As an internal medicine resident, a large chunk of my time is spent consulting other services to obtain their expert opinions. Sometimes, these consult requests are honored. Sometimes not. Equal parts frustrating and awe-inspiring, denying a consult is something of an art.
Here is a beginners guide to dodging consults: how to avoid doing your actual job, and letting someone else handle it. A guide to shirking your responsibilities, responsibly:
1. Master the technicalities of the order placement.
Internal Medicine: Hey, consulting you guys for suspicion of schizoaffective disorder. History of bipolar, but they’ve been off their meds for a while and they’ve had episodes of psychosis.
Psychiatrist: Wait, so is this a consult for schizoaffective or for bipolar?
Internal Medicine: Well, that’s why we’re consulting you. We’re not exactly sure.
Psychiatrist: You said schizoaffective, but the consult order said bipolar!!!
[whooping and high fives heard over the phone]
Internal Medicine: ….yeah, but…
Psychiatrist: If you want to consult us about shizoaffective, you’ll have to cancel that order and put in a new one, but we don’t take consults after 2 PM!
[The distinctive pop of a champagne cork is heard over the phone]
2. Question. Everything.
Internal Medicine: Hey, we’ve got a woman in her late 40s with 1 day of RUQ pain, febrile, white count, D bili of 5, and alk phos 900. History of gallstones. You guys mind taking a look at her? Ultrasound shows pericholecystic fluid. I’m pretty confident this is cholecystitis.
Surgery: Is that so?
Internal Medicine: …I think so.
Surgery: What’s her baseline alk phos? What type of pain is is it? When was her last CT? Who diagnosed these gallstones? Is she really a woman? How febrile is she? How long has she had this pain for? Who did the ultrasound? Who won the democratic presidential nomination in 1924? When –
Internal Medicine: Wait, so are you going to see her?
Surgery: Call us back when you have more of the history.
3. The Tautological Defense.
Internal Medicine: Good afternoon, esteemed colleague!
Dermatology: What’s up?
Internal Medicine: It’s a guy with really bad stevens johnsons. I’m not too comfortable managing it, wondering if you could help with some recs.
Dermatology: So if it’s an emergency, the on-call resident usually just sees them in the ER.
Internal Medicine: OK, but the ER admitted them.
Dermatology: Right, but we actually don’t see floor patients, just ER emergencies. If it’s a floor patient, we just schedule them in clinic as outpatient.
Internal Medicine: It’s really bad, dude.
Dermatology: But the ER didn’t call.
Internal Medicine: I know!
Dermatology: Exactly.
Internal Medicine: What?
Dermatology: We’ll see them in clinic on Tuesday.
4. Subtly undermine their credentials.
Internal Medicine: Hey, sorry to bother you guys, but we’ve got a COPDer who’s not responding to his nebs and is on a venturi now. We’d like you guys to take a look.
Pulmonology: Who is this?
Internal Medicine: Gen Med. I’m the intern.
Pulmonology: Where’s your upper level?
Internal Medicine: She’s in clinic all day today.
Pulmonology: Yeah, usually the upper level will just consult us directly.
Internal Medicine: But I went over the case with her, she asked me to consult you guys.
Pulmonology: Nice try, bud. I’ll be looking out for her call. Tomorrow.
5. The “I’m on your side.”
Internal Medicine: Hey, can y’all see this one today? It’s Jones, the 70 year old with prostate cancer and urethral strictures. Rising Creatinine. You saw him in clinic.
Urology: Hey, thanks for checking in.
Internal Medicine: Yeah. You guys gonna take him back to the OR?
Urology: Good question. I don’t know, man. My attending can be really weird with some of these soft consults.
Internal Medicine: What do you mean?
Urology: Trust me, I want to see them. Like I’ll even see them just by myself. But my attending has been super busy this week, and it seems like we just saw them in clinic, so you may have to hold off on the official consult until Monday. I know, man, it sucks, I know.
Internal Medicine: I see.
Urology: In my soul – deep down – I know that seeing them is the right thing to do. The moral clarity of your request shines brightly, as if a great, blazing torch lit atop an echoing mountain of freedom. I stand with you. But I stand in silence.
Internist: …
Urology: Just consult on Monday.
6. And, if all else fails, use one of these lines:
- “He doesn’t sound that sick.”
- “We don’t generally get consulted for that.”
- “Did you consult IR?”
- “Something something evidence based.”
- “Let me call you back after this case – it may take a few hours.”
- “I’m just stepping out for a conference.”
- “I’m rotating off service tomorrow – it may make sense to just hold off on that consult for a few days. Thanks!”
Love this! Funny and utterly on point. It gets even worse when you try to transfer a patient to another hospital… xoxo your parental unit in psychiatry
Both hilarious and indispensable! I would also add the multifaceted “technical difficulties” category: dead pager, broken pager, pager’s working just fine except for your pages, etc.
Ugh so many of these happened to me personally…just had flashbacks reading these. Great post!
Dr. Gold
Consults:
1) Should be Physician-to-Physician (Doc-2-Doc). When I received a call from a Nurse or Unit Secretary, I made certain I had the patient’s name, ward & bed number, AND the name of the requesting physician correct(I wrote them down, including the correct speellings. If not from the patient’s nurse, I asked to speak to them so I could get an accurate report of the patient’s condition, again I wrote this all down.
2) Assuming patient was stable, I then went to patient’s floor, reviewed the chart-All to frequently no written consult order was written by nursing and almost never by referring physician. I reviewed all labs and medical diagnostic images. In many post-operative patient charts, no operative not was in the chart(and some not even dictated in system).
3) I then contacted requesting physician, persistently (a problem if they weren’t on call then. None-the-less, I patiently went through covering doctors convincing them to have their colleague contact me.
4) After listening to consulting physician’s comments, et cetera, I patiently explained my need for their direect knowledge and reason for requesting a consult. I requested they give a telephone order to patient’s nurse so a record of consult order existed. I also made certain-Did the requesting physician want an opinion only, an opinion and co-management(could I write orders?), or did the requesting physician wish me to take over care partially or totally. Before I hung up, I thanked the referring physician for all the information with which I was provided. I repeatedly mentioned my concern was the health of this patient.
Some hospitals have rules, forms, and other mechanisms for consults. Many still don’t, unfortunately for other physicians and patients. Also, if I consulted another physician, I gave information I thought was needed, in as organized manner as I could muster, answered any and all questions (including questions interrupting my presentation). At the end of the conversation, I asked, “Can I provide any more information?” Finally, if I received responses similar to those in your blog, I asked, “Are you refusing this consult request?” Frequently, the consultant came to the bedside following this question.s