will feel like you are wasting my time. Be prepared when you make the call. Saying " I don't know I'm just cross covering and they asked me to call you" will get you abused. Saying I don't know why we are calling you, the attending just wants it gets you abused. Having your med student make the call and wasting my time before he sheepishly has to hand the call back to you because he cant answer my questions gets you abused. In general, it's a do unto others kind of thing. Pretend that you are going to be on the other side of the calls. This is often a busier resident or fellow than you are, and writing up a consult is often the least enjoyable part of his day. So make it easy on him. Have a short detailed history ready to go. Have the labs and vitals on hand when you make the call. Be clear on the question you want answered. If you are prepared, the calls usually go well. It's the ones who get on the phone, don't know the patient, and don't know why they are asking for the consult beyond "the attending wants it" that get abused.

Completely disagree. It's not the job of the team to justify the consult to you. All a consultant needs to know is patient, location, question, and urgency. If you can't figure out the rest, you suck.

I don't bother interns with extra questions. What's the point? The waste of my time is spending any longer than I have to on the phone and not doing the work.

 

[dragonfly99]

My only advice is
-make sure you make it clear what the reason is for the consult/what question(s) you want answered
-realize that some people will still be jerks...but you SHOULD know your patient well enough to know why you/your attending want the consult and/or what specific question(s) you want answered. I have done consults before only to discover after the fact that the primary team's attending had a totally different question in mind...so either the intern who called me didn't listen and didn't understand why the consult was even being called, or his attending didn't communicate it to him.

 

[danielmd06]

My only advice is
-make sure you make it clear what the reason is for the consult/what question(s) you want answered
-realize that some people will still be jerks...but you SHOULD know your patient well enough to know why you/your attending want the consult and/or what specific question(s) you want answered. I have done consults before only to discover after the fact that the primary team's attending had a totally different question in mind...so either the intern who called me didn't listen and didn't understand why the consult was even being called, or his attending didn't communicate it to him.

Right on.

 

[Arcan57]

Have a template down so you don't flounder in the middle of a call. Use the same template every time and you'll have it down pretty quickly.

"Hello, thanks for calling back. I'm _____ from service ____. I'm calling to request (insert consult team's specialty) on a patient by the name of (insert patient's name). (Insert patient demographics). (Insert request to perform a procedure or test primary team can't). Thanks."

The second to last sentence is key. Know 100% of the time why you are calling the consult. Don't pick up the phone if you don't.

 

[gutonc]

The second to last sentence is key. Know 100% of the time why you are calling the consult. Don't pick up the phone if you don't.

This, this, a thousand times this.

I don't need much when I get a consult. Last name and floor are enough with our EMR (by the time you get done stumbling through their 16 digit MRN I will have found them and added them to my consult list) and the question you want answered are all that I really need. A 1 sentence HPI is nice and if you've already done some stuff (that I may ask you to order before I see them), it's nice to hear about that too.

But if you can't tell me what question you want answered, I can't answer it. Full stop.

 

[gutonc]

Who cares if they don't like it? You're calling a consult your team thinks is necessary. Screw everyone else.


I used to handle it like this:


Them: "Are you seriously consulting us for such a simple issue?"

Me: "Yes. Do you have any other questions?"

I'm glad to see Tired is back.

 

[Smurfette]

This, this, a thousand times this.

I don't need much when I get a consult. Last name and floor are enough with our EMR (by the time you get done stumbling through their 16 digit MRN I will have found them and added them to my consult list) and the question you want answered are all that I really need. A 1 sentence HPI is nice and if you've already done some stuff (that I may ask you to order before I see them), it's nice to hear about that too.

But if you can't tell me what question you want answered, I can't answer it. Full stop.

I agree. As a surgeon, listening to a full H&P for a inpatient inguinal hernia consult is ridiculous. Tell me pertinent medical history only for the given problem, as anything less relevant I will see when I review the chart. If I want more info by phone, I will ask...and my additional questions are often so I can triage how urgent the consult is and figure out if I need to re-arrange my schedule, NOT because I am intentionally trying to torture the person on the other end. Similarly, when I call a consult, I give them what I think is the pertinent info BUT am prepared to give more info if they ask for it.

Honestly, calling consults is something that gets better with experience. You know the relevant info better, and can present it more succinctly.

And at my residency hospital, the typical ridiculous consult that the attending insisted on started with "I'm so sorry to give you this consult, my attending wanted it. Here's the info". Everyone (IM, surgery, ENT, etc.) knew to just suck it up and see the consult. Hard to get mad at the person on the other end of the phone when they acknowledge it's ridiculous too.

