Eric I. Rosenberg, M.D., M.S.P.H., F.A.C.P.
1. Why do physicians request medical consultation?
& For assistance in making a diagnosis in a patient with symptoms and signs suggestive of an unknown disease or syndrome
& To obtain advice on specific disease management (such as diabetes or hypertension)
& To obtain a procedure usually performed by a subspecialist (e.g., coronary angiogram in a patient with persistent angina)
& To evaluate a patient’s ability to safely undergo surgical procedures
& To obtain advice on specific disease management (such as diabetes or hypertension)
& To obtain a procedure usually performed by a subspecialist (e.g., coronary angiogram in a patient with persistent angina)
& To evaluate a patient’s ability to safely undergo surgical procedures
2. How can one assess the effectiveness of medical consultation?
& Is the consultation question answered?
& Does the patient benefit from disease improvement or promotion of better long-term health?
& Are the consultant’s recommendations actually implemented?
& Is the consultation question answered?
& Does the patient benefit from disease improvement or promotion of better long-term health?
& Are the consultant’s recommendations actually implemented?
3. What factors increase the likelihood that the consultant’s recommendations
will be ignored by the referring physician?
& Poor communication between the requesting physician and the consultant (occurring 12–24% of the time in some studies)
& Delayed response to the consultation request
& Failure to address the requesting physician’s key clinical question
& Prematurely ending the consultant’s involvement in the patient’s care
& Infrequent follow-up visits
will be ignored by the referring physician?
& Poor communication between the requesting physician and the consultant (occurring 12–24% of the time in some studies)
& Delayed response to the consultation request
& Failure to address the requesting physician’s key clinical question
& Prematurely ending the consultant’s involvement in the patient’s care
& Infrequent follow-up visits
Goldman L, Lee T, Rudd P: Ten commandments for effective consultation, Arch Intern Med 143: 1753–1755, 1983.
Horwitz RI, Henes CG, Horwitz SM: Developing strategies for improving the diagnostic and management efficacy of medical consultations, J Chronic Dis 36:213–218, 1983.
4. What are the 10 commandments for effective consultation?
A classic list of principles that Goldman proposed in an effort to improve the quality of medical consultation, including:
& Determine the question asked by the referring physician.
& Establish the urgency of the consultation request.
A classic list of principles that Goldman proposed in an effort to improve the quality of medical consultation, including:
& Determine the question asked by the referring physician.
& Establish the urgency of the consultation request.
& “Look for yourself” (always see patients and personally review data before providing recommendations).
& “Be as brief as appropriate.”
& “Be specific” (including specific dosages and durations of medications).
& “Provide contingency plans” (including suggestions for evaluation likely problems should they occur).
& “Honor thy turf” (keep the patient’s primary physicians updated on new information and support their role).
& “Teach . . .with tact.”
& “Talk is cheap and effective” (direct conversation with requesting physicians increases the likelihood that your recommendations will be followed).
& Follow up.
& “Be as brief as appropriate.”
& “Be specific” (including specific dosages and durations of medications).
& “Provide contingency plans” (including suggestions for evaluation likely problems should they occur).
& “Honor thy turf” (keep the patient’s primary physicians updated on new information and support their role).
& “Teach . . .with tact.”
& “Talk is cheap and effective” (direct conversation with requesting physicians increases the likelihood that your recommendations will be followed).
& Follow up.
Goldman L, Lee T, Rudd P: Ten commandments for effective consultation, Arch Intern Med 143:1753– 1755, 1983.
5. What is a curbside consult and why should it be avoided?
The practice of giving an impression and recommendation to a physician without actually
interviewing and examining the patient and reviewing the laboratory, radiographic, and medical
records data. “Curbsides” are sometimes appropriately requested to determine whether a
consultant feels a full consultation is needed. Consultants should avoid giving
recommendations without having seen a patient because the premise for the curbside may be
in error. For example, if a consultant is asked what dosage of warfarin a patient should
receive when the International Normalized Ratio (INR) is 4.5, a review of the record might
reveal that the patient has no medical indication to be on warfarin, and the proper
recommendation is to discontinue the medication rather than to reduce its dosage.
