MEdIC: The Case of the Difficult Consult – Expert and Community Response

On August 30th I posted the first case of the MEdIC (Medical Education In Cases) series that will be facilitated by Dr. Teresa Chan (@TChanMD) and I (@BoringEM). The Case of the Difficult Consult involved a junior resident in the emergency department who had a consult go bad. Our readers were thrust into the role of an attending physician wanting to help.

We were overwhelmed by the quality and quantity of the responses from both EM and non-EM physicians in the comments and on twitter. It was clear that the art of the consult is something that physicians substantial time contemplating.

This follow-up post includes

• The responses of our medical education experts, Drs. Rob Woods and Teresa Chan
• A summary of insights from the ALiEM community derived from the twitter discussion and comments
• Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities

Expert Response 1

Dr. Rob Woods MD MMEd FRCPC
EM Program Director, University of Saskatchewan

Oh, I can relate to the vignette when I think back to my training. As I progressed through residency, I eventually learned how to get my consults “wrapped up in a bow” before I picked up the phone. If I was not prepared, the conversation would not go well. It would take a long time and sometimes I would not get what I needed for my patient. It took lots of practice. Here are five tips on how to make this ‘trial and error’ learning process go a little smoother:

1. Gather your ingredients. Make sure you have all of your patient’s data in front of you: old chart, lab results, imaging results, names of previous specialists, rough dates of previous procedures/major investigations and other pertinent info! Before you call, think “What would you want?” and “If I were the consultant, what would I need to know in order to further manage this patient?” This is a good habit to get into when you are on the other side of the ER on offservice rotations. Get their perspectives so you can consult them effectively and efficiently when you get back to the ER.
2. Get the consultant’s name. It is amazing how often this fails to occur. e.g. You forget to ask, and 2 hours later your patient never got their ultrasound. You call the after 5pm person and she knows nothing about it. Q: “Who approved this ultrasound earlier?” Answer 1: “Uhhh…I don’t know…” Not good! Answer 2: “Dr. So-and-So approved it at 15:32.” Better!
3. Lead with the headline! Clarify the purpose and urgency of your consultation. Don’t present a history and physical exam but rather a diagnosis (or suspected diagnosis), the data that supports your thinking, and your question for the consultant. Then let the consultant ask what they need to know. It’s much more efficient this way.
4. When you ASSUME… Don’t set yourself up for failure by assuming you know what the consultant will do. Tell the patient you are going to talk to the consultant to ask their opinion. When the patient asks if they are going to get a particular test or treatment or be admitted, just say that’s up to the consultant. That way if you thought the patient needed an angiogram or a CT, but the consultant does not, the patient is not misinformed.
5. Look at the evidence. There are some great models out there (5C’s, PIQUED) designed as templates for ED consultation. Check them out and see what works best for you. I hope these tips can help you shorten the transition to competent consultations. You’ll still have the occasional difficult consult, but when you sound like you know your stuff, good things will happen for your patients.

Expert Response 2

Dr. Teresa Chan MD MHPE (Candidate) FRCPC
EM Physician, McMaster University

Consultations from the Emergency Department can be difficult. They are wrought with many layers of complexity – there are issues around hierarchy, interpersonal relations, competing interests, divergent values… The list goes on and on!

There have been two models recently that have sought to break down the complexity of the ED consultation into some simpler models. Chad Kessler (Associate Professor at Duke University’s School of Medicine), has derived and validated the 5C’s model of consultation (8,11). The components of the 5C’s are:

1. Contact
2. Communication
3. Core Question
4. Collaboration
5. Closing the loop

I have also studied the ED consultation phenomenon and created a mnemonic (PIQUED) aimed at learners delivering consults early in their career:

1. Preparation
2. Identification of all Parties
3. Questions
4. Urgency
5. Educational Modifications
6. Debriefing & Discussing

Both of these models might act as a framework for junior learners. Anecdotally, I have found that those learners who have trouble often left off some key item in either or of these models.  There are also other resources for improving outpatient referrals by Chris Stille et al. (2011), as well as numerous other studies that point towards the need for better communication when transitioning care (1,2,3)

Improving consulting skills is a key skill for any learner in the ED. By improving these interactions, we hope to improve communications, and ultimately enhance patient care.