 

[Doctor Bagel]

As a psych person, I also don't want anything close to the full H&P. Medicine folks are so into giving out lots of information orally when I'd honestly rather look through the chart to gather the information I'd need.

But yes, a question is a good thing. We get a lot of "we've got this pt who sees a psychiatrist -- can you see him?" types of stuff. Is the pt causing you problems, is there a medication you're concerned about -- how can we help you? And you deserve to be reamed (not that I would 'cause I'm generally fairly nice) if you do stuff like call me and ask if I can come down and see patients in the ED because your social worker is running behind. So, yeah, respecting a consultant's specialty is kinda key.

I think, though, we all do a lot of BS consulting because our attendings want us to so it's just part of the game. It does suck, though, to be that intern.

 

[captaincrunch]

I think there is a lot of variation between different hospitals (and even different attendings) on how consults are handled. Some attendings/hospitals call in way too many consults. In general, though, I think fellows/residents put up a lot of barriers when taking consults. In the private world, it's part of the job to do consults. Some consults are legitimate and others less so. But now that I'm in practice, I can tell you that bouncing consults is a good way to dry up your referral base and made enemies in the hospital.

Frankly, I very rarely regret a consult I've called. It may seem silly to consult cardiology for a NSTEMI if I know how to medically manage. But guess what? I don't cath patients, can't read echos, etc. The patient will also need a cardiologist post-discharge. Getting the consult is also the community standard, so there is a legal issue as well. In hindsight, the fact that fellows at teaching hospitals would roll their eyes at these consults, drag their feet, etc now seems unprofessional and immature.

Fellows often get too hung up on the "clinical question." I certainly agree that the referring MD should know the medical history, but sometimes consults get called by on-call doctors or covering doctors. They might not know the full history. As far as the clinical questions is concerned, my question is always the same: "if this were your patient, what would you do?" The consultant should perform an independent assessment and see the patient themselves. So why waste time grilling the intern on the patient's smoking history or whatever?

I start fellowship next year and I hope I bring a little real-world experience to my program and not try to dodge consults. One of my favorite consultants in my hospital actually called out of "curb-siding" too much. He basically told me to just call in the consult and he'll see the patient and put a dictation in the chart. I think that's the right approach.

Cheers.

 

[Ronin2258]

Surgical thread on how to consult/be a consultant.

 

[Doctor Bagel]

Why do we do this to each other? You're on psych, which means you call BS consults to medicine and surgery all the time. When I was on surgery, I called BS "clearance for surgery" consults to medicine all the time. Everyone makes those calls, and everyone gets those calls.

I'm about to go back to Ortho. I'm fully prepared for the psych ward consults ("Two years of shoulder pain, needs Ortho clearance before discharge"), the ER consults ("Small avulsion fracture of fibula"), and the medicine consults ("Wrist hurts, needs splint, we don't know how to make one"). That's life. Bitching out some poor intern who's just doing what they're told is stupid. Don't do it.

On psych, I've had a couple of situations where I've felt confident handling a lot of the basic non-psych stuff that pops up (HTN, high cholesterol, rashes, conjunctivitis, etc.), but I've had attendings who always want to consult on all the non-psych stuff. It's frustrating for us and for the people we're consulting.

Now I will say I don't think I've ever consulted ortho from the psych ward. I'm sure I'll wind up doing it tomorrow after posting this.

 

[gutonc]

On psych, I've had a couple of situations where I've felt confident handling a lot of the basic non-psych stuff that pops up (HTN, high cholesterol, rashes, conjunctivitis, etc.), but I've had attendings who always want to consult on all the non-psych stuff. It's frustrating for us and for the people we're consulting.

This is the most aggravating part of being a resident and junior fellow. The attendings who are so far out of med school and their basic training (and I think this is primarily an academic phenomenon) that they don't know how to handle basic stuff. I could give myriad examples but suffice it to say that, at this (late) point in my training, I'm (mercifully) able to say, "you know what, I have a pretty good idea what to do here, since Mrs. Jones is stable, why don't I try X, Y and Z and, if she's not better in the morning, I'll call Cards/Pulm/Renal/Derm."

Now...I don't generally do this for surgical issues (unless it's an SBO in which case I put the NGT in and call the surgeons with a heads up), but I can handle a lot of the medical issues that I get confronted with that my attendings want to get consults on.

Being an intern/junior resident is a lot like being a gay teenager. You're going to be humiliated and verbally abused but, it gets better when you get "older."

