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When you turn to a consultant for help in a complex case, are you sometimes sorry you asked? This primer shows how to make consultations more productive by checking out a specialist's credentials, asking well-defined questions, and resisting intimidation.
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Consultation has been integral to medical care since the time of the ancient Egyptians,1,2 and good communication has always been essential to its success. Yet with the rapidly shifting administrative and economic base of medicine in the 1990s and the emphasis managed care places on the primary care physician as the orchestrator of care, this age-old lesson needs to be learned once again. For consultation to be effective, the primary care physician must maintain sound communication with the other health- care providers who are caring for the patient, whether these are subspecialists, hospital house staff, nurses, or therapists.13
The cases that follow illustrate the critical role of communication in making consultations effective and ensuring excellent patient care. Available time, clinical experience, attitudes toward uncertainty, boundaries of responsibility, and trust are all variables that influence decisions about consultation.38 A set of guiding principles for effective consultations is provided in Table 1.
A 6-year-old boy was brought to a pediatrician because he had fainted after vigorous play on a warm afternoon. It was the first such episode in the boy's life, and it lasted several minutes. The physical examination was unrevealing. While the pediatrician thought this might have been a vasovagal episode, he was impressed by the reported physical exertion and by the duration of syncope. He ordered an electrocardiogram, which indicated a cardiac dysrhythmia. At this point, the pediatrician made a referral to the cardiology consultant listed by the child's health plan for confirmation of the dysrhythmia and a management plan. The pediatrician did not know the basic credentials of the consultant--whether she was board certified in cardiology or had appropriate clinical experience. This situation can occur when a managed care organization limits access to particular subspecialists the pediatrician may not know, or have worked with before.
The pediatrician did not telephone the consultant and did not make sure she had seen the ECG. In fact, she had not seen it, because the ECG was misplaced at the pediatrician's office and never sent. The consultant, whose clinical experience in cardiology was limited, concluded from the history that the child had had a vasovagal episode. Her letter to the pediatrician stated that an ECG was not necessary and that a cardiac dysrhythmia was unlikely. The pediatrician accepted her opinion, despite his original suspicions and the evidence of the ECG he had done.
A few months later, the child had another episode of syncope after vigorous exercise, this one unusually long and apparently associated with hypoxia. An emergency department physician made a diagnosis of cardiac dysrhythmia by ECG, the same dysrhythmia present on the initial ECG. The child suffered permanent cognitive impairment.
What went wrong? The relationship between physicians and the need for direct and ongoing communication are the key issues in this case.3,5,7,9 The referring pediatrician should have spoken directly to the consultant, sharing and discussing details of the history and the results of the original ECG.36 If this information had been available to the consultant before she saw the patient, the poor outcome might have been avoided.911
Direct communication would also have clarified the question the pediatrician was asking. Consider the possible difference if a specific question had been posed: "Is this presentation consistent with a cardiac dysrhythmia, given the ECG findings?" Without such communication, the consultant was left with only the questions she could infer: What is the etiology of this syncopal episode?" or "How should I manage this patient?" A direct question is more likely to result in a relevant answer.
Direct communication is also important after the consultant sees the patient.10 In this case, when the consultant's report seemed to disregard the results of the ECG, the pediatrician could have clarified the point rather than simply accepting the advice. In a study by Baker and Baker, 86% of primary providers wanted the consultant to call after the evaluation. We recommend the telephone for these conversations whenever possible. Written communication or even E-mail is not as rapid and does not provide the same opportunity for give and take.
In addition to the communication gap, there was another failure in this case. The pediatrician failed to check the credentials of the consultant and so did not know that she was not board certified in cardiology. Primary providers are responsible for assessing the skills of consultants, using all available resources: personal experience, the opinions of colleagues, professional publications, and the files of hospital credential committees.3 Other resources include the fellowship directory of the American Academy of Pediatrics, the Directory of American Medical Specialists, the National Practitioner Data Bank, and directories of local medical societies. Both the primary care physician and the consultant feel more comfortable about a consultation when they know and respect one another.
