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EFFECTIVE CONSULTATION

Ernie L. Esquivel, MD
Division of Hospital Medicine

First Commandment:
Look and Think for Yourself
Before calling a consult, consider the available data yourself carefully.
Reflect on the question that you are posing and anticipate whether the
consultant would want additional information or tests.
Develop your own hypotheses. This will make your question smarter.

Second Commandment:
Be available
If you page a consultant, make sure that there is an easy way for them to reach
you when they return your call.
If you need to walk away from the phone, provide them your mobile number
instead.

Third Commandment:
Determine the Question
Clearly communicate the question that you have for your consultant.
Start your phone call in the following manner:
I am consulting you for your opinion on Mr/Mrs. _____, a (age)-year-old
male/female, regarding the:
cause of ______ (state specialty-specific problem)
or
management of ________ (state specialty-specific therapy).

What constitutes a good clinical question?


Identify an intervention of concern (e.g. a treatment or a diagnostic test), the hoped-for outcome of
the intervention, and, if applicable, a comparison intervention.
Examples:
I have a 32-year-old patient who had chest pain in November 1997 and was found to have bicuspid
aortic valve with a gradient of 16. She is now pregnant with her third child. Is there any need to do
anything else?
I have a 47-year-old postmenopausal smoker with a positive family history of coronary disease.
She has a history of pain with stress, rest and indigestion, but not usually with exertion. She has
had 2 treadmill tests in 1995 and 1997, both normal. Would you recommend catheterization now?
I have a 43-year-old male with a strong family history of coronary artery disease who had some
atypical chest pain a few weeks ago during a time of stress, not exertion. He had no recurrence.
Exercise treadmill testing showed about 2 mm of ST depression in V5 and V6 late in stage 3 that
resolved 5 minutes after testing and was asymptomatic. He did reach 85% maximum heart rate.
Perfusion scanning showed 2 fixed defects (anteroseptal and inferior walls). Can you tell from this
what the likelihood of 2- or 3-vessel disease might be?

Association between Quality of Clinical Question and Outcome of a


Curbside Consult

Intervention or
Outcome

Questions, No.
(N = 708)

Unanswered
Questions,
No (%)

Recommendations
for a Formal
Consultation,
No. (%)

Nondefiinitive
Outcomes,
No. (%)

Neither

126

12 (9.5)

28 (22.2)

37 (29.4)

Only one

311

25 (8.0)

40 (12.9)

57 (18.3)

Both

271

11 (4.1)

18 (6.6)

27 (10.0)

Bergus et al., Arch Fam Med 2000

Fourth Commandment:
Establish Level of Urgency and Be Timely
Consultations can be emergent, urgent or elective.
If a consult is emergent or urgent, it would be best to discuss with your
consultant directly in order to clarify the issues expeditiously.
Do not call a non-urgent consult at the end of the day. Be aware that your
consultants have lives, too. Beware of the consult at 3:00 PM on a Saturday
afternoon. As much as possible, call consultants before 12:00 PM.
If you think that additional laboratory data or imaging are necessary for the
consultant to answer your question, order them expeditiously. Otherwise, if not
urgent, delay calling the consult until you have all the necessary data.

Fifth Commandment:
Have Data on Hand
Consultants will always want to know the following:
Who the attending is requesting the consult
Patients name and MRN
Where is your patient located
Be ready to have additional data that the consultant may request as you are
presenting the case.
Let them know whether the patient will have a procedure or may be away for
part of the day. Help the consultant organize their days schedule.
Make sure you are calling the correct consultant. May be an issue if there are
several consultant services in the hospital (private vs. academic)

Sixth Commandment:
Be as Concise (yet Complete) as Appropriate
Limit your presentation of the patients history and exam to what is pertinent to
the question you are addressing to your consultant.
Delete, delete, delete You are no longer a third year medical student. Focus
on what is critical information. Most of the time, family history is irrelevant.
When several clinical issues are active in your patient, only present those which
are relevant to your consultants consideration of the question and their
impending recommendations.
The initial presentation of a consult should be no longer than 2 3 minutes.