 

[Apollyon]

In the community, I've called ortho for a dislocated carpal with an associated fracture - and I was fine with splinting it that evening and having her see ortho in the morning (about 9 hours later). I have a CT surgeon that will cut neck to nuts - my medical director tells a story of how she had a woman with vag bleeding that wouldn't stop and some other stuff that meant she needed an immediate hysterectomy (don't recall the details); the women's hospital in town wasn't answering, and we didn't and don't have ob/gyn. This CT surgeon was ready - seriously - to do the hysterectomy. And this isn't some fossilized old surgeon. I call neurology, and I have someone there (from the community - not in house). ENT, likewise. Hell, I have my choice of two ID guys.

In the community, no one gives pushback (except for IM hospitalists formerly at my hospital and one peds hospitalist at the children's hospital - go figure). There's even the famous "I'm not comfortable with that" - I butchered a woman with a groin abscess in the past (not in residency, after), and that burned my confidence. Last pt I had with one, the surgeon was more than happy to come in and cut her (got 10mL pus out), and gave me no slack.

So, residents who either enjoy reaming other residents, or feel that it is their duty (like "this will hurt me more than it will hurt you", before they spank you) are either learning badly, or are enjoying it while they can, 'cause, post residency, as has been said, you live on this. Give me a hard time even once, "abuse me", whatever, and I tell my medical director, and you never get a consult from me again. There is one urologist in town that is +5 for referrals from me, because his competition is a total ***** (ironic, being urology). The comp gets no referrals, and no business, from me, and I'm there 25% of the time. I'm not sure he's even doing surgery at our hospital anymore.

Tired is right (even though I called him an idiot 4 years ago, and an overzealous SDN power-hungry mod dinged me for it - even though you can't - and couldn't - see it anymore), and listen to him (or don't, at your peril). Don't hate the playa - hate the game.

 

[jdh71]

I think one other small, but polite points about calling the consult is trying to call the consultant as early in the day as possible. If you know at 9:30AM that you want a consult on someone, don't wait until after noon-conference to let your consultant know.

 

[docB]

I'm fully prepared for the psych ward consults ("Two years of shoulder pain, needs Ortho clearance before discharge"), the ER consults ("Small avulsion fracture of fibula"), and the medicine consults ("Wrist hurts, needs splint, we don't know how to make one").

We hate these too. There are a lot of causes of stupid consults as well. When I was in residency some of the outpatient clinics would not see a patient that had not been referred in by their own service. Consequently we were frequently calling consultants to come down and refer (the pt had to show up with a referral signed by the service resident and there had to be a dictated consult in the computer). They never gave us much crap on those because they knew it wasn't our policy.

As an attending I have to call an ortho on every broken bone because we had some bad outcomes due to the ortho on call refusing to see a (uninsured) patient in the office. Their excuse was that they had never been called. So now, every fracture = a call just so we can document "Dr. Bones agrees to see pt in follow up."

 

[45408]

I think one other small, but polite points about calling the consult is trying to call the consultant as early in the day as possible. If you know at 9:30AM that you want a consult on someone, don't wait until after noon-conference to let your consultant know.

Absolutely. Likewise, if it's 2am and it can wait until 8am, do that too.

 

[gutonc]

Absolutely. Likewise, if it's 2am and it can wait until 8am, do that too.

Word.

 

[VA Hopeful Dr]

Being an intern/junior resident is a lot like being a gay teenager. You're going to be humiliated and verbally abused but, it gets better when you get "older."

That's just beautiful, I love it

 

[Apollyon]

Fun times, didn't realize you took a hit on that. As a rule I don't report posts, so someone must have been "watching."

Likely I was being an idiot. It happens a lot. I have the same level of ego and bitterness as 4 years ago, but I'd like to think I've become more refined.

But yeah, I'm definitely right on this one.

Dude, it was watching. I got hit again by another overzealous mod for obliquely (like, so oblique, it almost missed) insulting someone (like you had to interpret the statement - it wasn't "that guy is a tool and a *****").

You've earned your stripes. You know the truth from going through the pain.

If you get TDY or PCS to Hawai'i, I'll buy the beer(s). Mucho.

 

[Law2Doc]

Completely disagree. It's not the job of the team to justify the consult to you. All a consultant needs to know is patient, location, question, and urgency. If you can't figure out the rest, you suck.

I don't bother interns with extra questions. What's the point? The waste of my time is spending any longer than I have to on the phone and not doing the work.

