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MEdIC series: The Case of the Difficult Consult



Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@BoringEM), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month we will pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses will be made available for download in pdf format – feel free to use them!

If you’re a medical educator with a pedagogical problem, we want to get you a MEdiC. Send us your most difficult dilemmas and help the rest of us to bring our teaching game to the next level. 

The Case

Consultation skills are difficult to master.  One of the few things more difficult than acquiring this skill is teaching it. The first case of the MEdiC series poses just this dilemma. 

“Well… That did not go as I expected!” exclaimed Melanie. Melanie, an off-service first-year rotating through the emergency department, as she hung up. The strength with which the phone was slammed down suggested that it had gone much worse than she had expected.

“What’s wrong?” asked Geoff, a third year resident in Emergency Medicine, “You sounded like you were getting some push-back from the senior medicine resident, eh?”

“Yeah. I mean, I’ve called for consults before on the ward… but that was so much more difficult that usual,” she reflected. “He just kept on asking me question after question… He wanted the exact blood pressure of the patient, and when I couldn’t give it, he made some snarky response about how I should ‘know better’… Does that happen to you?”

“It used to happen a lot, but I think over the years I’ve found a way to give consults so that everyone seems to walk away happy,” replied Geoff. “Honestly, I don’t really know when that transition happened. But now, I just seem to get the consults I want, when I want them… Still, sometimes, even I have consults that don’t seem to go so well.”

Melanie leaned back and sighed. “There must be something you do differently. I can’t imagine doing this job everyday if I had to get that kind of push-back every time I talked to another doctor.”

You observe this interaction between Geoff and Melanie. 

Questions for Discussion

  1. What would you do if you were faced with The Case of the Difficult Consult?
  2. What advice would you give these two learners? 
  3. How would you intervene? 
  4. What wisdom would you share with them?

I look forward to hearing your thoughts over the weekend.*

Next Week*

We will post responses from two medical education experts who have published on the topic of consultation education.

  • Dr. Rob Woods (@robwoodsuofs) has a MMEd from the University of Dundee and is the Emergency Medicine Program Director at the University of Saskatchewan
  • Dr. Teresa Chan (@TChanMD) is working on her MHPE at the University Illinois at Chicago and of is a recent grad of the McMaster Emergency Medicine program

Thanks to Dr. Teresa Chan (@TChanMD) for inspiring this case series and drafting this first case. We will be sharing writing/editing/recruiting duties for this series from here on out!


All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.

*The ‘official’ response week ended on Sept. 6, 2013 when our subsequent expert & curated community commentary was released.  That said, you are very welcome to continue the conversation in the comment section below.  We’ve had an unprecedented response (40 comments as of September 10, 2013).


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Brent Thoma, MD MA
ALiEM Associate Editor
Emergency Medicine Research Director at the University of Saskatchewan
Editor/Author at
Brent Thoma, MD MA
  • Michelle

    Great idea for a series, Brent and Teresa! So much talk focuses on HOW to do a good phone consult, and I find there is less so advice on what to do AFTER it doesn’t go well. OK, not being a formal expert on this subject, I can share my initial thoughts:

    1. Assuming that Melanie did not fire back equally inflammatory responses, I would have commended her for keeping her cool. Hard to do, but angry retorts on the phone only do more harm than good. I try to reset my mind-frame/emotions by reminding myself — it’s about the patient and not about the consultant or me.

    2. If you are able to keep your cool during the phone conversation, one could try to bring the situation into a face-to-face conversation. It’s harder to be unreasonably demanding in person. Melanie could say “I don’t have the exact blood pressure on me, I can get it for you when you get down here.” and close the conversation with “Is there anything else I can track down for you while you are on the way?” The implied message is that we’re all on the same team trying to care for the patient, and I’m trying to help.

    3. In heated situations, I find that both parties often don’t feel like they are being heard. So make sure you verbally acknowledge that their question/comment (in this case about BP) as an important point — then transition to my point #2.

    4. And definitely, the more senior you get, the easier it’ll be, especially if you start the call by introducing yourself and your training level. I have the luxury of using “I’m the ED attending today” opening bit. It definitely squashes a lot of trivial issues.

    • Brent Thoma

      Great advice, thanks for weighing in!
      In particular, I think keeping the focus on what is best for the patient and not letting egos get involved is incredibly important.

  • njoshi8

    Love the interactive aspect of this series. This will take blog education to a new level. Very excited for this new endeavor!

    • TChanMD

      Any thoughts to share about the case? Have you had it happen to you? What’s your experience with coaching learners to consult?

    • Brent Thoma

      Thanks Nikita!

