1578185 – McGraw-Hill Professional ©CHAPTER 49Role of the Medical ConsultantSteven L. Cohn, MD, FACP, SFHMINTRODUCTIONMedical consultation has become an important component of Hospital Medicine. Theseconsultations include preoperative evaluation, perioperative management, and medicalcare of patients on various nonmedical services. Previous surveys found that manyprimary care physicians and hospitalists felt inadequately trained in perioperativemedicine, and as a result, this area received additional emphasis as part of the corecompetencies for Hospital Medicine. With the growth of the hospitalist movement, the roleof the consultant has evolved from providing evaluation and advice to includecomanagement of the patient in certain settings. The goal of this chapter is to review therole and responsibilities of the medical consultant, focusing on the principles ofconsultation and techniques to improve effectiveness.GENERAL PRINCIPLES OF CONSULTATIONMore than 25 years ago, Goldman and colleagues described the concepts for performingmedical consultations. His “Ten Commandments” for effective consultation included thefollowing:1. Determine the question.2. Establish urgency.3. Look for yourself.1578185 – McGraw-Hill Professional ©4. Be as brief as appropriate.5. Be specific and concise.6. Provide contingency plans.7. Honor thy turf.8. Teach with tact.9. Talk is cheap and effective.10. Follow-up.These concepts, which incorporated many of the ethical principles described by theAmerican Medical Association (AMA), are important and remain valid for the traditionalconsultation. However, some modifications are necessary to cover the new role ofhospitalists as comanagers.TYPES OF CONSULTATIONThe traditional or standard medical consultation consisted of a formal request from therequesting physician to evaluate a patient and answer a specific question (Table 49-1).The consultant was expected to address the question and to provide advice andrecommendations, but not to write orders or bring in other consultants; the requestingphysician 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 andaddressing other issues. Consultations were requested only when necessary and not forroutine management. The follow-up period was usually brief and did not involve dailyvisits for the duration of hospitalization.TABLE 49-1 Roles and Responsibilities of Different Types on Consultations  Traditional Comanagement CurbsideMD in charge overall RequestingphysicianShared responsibility Requesting physicianPrimary care ofmedical problemsRequestingphysicianMedical consultantSurgical—requestingphysicianRequesting physicianQuestion addressed Specific Broader issues—other medicalproblemsShould not address eitherbut offer to do formalconsult or give onlygeneral adviceOrder writing No Yes NoFollow-up Limited-asneededDaily until discharge No—no formalrelationshipThis traditional role of the consultant has been changing over the past 5 to 10 years. Asurvey by Salerno and colleagues revealed that many surgeons wanted the medicalconsultant to assume more of a comanagement role. Specifically, they wanted theconsultant to address all medical issues as necessary as well as to write orders and1578185 – McGraw-Hill Professional ©continue to follow the patient. Comanagement arrangements have most often been withorthopedic surgeons and more recently with neurosurgeons. Comanagement has potentialadvantages of decreasing length of stay and reducing complications. Surgeons andnurses often prefer comanagement; however, one possible disadvantage is that thecomanaging consultant may feel subservient to the surgeon and may be asked to assumeresponsibilities outside his area of training.Yet another type of consultation is the so-called curbside or informal consult in whichthe consultant is asked to provide an opinion or advice without personally seeing thepatient. Although these should be avoided from a medicolegal standpoint, they occurfrequently. Ideally the consultant should offer to perform a formal consult but if anyadvice is given, it should be generic and simple. The requesting physician should not referto the consultant in the medical record if he has not seen the patient, and if he has hadany contact with the patient, the consultant should write a note in the chart.PRACTICE POINTIf the consultant is asked to provide an opinion or advice without personally seeing thepatient (the “curbside consult”), the consultant should:Offer to perform a formal consult.Provide only generic and simple advice.Document any patient encounter in the chart.The requesting physician should not refer to the consultant in the medical record if theconsultant has not seen the patient.DETERMINING THE QUESTIONIn view of the multiple types of consultations, it is imperative that the requesting physicianspecify exactly what is being requested, and if there is any uncertainty, the consultantshould clarify this question by communicating directly with the requesting physician. Inaddition to specifying the role of the consultant, the requesting physician should bespecific as to the question being asked of the consultant. For example, a request forpreoperative consultation may be for surgical risk assessment, a “green light” to proceedwith anesthesia and surgery, a diagnostic or management issue, reassurance, ordocumentation for medicolegal purposes. As obvious as this may be, disagreementregarding the primary purpose for the consult still occurs between the requestingphysician and the consultant. Several studies noted that the consult requests were vagueand nonspecific (eg, clearance or evaluation), or did not even ask a question. Withoutclarifying the reason for the consult, the consultant may respond in a manner that fails toanswer the question being asked by the requesting physician.PRACTICE POINTIn view of the multiple types of consultations, it is imperative that the requestingphysician specify:The expected role of the consultant1578185 – McGraw-Hill Professional ©The question to be answered by the consultantIf there is any uncertainty, the consultant should clarify this question by communicatingdirectly with the requesting physician. The consultant should avoid makingrecommendations about the type of anesthesia and other areas outside his or her area ofexpertise.ANSWERING THE QUESTIONTraditionally, the consultant restricted his or her advice to the specific problem or question.However, more frequently the consultant is addressing other issues noted during theevaluations. Assuming these other findings and recommendations are relevant andimportant, most surgeons are in favor of this approach. What the requesting physiciandoes not want is a laundry list of things to do for minor problems or issues that do notneed to be addressed during the current hospitalization.If the consultation is for preoperative