Nope, not true at all. A lot of the time they aren't even calling the right service for what they need. The consultant is supposed to help guide them, not spin wheels for an hour trying to "figure out the rest". Often times the consultant can point them in the right direction if they can concisely and accurately explain what they actually want and a give bit of the patient's pertinent history. Suggesting that a consultant needs to spend an hour with the chart and the patient and "figure out the rest", only to write a note suggesting you really need to consult another department is a colossal waste of time. You can waste a lot less of your time making these things go away on the phone rather than spend time doing a consult that won't answer the question they need answered. The goal is to add value, not to give them a piece of paper that says you need to consult another team (something you could have told them over the phone without billing the patient). Now, if you are in private practice, you happily will take the guys money, but in academic settings, you really are doing both the referring doctor and yourself a disservice if you don't point him in the right direction, and spend your time actually doing consults where the patient's problem isn't obviously related to a different subspecialty. And that, my friend, is why you need more telephonic info. So you don't waste everybody's time unnecessarily.

 

[MD2b06]

As a cards fellow, these are my recs:

1. Know your patient including pertinent hx
2. Know what the clinical question being asked of the consultant is
3. Do not throw your med student under the bus and have them call in consults for patients they do not know very well just so you won't get yelled at. (poor form)
4. Try to have done some basic w/u. Don't call cardiology for chest pain, and not have an EKG on the chart or cardiac enzymes pending.
5. Don't call in consults for "patient known to you" in an academic setting. Yes, the patient may be known to one of my attendings, but 1) that attending is not necessarily rounding on the consult service and 2) as a busy fellow, a non-urgent consult like that is not going to be given much priority
6. Try to limit non-urgent consults overnight.
7. Poor planning on your part does not constitute an emergency on my part. Essentially, don't wait till the end of the day to call consults and expect to have them seen or staffed the same day.

 

[Law2Doc]

As a cards fellow, these are my recs:

1. Know your patient including pertinent hx
2. Know what the clinical question being asked of the consultant is
3. Do not throw your med student under the bus and have them call in consults for patients they do not know very well just so you won't get yelled at. (poor form)
4. Try to have done some basic w/u. Don't call cardiology for chest pain, and not have an EKG on the chart or cardiac enzymes pending.
5. Don't call in consults for "patient known to you" in an academic setting. Yes, the patient may be known to one of my attendings, but 1) that attending is not necessarily rounding on the consult service and 2) as a busy fellow, a non-urgent consult like that is not going to be given much priority
6. Try to limit non-urgent consults overnight.
7. Poor planning on your part does not constitute an emergency on my part. Essentially, don't wait till the end of the day to call consults and expect to have them seen or staffed the same day.

Agreed. Especially #3.

 

[Mattchiavelli]

As a cards fellow, these are my recs:

4. Try to have done some basic w/u. Don't call cardiology for chest pain, and not have an EKG on the chart or cardiac enzymes pending.

I'm an intern on cardiology consult and Friday was asked to see a pt for preop evaluation with previous hx of CAD... And no ekg ordered, no attempt to get older ones from OSH.. Wtf.

Consults should be "I have worked this patient up to the best of my clinical ability but I am going to defer to someone of more expertise for the benefit of the patient" rather than "I don't want to do my work and you work with this organ"

My goal for every rotation that's not in my specialty is to learn how to make better consults and start to figure out where my consult threshold is going to be in the future.

 

[jdh71]

Nope, not true at all. A lot of the time they aren't even calling the right service for what they need. The consultant is supposed to help guide them, not spin wheels for an hour trying to "figure out the rest". Often times the consultant can point them in the right direction if they can concisely and accurately explain what they actually want and a give bit of the patient's pertinent history. Suggesting that a consultant needs to spend an hour with the chart and the patient and "figure out the rest", only to write a note suggesting you really need to consult another department is a colossal waste of time. You can waste a lot less of your time making these things go away on the phone rather than spend time doing a consult that won't answer the question they need answered. The goal is to add value, not to give them a piece of paper that says you need to consult another team (something you could have told them over the phone without billing the patient). Now, if you are in private practice, you happily will take the guys money, but in academic settings, you really are doing both the referring doctor and yourself a disservice if you don't point him in the right direction, and spend your time actually doing consults where the patient's problem isn't obviously related to a different subspecialty. And that, my friend, is why you need more telephonic info. So you don't waste everybody's time unnecessarily.

Still disagree. At least in my line of work. There's no one else taking care of the lungs - and triage of who needs to be involved next IR, CTsurg, or us is up to our opinion. But you're a surgeon. I don't waste a ton of time on the phone with you guys.

 

[Apollyon]

Still disagree. At least in my line of work. There's no one else taking care of the lungs - and triage of who needs to be involved next IR, CTsurg, or us is up to our opinion. But you're a surgeon. I don't waste a ton of time on the phone with you guys.

I don't think s/he is a surgeon, but I don't have definitive proof. I haven't even ever seen him/her say anything concrete that convinces me s/he is even a doctor. His/her advice is about on par with the people that say "you can get a nonclinical job" (i.e., generally useless), but, actually, it's lower, because the people that say that don't make stuff up out of the air, and refuse even the most innocuous requests to show truth to the outrageous lies they've made up.