Curated from the Community

A qualitative methodology was used to curate the community discussion. Tweets and blog comments were analyzed, and four overarching themes were extracted from the online discussions. Prior to publication, we sent this analysis to two of our community members to perform a ‘member check’ to ensure credibility. Thank you to  Elisha Targonsky and Amy Walsh for their participation in this process. I would like to thank them and the rest of the discussion participants Drs. Susan Shaw, Michelle Gibson, Lindsay Melvin, Nikita Joshi, Tom, Dina Wallin, Corey Heitz, Justin Ryel, Todd Raine, Anand Swaminathan, Terry Kind, Rob Bryant, Seth Trueger, George F and Richard van Wylick for their insightful contributions.

1. Be respectful and professional. The need to maintain composure was the most often cited item. Many comments noted that problems escalated if this did not occur. Tips for making it a priority included a complete introduction, keeping the patient central in the discussion, remembering that you and the consultant are on the “same team,” inviting an in-person discussion whenever possible, thanking the consultant for their assistance and never disparaging the patient or other staff.
2. It is a two-way street. This is an item that I think I have been guilty of neglecting a few times while working busy shifts. It is easy to forget that, for any number of reasons, the consultant could be having a very bad day. Tips for incorporating this understanding into consultation behaviors included noting that the patient is in need of their expertise, ensuring that you are truly listening to their perspective, and empathizing with any difficulties that you are aware of (ie a backlog of consults or a poor outcome for a recent patient).
3. Preparation is key. Beyond taking the common steps of gathering all of the necessary information, having a standard approach and formulating a specific question, there were several tips for preparation. The importance of “knowing the audience” in terms of their usual approach to receiving consults and the information that they want was highlighted along with the need to “close the loop” on the plan for the consultation.
4. Consultation skills need to be taught by an experienced coach. There was widespread agreement that the teaching of this communication skill was not commiserate to its importance. Suggestions for teaching the skill included teaching consultation frameworks such as SBAR, the C’s or PIQUED, having learners observe consultations, priming learners for their own consults, and having them do a ‘mock consult’ with you before calling the consultant. Our participants thought that teachers should coach learners to “lead with the headline” and state what they are requesting up front. They should also be clear about the urgency of the consultation.

Case and Responses for Download

The use of this case and its expert responses is encouraged for the purposes of continuing medical education and faculty development.

PDF copies can be downloaded by clicking here or on the picture.

We’d love to hear how you’ve used these resources! So if you do please email <teresamchan(at)gmail.com> or tweet us (@BoringEM and @TChanMD) to let us know.

References

Descriptive Studies on Consultations

1. Salerno, S. M., Hurst, F. P., Halvorson, S., & Mercado, D. L. (2007). Principles of effective consultation: an update for the 21st-century consultant. Archives of internal medicine, 167(3), 271.
2. Iwata M, Yamanaka K, Kitagawa Y. The level of agreement regarding patient disposition between Emergency Physicians and consultants in the emergency department. Int J Emerg Med. 2013;6(1):22
3. Boulware, D. R., Dekarske, A. S., & Filice, G. A. (2010). Physician preferences for elements of effective consultations. Journal of general internal medicine, 25(1), 25-30.

Observational Studies

1. Matthews AL, Harvey CM, Schuster RJ, Durso FT. Emergency Physician to admitting physician handovers: an exploratory study. Proceedings of the Human Factors and Ergonomics Society 46th Annual Meeting; (2002). Baltimore, MD: 1511-1515.

Reviews on Consultations

1. 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):753-758.
2. Kessler CS, Asrow A, Beach C, et al. The taxonomy of emergency department consultations–results of an expert consensus panel. Ann Emerg Med. 2013;61(2):161-166.
3. Lee RS, Woods R, Bullard M, Holroyd BR, and Rowe BH. Consultations in the emergency department: a systematic review of the literature.  Can J Emerg Med. 2008;(25):4–9.

Models for Consultation

1. Kessler CS, Kalapurayil PS, Yudkowsky R, Schwartz A. Validity evidence for a new checklist evaluating consultations, the 5Cs model. Acad Med. 2012;87(10):1408-1412.
2. 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. Can J Emerg Med 2013 Jan 1;15(1):42-51.
3. Stille, Christopher J., et al. Development and validation of a tool to improve paediatric referral/consultation communication. BMJ Quality & Safety 20.8 (2011): 692-697.

For Medical Educators

1. Kessler CS, Afshar Y, Sardar G, Yudkowsky R, Ankel F, Schwartz A. A prospective, randomized, controlled study demonstrating a novel, effective model of transfer of care between physicians: The 5 Cs of consultation. Acad Emerg Med. 2012;19(8):968-974.

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