Interacting With Consultants and Primary Care Physicians

This chapter was reproduced from the Emergency Medicine Clerkship Primer, 2008, Chapter 17, with the permission of the Editor, for ease of viewing on mobile devices.

In emergency medicine practice, we interact daily with specialty consultants and our patients’ primary care physicians. In addition, we must relay important patient-related health information to the inpatient service assuming care of our admitted patients. Communication is also necessary to facilitate follow-up care after a patient is discharged from the emergency department. Many times this task can be accomplished with clearly stated written discharge instructions; however, a phone call to the patient’s primary care provider or to a specialist may be needed to facilitate follow-up care in a timely fashion. It is therefore imperative that we communicate effectively with other members of the health care team.

Consultation is a necessary and essential part of the practice of emergency medicine. Because of the challenges we face providing care across the spectrum of age and illness, emergency physicians rely on the consultation process to assist in delivering high-quality health care. “Emergency department consults” vary in urgency from the routine nonurgent consult to the “stat” consult, in which a specialist is needed at the bedside of a patient requiring an emergent procedure or operation. For effective consultation to occur, students must better understand the process. Consultations are often initiated over the phone. Some occur during routine business hours, whereas others unfortunately occur in the middle of the night. Keep this in mind, as many of our professional colleagues are not “shift workers” like most emergency physicians, and many will have clinical responsibilities the next day.

For this reason, do not burden consultants with routine or nonurgent phone calls during sleeping hours. From the consultant’s stand point (and rightly so), nonurgent patient evaluations or procedures can often wait until the next morning. That being said, in an emergency, do not hesitate to involve a specialist if his or her services are required to assist in the care of the patient, regardless of the time of day.

  • Effective communication is one of the keys to a mutually beneficial interaction and relationship with your consultant. As a general rule, consider the following when talking with a consultant:
  • Speak clearly and start slowly, especially if you’ve woken a consultant from sleep.
  • Introduce yourself by name as a medical student and give the name of your supervising resident or faculty.
  •  Learn with whom you are speaking (name, service, position), not only to document this information but also to confirm that you are speaking with the correct person or service.
  • Be respectful and expect respect in return.
  • Be focused and direct with your presentation.

Often, it is best to begin with a diagnosis (known or suspected) rather than the traditional case presentation. For example, you may start your assessment-oriented presentation to your surgical consultant with the following:     All consultations should be initiated with a goal in mind. Effective communication is one of the keys to a mutually beneficial interaction and relationship with your consultant.

Hi Dr. Stevens, I am Michael Jones, a senior medical student work-ing with Dr. Taylor in the emergency department. We are consulting you on a 24-year-old male who we are concerned has acute appendicitis. He presents with approximately 4 hours of abdominal pain that has migrated to his right lower quadrant associated with a fever of 101ºF, nausea, and anorexia. On physical examination, his heart rate is 88, his blood pressure is 136/84 mm Hg, and he has rebound tenderness in the right lower quadrant. We would like you to come to the emergency department to evaluate him.

  • Be flexible with your presentation style.
  • With experience, you will realize that some consultants prefer a detailed presentation, whereas others are satisfied with a focused presentation over the phone and a more detailed presentation at the bedside.
  • Speak your consultants’ languages, and tailor the presentation to the specific service.
  • Whether you are describing a fracture for an orthopedist or interpreting an ECG for a cardiologist, it is necessary to communicate effectively to facilitate the best patient care.
  • All consultations should be initiated with a goal in mind. This goal may range from facilitating an admission to a particular service, a recommendation for antibiotics or a bedside consultation. At times, it will be necessary to explain to the consultant exactly why you are calling him or her. Keeping this in mind; excellent communication skills will work in your favor. Remember, a subtle yet important distinction exists between telling a surgical consultant “you need to take this patient to the operating room” versus “I have a patient that I believe needs to go to the operating room.”
  • Summarize the expectations or agreements communicated at the end of your conversation. This should help avoid any misunderstandings. Examples might include how urgently the patient needs to be seen or how long before the consultant expects to see the patient in the emergency department. This is also a good time to clarify whether the consultant has further questions or needs additional information.
  • Document the discussion with your consultant. Include the consultant’s name, service, time you spoke, and a brief notation regarding the conversation (i.e., “9:00 PM, case discussed with Dr. Michaels, orthopedics. He will be down to see the patient in 30 minutes.”).

Keeping these points in mind, the effective partnership established between emergency physicians, consultants, and primary care physicians will undoubtedly result in improved health care outcomes for all patients who present to the emergency department for unscheduled care. However, despite our best efforts, there are times when an interaction with a professional colleague is challenging. Some of these situations may result because of time pressures and workload frustrations and should not be taken personally.

Other times, challenging interactions may occur as a result of differences of professional opinion, different expectations, or, on rare occasion, unprofessional behavior. It is important to emphasize that, if an interaction occurs with a colleague that you view as unprofessional (i.e., condescending language), avoid the tendency to be unprofessional in return. If a situation such as this should arise, it is always of utmost importance to keep in mind the patient’s best interest and well-being.

In summary, outstanding communication and interpersonal skills are necessary to be a successful clinician. In many ways, putting forth the effort to have collegial working relationships with your professional col-leagues is as important as striving to enhance patient satisfaction. Like any other activity in medicine, the art of consultation and communication is important for patient care and consultant or primary care physician satisfaction. If necessary, rehearse your presentation with your supervising faculty or resident before presenting the case to a consultant. Discuss the most important features of the case, including strategies to use if specific questions or concerns are raised. Be direct and concise, clearly expressing your goals to the consultant or primary care physician. Flexibility with your communication style is crucial, because consultants from different specialties generally prefer emergency department presentations to have slightly different styles. Because consultants and primary care providers are integral to emergency medicine practice, learning the importance of professional interactions early in your training is critical to your future success as an emergency physician.

Suggested Reading

  • Garmel GM. Conflict resolution in emergency medicine. In: Adams J, ed. Emergency Medicine, Elsevier (expected publication date 2008).
    • This chapter is a review of the challenging topic of conflict resolution, including a discussion of the consultation process. This chapter also describes approaches to improve interactions with colleagues.
  • Guertler AT, Cortazzo JM, Rice MM. Referral and consultation in emer-gency medicine practice. Acad Emerg Med. 1994;1:565–571.
    • This article describes the referral and consultation process in emergency medicine, sharing how their appropriate use can improve the quality of patient care.
  • Holliman CJ. The art of dealing with consultants. J Emerg Med. 1993;11:633– 640.
    • This is a classic article that presents guidelines for interactions with consultant physicians. Descriptions of several political issues and the importance of main-taining good relations with consultants, and how these relate to emergency care, are provided.
  • Lee RS, Woods R Bullard M, et al. Consultations in the emergency department: a systematic review of the literature. Emerg Med J. 2008;25:4–9.
    • This review discusses many important aspects of the consultation process in emergency medicine.
  • Murphy-Cullen CL, Morgan LW, Streiff I, et al. Consultation skills for residents. J Med Educ. 1988;63:873–875.
    • This article focuses on consultation skills needed by residents. It also discusses pitfalls in the consultation process.
  • Salerno SM, Hurst FP, Halvorson S, et al. Principles of effective consultation: an update for the 21st century consultant. Arch Intern Med. 2007;167:271–275.
    • This research is the result of a survey completed by primary care and specialty consultants addressing the “ideal” relationship with consultants. The main conclusion of this article is that specialty-dependent differences exist in consult preferences of physicians.