Your opinion, like many of the other people in this thread, is valuable, especially because it has context and is rooted in fact and experience.

 

[QofQuimica]

I just started my internal medicine residency and had a quick question for you guys. I'm having some difficulty calling in consults without being scolded by the person i'm talking to. I usually try and be as direct as possible but half the time I get the response, " are you seriously consulting this?" I dont really like to respond by stating my attending told me to but half the time I feel like I need to.

You guys got any tips on how to call in consults without being yelled at by the other person?

I don't think there is anything wrong with pulling the attending card on someone who is busting my chops because he's unhappy with the consult and thinks he can take it out on me just because he outranks me. As in, "well, my attending does think the consult is necessary, so would you like to speak him about it?" Somehow, the one person I've asked that to didn't want to take me up on it.

If you find that you're having to do that a lot though, the advice everyone else gave about having a clear question and access to all the labs and HPI is good. I learned that the hard way on my first day. My senior resident asked me to call a consult on a patient that wasn't mine, and I was completely unprepared and couldn't answer any of the consultant's questions. The consultant was nice about it, but she made it clear that I needed to always do X and Y before calling and have Z info available. I have tried to follow that advice any time I have to call a consult, and it really does make things go more smoothly most of the time.

 

[smq123]

I will say that in my admittedly limited experience there is a drastic difference between private practice and academia. In academia, a consult just means more work for an already slammed resident/fellow who is already working on a fixed income. It's not hard to understand the push back. In private practice, you're consulting an attending who makes their dinero off of just such consults, and they will jump all over it.

Not just that, but in a lot of community hospitals staffed by private practice groups, you don't even call the consult in yourself. Most of the time, the specialists have their own clinic, or are at another hospital, so the unit secretary or nurse will call it in to their answering service. It's such a different world. I mean, it does require that you write down a succinct reason for the consult with your order (i.e. "Pt. with palpitations; consult cards" or "Pt. with new onset hematuria; consult urology"), but it's a pretty good system that works.

And like you said, the consultants in private practice make money off even the dumbest consults. When I was an intern, I had specialists pulling me aside and saying, "If you have any questions about ANYTHING don't hesitate to consult me at any time. There's no such thing as a stupid question."

 

[Doctor4Life1769]

Luckily, I've not had to pull the attending card yet. I will have a good reason and ask the attending always in terms of "why" a consult (especially if I'm clueless, otherwise, I won't) so I can have a good idea of how he/she thinks. I also do know about my patients (enough) to state important stuff. If it's me doing an admission from the ED, I'll think about if the patient is acute or not. If we can manage, I won't. If we need more help, I will. I'll bring up "I will/won't consult..." for each patient I admit to the senior resident (we have to present the patient and our plan to our senior). They'll typically agree (if they disagree, I have them explain to me the reason for my own learning and experience) and do as they say.

 

[dpmd]

And at my residency hospital, the typical ridiculous consult that the attending insisted on started with "I'm so sorry to give you this consult, my attending wanted it. Here's the info". Everyone (IM, surgery, ENT, etc.) knew to just suck it up and see the consult. Hard to get mad at the person on the other end of the phone when they acknowledge it's ridiculous too.

So agree with this approach to the consult you know is stupid, that you may or may not have tried to talk the attending out of (some attendings are just consult ******), and that you are forced to call. Everyone likes to talk about how in the community everybody is falling all over themselves to get even the stupid consult, but they typically aren't getting up out of bed to see the crap like we have to at a training institution. We rotate at a small community hospital, and if someone comes in with an appy/chole/whatever can be pawned off until morning after the surgeon has gone home they are getting admitted by the ER doc (possibly to the hospitalist service) after a brief phone call to the attending. At another hospital they don't even call the surgeon after 10 pm for most stuff-it just gets admitted to them. Of course, every once in a while I came in to find a really sick patient who should have been managed differently, but that is what they have worked out so that during the day they are more than happy to see the patient admitted for MI who happens to have had a reducible hernia for 10 yrs (even though there isn't a chance in hell he is getting operated on soon). Honestly though, stupid ones like that were just not as frequent as at training institutions. Not sure what it is that makes the attendings less likely to filter appropriately (outpatient versus inpatient consult, timing-although at my institution our first call resident is in house and it is better to just call when you have it rather than wait until some arbritary time and have 10 consults piled up). At least if you let me know you realize it is stupid I don't worry about what you are learning, and I also know that the patient won't be harmed if I work on some other stuff first.