Parents brought an afebrile, 3-week-old girl to the pediatrician's office after a full day of somewhat forceful emesis, some of which was green-stained. The pediatrician admitted the infant to the hospital with the primary diagnosis of sepsis. The house officer, impressed by the history, suggested the possibility of an intestinal obstruction, but the child's pediatrician held to her admitting diagnosis and ordered the house officer to do a work-up for sepsis. Still concerned, the house officer approached a pediatric surgeon and asked for a "curbside consult." The infant had minutes before thrown up some green-stained vomitus. The surgeon, unaware of the recent vomiting episode, did a brief examination of a tummy by then soft and relaxed, and concluded that the baby did not have an intestinal obstruction. Some time later, as the baby continued to vomit bilious emesis, the house officer ordered an abdominal film. The radiologist who read the film said it indicated a possible obstruction. The house officer spoke to the child's pediatrician, who now agreed that a formal surgery consult was indicated. The surgeon who had given the curbside consult was now formally consulted and agreed that the symptoms indicated possible obstruction and exploratory surgery. At surgery, much of the intestine was found to be compromised by obstruction and needed resection, resulting in a debilitating "short gut" syndrome in the infant.
Intimidation by hierarchy. The influence of hierarchy on relationships among physicians is most evident in an academic medical center. This case demonstrates how that hierarchy may create barriers to the flow of communication during a consultation. The house officer tried to communicate his concerns to the pediatrician and the surgeon, but these concerns were not addressed because--at the brief moments when these physicians saw the infant--the physical examination did not suggest obstruction. Yet the house officer's persistence led eventually to a formal surgical consultation and appropriate, though delayed, diagnosis and management. The lesson here is that all members of the medical team need to respect and value each other.7,11 After all, the low man on the totem pole may, despite lower status, know what he is talking about. Superiors should not discount that often proven possibility.
Curbside risks. This case also demonstrates the danger of curbside consultations, which deny the consultant the opportunity to see the patient formally, take the time for a full assessment, and receive compensation for the effort. The consultant's advice, possibly based on incomplete or inaccurate data, may be inappropriate.1214 If the inappropriate advice is recorded in the medical record, it may lead to litigation. Curbside consults have their uses, in clarifying specific questions or getting quick reassurance or an immediate answer--especially in an emergency. Such interactions are generally brief and the consultant's name should not be written in the chart.13 If the issue is too complex for brevity and an immediate answer, the referring doctor should request a formal consultation. Physicians who have an ongoing relationship may run less risk in exchanging curbside advice than strangers do.
A 32-month-old, otherwise healthy boy was admitted to the hospital with fever that had persisted for three weeks. His only accompanying symptoms were anorexia, weight loss, and an obvious loss of vitality. A cat had bitten his hand about four months before admission, and he had continued playing with the cat after the bite. The child had been given a variety of antibiotics and had an extensive work-up, which included an abdominal ultrasound because of some brief, intermittent complaints of umbilical pain and nausea. According to the radiologist who read the film, the ultrasound revealed a plethora of "cysts" in the liver and spleen. When the pediatrician got the radiologist's report, he told the parents that a liver biopsy would be necessary and referred the child to an academic medical center.
The physicians at the referral hospital disagreed about whether the ultrasound findings mandated a biopsy. Hepatic and splenic involvement has been reported after cat scratch or bite, and a serum study for Bartonella henselae would have been sufficient to confirm a diagnosis of cat-scratch disease. Nevertheless, the biopsy was performed. Before the results were available, serology confirmed cat-scratch disease. A trial of rifampin, recently reported to be effective against that disease, resulted in defervescence after one day. When the biopsy results came in, they showed only a nonspecific granulomatous inflammation.
The problem with this consultation can be simply described. The parents had been told firmly by the referring physician that a liver biopsy would be necessary. Several members of the consultant team did not agree. In their view, the pet cat, the bite marks on the child's hand, the clearcut liver and spleen involvement shown on the ultrasound, and the opportunity for a trial of rifampin all indicated that the potentially risky biopsy procedure could be delayed. The situation was certainly not an emergency. Why, then, was the biopsy done?
The primary consultant, despite the considerations we've listed, felt bound by the referring physician's request and the parents' belief that the biopsy was necessary. We do not intend to argue for or against biopsy. Our message is that a primary care provider asking for a consultation should leave room for flexible decision-making and an exchange of opinions.
The general surgery team requested a consultation by telephone to "rule out otitis media" in an infant who had had a liver transplant some months before. A general surgery intern made the call to the pediatric resident, who relayed the information to the pediatric attending physician. Information in the hospital chart was sparse. The girl was 9 months of age. She had been admitted two days earlier for fever, and had taken oral antibiotics for the preceding two weeks for recurrent otitis media. Several immunosuppressive medications were listed on the order sheet. One of the surgeons had ordered a complete blood count, blood culture, and chemistry panel. The results were available by computer but not listed in the medical record.