Seventh Commandment:
Be a reliable source
Consultants rely on your admission and progress notes to understand complex
cases, particularly when the patients have been hospitalized for a long time.
Ensure that your notes are accurate and complete. Document an accurate daily
physical exam.
Use the handoff tab to detail critical events in the hospitalization.
Always indicate how many days it has been since you started a particular
antibiotic.
If you did not feel like anyone ever looked at your note as a medical student, get
over it. Now they will start reading your note and relying on the data you
document.

Eighth Commandment:
Continue Thinking
Although your consultant is on board, continue to think about the question and
read on your own.
Do not write in your progress note: Plan per Renal/GI/Cards/Heme, etc. This
reflects poorly on you. Understand their recommendations and summarize the
plan briefly in your note.
If you are unclear about the recommendation, clarify with them.
Ultimately, your patient is your own. Be their best advocate.

Ninth Commandment:
Respect Differences in Opinion
Consider the recommendations provided by your consultants. If certain tests
have already been performed, but not seen by your consultant, do not reorder.
Instead, let them know of the additional data.
If a consultants recommendations do not make sense to you:
1. He or she may not have understood the question you wanted answered
2. His or her note is incomplete
3. He or she may have missed some salient feature of the case.
If so, pick up the phone and clarify any confusion.
If you choose not to implement the recommendations of your consultant (which
is your right), pick up the phone and discuss your reason.
If multiple consultants disagree, facilitate a multidisciplinary discussion.

Tenth Commandment:
Get smarter
Take advantage of your consultants and learn from them. Pose smart
questions, discuss the case in person, show interest in their perspective.
Request your consultant to refer you to seminal articles that have driven their
decision.
Be where they are. If they are looking at the blood smear, join them. If you do
not know how to spin urine, ask the Renal fellow.
Think of each interaction as a potential audition. You may wish to become a
specialist also.

Curbside Consults
Definition: an informal interaction in which one physician asks another for
advice or input on how to handle a particular patient issue, during which the
person to whom the physician is speaking:
is not in the presence of the patient
does not necessarily know or has has never met the patient.

Not routinely documented in a standard fashion. If so, usually the requesting

service will document a conversation in the chart without the consultant being
aware that he or she is being cited.
If a physicians name is noted in the chart as having offered advice, they
become legally culpable in case of litigation.
Quality of care may be compromised because a less comprehensive
assessment is performed than for a standard consult

Curbside versus Formal Consultation


Curbside Consultations, N (%)
Total

Accurate and
Complete

Inaccurate or
Incomplete

47 (100)

23 (49)

24 (51)

Advice in formal consultation differed


from advice in curbside consultation

26 (55)

7 (30)

19 (79), p < 0.001

Formal consultation changed


management

28 (60)

6 (26)

22 (92), p < 0.0001

Minor change

18 (64)

6 (100)

12 (55)

Major change

10 (36)

0 (0)

10 (45)

18 (39)

2 (9)

16 (67), p < 0.0001

Curbside consultation insufficient

Burden et al., J Hosp Med 2013

Differing perceptions about quality of information


during curbside consultations
Primary Subspecialists Cards
GI
Heme/Onc Pulm
ID
Care
(All)
(n = 53) (n = 31)
(n = 31)
(n = 26) (n = 13)
(n = 213)
(n = 200)
Insufficient clinical information is often
exchanged during a curbside consultation

49.8

80.2

75.5

74.2

71.0

84.6

92.3

Because consultants do not see the patient


during a curbside consultation, important
clinical findings are frequently missed

43.5

77.6

75.5

61.3

74.2

84.6

92.3

Kuo et al., JAMA 1998

If you think you are working hard as an intern, your consult fellow is likely
working even harder. Their patient lists will likely be two or three times longer
than yours. Be thankful!