Sunday, September 28, 2008

Consults

We were talking about this phenomenon the other day: on very consult service I've ever been on, they whine and complain about the crappy, bogus consults they get, yet when those very same residents are on other services, they make those same bogus consults. One resident felt ardently that you should not call a consult unless you've done most of the workup yourself, ie, if you're calling a consult for altered mental status, then you should probably have actually checked the mental status. Others felt like they would call consults for things their physical exam was lacking, ie, calling an gyn consult to do a pelvic exam, whereas I KNOW the ob/gyn docs whine about those consults ("oh my god, we're all doctors, you learned how to do a freaking pelvic exam in medical school"). So when is it appropriate to consult?

For starters, it helps to have a specific consult question. Your question may be diagnosis (What the eff does this person have??), workup (What kind of tests do I need to run?), management (What do I give this person?), or a combination of the above. You may need to consult a procedural service, such as surgery for belly pain or GI for a colonoscopy. Prognosis is another type of consult question, when the consulting service knows the diagnosis but isn't sure what it means for that particular patient. For C/L psych, the consult question may be "This patient is a pain in the ass", meaning that you may have to deal with the patient, or you may have to deal with the staff (or both).

Don't be vague; if you don't have a clue what's going on then say so, but the more information you can give about the patient, the better. In other words, if you're calling a consult for belly pain, say "66yo WF with DM, HTN, Afib, now with intermittent diffuse abdominal pain worse after eating", not "she says her tummy hurts." If the diagnosis isn't clear to you, then give more information, and tell the consultant that's why you're calling ("Look dude, I don't have a freaking clue" usually works, as does "I'm only an intern.")

Of course, following consult etiquette is also important. It's usually best to actually speak to the consultant (or resident) on the phone to give them the patient's info, previous workup, and of course, the consult question. Most hospitals will let you order a consult in the EMR or the chart, but it's good manners to actually talk to the doctors whose help you are requesting. Be polite, always; after all, you're asking them to do you a favor (a favor which is part of their job, but still, they've got plenty to do without your consult). One bonus to the phone thing is that you can request the "curbside" consult--in other words, if you just had a quick question ("What dose of enalapril would you use in a dude with HTN, DM, and a creatinine of 2.5?"), then it doesn't entail a full consult note, just a quick phone chat. Also, if you call, and the consultant thinks it's a crap consult, they have a chance to turn it down ("Hey, man, don't you have UpToDate? Why are you calling me with this crap!")

Where it gets crappy for everyone is in the gray area around the above questions. Sometimes, an attending or upper-level resident may ask the intern to call a consult on a patient they're unfamiliar with, so that when you call, you don't have pertinent patient information. Bad situation. Sometimes, your team will have a plan, but will call a consult "just to get Heme/Renal/Neuro 'on board'". This may or may not be appropriate, so just keep in mind that getting so-and-so "on board" requires them to come write notes, perhaps daily, and it may not be an urgent inpatient matter. Psych patient who is psychotic in the hospital? Sure! Psych patient with a remote hx of depression, not on meds, doing fine, in the hospital for something else? Probably not.

Sometimes, you disagree with your upper level or attending about the appropriateness of the consult, but you have to call anyway. This sucks. However, you just have to suck it up and do it. If the consultant says "Okay, I'll come", then great. If they say "Uh, no, that's a crappy consult", then you shouldn't really say "Oh, yeah, I thought so, but my attending wanted it..." I think it's okay to say "My attending requested that I call you," but badmouthing your attending is never a good idea, unless you're home with your non-medical spouse and you're sure no one else is within a 50-mile radius.

Other than the basic rules, just keep in mind when you're on a consult service that no one else in the hospital has the expertise that your team does in your subject. Sure, you think "Well, we all went to med school, they should know such-and-such," but that's not always the case. Also, teams are busy, and may not have or want to take the time to research a topic they're unfamiliar with. So instead of thinking "OMFG, not another consult for Bell's palsy/remote psych hx/benign tachycardia/delirium/benign colonization of urine with a Foley," try to think of it as an opportunity to teach. Or, if you prefer, a time to feel really smart compared to someone else. And just remember, when you're on your next rotation, to kiss up a little when you call your old team for a crappy, bogus consult.

1 comment:

Barbie said...

I just read your disclaimer. Here is your annual reminder to shave your back. I will call you Hank.