Introduction
Medical consultation has become an important component of Hospital Medicine. These consultations include preoperative evaluation, perioperative management, and medical care of patients on various nonmedical services. Previous surveys found that many primary care physicians and hospitalists felt inadequately trained in perioperative medicine, and as a result, this area received additional emphasis as part of the core competencies for Hospital Medicine. With the growth of the hospitalist movement, the role of the consultant has evolved from providing evaluation and advice to include comanagement of the patient in certain settings. The goal of this chapter is to review the role and responsibilities of the medical consultant, focusing on the principles of consultation and techniques to improve effectiveness.
General Principles of Consultation
More than 25 years ago, Goldman and colleagues described the concepts for performing medical consultations. His “Ten Com-mandments” for effective consultation included the following:
Determine the question.
Establish urgency.
Look for yourself.
Be as brief as appropriate.
Be specific and concise.
Provide contingency plans.
Honor thy turf.
Teach with tact.
Talk is cheap and effective.
Followup.
These concepts, which incorporated many of the ethical principles described by the American Medical Association (AMA), are important and remain valid for the traditional consultation. However, some modifications are necessary to cover the new role of hospitalists as comanagers.
The traditional or standard medical consultation consisted of a formal request from the requesting physician to evaluate a patient and answer a specific question Table 42-1. The consultant was expected to address the question and to provide advice and recommendations, but not to write orders or bring in other consultants; the requesting physician remained in control and responsible for the patient’s overall care and treatment. The consultant also focused on the specific problem rather than looking for and addressing other issues. Consultations were requested only when necessary and not for routine management. The follow-up period was usually brief and did not involve daily visits for the duration of hospitalization.
| Traditional | Comanagement | Curbside | |
|---|---|---|---|
| MD in charge overall | Requesting physician | Shared responsibility | Requesting physician |
| Primary care of medical problems | Requesting physician | Medical—consultant Surgical—requesting physician | Requesting physician |
| Question addressed | Specific | Broader issues—other medical problems | Should not address either but offer to do formal consult or give only general advice |
| Order writing | NO | Yes | No |
| Follow-up | Limited, as needed | Daily until discharge | No, no formal relationship |
This traditional role of the consultant has been changing over the past 5–10 years. A survey by Salerno and colleagues revealed that many surgeons wanted the medical consultant to assume more of a comanagement role. Specifically, they wanted the consultant to address all medical issues as necessary as well as to write orders and continue to follow the patient. Comanagement arrangements have most often been with orthopedic surgeons and more recently with neurosurgeons. Comanagement has potential advantages of decreasing length of stay and reducing complications. Surgeons and nurses often prefer comanagement; however, one possible disadvantage is that the comanaging consultant may feel subservient to the surgeon and may be asked to assume responsibilities outside his area of training. This new role of comanagement will be discussed in detail in the next chapter.
Yet another type of consultation is the so-called “curbside” or informal consult in which the consultant is asked to provide an opinion or advice without personally seeing the patient. Although these should be avoided from a medicolegal standpoint, they occur frequently. Ideally the consultant should offer to perform a formal consult but if any advice is given, it should be generic and simple. The requesting physician should not refer to the consultant in the medical record if he has not seen the patient, and if he has had any contact with the patient, the consultant should write a note in the chart.
If the consultant is asked to provide an opinion or advice without personally seeing the patient (the “curbside consult”), the consultant should:
The requesting physician should not refer to the consultant in the medical record if the consultant has not seen the patient. |
