Professionalism Part 2: Consultations
As part of an ongoing discussion on professional behaviours, I would like to submit my views on what I consider professionalism when asking for, receiving and doing consultations. Not all consultations are the same. They may be formal or informal; urgent or routine; hospital or outpatient. I would like to address the various circumstances in which consultations may occur in cardiothoracic surgery and how I believe they should ideally be handled.
Before delving into consultation "etiquette", there are some basic principles: There is no such thing as a stupid question; when someone asks for help, be helpful; whenever possible, take the opportunity to teach; be polite.
I believe that it is more difficult to ask for a consult than it is to answer one. To ask for a consult one must formulate a clear question; one must be humble and have enough insight to know and accept that others may be more expert than you on a subject; one must be willing to take advice; and, very importantly, one must know when to apply and when to reject the advice given. All of this may be very difficult to do, especially in a life or death situation.
When asking a consultant to see your patient in hospital, it is best to do a formal request. This should be in writing and, ideally, should be communicated directly to the consultant by you. This allows the opportunity to discuss the important issues about the case and communicate precisely what is the question to be answered and in what time-frame. Additional tests may be requested in advance to make the consultation more efficient. If the consultation is informal, one should never write the consultants opinion in the medical record, or the fact that the case was discussed with the consultant, because you have not given them the opportunity to review the case in it's entirety. If their opinion is relevant enough to the case, a formal consult should be requested. After the consultation has been done, call to thank the consultant and to ask any relevant questions. It is very important to realize that you are not obligated to follow a consultants recommendation, but you must be very clear as to why.
Requesting a consultation on an outpatient is not too dissimilar in principle, however, much of the verbal communication may not be necessary, unless there are specific concerns that are best addressed with a phone call. When requesting an outpatient or office consultation, a formal lettre of request should be sufficient. This should be a dictated note and all the relevant information and investigations should be made available to the consultant, to avoid wasting the patient's and consultant's time.
When answering a consult, it should be done in a timely fashion. Urgent consults should be answered ungently, regardless of the time of day. Routine consults of inpatients should be answered within 24 hours, even when no final opinion can be given at that time. Routine outpatient consults vary in time-frame. I believe that patients with cancer should be assessed as soon a possible. Similarly, patients who are very symptomatic must be seen promptly. The timing may depend on the resources available, but necessary adjustments should be made in scheduling to accommodate these cases.
When giving recommendations on an in-patient, write them down in the progress notes only, or write them down as suggestions in the order sheets. Dictate a note. Communicate directly with the requesting consultant to discuss them. Allow them to execute your recommendations. Respect the fact that it is their patient and they should know what is best in the overall picture of their care. Be assured that if you demonstrate competence in your knowledge and skills, it is only exceptionally when others will not follow your suggestions.
Consultations on outpatients may come with some implicit or explicit requests. You may be asked to simply give an opinion or you may be asked to go ahead and take over the patient's care if the need for surgery is evident. One must be sensitive to this difference and if there is any doubt, communicate directly with the requesting doctor. Dictate a note within 24 hours of seeing the patient and send it to their primary and consulting doctors. If they need to know something sooner, call. For the most part, routine outpatient consultations can be handled without directly speaking with the requesting M.D., but the threshold to pick up the phone should be low. Document this communication. It is also very important to make it clear, verbally or in writing, what will be your level of involvement in the patient's care. Remember, you are a specialist and not a primary care provider.
In general, one should never refuse a consult and one should never view a consultation as trivial or stupid. Whether formally or informally, someone is asking a question because they may need support for an opinion already held; they may need help with a complex problem; they really do not know what to do; or for reasons you may not really understand. When answering the consult, give your honest opinion as an expert. However, take the time to reassure if they are doing the right things; acknowledge the complexities and difficulties being faced; and take the opportunity to teach if this is appropriate.
If you do not know what to do or are unable to provide what is needed for the patient, it is your obligation to let the requesting doctors know. It is also your responsibility to seek out, or help them seek out, someone who will be able to help the patient with their particular problem.
