I remember being a first-year physician in training, picking up the phone, and calling consults. I remember calling consults even if I found I did not always understand the question we had for our consultants. It bothered me at the time, but I was so busy, and asking why sometimes seemed like more energy than I could muster.
Now, I am a more advanced physician and a consultant on the other side of that equation, and I find myself facing the same sorts of frustrations. Often, consults are placed with no specific question in mind. Instead, “So I have this consult,” is a pretty standard page for me. It is almost always followed by, “I think this is rheumatologic” without justification for why. “I think this is rheumatologic” is not a diagnosis. What is missing is the synthesis of patient history and exam. The lack of specificity makes it difficult for me to evaluate my consultee’s knowledge base and offer teaching. For example, “I am worried this patient may have arthritis because their knee joint is warm and stiff” allows me to offer feedback (in fact, you technically need swelling to have arthritis, but it is concerning that the knee is warm and stiff). As a medical educator, I find myself wondering what can be done to improve this interaction.
What is the issue?
There is little to no formal training on how to effectively conduct consults (either in asking for them or in giving the advice).
Why should we care?
The act of consultation can be defined as seeking expert advice on patient care. In the inpatient setting, training resident physicians frequently seek the advice of consultants (often consisting of training fellows) on behalf of their teams and supervising physician. Inherent in the process is the need for effective communication on both sides. This is critical, as breakdowns in communication lead to medical errors, which can cause patient harm.
The consultation process is also a critical time for both training residents to learn and training fellows to develop their teaching skills. Despite this, studies have shown that residents do not feel they receive sufficient teaching from fellows. There is also evidence that many fellows do not receive formal training on how to teach and do not receive feedback on their teaching skills during fellowship.
What barriers prevent effective consults?
When it comes to consults, two major domains of barriers have been found: systemic and personal. Systemic barriers include the culture of the institution, which involves how a consult is placed, the timeliness of getting a response, the quality of the consult (i.e. is there a specific question), and the primary team structure (i.e. team dynamics and physical location that may inhibit the consultant from finding them for in-person teaching). A major barrier identified is experience. Fellows early in training report they feel reluctant to teach, and residents early in training report they do not understand how to ask for the consult.
Closely tied to these factors are personal barriers, such as expectations between the resident and fellow, which are not often expressly stated. There is also concern for “pushback” from the consultant, wherein the consultant tries to decline the consult. In fact, fear of “pushback” is a common reason for resident dissatisfaction with consults.
Has anything been done?
There have been initiatives in some institutions to try and improve consultations from the resident side, including The 5 C’s, CONSULT, and PAGE. There has also been an evaluation of a fellows as teacher curriculum aiming at improving the teaching offered by fellows. These initiatives offer promising results in improvement in communication and teaching skills. Nevertheless, the problem persists, in part because there has not been integrative work targeting residents and fellows together, and in part because systematic barriers are not being addressed effectively.
How can educators impact this?
As educators, we risk not only patient well-being but also losing important and valuable learning opportunities if we do not address how to effectively conduct consults. As a clinical fellow interested in medical education, I start by trying to meet my residents where they are. I set expectations for the consult and try to help the resident identify the question they are asking me. For instance, instead of “this patient seems rheumatologic,” I ask them to identify the symptoms the patient is having and then to piece those symptoms together to point towards a diagnosis. I also conduct in person teaching, feedback, and consult advice.
While this is by no means perfect, it is a start towards addressing the problem. In reality, systematic barriers, such as fellow and resident physician workload, need to be addressed by the institution. Personal barriers, such as willingness to engage, as well as expectations of both residents and fellows, should be addressed early in training, and feedback should be given. The introduction of formal curriculum, such as those mentioned above, can assist with some of these barriers. Above all, awareness of the issue is the key towards starting to improve the problem.
What has been your experience with consulting? What ideas do you have to help address the barriers facing resident and fellow physicians in training in this situation?
Did you know that the Harvard Macy Institute Community Blog has had more than 190 posts? Previous blog posts have explored topics including making positive feedback truly positive, frame based feedback, and bedside teaching.
Katherine (Katie) Schultz
Katherine (Katie) Schultz, MD is a medical educator and clinical fellow in Pediatric Rheumatology at Cincinnati Children’s Hospital. Katie’s areas of professional interest include addressing the impending pediatric rheumatology physician shortage, making consultation effective and efficient, and the use of gamification for teaching musculoskeletal history and exam taking skills. Katie can be followed on Twitter.