New commandments for consults

It's time to update the 10 commandments, according to hospitalist Heather Nye, MD, PhD, FACP.

She was referring not to the ones in the Bible, but to those handed down by one of the fathers of hospital medicine, Lee Goldman, MD, FACP, and colleagues in the 1983 article, “Ten Commandments for Effective Consultations.”

“Many of these are still true today,” said Dr. Nye, who is associate chief of medicine at the San Francisco Veterans Affairs Health System and a professor of medicine at the University of California, San Francisco.

But some of the commandments for performing consults could use an update for the 21st century, which she provided during a talk at Internal Medicine Meeting 2023, held in San Diego in late April. Dr. Nye also offered her advice on the opposite situation, when a hospitalist asks a subspecialist for a consult.

To the original first commandment, determine the question, she had some additions. “Go the extra mile,” she said. “You're going to see all five, six, seven ways to Sunday where this patient may be going south. It's incumbent upon us to really share that and act on that as well.” Also during that initial conversation with the physician requesting a consult, get the attending's name, even if you're dealing with a resident.

Establishing the urgency of the team requesting a consult is also still important, Dr. Nye noted. “Most of us are doing this in well less than 24 hours—more like two to five hours on average—but make sure you have a sense if this is needed tout suite.”

The commandments to be specific and provide contingency plans also hold, but she had some new advice on how to provide recommendations.

“Both verbal and written recommendations are super important, both medicolegally and from a timeframe standpoint,” Dr. Nye said. “It's an extra step, and it's a pain in the neck—you've got to know the number that you're calling back. But it is really, really important.”

After providing verbal recommendations, document in the note who received them, and if you weren't satisfied with the conversation, continue up the chain. “The resident says, ‘I'll talk to my chief,’ and I never hear the words ‘attending surgeon,’” said Dr. Nye. “It's important for us to not be too shy to say, ‘Who's your attending? I'd like to talk to them,’ if there is any concern about transmission of information.”

Written documentation of a consult should also include the time the patient was seen, the urgency of the consult, the recommendations, and planned follow-up. “If it's not in the chart, in the medical-legal world it didn't happen, despite all the effort and thought undoubtedly you put into the patient,” she said.

Hospitalists should also explain at least a little of their thinking to whomever requested the consult, she recommended, citing a 2010 study in which 64% of physicians wanted consultants to include their rationale, although only 7% thought references were needed.

“Make your consults a teachable moment,” said Dr. Nye. “It's a little like parenting. We're hoping to show them the ropes and empower them to potentially at least know the first steps next time they see this problem.”

After performing the consult, remember to follow up on your recommendations, including any suggested labs. “Many times, they're normal and boring, but if you don't circle back and write that in your note, there can be problems down the road,” she said.

This step includes checking to see if recommended actions were taken. “You don't know why they're not getting the labs you asked for or the study you asked for—anybody ever had that happen? Usually, I get angry. My first go-to is, ‘They're just blatantly ignoring me,’” Dr. Nye said. But often it can be an oversight, she noted.

“Always reach out again and say, ‘I just noticed you didn't do anything that I said.’ It may be they disagree with you wholeheartedly, in which case you sign off and you're done,” she said.

Until you do sign off, leave daily notes on the patient. “It does not need to be extra work. It doesn't mean you have to see the patient,” said Dr. Nye. “Just write that sentence. Say, ‘Still following patient. Everything the same, no additional updates.’ … It means I've looked at the vitals. It means I'm still involved.”

When it is time to sign off, be clear about doing so and leave a number for the other physicians to call with questions. “If you're rotating off service tomorrow, make sure that's a pager or a phone or some general service-related contact number so that people don't get lost,” she said.

Also consider arranging outpatient follow-up for the patient when appropriate. “This is more for people who are in subspecialty medicine and who might have much better connections,” said Dr. Nye. “Because that is exactly where balls get dropped. Recommendations are left to follow up with a clinic, and it never happens.”

Balls also often get dropped in consulting and comanagement relationships because of unclear delineation of responsibilities, she noted.

“Service agreements can encompass a lot of things, but they cannot capture every scenario,” Dr. Nye said. “That involves ongoing communication … If you can have continuity of care, that helps increase communication between specialties. Checklists sometimes help, [as well as] multidisciplinary rounds and huddles and making relationships with people so that they feel comfortable calling you.”

It's critical for everyone in a consulting relationship to feel comfortable communicating, noted Dr. Nye, as she shifted to offering advice on getting consults from subspecialists. “Every single one of those commandments, I would hold my consultants to.”

She cited a 2017 study of hospitalists' perspectives on consults from subspecialists, which found that most preferred in-person communication but that this occurred less than half the time. “And then 64.4% received pushback. No surprise here, we've all received pushback,” said Dr. Nye. “This probably is what underlies our reluctance to call a service twice and a third time with a question.”

Hospitalists must overcome that reluctance, she said. “You've got to manage your consultants. Take them by the horns. They're not charging you; they are there for you and your patient.”

That entails making sure that consultants follow up on the results of any studies they've recommended and give their opinion on what to do next. “Never assume they're talking to one another or even reading the chart,” she said. “Take upon yourself the extra role of being the conduit of information.” Also, get consultants to document any verbal recommendations in the chart, for both clarity and liability.

Be clear on when the consultant has signed off, and if questions arise after that, call. “You know how they always put that little tagline, which is sort of a please don't call: ‘Please call with questions. Thank you for this consult,’” said Dr. Nye. “Make sure you get a number. If you don't see it in the note, call the service pager and say, ‘What's your general consult number?’”

Finally, check back in with the consultants before discharge, being sure to discuss follow-up care for the relevant condition. “I make it a habit of saying like, ‘Let's just circle back with GI. They're going to see him in the outpatient setting,’” said Dr. Nye. “This makes sure that there's nothing else they want us to do. It goes a long way, and it helps the patient.”

Even if you sometimes get a little attitude in return, you shouldn't feel bad about making the most of a consult, Dr. Nye concluded. “That's what they're there for.”