Despite the handful of my brethren who have the self opinion of knowing all and doing all most physicians ask for help in certain situations. In medical lingo this is known as a “consult” (although I readily admit that consults are not exclusive to medicine). Here is my perspective on the use and abuse of this part of medical practice.
“I need your help.” A not infrequent statement that I have made, or have heard, through the years. It derives from the need for the additional expertise that either a medical subspecialist or surgeon can provide. This expertise comes in the form of a medical or surgical “consult”. So why do physicians request consults? Because they need answers to one, or all, of the following “essential questions”: 1) what’s the problem?, 2) how does the problem get diagnosed?, and 3) how does the problem get fixed? In response to the consult request the consultant obtains/reviews historical information, examines the patient, reviews relevant laboratory and radiographic information and may speak to other healthcare personnel involved in the case. With the pertinent information in hand the consultant then provides answers to the “essential questions” outlined above in a written report. This serves as a guide to the requesting physician regarding all three questions leaving implementation to said physician in all aspects or, not infrequently, the consultant assists in their implementation.
Sometimes a consult takes the form of patient management only. An example would be a consult for management of the care of a critically ill patient. Essential questions #1 and #2 may already have been answered (or not) but the primary focus is now most often on “fixing” (#3). Management can range from the fairly straightforward to quite complex (often with other consultants involved) to the impossible (kind of like putting back together grandma’s most prized vase which now lies on the tile floor smashed into a million pieces–see examples in my previous blog Conversations)
Occasionally there are “curbside consults” where a physician may informally ask (“curbside” ) a specialist for some guidance regarding one of the essential questions (e.g. “I have a patient who is short of breath.” The curbside answer is couched as general advice such as, “Well, if you think it is a lung problem, you may think about getting a pulmonary function test”). Responses to a curbside consult are generally broad and, to a measured degree, non-specific. Curbside consults are not written up and physicians (at least at one time) knew they were not to be abused.
Consultants don’t show up at the bedside by magic nor do they wander the halls until they hear of a situation where help is needed (Code Blues excepted). Consultants have to be asked. In the first 25 years or so of my practice the typical scenario was: Dr. X requests a consult from a medical subspecialist or surgeon. The request is written as an order in the chart and the chart is placed on the hospital secretary’s desk. If the request is not felt to be urgent nothing might be said to the secretary. If urgent, the physician would (sometimes) mention something to make the secretary aware. In either case once the secretary was aware of the consult the specific subspecialist’s office (or answering service if after hours) would be notified. Not infrequently (and irritatingly) the order would read , “Consult [subspecialty]” but no reason for the consult was provided. And it was not uncommon that awareness of the consult became known only after the subspecialist was no longer at the hospital. It takes no imagination to see that responses to consults could be delayed as the subspecialist attempts to determine the urgency of the consult. In the early days of practice I would come in for any consult– even after hours, regardless, as I assumed that was how it was done. My more seasoned partners, upon learning about my “due (and exhausting) diligence”, advised me to speak with a nurse caring for the patient, get some information, then decide about the immediacy of answering consults especially if after-hours. Dutifully armed with this advice I began to apply it and it worked well– most of the time. I recall one evening when I was notified of a “consult pulmonary” order with no reason given. Calling the hospital I was able to speak to a charge nurse who also didn’t know why there was a consult. Perusing the patient’s chart she provided some historical information and then said, “Oh, here, her oxygen level today was 45 [not good!].” I completed the consult that night on a paranoid schizophrenic woman who smoked “like a chimney” and had no intentions of quitting and did not want to wear her prescribed supplemental oxygen. [The consult had been requested by a frustrated resident who, in a fit of pique, wrote for the consult and then…went home]. I wrote up a brief consult report, made some suggestions, and, at the bottom of the consult sheet wrote (in my own fit of pique), “I AM NOT HER MOTHER!” Fortunately consult requests have since evolved and, especially with the advent of cell phones, physician to physician contact gradually became easier. In fact in my last 11 years of practice physician-to-physician contact for hospital consults was mandatory.
Office consults sometimes had their own challenges. More often than not the consultant knew the reason for the consult, but not always. Imagine, if you will, a patient sitting in the office, not knowing why they are there, and no reason for the consult was provided. Both patient and consultant are in the dark as to the issue. Questioning may begin with, “Why are your here (or what is bothering you)?”, the patient mentions something and so questions pertaining to that complaint come to the forefront. Toward the end of the appointment time, however, the patient’s Xray’s are reviewed only to note a lung mass (which, in this example, was the reason for the consult in the first place). Take home message–if your physician wants you to see a consultant, know why.
And, not to be forgotten, what about the “dispensation consult” with which I teased you in the title? While some of the consult examples above abuse time or illustrate some inconveniences, dispensation consults, in my opinion, abuse time and money, driving up the cost of healthcare. Most often a dispensation consult will be requested for a hospitalized patient. So, what are they? For some physicians they provide reassurance for simple straightforward problem diagnosis or treatments already instituted by them or, for others, provide “cover.” I encountered my first dispensation consult shortly after I started my pulmonary practice. The consult request dealt with a young woman with a small collection of fluid sitting between her lung and chest wall (a pleural effusion). As a dutiful consultant I reviewed the case including all pertinent data, interviewed and examined the patient, and wrote up the consult. Leaving the hospital I ran into the consulting physician and spoke to him about the consult, reassuring him that he had addressed the three essential questions, and opined that the patient’s issue would resolve. “Oh, I knew it would,” he said, “but I wanted some cover with any lawyer if it didn’t.” Welcome to the medical world of CYA. Remember, other than curbside consults, consultants don’t work for free. Unfortunately I’ve noted over the last 15 years of my practice, especially, a gradual (at least perceived) increase in the use/abuse of the dispensation consult with a resultant waste of consultants’ time and somebody’s money.
Lastly, while the cost added to the overall healthcare bill that could be attributed to dispensation consults specifically would be difficult to determine (easier to separate the wheat from the chaff), the utilization of medical consultations on inpatient hospitalizations has been looked at (1). Analyzing data collected in 2014 the authors illustrate costs and consultation patterns and raise the question as to whether hospitals are in a position to optimize consultation care. If so, I have yet to see it.
(1) OriginalInvestigation | HealthPolicy
Association of Medicare Spending With Subspecialty Consultation for Elderly Hospitalized Adults Kira L. Ryskina, MD, MS; Yihao Yuan, MS; Rachel M. Werner, MD, PhD. JAMA Network Open. 2019;2(4):e191634. doi:10.1001/jamanetworkopen.2019.1634
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