evaluation, the consultant needs to:1. Assess the severity and degree of control of the patient’s medical problems.2. Estimate surgical risk.3. Determine if the patient is in his or her optimal medical condition for surgery.4. Decide whether further tests or interventions are indicated.5. Make recommendations regarding the patient’s medications and any necessaryprophylaxis.The consultant should avoid making recommendations about the type of anesthesiaand other areas outside his or her area of expertise. Also, the consultant should refrainfrom using the term “cleared for surgery,” even if consulted for that reason, as this impliesa guarantee that the patient will not have a complication.OPTIMIZING EFFECTIVENESSFactors influencing or improving complianceVarious studies found a number of factors that have been associated with improvedcompliance with the consultant’s recommendations (Table 49-2). In general, followingGoldman’s Ten Commandments or Salerno’s modification (see Salerno SM, Hurst FP,Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med. 2007;167(3):271-275) will result in effectiveconsultation.TABLE 49-2 Factors that Influence or Improve Compliance with ConsultantRecommendationsPrompt response (within 24 h)Limit number of recommendations (≤ 5)Identify crucial or critical recommendations (vs routine)Focus on central issuesMake specific relevant recommendations1578185 – McGraw-Hill Professional ©Use definitive languageSpecify drug dosage, route, frequency, durationFrequent follow-up including progress notesDirect verbal contactTherapeutic (vs diagnostic) recommendationsSeverity of illnessFrom Cohn SL, Macpherson DS. Overview of the principles of medical consultation. In: Basow DS, ed.UpToDate. Waltham, MA: UpToDate; 2009; with permission.Determine and clarify the question: As noted, the reason for the consultation needs tobe clearly defined by the requesting physician and understood and addressed by theconsultant.Punctual response: The consultant should be available to respond in a timely fashion,depending on the urgency of the consultation. Truly “stat” consults should be answered inless than 30 minutes, and in general, elective consults should be answered within 24hours, preferably the same day they were requested.Recommendations:1. Prioritize and limit: The consultant should make specific, precise recommendationsthat should be listed in order of importance. Crucial or critical recommendations aremore likely to be followed, as are those at the top of the list. For this reason, it waspreviously felt that the number of recommendations should be limited to no morethan five, but more recently the feeling is to leave as many recommendations asneeded to answer the consult and offer to help with writing and implementing them(comanagement). Therapeutic recommendations are more likely to be followed thandiagnostic ones.2. Language: The consultant should use definitive language, be specific with hisrecommendations, and provide contingency plans. For example, recommendationsfor medications should specify the drug name, dose, frequency, route ofadministration, and duration of therapy. The requesting physician should be toldwhat response to expect, how long it will take, as well as how and when to adjustthe medication dose if necessary.3. Communication: Direct verbal communication with the requesting physician iscrucial and preferable to just leaving a note in the chart. A quick call to therequesting physician will let him know that the consult has been answered, what therecommendations are, and what needs to be done so the orders can be written andthe process expedited. It is also important to communicate with other members ofthe health care team to coordinate care.4. Follow-up: Appropriate follow-up visits will reassess the patient’s condition andensure that recommendations were followed. The consultant should clearlydocument his findings and update recommendations in the medical record. There isno standard regarding how often the consultant needs to see the patient, but thisshould be determined by the patient’s medical condition, type of surgery, andwhether the requesting physician wants comanagement or not. When the patient ismedically stable and there is no longer a need for the medical consultant, he should1578185 – McGraw-Hill Professional ©sign off and document this in the chart. Recommendations and arrangements forlong-term follow-up can also be noted at this time.PRACTICE POINTThe consultant should document:Specific and precise recommendations listed in order of importanceName, initial dose, frequency, route of administration, titration, and duration ofrecommended therapyThe consultant should provide:Prompt serviceDirect verbal communication with the requesting physician upon completion of theinitial consultUpdates and follow-up as appropriate depending on requested roleCONCLUSIONThe ideal medical consultant will “render a report that informs without patronizing,educates without lecturing, directs without ordering, and solves the problem withoutmaking the referring physician appear to be stupid.” It is hoped that by following theseprinciples, the medical consultant will be effective in providing useful information andrecommendations to the requesting physician who will then implement them in an attemptto improve patient outcome.SUGGESTED READINGSChoi JJ. An anesthesiologist’s philosophy on “medical clearance” for surgical patients.Arch Intern Med. 1987;147(12):2090-2092.Cohn SL, Macpherson D. Overview of the principles of medical consultation. In: Basow D,ed. UpToDate. Waltham, MA: UpToDate; 2015.Devor M, Renvall M, Ramsdell J. Practice patterns and the adequacy of residency trainingin consultation medicine. J Gen Intern Med. 1993;8(10):554-560.Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch InternMed. 1983;143(9):1753-1755.Kleinman B, Czinn E, Shah K, Sobotka PA, Rao TK. The value to the anesthesia-surgicalcare team of the preoperative cardiac consultation. J Cardiothorac Anesth.1989;3(6):682-687.Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primarycare physicians and medical subspecialists. JAMA. 1998;280(10):905-909.Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on theeffectiveness of medical consultations. Am J Med. 1983;74(1):106-112.Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of theirresidency training needs: results of a national survey. Am J Med. 2001;111(3):247-254.1578185 – McGraw-Hill Professional ©Rudd P, Siegler M, Byyny RL. Perioperative diabetic consultation: a plead for improvedtraining. J Med Educ. 1978;53(7):590-596.Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: anupdate for the 21st-century consultant. Arch Intern Med. 2007;167(3):271-275.For This or a Similar Paper Click Here To Order Now

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