And somebody said to tell them to just suck it up and do their job, my job is to see consults that are appropriate for general surgery (and certain subspecialties). If the consult should go to someone else I am going to tell you that and refuse the consult. It doesn't happen often, and I am more than happy to talk to your attending and explain why. Luckily I know my attending will back me up if it comes to that.

 

[gutonc]

5. Don't call in consults for "patient known to you" in an academic setting. Yes, the patient may be known to one of my attendings, but 1) that attending is not necessarily rounding on the consult service and 2) as a busy fellow, a non-urgent consult like that is not going to be given much priority

Oh man...this one drives me nuts. We're a medium-sized cancer center but still have ~40 attendings, all covered for by one fellow after hours/weekends (never mind the other 12 fellows who have their own patient panels). So when I get a call (often from the ED but many times from the ICU or a surgery service) and hear, "hey, we've got Mr. Jones down here...do you know him?" I want to reach through the phone and strangle the person on the other end. "Sure...I'm randomly very familiar with the one of 7500+ patients we see in our clinic annually."

 

[Arcan57]

Oh man...this one drives me nuts. We're a medium-sized cancer center but still have ~40 attendings, all covered for by one fellow after hours/weekends (never mind the other 12 fellows who have their own patient panels). So when I get a call (often from the ED but many times from the ICU or a surgery service) and hear, "hey, we've got Mr. Jones down here...do you know him?" I want to reach through the phone and strangle the person on the other end. "Sure...I'm randomly very familiar with the one of 7500+ patients we see in our clinic annually."

Being on the other end of the phone, I will often ask if you've heard about Mr. X since Mr. X is claiming that a doc from your group told him to come to the ED. Especially when the reason they've presented to the ED is opaque ("abnormal labs" on a Saturday morning without an indication of which lab is abnormal being a favorite). I don't expect you to know (because Mr. X talked to the NP answering the phone or just made up the whole interaction), but if you do that can save the patient and the system a ton of money.

Also, for the consult services out there: if you're using a primary service as a pass-thru (because you don't have admitting privileges, for example) don't be mysterious about it. Give me a call and let me know why the patient is coming to my service and what you expect to be done. Otherwise I will have zero sympathy that your elaborately crafted plan fell through because no one told me it even existed.

 

[gutonc]

Being on the other end of the phone, I will often ask if you've heard about Mr. X since Mr. X is claiming that a doc from your group told him to come to the ED. Especially when the reason they've presented to the ED is opaque ("abnormal labs" on a Saturday morning without an indication of which lab is abnormal being a favorite). I don't expect you to know (because Mr. X talked to the NP answering the phone or just made up the whole interaction), but if you do that can save the patient and the system a ton of money.

Fair point. If I could get the attendings (or more specifically, their nurses) to let us know if/when/why they sent somebody to the ED it would make everybody's life easier.

But I was speaking more in terms of not getting any relevant CC, PMH or HPI up-front because "you know Mr. Jones, right?".

 

[Buzz Me]

I feel like there should only be three main categories of consults:

(1) When you need something specific that only the consultant can do, e.g. Renal to initiate dialysis, or Infectious Disease to start Zyvox
(2) When you have a specific question, e.g. "how long should we continue vancomycin in our patient with line sepsis?"
(3) When you have no idea what's going on and just want someone else "on board"

Unfortunately many consults fall into the third category.

 

[Ypo.]

All this mention of needless consults makes me think of an attending I had who didn't want to consult anyone. 50 yo IV drug abuser with bacteremia and mediastinitis and a retrosternal abscess? Let's just handle that ourselves. T4 paraplegic with extensive stage iv decubitus ulcers and osteomyelitis of the pelvic bone? We got this.

Sometimes I feel a little relieved when my attendings want to consult.

 

[IMdocT]

All this mention of needless consults makes me think of an attending I had who didn't want to consult anyone. 50 yo IV drug abuser with bacteremia and mediastinitis and a retrosternal abscess? Let's just handle that ourselves. T4 paraplegic with extensive stage iv decubitus ulcers and osteomyelitis of the pelvic bone? We got this.

Sometimes I feel a little relieved when my attendings want to consult.

oh man, that's crazy. the worst opposite situation i had was an 85 year old comes in extremely somnolent, 2nd time in a month. typical work up for AMS was negative. chart review indicated that patient was placed on high dose seroquel for the first time (for anxiety? was not explained why), about a month ago 2 admissions ago. i asked the attending, maybe we should taper the seroquel and see what happens. but instead he consulted ID, neuro, psych. got repeat CT's, EEG, repeat pan-culture, the works. patient intermittently throughout the day would be alert enough to administer oral meds and a little bit of food then fall back asleep. went on for like 5-6 days, then we halved the seroquel and patient was more alert after a day or 2.

