Consult Courtesy Open Access

1. Recognize the Inevitable Outcome A consultation request almost always results in the complete evaluation of the patient by the consulting team. By accepting that no matter what one says to the consulting team, the patient will still need to be seen and evaluated, the initial struggle to deflect the consult can be avoided. Junior residents, who typically answer consult calls, should rarely refuse consults, since their medical knowledge and experience are limited. Thus, if a team calls for a consultation, a complete assessment is indicated with very few exceptions. Once the acuity of the consult is assessed, the only acceptable and courteous answer is, “We would be happy to see the patient as soon as we can.”

2. Willingly Provide Clinical Teaching Points Along with clinical recommendations regarding the common scenarios related to the consultation, willingly provide clinical teaching points. Recognize that you are interacting with learners who have variable levels of knowledge in your specialty, and this may be a key teachable moment. By making a consult an educational experience, you may help use resources in the hospital in the future. If a patient's condition is appropriate for outpatient care, then an inpatient consult may be as much of a burden on the health care system as an unnecessary test.

3. Avoid Negative Assumptions Regardless of the time of day, it is important to interact in a professional manner. There is no reason to automatically be unpleasant on the phone simply because the call occurs at 3 am. Assume that the consulting service or nurse is acting in the patient's best interest. A common scenario is a nighttime nursing call answered by a resident with a negative tone. Who else should the nurse call at this hour except the resident who is assigned to be on call? Listen to the nurse and respond appropriately and as a team member. If the call was truly inappropriately timed, then kindly say that this issue could have waited until the morning. If it is a recurring theme, instead of getting enraged with an individual, talk to the charge nurse the next day to effect useful changes.

The same assumption—that we are all working together, on the same team—also improves interactions with primary teams at the time of a consult. In the scenario described above, the lesion did require biopsy to rule out malignancy. Thus the consult, initially assumed to be inappropriate, was indeed in the patient's best interest.

1. Call Consults as Early in the Day as Possible Most surgical teams round at 6 am before starting the day's operative cases. An early consult helps to get the patient seen and “staffed” by the appropriate attending physician in a timely fashion, which is often between operating room cases or clinic patients. Since most inpatient medicine teams round until midmorning, this may mean calling consults before or during rounds.

2. Have Pertinent Clinical Information Available In a large hospital there can be a tendency toward overreliance on specialists at the expense of both generalist education and goodwill between services. Start the workup of the problem and complete appropriate basic tests before calling the consult. Anticipating what a consultant will want has educational value and engages the primary team. Make sure the person calling the consult has completed a thorough, problem-focused physical examination.

3. Be Judicious With Consults While it can seem like patient-centered care would address as many problems as possible during an inpatient stay, the realities of inpatient medicine make this impossible. Nonemergent problems that are generally seen in an outpatient clinic are rarely an indication for an inpatient consultation, even if currently symptomatic. A chronic problem present before admission could also be better treated in a clinic visit, where necessary equipment and staff are readily available to address the problem more efficiently.

4. Use Each Consult as a Learning Opportunity If the primary team is genuinely interested in what they can learn from the consultant, the stage will be set for a much more positive interaction. Consider how the outcome of this consult may change how a patient with a similar complaint is managed in the future, in both inpatient and outpatient settings.

Ideally, the hospital provides a professional and courteous environment with varied staff caring for patients in the most efficient way possible. It should be a place where consultant teams happily offer their assistance, and consultation requests are appropriate and judicious. These suggestions are offered to minimize the sometimes negative attitudes surrounding consults and to produce a more enjoyable and educational hospital environment as well as improved patient care.