Pearls for Consultations Between Medicine and Surgery

Diane B. Wayne, MD, Program Director, Internal Medicine, and Jeffrey D. Wayne, MD, FACS, Residency
Department of Medicine, Northwestern University Feinberg School of Medicine

Background

Consultations between medical and surgical residents occur frequently in both the inpatient and outpatient setting. Several reports have suggested that joint management of patients can reduce postoperative complications, increase adherence to treatment guidelines, and decrease preoperative length of stay.^1-3 Although there is little data regarding the adequacy of instruction in "consultation medicine" during residency, one graduate survey targeted communication strategies and management of common consultative problems as areas for improvement.⁴ As the Accreditation Council for Graduate Medical Education shifts to outcomes-based accreditation standards, residency programs will need to provide education and monitor their trainees' achievements in core competencies such as professionalism, systems-based practice, and interpersonal skills and communication.⁵ Thus, formal education in consultation medicine and evaluation of residents' interactions with other healthcare providers may be useful in order to best prepare graduates for practice and to comply with residency accreditation requirements.

Principles of Effective Consultation

During the 2003-2004 academic year, the residency programs in internal medicine and general surgery at our institution attempted to increase the effectiveness of consultations between departments and provide didactic instruction for residents in interdepartmental consultations. Changes in staffing in both programs, due to new work-hours restrictions and a desire to respond to issues raised by housestaff, were the major reasons for the effort to focus on medical-surgical consultations. A committee comprised of surgical and medical housestaff and faculty was formed to identify problem areas and institute a forum for discussion and planning. Conferences were held in both departments to review expectations and goals. The process of committee and department level work increased knowledge about the structure and clinical demands of the programs and established policies and procedures for both initiating and responding to consultation requests. After the meetings and conferences, we were left with the following pearls regarding consultations:

1. Each program should set expectations. At the time when residents begin to serve as consultants, their role should be clearly defined and expectations for clinical and behavioral performance should be outlined. Department-specific requirements for initiating, responding to, and reporting the findings of consultations should be reviewed. The issues of when and how to involve senior residents and faculty members should be explained. The creation and use of written policies may be especially helpful in examining expectations.
2. Communication between departments is essential. Interdepartmental communication was especially important as a result of changes in residency structure and call schedules after the initiation of the 80-hour work week. Improved communication allows for greater understanding of staffing, conference times, and call schedules. Non-urgent consults can be placed at a time when a particular service is best equipped to respond. Increased communication also allowed us to minimize confusion in contacting consultants by allocating unique pagers for consult services and posting call schedules on a hospital-wide Web site.
3. Physicians should behave in a professional manner. In keeping with the core competencies in which residents are evaluated, faculty members and residents should be courteous, respectful, and polite. Faculty members have the responsibility to model this behavior despite challenges that may arise due to heavy clinical workload or other responsibilities. Unprofessional responses to consultations should be strongly discouraged for both residents and faculty.
4. Reasonable time expectations should be set. One area of frustration for residents is services having differing opinions on the level of urgency of a particular consultation. Setting levels of consultations such as non-urgent, urgent, and emergent with agreed upon criteria and time periods in which consultation patients should be seen may be helpful in alleviating the problem of different expectations.
5. A knowledgeable person should place and accept consults. Understanding the role of medical students and junior residents in the educational structure of other programs is helpful. While physician-to-physician consults may be required in some cases, services requesting a consult should always ensure that the person contacting the consultant has access to all relevant data and is able to answer clinical questions the consultant may pose. Similarly, persons responding to consultations should be able to initiate basic testing and treatment until the faculty member or more senior trainee is available.
6. Questions posed and answers given should be clear and concise. When placing a consultation request, it is important to have a well thought out reason for the consultation and a specific question to be answered. The primary role of the consultant is to respond to the specific question posed by the requesting service.
7. Written communication should be legible and complete. In systems using paper medical records, it is critical for recommendations, physician names, and pager numbers to be legible. Whether on paper or through an electronic medical record, a list of final recommendations and the names of and contact information for all residents and faculty involved should be included. Additionally, some consensus should be reached regarding the writing of patient care orders by members of consult services.
8. Verbal communication is critical. Although procedures for requesting and responding to consultations may vary between institutions, verbal communication should always be encouraged. In this way, consults can be appropriately triaged by level of urgency, specific clinical questions can be addressed, and initial treatment or testing can be instituted. In the inpatient setting especially, communication solely through the medical chart should be discouraged.

Conclusions

Residents from a variety of specialties will need to interact frequently in patient care activities during residency and in their future careers. Formal instruction in the principles of consultation may be useful to best prepare residents for practice. Tools to evaluate residents' interactions with medical colleagues and paramedical staff are available and may provide valuable insight into their accomplishments in the core competencies.⁶ Lastly, opening channels of communication between departments may increase the effectiveness of communication and decrease friction on the clinical services.

References

1. Huddleston JM, Long KH, Naessens JM, et al: Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004; 131:28-38.
2. Keating NL, Landrum MB, Ayanian JZ, Winer EP, Guadagnoli E: Consultation with a medical oncologist before surgery and type of surgery among elderly women with early-stage breast cancer. J Clin Oncol. 2003; 21:4532-9.
3. Macpherson DS, Lofgren RP: Outpatient internal medicine preoperative evaluation: a randomized clinical trial. Med Care. 1994; 32:498-507.
4. Devor M, Renvall M, Ramsdell J: Practice patterns and the adequacy of residency training in consultation medicine. J Gen Intern Med. 1993; 10:554-60.
5. ACGME Outcome Project. Accreditation Council for Graduate Medical Education Web site. Internet (http://www.acgme.org/Outcome/). Retrieved September 8, 2004. Accessed September 8, 2004.
6. Linn LS, Dimatteo MR, Cope DW, Robbins A: Measuring physicians' humanistic attitudes, values, and behaviors. Med Care. 1987; 25(6):504-15.