The time and action specific consultation

As emergency physicians we spend a great deal of time interacting with consultants, but we don’t think about this as a skill. In fact we probably interact with fellow physicians more than any other specialty, but rarely is the interaction itself included in any type of formal curriculum. The well being of our patients often depends on our ability to get a particular consultant involved in a case.

Each emergency doctor has their own approach to consultation, from the buddy-buddy type of interaction to the frankly hostile. When junior physicians call consultants they often simply state what sort of case they have and see what the consultant has to say; ‘I have Mr. X here, a 65 year old man with chest pain….’ Unfortunately this leaves the consultant in the position of guessing what the emergency physician (and the patient) wants or needs. The consultant may respond with management advice when what the emerg doc really wanted was for them to come see the patient in consultation or accept the patient for admission.

A better system is the time and action specific consultation. This allows the emerg doc to clearly communicate their request to the consultant in a way that is non-confrontational, but also unambiguous. The phone call opens with an introduction; ‘Hi I’m Dr. J in the emerg, who am I speaking to?’ This allows both parties to know exactly who they are dealing with. Then (after the exchange of niceties that are an important part of collegial community practice) the emergency doc briefly summarizes the case and makes a specific request of the consultant and gives a specific timeframe.

An example might look like this:

“Hi it’s Dr. J in emerg, who am I speaking to?” “Oh hi Dr. Cardiology, happy new year! Listen I have a 65 year old man with chest pain, unresponsive to nitro and morphine. He has some ischemic ECG changes. I’d like you to come down and see him in consultation in the next 15 minutes.”

When you need advice rather than in person consultation it is equally important to say so:

“Hi it’s Dr. J in the emerg, who am I speaking to?” “Oh hi Dr. Opthalmology, thanks for calling me back. Listen, I have a contact lens wearer with a corneal abrasion. I’d like to put him on antibiotics, but he is allergic to quinalones. Can you recommend an appropriate non-quinalone antibiotic for corneal abrasion in a contact lens wearer and see him in follow-up tomorrow?”

The time and action specific consultation allows the emergency doctor, who has seen the patient, to set the pace of the consultation. This is appropriate since the emerg doc has the best idea of the actual acuity of the patient, but can be lost when the conversation lacks specificity. Most of the time your consultants will appreciate the brevity of your patient presentation, and directive approach to consultation.

Disagreements will occur and will mostly be about the need to see the patient or the timeframe within which they should be seen. When this occurs I suggest first identifying the conflict and then giving the consultant more clinical information to explain why you have made a specific request. Suppose the opthalmologist in the above example suggests a 1 week follow-up;

“Thanks for the advice Dr. Opthalmology, I will start the patient on gentamicin drops right away. I see we have a difference of opinion about when this patient should be followed up; this patient is a contact lens wearer and he has a large corneal abrasion right in the centre of his visual axis. It looks deep. I am worried about this patient so I think he should be seen tomorrow, rather than in a week.”

Most consultants will grant your request once more information is given. Occasionally the conflict will persist and negotiation will be required. When this happens remember to be polite, but also remember that your primary responsibility is to your patient.

Finally I suggest closing the loop, briefly repeat the plan back to the consultant and make sure you are both on the same page. Then document on the chart the consultants name, the action, and the timeframe.

“Thanks Dr. Opthalmology, I will put the patient on gentamicin drops and have him call your office in the morning for an appointment tomorrow.”

In summary a managed approach to conversations with consultants can benefit both parties, by expediting conversations, and making expectations clear from the outset. Managed conversations leave less room for ambiguity, assumption and error. The steps to the time and action specific consultation are :

  1. Identify yourself and the consultant
  2. Give a very brief summary of the case
  3. Ask the consultant to perform a specific action (advice, in person consultation, admission, etc.)
  4. Tell the consultant the time frame in which you need them to perform this action
  5. Identify and resolve any disagreement or conflict
  6. Close the loop by repeating the specified plan and time frame back to the consultant
  7. Document all of the above for the chart and the patient

Comments

  1. Graham says:

    Couldn’t agree more. Just wrote something similar in an upcoming column.

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