Effectively working with consultants

Definition

• “The chief function of a consultant is to make a rectal examination that you have omitted.” Sir William Osler.
• More practically, it is a service type provided by a physician whose opinion or advice regarding evaluation or management of a specific problem is requested by another physician.

Skills for success

• Organizational skills: Focused. Concise. Prompt. Prepared.
• Interpersonal/Comm Skills: Polite. Be willing to help. Clear communication
• Medical knowledge: Accurate. Investigating the problem. Owning the patient.
• Conflict resolution: Concession. Compromise. Negotiation.

The "5 C's" of ED Consults

1. Contact: Full name. Rank and service. Identify attending. (This is “Dr. Smith (not Bill), the EM resident”. Be nice, not weak. You earned the title.
2. Communicate: Concise story (Give the diagnosis up front). Clearly speak. Clarify issues. Patience. (Please no "what do you want us to do"...weak)
3. Core question: Specify the need (e.g. admit, consult or procedure) for the consultant. Know your goal and then state it clearly to them.
4. Collaboration: Result of the discussion.
5. Closing the loop: Ensure both parties on same page, update with any changes.

Conflict Resolution

• Do not criticize or question the other physician in front of the patient/family
• Always maintain professional standards regardless of their behavior

Different Spin and Summary from allbleedingstops.blogspot.com

• Never call without first knowing exactly what it is that you want. Know in advance what the desired outcome of the conversation will be.
• Be direct when presenting on the phone. Don’t make them wonder.
• Make a compelling sales pitch. Just make the sale and convince them as succinctly as possible. Three sentences presentation should suffice.
• Never lie. They will find out. One can begin the conversation with “I am sorry but this is a social admission, and it is necessary because…”
• Start with the case FOR your diagnosis and plan, then acknowledge countervailing facts. If they detect uncertainty, they will pounce and you are lost.
• Anticipate and pre-empt obstacles. Figure out the roadblocks, address them, and have an answer for the objection before it is said (see blockers).
• Be reasonable. Listen to them.
• Close the deal. Once you and the consultant have agreed upon a plan, be very concrete in defining the next step. “I will admit them to telemetry."
• Be pleasant. Get to know their names, chat and joke as the situation and time of day allow. Social niceties lubricate and facilitate these interactions.
• Become involved in your hospital medical staff. The better your consultants know you, the more credibility and trust you will accrue.

Avoid the Blockers! (#6 from above)

• Have you ruled out PE? Preempt with: I considered PE, but they are not tachycardic and have no risk factors (blah blah) and so my clinical concern is low.
• AMS? What about an LP? Preamp: Meningitis is unlikely because of (insert clinical reasoning), so I did not do an LP. After you have seen the patient I am sure you will agree with me.
• Did you order (insert reasonable but obscure and time-consuming test)? Preemption: Yes (as I write it on the admitting order sheet) and it should be resulted by the time you see the patient on the floor.
• Can you hold the patient in the ED until (sometime in the future)? Preemption: I have ordered tests X, Y and Z, but the patient is stable and I have 40 patients in the waiting room, so with your permission I will write holding orders, and you can see him on the floor.
• Other popular ones are “Is the patient stable enough for the floor/sick enough for the ICU/well enough to go home?” (Often all of the above amusingly applied to the same patient) Or “shouldn’t this be admitted to (some other specialist)?” If you can anticipate the concern and address it in advance, you are much more likely to move the patient out of the ED in a timely manner.

EMRAP Approach

• If seen in the ED, help them if they are looking for a patient, nurse, etc. “What can I do to help? These relationships pay dividends in the future.
• Consultants are like a house guest so greet them and be social, e.g. “What happened to the patient we admitted with peritonitis the other day?”

• When you dump on them, and you will dump on them, admit it. “Look, there is nothing wrong with this lady, but we can’t get the family to take her home. We are calling her a TIA but don’t go nuts trying to find out a reason for it, we just need to get her into the hospital.” They will be more understanding than if you lie to them.
• Do M & M conferences with other groups and know with some of their literature.
 Participate on committees, preferably one of the worst committees. It is invaluable.
• Show up at the social events that ED docs never attend. You might hate it, but it will pay you back in spades.

• Don’t have a confrontational attitude. It is not us versus them. Life is so much easier when you have the medical staff on your side. You can cajole and get what you want without fighting for the most part. 
 The definition of emergency medicine is understated confidence. You don’t have to go around thumping your chest. They are going to know it by what you do. Having a good relationship with consultants means ‘if you say the patient needs to be admitted, it needs to be admitted.’”


Key Points of Dale Carnegie "How to Win Friends and Influence People

• Become genuinely interested in other people.
 Be a good listener and friendly. Make the other person feel important and do it sincerely.

• Show respect for the other person’s opinions. Don’t say “You’re wrong”. See if from their viewpoint.
• Keep your friends close and your enemies closer (okay, this is from Don Corleone, The Godfather)

References

• Consultation in the emergency department: a qualitative analysis and review.J Emerg Med. 2012 Jun;42(6):704-11. doi: 10.1016/j.jemermed.2011.01.025. Epub 2011 May 26

Authors

John E. Hipskind, Ross Donaldson, Claire