  • Tom

    Great topic Brent. I’m a new ED attending at a community shop and many of the other docs don’t know me yet. Just had a phone encounter with a surgeon the other day for a patient who was sick and needed more than I could provide in the ED. It started with her inquiring who I was in a (seemingly) rude manner, then pestering me with questions I couldn’t answer, and ending with me ending the call feeling like I had my tail between my legs. And I still didn’t feel like I was sure she was even going to see this patient. It’s amazing how some interactions can leave you feeling. I knew all about the 5 C’s from Chad Kessler but in the heat of it sometimes it’s tough to not feel really small.

    Definitely very interested in seeing the replies to your post on this, and some of the other suggestions offered up, both in how to deal with difficult consultants and how to teach this skill to my students and residents.

    • Brent Thoma


      I think that’s happened to all of us more than once! I imagine it must be particularly tough starting off in a new location. Flipping things around, I feel like much of the reputation of a consultant depends on how gracefully (or ungracefully) they accept/deny/redirect a consult. In fact, I think that (how to teach an ED doc to gracefully respond to a consult from a peripheral physician, for example) might be fodder for another MEdiC case!

      Thanks for posting one of our first comments – look for the reply next week!

    • TChanMD

      Hi Tom,
      Thanks for jumping in! Really interesting how your reputation is important! I’m a new ED attending in an academic shop where I was a resident for 5 years. So, I sort of take it for granted that I’ll likely know the ppl on the other end of the line. Still… every so often I’ve still encounter problems with new ppl. Ironically, I am now most often having the most difficulty with new junior residents that never knew me as a resident… And no problems with the staff under whom I served as a resident (e.g. the surgeons). If you think having a staff surgeon question ya was tough, try playing 20 questions with a second-year radiology resident at 3am… They can be just as tough!! 😀

      Thanks for adding your personal anecdote. Looking forward to reading more as the conversation continues!

    • njoshi8

      I had a similar situation where I wanted to admit a pt to the ortho service, the pt had pure pus coming from his knee superficially!!! I know that’s definitely an infected knee!! And he wanted me to send the pt home… i did my best to stay respectful, asked his recommendations while pointing out all the important physical exam findings, and ended up admitting the pt, with IV abx, NPO … HOPEFULLY to get OR in the morning by that same ortho attending!

      But its tough when the consult on the other end ignores what you have to say.

  • Elisha Targonsky

    Nice topic for discussion. “Pushback” from consultants can be very frustrating. From my experience, a lot depends on who the consultant is, but more depends on how the referral is made.

    Introduce yourself, first and last name, and address the consultant, especially if you know them, by their first name. There should be an even playing ground right off the bat.

    I think a few things help in making a referral more palatable to a consultant. For one, it helps to express your concern for the patient and be up front about the reason for your referral. For instance, “Dr Smith, I have a patient I would like you to see. She is an 80yF with pneumonia and hyponatremia. She is quite unwell… (then your details)” Further to Michelle’s comment previously, mention what you’ve done and what else the consultant would like you to do. “She has received 2L of NS and 750 of levofloxacin. Is there anything else you like me to order? Would you like urine electrolytes ordered?”.

    If you don’t know what’s going on with the patient, just be straight up about it. “Dr Smith, I have a patient I would like you to see. He is a 55yM with an altered LOC. I am not sure what the underlying cause is and I would like your help.”

    It also helps to know your consultant. Some are naturally harder to “sell” a patient to whereas others want a diagnosis and that’s it. When you know your consultants well, it prepares you better for the encounter.

    Always – do what’s in the best interest of the patient and advocate on their behalf.


    • Brent Thoma

      Thanks for reiterating the importance of the introduction. The rare times I received consults as an ICU resident I found nothing more frustrated than getting a complicated story without being orientated to who is talking to me, where they are and what the presentation/diagnosis of the patient is.

      I think a strong theme of respect and honesty is coming in throughout the comments.

    • TChanMD

      A little ‘Hi, my name is…” and “How are YOU doing tonight?” goes a LONG way. Sometimes we just all need to commiserate over the fact that we are at work, awake at 0400h…. And then we sometimes need to remind our colleagues that we appreciate their help with saving/helping/improving a patient’s care….

      I always love starting my consults (after introductions and other social niceties) with the line…. “I have a patient who really could use your help…”

    • CommunityDoc

      I’ve found that ER docs often initiate conversions with “Hello Dr. X, this is Mike down in the ED.” Often using the term of respect for the consultant while using their own first name. I’ve found this immediately creates a power differential that doesn’t exist and can lead a patient discussion down the wrong path before it even gets going. I find I have better experiences when I use the consultants first name if I’m going to use mine or introduce myself as doctor as well if I’m going to call them “Dr.”

