Approach to Medical Consultation¶

Chapter 490 | Consultative Medicine | Part 19 · Parts 19-20 – Consultative & Emerging Topics · Chapter 490

Key Clinical Points¶

Consultation is defined as seeking expert advice; 'consultation' also refers to the meeting or outcome resulting from that request.
Requesting physicians must provide specific, clear reasons for consultation; vague requests like 'Please evaluate' are unhelpful.
Consultants must independently assemble a database (history, physical exam, and review of laboratory, imaging, and pathology studies) to provide an actionable synthesis.
Recommendations should be concrete and action-oriented (e.g., 'I will arrange...' rather than 'Possible...').
Consultations must be driven by clinical purposes only, not for entrepreneurial or relationship-building goals.
Curbside consults are informal, unwritten opinions of limited scope, often based on provided information and medical records.
Communication clarity regarding the desired outcome (single evaluation vs. ongoing co-management) is more important than the method of contact.
Health systems must ensure a qualified workforce, access to specialists, and infrastructure for efficient information exchange.
Consultations should be triaged and dispatched appropriately, especially in high-volume inpatient settings.
Patient engagement and understanding of the consultant's role are essential before initiating a consultation.

DEFINITION & OVERVIEW¶

• Medical Consultation: A fundamental component of effective health care requiring teams of generalists and specialists with complementary expertise. • Distinction of Terms: ◦ Seeking advice from an expert = Consultation ◦ The meeting or outcome resulting from that request = Consultation • Forms of Medical Consultation: ◦ Traditional forms: ◦ In-hospital consultation: Physicians provide recommendations recorded in the medical record or perform procedures for hospitalized patients. ◦ Outpatient consultations: Patients are seen in an office setting. ◦ Contemporary forms: ◦ E-consultations: Electronic consultation methods. ◦ Telemedicine evaluations: Remote patient assessments. ◦ Remote medical second opinions: Distant expert review without direct patient contact. ◦ Note: In contemporary forms, the consultant may not see the patient but must still evaluate clinical data, analyze findings, and provide a synthesis and appropriate recommendations.

RESPONSIBILITIES OF THE REQUESTING CLINICIAN¶

• Pre-Consultation Requirements: ◦ Ensure patient engagement: The patient must endorse the purpose of the consultation and understand the consultant's role. ◦ Outcome Planning: Anticipate likely outcomes and define the specific goal (e.g., single evaluation vs. ongoing co-management). • Communication Requirements: ◦ Clarity of Request: Be specific; avoid vague messages such as 'Please evaluate'. ◦ Information Summary: Provide relevant clinical information summarized as succinctly as possible. ◦ Urgency: Communicate urgency clearly, typically via a phone call or other direct communication for urgent matters. ◦ Communication Method: Use the manner mutually desired by both parties; note that clarity of information and outcome is more important than the specific mode of contact. ◦ Follow-up: Arrange follow-up as desired. • Clinical Integrity: ◦ Purpose: Consultations must be for clinical purposes only; they should not be driven by entrepreneurial or relationship-building goals. ◦ Selection: Always direct requests to qualified consultants.

RESPONSIBILITIES OF THE CONSULTANT¶

• Inpatient Service Considerations: ◦ Triage: Incoming consultations must be triaged and dispatched as clinically appropriate. ◦ Scope of Involvement: Determine the requested level of involvement; do not assume long-term co-management is sought unless specified. • Data Synthesis: ◦ Independent Database: Consultants must assemble their own database to provide an independent, actionable synthesis. ◦ Components: History, physical exam, and review of laboratory, imaging, and pathology studies. ◦ Note: Without independent data assembly, the consultant may be unable to provide a useful synthesis. • Communication Style: ◦ Specificity: Recommendations must be specific and focused. ◦ Concrete Actions: Use concrete language rather than vague suggestions. ◦ Poor Example: 'Possible malignant ascites' ◦ Good Example: 'I will arrange paracentesis to exclude the possibility of malignant ascites' ◦ Avoidance: Do not suggest 'considering' a diagnosis or test without specificity. ◦ Communication Preference: Coordinate whether to be contacted after seeing the patient or if communication should be handled via the medical record, based on urgency and complexity.

RESPONSIBILITIES OF HEALTH SYSTEMS, HOSPITALS, AND MEDICAL ORGANIZATIONS¶

• Workforce and Access: ◦ Ensure qualified consultants are accessible and available on the medical staff. ◦ Maintain adequate specialty workforce to enable appropriate access. • Culture and Communication: ◦ Foster a culture of team-based care and collegiality. ◦ Maintain standards of professionalism, including availability, communication, respect, and collegiality. ◦ Appreciate levels of urgency and respond appropriately. • Infrastructure: ◦ Support systems for efficient exchange of clinical information. • Reimbursement Considerations: ◦ Variability: Reimbursement varies among payors and may impact self-pay or unreimbursed expenses for providers/systems. ◦ Priority: Clinical needs of the patient must be prioritized over reimbursement models.

SPECIAL ISSUES IN MEDICAL CONSULTATION¶

• Curbside Consults: ◦ Definition: Requests from one physician to another for an informal and unwritten opinion about a specific patient care matter. ◦ Scope: Typically limited in scope. ◦ Basis: Derived from information provided by the consulting physician and/or medical records (e.g., labs and imaging). ◦ Distinction: Must be distinguished from formal consultation requests; they are considered informal opinions rather than formal consultations.

Reference Tables¶

TABLE 490-1 Stakeholder Responsibilities in the Medical Consultation Process¶

Harrison's 22e, p.3897

REFERRING PHYSICIAN OR PROVIDER	CONSULTANT PHYSICIAN	HEALTH SYSTEM, HOSPITAL, OR CARE ORGANIZATION
• Ensure patient participation and engagement • Be specific regarding clinical question and desired outcome • Communicate level of urgency • Avoid consulting for nonclinical purposes	• Maintain standards of professionalism, including those pertaining to availability, communication, respect, and collegiality • Appreciate levels of urgency and respond appropriately • Assemble and develop one’s own database • Be specific in synthesis and recommendations • Understand desired outcomes, including arrangements for follow-up • Communicate with referring provider in whatever manner is mutually desirable	• Maintain adequate specialty workforce to enable appropriate access • Support systems for efficient exchange of clinical information • Develop culture of collegiality and team-based care