Demystifying ED Consultations!!

One of the most crucial things that we do everyday at work is “asking for a consult/referral”. ED Consultations can be really difficult at times revolving around self-respect – diverse values – bonding - interests and interpersonal relationships. But “How to ask for a consult” is something that is rarely taught to EM residents, at least I was never taught this as a junior trainee in EM. Lets find out what’s the best way to get a consultation:

As Emergency Physicians deal with multiple other subspecialists, 24X7. It is our responsibility to take care of the sickest and simultaneously pass on the information and arrange for definitive care. To do this, we must have a thorough subject knowledge about General Emergency Medicine and also the competency to pass the information appropriately. There is not much of literature out there on this particular topic. Trainees screw up time and again; learning this skill gradually with their own goof ups gauging them as per the requirements of various consultants.

Whether this info is passed on to the specialty consultants/Attendings or Specialty Registrars/Residents depends on the institutional protocols. Here we are going to set some general rules that should probably work for everyone.

1)    Why/ When do you need a consult – Lead with a headline

You must have a succinct idea about this – Clarify the purpose and urgency of your consult. Do not start your medical school kind of presentation with a detailed history. They are too busy for that. Cut it short and come to the point ASAP, have your thoughts organized and the data that supports your thinking. Don’t ask for a consult just because the consultant is available; ask for it only if it is required.

2)    Gather your ingredients

Get all the data with you before you call them – history – old blood reports – meds – previous procedures - imaging etc. Another way of doing this is, by thinking, if you were in their shoes, then “what would you want”? When you do your rotations with them, understand their perspective to smoothen your consultations when you get back to the ED.

For instance - Few important specialty-specific questions that they love to know are:

(Note: This by no means is a complete list)

·      Neurosurgery: GCS, Na, Pupillary Response

·      Cardiology: ECG, Troponin, Previous Stress tests

·      Nephrology: Urine Output, K, Urea/Creat

·      OGYN: GPLA, LMP

And if you don't have an answer to something – never cook up a story or numbers – Be blunt and let them know that you DON’T KNOW.

3)    Negotiate

Whenever there is a difference of opinion, try to negotiate and settle down the differences. For instance, if the neuro consultant is too busy for a suspected epidural abscess and wants ED to get some sort of imaging first, ask him to send at least someone from neurology services (may be a resident/registrar) to evaluate the patient as you arrange for the imaging.

4)    Be Nice

Don't have a prejudice and avoid judging them if you have had a bad experience with them. Anyone will get upset if you call and tell them to come to the ED right away – This is human nature. Be nice and soft, but never compromise patient care.

All this can be summarized in the “5C” model of consultation:

5C Model

ü  Contact - Introduction of consulting and consultant physicians. Building of relationship.

ü  Communicate - Give a concise story (30-60seconds) and ask focused questions. DON’T START MEDICAL SCHOOL CASE PRESENTATION – They don't have the time for that.

ü  Core Question - Have a specific question or request of the consultant. Decide on reasonable timeframe for consultation. Come to the point ASAP.

ü  Collaboration - A result of the discussion between the emergency physician and the consultant, including any alteration of management – BARGAIN/ NEGOTIATE.

ü  Closing the Loop- Tell them what is the plan and whatever you understood

Document your conversation (better to record all telephonic conversations)

+ Don't forget the kindergarten basics

Ø  Greet & Introduce yourself

Ø  Confirm their name (Occasionally, some of them might get upset if you ask their name!)

Ø  Permission: Do you have a moment to discuss a case?

Ø  Be confident and pleasant

Ø  Listen to them and show respect for their opinion

Ø  Thank them

Ø  Also, practice a few times with your supervisor before you actually call them

Difficult Consults:
We all have seen nasty consultants who come to the ED and start throwing things around. 
Consultants are like "guests in your house". Treat them the way you treat your guests. This is going to turn things in your favour often getting them to do stuff you wanted to be done (procedure, admission etc.)

Use Key phrases: Often required to make people feel valued:

Ø  We need your expertise/help….

Ø  Your opinion is really going to make a difference….

Ø  I am concerned because….

Ø  I think this is best for the patient….

Ø  I would really appreciate if you could come down and see him once.…

Ø  I know you guys are really busy abut I cannot miss this diagnosis….

Ø  I don't want to waste your time but no one else can do it….

Ø  I know, It was a really busy day for you – but I need your help..

If nothing is working to get them down to the ED, Remember:

• Not to raise your Voice or Swear – Bad for you and for the patient as well
• Don’t threaten them

Occasionally, despite doing your best, things are not going to turn out well. Then, just be polite and tell them you are going to speak to your consultant/supervisor/attending and get back

OR

Tell them respectfully : “This discussion is not going anywhere, I think we both need to think over it and I shall get back in sometime”.

These methods may not always work but definitely provide us with a good framework for asking a consultation from the ED. Factors like your rapport, previous interactions with them also play an important role when you ask for a consultation.

Take Home Points

1)   5 Cs:  Contact, Communicate, Core Question, Collaborate & Close the loop

2)    Never raise your voice or swear at them

3)    Don't forget the Kindergarten Basics

4)    Know the key statements to get them down!

Thanks!

For further reading:

1. Salerno, Stephen M., et al. "Principles of effective consultation: an update for the 21st-century consultant." Archives of internal medicine 167.3 (2007): 271-275.
2. Kessler, Chad S., et al. "A prospective, randomized, controlled study demonstrating a novel, effective model of transfer of care between physicians: the 5 Cs of consultation." Academic Emergency Medicine 19.8 (2012): 968-974.
3. EMRAP - Feb 2011 Episode Summary
4. EMRAP - Sep 2013 Episode Summary
5. http://shortcoatsinem.blogspot.com.au/2012/10/sweating-bullets-and-killing-em-with.html?spref=tw
6. http://lifeinthefastlane.com/referring-patients-from-the-emergency-department/