6. What are some examples of common and appropriate areas of consultation for the internist?
& Chest pain
& Uncontrolled hypertension
& Uncontrolled diabetes (hyper- or hypoglycemia)
& Newly diagnosed thyroid disease
& Electrolyte abnormalities (hypo-/hypernatremia; hypo-/hyperkalemia)
& Unstable vital signs (fever, hypoxia, tachycardia, tachypnea)
& Edema
& Delirium
& Management of alcohol withdrawal
& Malnutrition
& Preoperative evaluation
& Medication reconciliation and polypharmacy
& “Second opinions”
7. How does an internist perform a consultation for “multiple medical problems”?
By initially focusing on the most significant problem for the patient and referring physician. Most
patients with “multiple problems” actually have an extensive, sometimes inactive past medical
history. By setting the priorities, the internist can then focus care toward the acute, active, or neglected
medical issues that can be effectively treated during the patient’s hospitalization. The consultant may
also help return (or start if necessary) the care to a primary care physician in the outpatient setting.
8. What are key issues that a consultant should review prior to seeing a patient in consultation?
& The patient’s most important underlying diagnosis. A patient with advanced Alzheimer’s
disease or other terminal diagnosis will most likely need supportive care instead of extended
testing or new medical or surgical interventions. A patient with a fractured hip is more likely in urgent need of repair instead of surgical delay to diagnose a possible history of asymptomatic chronic obstructive lung disease. The most important diagnosis may not be the reason the consultation was requested.
& Reconciliation of home and hospital medications. Is this patient receiving his or her
customary medications? Uncontrolled hypertension or diabetes in the hospital is often
because the patient is not receiving the usual prescriptions.
& Previous care by a primary care physician.
& Any previous evaluation of this medical problem.
9. What are the ways of succinctly documenting the findings of a medical consultation?
A consultation report should not read as an unfocused history and physical examination or
generic progress note, but should answer the question(s) posed by the requesting physician
and provide clear and specific recommendations.
& Example of appropriate initial consultation note:
& Impression: A 72-year-old diabetic man with probable sepsis s/p recent amputation for
gangrene now with recurrent fevers, leukocytosis. Leg wound with foul, purulent
exudate. Already on empirical antibiotics given history of resistant pseudomonas and
methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Hypoxemia and crackles
on lung examination concerning for possible pneumonia. Sugars are suboptimally
controlled, contributing to infection.
& Recommendations
& Will likely need drainage of leg wound tonight.
& Repeat blood cultures 2 sets.
& Urinalysis (UA) with culture and sensitivity (C&S) today.
& Chest x-ray (CXR) today.
& Increase neutral protamine Hagedorn (NPH) insulin to 35 units.
(These were discussed with Dr. Cutsalot and orders were written by me.)
& Example of appropriate follow-up consultation note:
& Impression
& Fever: Resolved after drainage of massive abscess from stump wound. Cultures
growing MRSA. CXR showed no evidence of pneumonia, still hypoxic.
& Delirium: Improving. Likely secondary to sepsis.
& Hypoxemia: Need to consider pulmonary embolism in patient at prolonged bed rest,
s/p surgery.
& Hyperglycemia: Diabetes control improving on increased NPH.
& Recommendations
& Can likely discontinue imipenem (will discuss with Infectious Disease consultant).
& Ventilation-perfusion ratio ( / ) scan today to evaluate for pulmonary embolism (PE). V Q
& Continue present dose insulin.