 

[DHT]

oh man, that's crazy. the worst opposite situation i had was an 85 year old comes in extremely somnolent, 2nd time in a month. typical work up for AMS was negative. chart review indicated that patient was placed on high dose seroquel for the first time (for anxiety? was not explained why), about a month ago 2 admissions ago. i asked the attending, maybe we should taper the seroquel and see what happens. but instead he consulted ID, neuro, psych. got repeat CT's, EEG, repeat pan-culture, the works. patient intermittently throughout the day would be alert enough to administer oral meds and a little bit of food then fall back asleep. went on for like 5-6 days, then we halved the seroquel and patient was more alert after a day or 2.

Did you remind your attending that gomers never die? That may have saved some consults

 

[maxheadroom]

Nope, not true at all. A lot of the time they aren't even calling the right service for what they need. The consultant is supposed to help guide them, not spin wheels for an hour trying to "figure out the rest". Often times the consultant can point them in the right direction if they can concisely and accurately explain what they actually want and a give bit of the patient's pertinent history. Suggesting that a consultant needs to spend an hour with the chart and the patient and "figure out the rest", only to write a note suggesting you really need to consult another department is a colossal waste of time. You can waste a lot less of your time making these things go away on the phone rather than spend time doing a consult that won't answer the question they need answered. The goal is to add value, not to give them a piece of paper that says you need to consult another team (something you could have told them over the phone without billing the patient). Now, if you are in private practice, you happily will take the guys money, but in academic settings, you really are doing both the referring doctor and yourself a disservice if you don't point him in the right direction, and spend your time actually doing consults where the patient's problem isn't obviously related to a different subspecialty. And that, my friend, is why you need more telephonic info. So you don't waste everybody's time unnecessarily.

Big agree. Was called recently by OSH requesting to transfer patient with foreign body in posterior pharynx. WTF?? "Um, why are you calling Plastics? Don't you want ENT?" Response, "You're on for Face tonight and the pharynx is part of the face, right?" Ha ha ha, "Nope, you want ENT. Plastics doesn't do airway."

 

[Groove]

Try to be professional but stick to your guns. You need to be willing to get mean if need be to get what you want because you're fighting for the pt's best interest. Know why you are calling and how to succinctly articulate your reasoning in the consult, regardless of whether they agree "over the phone" or not, you're the one looking at the pt. You'll get better and more confident with time after you learn hospital politics and your ability to recognize the bluster and bluffing on the other end of the phone.

Don't use the "my attending told me to..." card...ever. It undermines your confidence in your attending, implies you don't understand the reason for the consult or even worse...don't agree with the reason for the consult. If you don't understand why your attending is requesting...ask him why. If he tells you and you anticipate a problem or disagree with a particular aspect of the consult, tell him your concern and the difficulties you anticipate in advance of the consult and come to a plan together beforehand. This kind of stuff just comes with experience and knowing the political framework of the hospital and the particulars of different services. It can get rather silly sometimes.

If worse comes to worse, don't throw the "my attending told me...." card. Use a different one...."Hey listen, I don't have time to argue with you about this, could you tell me your attending on call today/tonight? We'd like to give him a call if you can't help us with this..." You'll get quick compliance, guaranteed.

Hey, listen though...you're an intern. You're going to have bad consults where you feel humiliated or unprepared. The art of consulting is like fencing or any other sport. You get better at it with practice and learn your own maneuvers and strategies. You can't expect to be good at it from the very beginning with someone who's a veteran at finding sneaky ways to get out of them.

I work in the ED, and sometimes it's been as simple as scrutinizing the case manager's criteria for hospital observation status or full admission with certain patients, or simply calling them beforehand when I anticipate a soft admit but one that we don't feel comfortable sending home. Once I verify they meet criteria, I've on more than one occasion had a resident/fellow say..."look, I can't admit them for this...they don't meet admission criteria". "Sure they do...they have x,x,x and x, which meets 23h obs/ or inpatient admission."... and you're done.

Again, this is more of the perspective of academics from a resident standpoint. I'm sure it's different and the approach is different out in private practice land.

One more thing. As a resident, know if you need a formal vs a "curbside" or telephone consult. Do you definitely need them to eval the pt and write a note? If not, give them the courtesy of a phone consult and run whatever by them. They will appreciate it and remember you in the future when you really do need a formal consult.