The infant's parents told the pediatric attending about the child's liver transplant. They were worried because the baby had become irritable over the last 24 hours, was unable to sleep, and had lost her appetite. It was clear on examination that she did not have otitis media, yet she was markedly febrile with no ready explanation for the irritability and for the hyponatremia evident from the chemistry panel.
The pediatric attending, worried about sepsis or meningitis in an immunocompromised patient, thought that a complete sepsis workup including lumbar puncture was indicated, in addition to starting parenteral antibiotics. She also thought the complexity of the patient's immune status warranted an infectious disease consultation. She called the surgical resident, who agreed. The surgical resident asked the pediatric attending to speak with the family, because he and his surgical team were in the midst of surgery, and asked, too, that the pediatric house staff complete the requested procedures. The pediatric attending then assured the family that a complete work-up would be done.
The surgical attending, informed of the approach some 45 minutes later, thought it too aggressive and had the surgical chief resident cancel the orders. Neither he nor any of the surgical team had seen the patient yet that day and, still operating, they would not be available for several hours. The pediatric attending felt compromised in her relations with the parents and worried about the infant. She felt that the workup was necessary and needed to be done expeditiously, and she had already informed the parents and written her recommendations in the chart. She could not speak directly to the surgical attending since he was scrubbed for surgery. She asked the gastroenterologist on the liver transplant team to see the patient immediately. He agreed with her assessment and expressed his concern directly to the surgical attending, who was now available, and the necessary action was taken.
What's the question? This case demonstrates the importance of asking the right question (Table 2).9 What did the surgeons really want to know: Whether the child had otitis media? Or, more broadly, what was causing the fever? In one study that compared the referring physician's reason for consultation with what the consultant thought the reason was, answers differed in 14% of the cases.6 What was the role of this consultant? Should she have limited herself to the judgment of otitis media? Her professionalism and the severity of the infant's presentation demanded more.
Again, communication is the key. This case included many physicians and many relationships: surgery house staff to pediatric house staff; surgery house staff to pediatric attending; pediatric attending to subspecialty and surgery attending; and subspecialty attending to surgery attending. The surgery attending, isolated in the operating room, may not have accepted the advice of the pediatrician because he was unaware of the patient's increasing fever, irritability, and toxic appearance. He was also unfamiliar with the consultant's style, clinical expertise, and training. Yet the pediatric attending needed to act expeditiously and to remain involved until the best interest of the patient was served, continuing to maintain an open and direct line of communication, supporting the surgeons, and not usurping their role in the eyes of the parents.9,15 It took the involvement of a mutually respected colleague, the gastroenterologist on the transplant team, to assure that appropriate steps were taken. Poor communication served the patient poorly. What finally saved the situation was the continuity of care provided by the surgical team and an established relationship between the consultant and the gastroenterologist, who could vouch for her credibility.
A 13-year-old boy with a rare form of muscular dystrophy, ventilator and wheelchair dependent, was referred to the emergency department by his primary care pediatrician because of steadily intensifying, bilateral tingling sensations over his face and upper thorax. In the ED, the patient was obviously fearful: "I'm scared I'm having a heart attack or a stroke or something," he said.
His vital signs were stable. An ECG was normal. His pediatrician arrived and agreed with the ED staff's recommendation for a neurology consultation. The neurology resident who answered the consultation request said the likelihood of a stroke was slim, no more than 1 in 1,000. The distribution of the tingling followed no reasonable neurologic pattern, and a CT scan of the head revealed no sign of hemorrhage or ischemia. Nevertheless, the neurology resident's recommendation was "admission for a possible evolving stroke."
The boy's pediatrician, assuming (mistakenly) that the neurology attending physician had examined the patient, went along with the recommendation. Since the patient was ventilator dependent, he had to be admitted to an intensive care unit. The cardiology staff in the ICU undertook a search for emboli and ordered an echocardiogram, "just to be sure." The cardiologists, however, were unable to do an adequate study because the patient had a Harrington rod in place for scoliosis. They therefore recommended a trans-esophageal echocardiogram. The primary pediatrician refused the study, feeling that the likelihood of finding something wrong was slight and the potential morbidity for the frightened adolescent was great.
