There is nothing quite as daunting as dialing up a consultant service for the first time. As a clerk, I hated paging anyone because I worried that I would be interrupting them in the midst of something important or would get stumped by their questions. As a resident, I feel more relaxed because I’ve developed a smidge of consult-related finesse and been on the other side of the phone as an off-service junior.
Consults are important, but they’re also tricky. A consult is not a one-way handover; it’s a way to ask for help that leads to shared responsibility and collaborative decision-making. About 40% of emergency department visits require consultation (1,2), so learning how to deliver an effective and artful consult benefits learners, staff, and patients alike.
During my off-service year, I’ve learned that one’s brain simply doesn’t function all that well at 3a.m. My attention tends to wander as I half-listen to long histories regurgitated by junior learners, ears perking up only at the sound of key phrases (think ‘open fracture’ on orthopaedic surgery, or ‘acute abdomen’ on general surgery). The experience of accepting consults as a sleepy off-service junior has taught me a lot about how to deliver an effective consult, and while I’m certainly not a pro yet, I do have a few tips to pass on.
So, when you call me tonight for a consult, please:
- Greet me politely.
Courteous and polite relationships facilitate good, collaborative patient care. Also, if I just woke up, this gives me a chance to shake my head and blink my eyes back into focus before you get to the important stuff.
Try: Hi, is this general surgery? Thanks so much for calling me back.
- Explain who you are and where you are calling from.
It’s easier for me to help you if I know who you are, your level of training, and where your patient is. In particular, if you’re a new clerk and I’m not too sure about your assessment, I may need to ask you additional questions about the presentation and stability of the patient (3). This may make you nervous initially, but it will guarantee the best care for your patients while showing your ability to prepare and respond to important matters.
Additionally, knowing your level helps me understand whether I should give you feedback, which I’m likely to do if you’re a clerk, but absolutely will not do if you’re at or above my level of training (4).
Try: I’m Luckett, one of the clerks/residents working in Emerg with Dr. Chan.
Pro-tip: Sometimes telling the consultant service your name and the name of your supervisor can be immensely helpful (3). Maybe your staff is known to call early, signalling to the consultant service that they may be receiving an undifferentiated patient who will require work-up. Alternatively, your staff may be someone who calls only when the situation is dire, in which case the consultant service will understand they must move quickly. Finally, remember that a good reputation can be a conflict-mitigating factor during more contentious consults (5).
- Ask me a question or tell me what you want.
I used to think I was doing something wrong if I didn’t give the consultant a full story that let them reach their own conclusions about what was troubling the patient. Now, there is nothing I dislike more than getting a call that requires me to listen for five minutes before I know what the person on the other end wants. Please, no plot twists. Lead with the headline.
Try: I have a 34 year-old woman down here with CT-proven appendicitis who I’m hoping you can see for surgical management.
Pro-tip: Anticipate the questions that I’ll need to ask for my particular consult service (3). Clear answers facilitate good patient care. If you don’t know the answer, own up. Lying destroys the important trust relationships we need to build if we are to work well together.(5)
- Now tell me the story.
Once I know why I was called (read: woken up from 15 minutes of sleep), I can free up some brain cells to listen to the condensed version of the story that you’re about to deliver. Tell me what is relevant and no more, please.
Try: This young woman presented this evening with about 24 hours of abdominal pain that was initially diffuse but is now localised to the right lower quadrant. She has no appetite and is nauseated but hasn’t vomited. She has no other symptoms. On physical exam, she’s tender at McBurney’s point with no peritoneal signs. She’s stable and afebrile with a bit of a white count at 13.
Pro-tip: If you want to really please your consultant, start with a strong headline, present a (suspected) diagnosis, and express the urgency with which the patient should be seen (Chan et al., 2013). Nothing gets me running faster than a patient who is unstable and needs attention right away. On the other hand, if you haven’t told me that you’re concerned about the patient, I may stop a while to brush my teeth or grab a cup of coffee on my way down.
- Explain what treatment and work-up has already been done.
Consulting services often prefer that certain investigations or treatments are initiated prior to their involvement, and it’s helpful to know whether this has been done. Don’t be offended if you are asked to perform additional tests or change part of your management (5). Patient care requires a collaborative meeting of the minds.
