A while back I was working in pediatric urgent care and had occasion to do something I have done many times since starting out in medicine. I called a consult. The reason, like many consults, was an abnormality on a study that required a specialist’s opinion. I paged the resident on call for this particular specialty. When they called back I was treated, right from the get-go, to some serious attitude. This was a legitimate consult and I had a question that I needed answered, so I pressed on. I also called him on it, which seemed to surprise him a bit. Now, I have a sense of humor and a fairly thick skin at this point. Feel free to point out something I’m missing or rib me a little good-naturedly. But I can’t abide downright disrespect. This isn’t just about a bruised ego. Doctors disrespecting each other or dismissing a request for help isn’t just rude, it’s bad for the patient.
But, I’m getting ahead of myself. Let me start from the beginning.
Fledgling physicians all start out on pretty much equal footing early in medical school. The curriculum is fairly standard. We all make our way through biochem, gross anatomy, and physiology. Even well into the third year clinical rotations there isn’t much variation. Somewhere around the 4th year of medical school our paths start to diverge as we take an interest in a particular specialty. And after residency begins, there is no looking back. Physicians’ jobs vary dramatically depending on their specialty. In general, this is probably a good thing. We love to poke fun with stereotypes, but the truth is that each medical specialty does fit a certain skill set. The folks who are great neurosurgeons may not have been the best internists and vice-versa. But this does mean we have fairly limited real understanding of what our colleagues day-to-day routine looks and feels like. Their frustrations, their joys.
Now back to the consults. After all this sifting and winnowing we physicians divide ourselves up into two major groups: those who call the consults (primary care docs, ER docs, hospitalists) and those who get the calls (surgeons, specialists). The art of the consult is not easy. There are a few important things that must occur for a consult to be productive.
The person calling the consult:
- Must carefully select which patients to call a specialist about and which patients they can care for on their own. This is an art that develops over time and should be respected. If I call a consult for a handful of kids each month, it means there are (literally) hundreds of others that I’ve managed on my own.
- Must know their stuff. When I call a specialist I should know my patient forward and backward. I should be able to easily summarize the history and exam. I should be able to report their lab results without much hesitation. I should have an assessment of what I think is going on.
- Must know why they are calling: I should have a specific and actionable reason to bother the specialist (whether day or night). A study that concerns me. A critical lab result. A surgery that needs doing.
- Must respect the skill set of the person they’re calling. If I’m calling a specialist about something it likely means they know more about the topic than I do. I appreciate that and I’ll carefully consider their opinion.
- Must be nice. The person I’m calling might be managing a crashing patient. They might be in the middle of a surgery. They might have gotten eight admissions that night. I’ll respect that and give them the benefit of the doubt if they don’t call back right away or seem a bit stressed.
The person receiving the consult:
- Must listen. My kid in urgent care might not be the most exciting or interesting case that day, but they’re a patient that needs care. I’ve called because I need help. Remember all those kids I didn’t call about and managed on my own? Something about this kid was different or worrisome. That deserves a moment of the consultant’s full attention and thought.
- Must try to answer the question. After hearing all of the information, I hope the specialist will consider it well. Look at the study I called about. Ask me more questions. Tell me to order another study. Talk to their attending. Or, better yet, see the patient.
- Must respect the skill set of the person calling. Here’s the thing. I couldn’t begin to do the specialist’s job. I’m not trained for it. I don’t understand their frustrations or how busy they are. But, they probably don’t get mine either. I’ve been at this primary care stuff a little while now. Getting through an overbooked schedule. Deciding which patients I can safely treat and send home, and which ones are sick enough to stay. I fancy myself fairly decent at it. But it’s not easy. It doesn’t really help anyone for a specialist to start out by talking down to me or pimping me on the part of the conversation that is supposed to be their job. And, that brings me to:
- Must be nice. As long as I’ve fulfilled my part of the consult bargain (see above), the colleague I’m consulting should do me a solid and answer my question without all of the attitude. I might not describe the study I’m calling about exactly as they’d like. No matter. Being kind is still the right thing to do. Because I’m doing my best. Because we are colleagues. Because I care about this kid I’m calling about and they deserve to get the best care possible.
The majority of the time this process goes great. I have amazing specialist colleagues. Folks I can count on to provide thoughtful, collegial, patient-centered care, day or night.
But, once in a while it doesn’t go so well. And I can’t let it slide. Because if I start to feel uncomfortable, or if the specialist starts acting disrespectful or put-upon, patients don’t get good care. Because then the conversation starts to be about their attitude and my frustration. The patient is lost. And that’s just not okay.
Well Well Well
Things have not changed from almost 25yrs ago !!!!!!
Esp when a primary care physician calls to transfer a Reyes syndrome patient to a tertiary
Attitude was the problem
I read again. Very, very nice.
Sent from my iPad
I enjoyed this post of yours quite a bit. Saw it over at kevinmd.com but comments were closed and I wanted to reply. I may even print this up and give it to the residents or the program director. Calling consults and being able to effectively communicate with specialists is a critical skill.
I’m now on the receiving ends of those consult calls and goodness knows, I appreciate docs like you who have considered each of those items you listed above. My particular pet peeve (particularly from younger residents) is when someone calls for a consult without knowing the details of the patient. Nothing gets me annoyed more quickly than hearing “oh, i just picked him up, I don’t know” when I ask a rather basic question. I’ve even on rare occasions asked residents (when it’s not an urgent question) to call me back when they have had a chance to look at the chart and know what question they want us to address.
I do recognize, however, that as consultants we are there to help. I’m happy that you are there to take care of the rest of that patient’s issues while I focus on my specialty. And if I can teach a little while doing it to help with the hundreds of other cases you don’t call me on, so much the better. Again, like you said, good communication between doctors ultimately benefits the most important person, the patient.
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