 

[FutureInternist]

In my world, consults usually fall into 4 categories:

1) A succinct problem/question- the majority
2) The pan consult- primary team orders a scan for some reason, sees a mass and then consult surgical oncology, medical oncology, and radiation oncology with no true plan and when said work up has nothing to do with the admission. These patients could be referred on discharge for work up and seen in a more organized fashion. Limited value in having 3 consultants say "final decisions pending pathological confirmation"
3) The what are you thinking- patient admitted for MI, has a follow up in a week for prostate cancer and primary team is worried about them missing their appointment so we get the consult: PKTY (patient known to you).
4) The train wreck- A case where the patient is in bad shape or is a problem patient and the primary team consults soley to have another physician on board to deal with the patient even when they know there is no role for us.

Thankfully, 1 is the most frequent, 2-4 will usually get the consulting resident/fellow an earful since it's wasteful, inefficient, and usually just confuses the patient more. The my attending told me to do it thing only works so far. If you're a resident and can't eloquently explain the reason for consult, you should have talked to your attending before placing a consult to further understand or if you disagree try to discuss with your attending before placing.

Good Stuff !! Unfortunately our private attendings (but mostly their 3 months out of school PA/NPs) are notorious for # 3.
Mass in lung --> call pulm and Hem/Onc even though biopsy is either not done or is pending over the weekend.
Has COPD exacerbation --> call pulm on day of d/c so "they don't get lost in the system" ....doofuses trying to pass it off as if they care about the patient
The absolute worst, and the one for which I got in trouble for, when I paged the resident and asked him if he really was an idiot or just acting like one, was for a post-traumatic femur fx in a new guy to the community...IM consult to "establish PCP" ??? I walk in, give the guy my card, tell him to make an appointment and then call the surgery resident to write an order to d/c the consult...FUN times

 

[michaelrack]

...IM consult to "establish PCP"

when I was a res, I sometimes did have to consult a serice to get the patient seen quickly after discharge as an outpt. When the system at your institution makes this necessary, it's best to be upfront about exactly what you need from the resident you are consulting so a minimum of time is wasted on both sides.

 

[michaelrack]

...."Hey listen, I don't have time to argue with you about this, could you tell me your attending on call today/tonight? We'd like to give him a call if you can't help us with this..." You'll get quick compliance, guaranteed.

.

IF they call your bluff and give you the name of their attending, then in most cases it is best to have your attending call their attending (rather than do a resident to attending call), especially if the service you are trying to consult has a higher status than yours (in many programs, Psychiatry trying to consult gen surg, for example)

 

[SouthernSurgeon]

Hey, listen though...you're an intern. You're going to have bad consults where you feel humiliated or unprepared. The art of consulting is like fencing or any other sport. You get better at it with practice and learn your own maneuvers and strategies. You can't expect to be good at it from the very beginning with someone who's a veteran at finding sneaky ways to get out of them.

I know we all play these games at times during residency...but I disagree with the spirit of this. Consulting should not be a war between services, and I as a consultant will never give someone grief for an appropriate consult; likewise when I am calling a consult and it is appropriate I haven't really had trouble getting someone to see my patient.

And when you do come across the occasional a** whose sole goal seems to be to weasel out of seeing any consult...the attending card is very effective (either their attending or mine). I on one occasion actually walked down to IR and spoke to their attending after the fellow refused to perform a necessary procedure on a sick patient. I got very quick results and an apology from the fellow.

One more thing. As a resident, know if you need a formal vs a "curbside" or telephone consult. Do you definitely need them to eval the pt and write a note? If not, give them the courtesy of a phone consult and run whatever by them. They will appreciate it and remember you in the future when you really do need a formal consult.

I almost NEVER let someone "curbside" me, unless it is for the most routine question. If I give someone advice via curbside it doesn't get staffed with an attending, and then I'm the one liable. I'd rather take the extra time to see the patient and give real recs.

 

[Socrates25]

this conversation reminds me of an infamous consult I heard the other day:


Pediatrics resident in the ER: "Hi, this is Dr X with peds, we have a 2 y/o child here in the ER, he was riding w/ his dad on an ATV that flipped over. His CT scan shows a small intracranial hemorrhage, no skull fracture, but he's got significant hydrocephalus"

Neurosurgery resident: "Whats the clinical question?"

Pediatrics resident: "Uhh, with his CT showing hydrocephalus and his deteriorating mental status...."

Neurosurgery resident: "I'll ask you again, WHATS the clinical question?"

Pediatrics resident: "We need your assistance with possible surgical intervention for his hydrocephalus"

Neurosurgery resident: "So what do you want us to do, whats the question?"

Peds resident: "THE ****ING QUESTION IS ARE YOU GOING TO COME DOWN HERE AND PUT A EVD (external ventricular drain) IN THIS KID OR DO YOU WANT ME TO DO IT?"