Knowing that the patient had an intense fear of death and a great need for reassurance for even minor complaints, the pediatrician urged that the neurology and cardiology consultants take these factors into account when planning management. She supported hospitalization only because of the rarity of the patient's disease process, the uncertain prognosis, and her mistaken assumption that the attending neurologist--who had more experience than she did with this rare disease--had examined the patient and agreed with the plan. She worried that admission might not have been justified and that she had been wrong in deferring to the consultant. After all, it was more probable that her patient was having a conversion reaction or an anxiety attack.16
The patient's anxiety and the tingling increased markedly over night, but his symptoms did not become more focal. The patient himself suggested that anxiety might be playing a role. The neurology attending finally examined the boy the following morning, declared there was no evidence for a stroke, and recommended immediate discharge. Unfortunately, the patient persisted for months with the conviction that he had had a stroke. He and his mother did, however, agree to a mental health referral to help him address his anxiety, something the primary care pediatrician had been encouraging for over a year.16
Who conducts the orchestra? This case involves a number of specialists: emergency department physicians, ICU staff, neurology subspecialists, and cardiologists. So the crucial question becomes, who coordinates the patient's care? It is the responsibility of the referring pediatrician to be the primary communicator and to share relevant information with other health-care professionals.1,3,5 This role becomes more difficult to maintain when an acute situation leads to referral to the emergency department and subsequent admission to an ICU. The primary care provider, perhaps not well known in these settings, must often struggle to remain in charge on unfamiliar turf,17 particularly in academic centers where decisions made by committee are the habit.2 Also, it can be quite difficult for a primary care pediatrician whose practice is geographically distant from the medical center to remain involved. Nevertheless, the primary pediatrician cannot accept the back seat position. He or she must help the patient and family weigh the benefits and drawbacks of possible interventions, so that the options are given sound evaluation. The PCP's intimate knowledge of the patient and family is essential to good care. This sometimes tricky role is easier to pull off when the PCP has an established relationship with the academicians, but whether or not that is the case, continued involvement is essential for the well-being of the patient.
In this case, all the physicians shared a degree of uncertainty. The referring pediatrician asked for a consultation to get expert help in establishing a diagnosis, to reduce patient, family, and physician anxiety, and to share the management responsibility.1,3,4,7 The neurology resident recommended admission despite the very slim probability of a stroke, most likely influenced by the rarity of the disease and the grim prognosis rather than by the strength of the physical findings or considerations of emotional or financial costs. The neurology attending, who might have prevented these potentially unnecessary interventions, did not enter the process until after these decisions had been made.
Who makes the ultimate decisions? When referring physician and consultants disagree, whose judgment should prevail? The primary provider is not compelled to yield to the consultant and must retain a central role. Disagreement intensifies the need for close and constructive communication in which patient and family should be active participants. The closer the pediatrician's relationship with the family, the more likely this communication will take place.
Rejecting the advice of a consultant is a weighty decision, and the referring physician must have a good reason for doing so. The consultant's views as a specialist are always worth serious consideration, and--if litigation should arise--will probably carry more weight in court than the primary provider's opinion.18 The best way to handle a disagreement with a consultant is to talk it out. Express your concerns directly, omitting nothing but avoiding unconstructive tension, so that the best interests of the patient may be served.3,6,9,11
These case reports demonstrate that good communication is at the heart of effective consultation. When you ask for a consultation, make sure you know what the question is and express it directly. Recognize the uncertainties in the case, know your consultant's qualifications, and don't relinquish your role as the orchestrator of care. When you provide a consultation, give full and prompt answers, collaborate with the referring physician, and treat your colleagues' opinions with respect. On both sides of the exchange, make sure the family's concerns are addressed and the patient's needs are the primary focus. There is nothing new in these recommendations, but they are as relevant today as ever. Following them will improve the outcome of care for your patients.
DR. SERWINT is Associate Professor of Pediatrics and Medical Director of the Harriet Lane Primary Care Clinic, The Johns Hopkins Children's Center, Baltimore, MD.
DR. SEIDEL is Professor Emeritus of Pediatrics, Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD.
We thank Fred Heldrich, MD, for his critical review of the manuscript and Therese Sorrentino for her secretarial expertise in preparing it. These reports represent actual circumstances with some modifications to obscure time, person, and place.
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