Try: We’ve given her some hydromorphone, normal saline, and Gravol and she’s comfortable now. As I mentioned, we do have a CT, and that’s been reported as non-perforated appendicitis. Her urine pregnancy test is negative, and her lactate is normal.
- Thank me and ask if anything else should be initiated before I come to see the patient.
This is not only a nice thing to do but also recognizes the fact that I may already have my hands full, and that there are things you can do in the meantime to help your patient.
Try: Is there anything else you’d like me to start before you head down? Thanks again for coming to see her.
Pro-tip: This can also be a good time to ask the consultant’s name, which you can note down in the chart. Part of effective charting is showing clearly when you communicated with consultant services and whether they suggested any changes in management.
To help you put this advice into practise, I highly recommend using the PIQUED model by Chan et al. (2013). This framework, developed through feedback from staff physicians and residents from various specialities, is meant to help learners develop a systematic, evidence-based approach to consults.
P – Preparation and Review: The initial work-up, resuscitation, and review of investigations should occur prior to picking up the phone.
I – Identification of Involved Parties: At the very least, this should include the patient, you (the junior learner), your staff physician, and your consultant physician.
Q – Questions: Make sure your questions are clear and take time to anticipate and answer those of the consultant.
U – Urgency: State this as clearly as possible, since this will guide the consultant’s immediate behaviour and communication.
E – Educational Modifications: Notify others of your experience (or lack thereof) so they can ask questions and teach you appropriately.
D – Debrief and Discuss: Eliciting and providing feedback regarding the case will help you improve future consultations and patient care.
1. Woods RA, Lee R, Ospina MB, et al. Consultation outcomes in the emergency department: exploring rates and complexity. CJEM. 2008;10:(1)25-31. [pubmed]
2. Cortazzo JM, Guertler AT, Rice MM. Consultation and referral patterns from a teaching hospital emergency department. Am J Emerg Med. 1993;11:(5)456-9. [pubmed]
3. Chan T, Orlich D, Kulasegaram K, Sherbino J. Understanding communication between emergency and consulting physicians: a qualitative study that describes and defines the essential elements of the emergency department consultation-referral process for the junior learner. CJEM. 2013;15:(1)42-51. [pubmed]
4. Chan T, Sabir K, Sanhan S, Sherbino J. Understanding the impact of residents’ interpersonal relationships during emergency department referrals and consultations. J Grad Med Educ. 2013;5:(4)576-81. [pubmed]
5. Chan T, Bakewell F, Orlich D, Sherbino J. Conflict prevention, conflict mitigation, and manifestations of conflict during emergency department consultations. Acad Emerg Med. 2014;21:(3)308-13. [pubmed]
Editor’s note: This piece was reviewed by Teresa Chan. It was initially part of the BoringEM.org #TipsForNewDocs series and was reposted on June 30th as the ‘Throwback Thursday’ post of the week.
Reviewing with the Staff
This topic is certainly a topic that is near and dear to my hear (I did my residency research project on this exact topic, so I think it is worthwhile knowing and understanding, obviously!). I think that it is an essential skill for any physician - regardless of your specialty. In the end, medical life is surely much more like \"Who wants to be a Millionaire?\" and you do actually get to phone-a-friend when needed. That being said, it is VERY important to consider how one might optimize inter-physician communications (e.g. Consults) so that we can be efficient, but also accurate. Most studies around medical error track back to poor communication, and as such, it is important to work on this skill set - even though some would regard this as a \"soft skill\". Whereas we have only focused on one particular model for consultation (there are others, including Chad Kessler\'s 5Cs model), there are actually many ways to do this - and it is important to try different approaches.
For those of you who are more junior, one brief overview of the approach would be a paper by Kessler et al. 2013 which details different aspects of the consultation skills process (6).
6. Kessler CS, Chan T, Loeb JM, Malka ST. I\'m clear, you\'re clear, we\'re all clear: improving consultation communication skills in undergraduate medical education. Acad Med. 2013;88:(6)753-8. [pubmed]