And finally, the most important thing to be is polite.
Before delving into consultation "etiquette", there are some basic principles: There is no such thing as a stupid question; when someone asks for help, be helpful; whenever possible, take the opportunity to teach; be polite.
I believe that it is more difficult to ask for a consult than it is to answer one. To ask for a consult one must formulate a clear question; one must be humble and have enough insight to know and accept that others may be more expert than you on a subject; one must be willing to take advice; and, very importantly, one must know when to apply and when to reject the advice given. All of this may be very difficult to do, especially in a life or death situation.
When asking a consultant to see your patient in hospital, it is best to do a formal request. This should be in writing and, ideally, should be communicated directly to the consultant by you. This allows the opportunity to discuss the important issues about the case and communicate precisely what is the question to be answered and in what time-frame. Additional tests may be requested in advance to make the consultation more efficient. If the consultation is informal, one should never write the consultants opinion in the medical record, or the fact that the case was discussed with the consultant, because you have not given them the opportunity to review the case in it's entirety. If their opinion is relevant enough to the case, a formal consult should be requested. After the consultation has been done, call to thank the consultant and to ask any relevant questions. It is very important to realize that you are not obligated to follow a consultants recommendation, but you must be very clear as to why.
Requesting a consultation on an outpatient is not too dissimilar in principle, however, much of the verbal communication may not be necessary, unless there are specific concerns that are best addressed with a phone call. When requesting an outpatient or office consultation, a formal lettre of request should be sufficient. This should be a dictated note and all the relevant information and investigations should be made available to the consultant, to avoid wasting the patient's and consultant's time.
When answering a consult, it should be done in a timely fashion. Urgent consults should be answered ungently, regardless of the time of day. Routine consults of inpatients should be answered within 24 hours, even when no final opinion can be given at that time. Routine outpatient consults vary in time-frame. I believe that patients with cancer should be assessed as soon a possible. Similarly, patients who are very symptomatic must be seen promptly. The timing may depend on the resources available, but necessary adjustments should be made in scheduling to accommodate these cases.
When giving recommendations on an in-patient, write them down in the progress notes only, or write them down as suggestions in the order sheets. Dictate a note. Communicate directly with the requesting consultant to discuss them. Allow them to execute your recommendations. Respect the fact that it is their patient and they should know what is best in the overall picture of their care. Be assured that if you demonstrate competence in your knowledge and skills, it is only exceptionally when others will not follow your suggestions.
Consultations on outpatients may come with some implicit or explicit requests. You may be asked to simply give an opinion or you may be asked to go ahead and take over the patient's care if the need for surgery is evident. One must be sensitive to this difference and if there is any doubt, communicate directly with the requesting doctor. Dictate a note within 24 hours of seeing the patient and send it to their primary and consulting doctors. If they need to know something sooner, call. For the most part, routine outpatient consultations can be handled without directly speaking with the requesting M.D., but the threshold to pick up the phone should be low. Document this communication. It is also very important to make it clear, verbally or in writing, what will be your level of involvement in the patient's care. Remember, you are a specialist and not a primary care provider.
In general, one should never refuse a consult and one should never view a consultation as trivial or stupid. Whether formally or informally, someone is asking a question because they may need support for an opinion already held; they may need help with a complex problem; they really do not know what to do; or for reasons you may not really understand. When answering the consult, give your honest opinion as an expert. However, take the time to reassure if they are doing the right things; acknowledge the complexities and difficulties being faced; and take the opportunity to teach if this is appropriate.
If you do not know what to do or are unable to provide what is needed for the patient, it is your obligation to let the requesting doctors know. It is also your responsibility to seek out, or help them seek out, someone who will be able to help the patient with their particular problem.
And finally, the most important thing to be is polite.
posted by Luis G. Quiñonez, M.D. at
10:23 AM
1 Comments:
Clear and elegant.
Good for an undergrad and the early intern, and if you haven't gotten it by then, who knows if you ever will!
I obviously like part 2 much better than 1!
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