The practice of giving an impression and recommendation to a physician without actually
interviewing and examining the patient and reviewing the laboratory, radiographic, and medical
records data. “Curbsides” are sometimes appropriately requested to determine whether a
consultant feels a full consultation is needed. Consultants should avoid giving
recommendations without having seen a patient because the premise for the curbside may be
in error. For example, if a consultant is asked what dosage of warfarin a patient should
receive when the International Normalized Ratio (INR) is 4.5, a review of the record might
reveal that the patient has no medical indication to be on warfarin, and the proper
recommendation is to discontinue the medication rather than to reduce its dosage.
6. What are some examples of common and appropriate areas of consultation for the internist?
& Chest pain
& Uncontrolled hypertension
& Uncontrolled diabetes (hyper- or hypoglycemia)
& Newly diagnosed thyroid disease
& Electrolyte abnormalities (hypo-/hypernatremia; hypo-/hyperkalemia)
& Unstable vital signs (fever, hypoxia, tachycardia, tachypnea)
& Edema
& Delirium
& Management of alcohol withdrawal
& Malnutrition
& Preoperative evaluation
& Medication reconciliation and polypharmacy
& “Second opinions”
7. How does an internist perform a consultation for “multiple medical problems”?
By initially focusing on the most significant problem for the patient and referring physician. Most
patients with “multiple problems” actually have an extensive, sometimes inactive past medical
history. By setting the priorities, the internist can then focus care toward the acute, active, or neglected
medical issues that can be effectively treated during the patient’s hospitalization. The consultant may
also help return (or start if necessary) the care to a primary care physician in the outpatient setting.
8. What are key issues that a consultant should review prior to seeing a patient in consultation?
& The patient’s most important underlying diagnosis. A patient with advanced Alzheimer’s
disease or other terminal diagnosis will most likely need supportive care instead of extended
testing or new medical or surgical interventions. A patient with a fractured hip is more likely in urgent need of repair instead of surgical delay to diagnose a possible history of asymptomatic chronic obstructive lung disease. The most important diagnosis may not be the reason the consultation was requested.
& Reconciliation of home and hospital medications. Is this patient receiving his or her
customary medications? Uncontrolled hypertension or diabetes in the hospital is often
because the patient is not receiving the usual prescriptions.
& Previous care by a primary care physician.
& Any previous evaluation of this medical problem.
9. What are the ways of succinctly documenting the findings of a medical consultation?
A consultation report should not read as an unfocused history and physical examination or
generic progress note, but should answer the question(s) posed by the requesting physician
and provide clear and specific recommendations.
& Example of appropriate initial consultation note:
& Impression: A 72-year-old diabetic man with probable sepsis s/p recent amputation for
gangrene now with recurrent fevers, leukocytosis. Leg wound with foul, purulent
exudate. Already on empirical antibiotics given history of resistant pseudomonas and
methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Hypoxemia and crackles
on lung examination concerning for possible pneumonia. Sugars are suboptimally
controlled, contributing to infection.
& Recommendations
& Will likely need drainage of leg wound tonight.
& Repeat blood cultures 2 sets.
& Urinalysis (UA) with culture and sensitivity (C&S) today.
& Chest x-ray (CXR) today.
& Increase neutral protamine Hagedorn (NPH) insulin to 35 units.
(These were discussed with Dr. Cutsalot and orders were written by me.)
& Example of appropriate follow-up consultation note:
& Impression
& Fever: Resolved after drainage of massive abscess from stump wound. Cultures
growing MRSA. CXR showed no evidence of pneumonia, still hypoxic.
& Delirium: Improving. Likely secondary to sepsis.
& Hypoxemia: Need to consider pulmonary embolism in patient at prolonged bed rest,
s/p surgery.
& Hyperglycemia: Diabetes control improving on increased NPH.
& Recommendations
& Can likely discontinue imipenem (will discuss with Infectious Disease consultant).
& Ventilation-perfusion ratio ( / ) scan today to evaluate for pulmonary embolism (PE). V Q
& Continue present dose insulin.
With this blog you really took our attention to the points that we never thought about. Thanks for sharing this with all of us. All the best, way to go
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