      • TChanMD

        Totally interesting. I think leveling the playing field is important. So in the community it probably means you need to be either on familiar terms (first names) or formal terms (Dr. _____).

        In the ivory tower, we sometimes have a junior ‘Dr. So-and-So’ answer the first-call page… and I try to respect the juniors when they evoke their ‘Dr.’ status. So, even when the R1 off service resident says he or she is ‘Dr. So-and-So’, I try to respect it.

        It’s so hard when you’re starting out to say that and believe it… So I just flip the paradigm, trying to lead by example and say, ‘Oh hi there Doctor… I’m Dr. Chan… but you can call me Teresa. I’m the attending physician in the Emergency Department today. Are you able to take my consult?’

        So far this has produced relatively good results. Puts them on good terms with me, but identifies my role/title to them as well.

  • njoshi8

    One of the biggest recommendations I would give, and this is from experience – is to ALWAYS remain calm and professional. I have felt, from my past experience, and seeing others go through difficulty consults, that the most important thing is to remain respectful. Because if the conversation deteriorates, and complaints are filed, anything you say, even if it is somewhat out of line, may be seen as out of line, disrespectful and grounds for discussion. Even if you feel that the actual discussion should be about the patient care!!! (I have a situation that I was involved with as a residents that I felt was a complaint filed against me unfair when I was trying to advocate for pt care!).

    I have also found in my few years of practice, that it is ok to call someone out, especially if they are being unprofessional.. BUT BUT BUT!! You must do it in a professional and respectful manner. NEVER raise your voice, NEVER use bad or even colloquial language….

    But man.. it is tough, it is a tough line to tow, especially when all you want to do is admit the pt, and all the consult wants to hear is the BP that the pt had 3.45 hrs into their ED stay.

    Bottom line – stay professional

    • Brent Thoma

      Totally agree! And yet it is a challenging feat if the person on the other end of the phone is being… well… less than professional in response.

      On a somewhat unrelated note, I think this would be an exceptionally good thing to simulate for senior residents. Staying calm, professional and on-message while speaking with a tired, rude consultant seems like an important thing to practice.

    • amywalsh

      When I was first learning my consulting skills and not accomplishing my goal for the call, I found when my frustration was about to boil over that it was helpful to pause, place some blame on myself (“I’m sorry, I feel I’m not communicating very well, but I’m concerned about this patient or X problem and I’d like you to see the patient”) Obviously ideal to build consulting skills, but that helped me keep things polite and get the patient cared for appropriately.

      • Michelle

        OOOH! Love this ninja move. Taking blame for the poor communication process (whether true or not) would certainly disarm me, if I were the consultant. I’ll have to remember this one. Thanks!

        • Brent Thoma


  • Lindsay Melvin

    As a senior medical resident on the other end of these encounters, this is particularly interesting and relevant to me! I love having easy, collegial discussions with the consulting party on the phone. However, sometimes (often notoriously difficult individuals) – the situation goes sour. I’ll respond as best as I can as an SMR….

    1. Usually, I find it best to reiterate that I will absolutely see the patient (we cannot refuse consults in our institution). It is usually a question of what is done first / when I can get there / if I am most appropriate to admit… and sometimes, I need a little more info to determine that.

    2. Acknowledge to both learners that the consultant isn’t asking questions to be difficult (usually/hopefully), rather to build a picture for themselves. Basics like introducing yourself and speaking respectfully and in a friendly way go far. The sooner the consultant / referee become a team, the better. That starts as soon as the phone call connects.

    As for intervention and wisdom.. not sure I have any. I’ve always found that I have had most success with a friendly disposition, and the reminder that I’m just trying to do right by the patient as well.

    My question for the group is how to handle the notoriously difficult individuals. I find the issue is hostility: being treated/spoken to poorly, providing inadequate (or incorrect!) information, referral to the wrong service (with refusal to acknowledge or assist). It is rare, but incredibly frustrating, as I’m a resident and these are often people senior to me. Tips?

    • TChanMD

      Thanks for chiming in Dr. Melvin! Your comments from the ‘other side’ are much appreciated. Unprofessional behaviour can come from both sides. And ego can be a huge barrier to taking care of patients. I think, sometimes the ED can be the best team to help mediate when there are difficulties in deciding which team should take a patient. Once I facilitated a conversation between an IM attending and the MedOnc attending over the transfer of a febrile neutropenic – and that resulted the two of them soap boxing and then angrily yelling at each other. In the end, I just whispered that I would call my chief of ED and we’d take care of the patient…

      We found a work around… (i.e. I continued resuscitation & then transferred to my ED chief who was working at the other hospital, who subsequently consulted MedOnc for admission…)

      But it got ugly there for a bit.

      So, I totally empathize that it can be tough to actually find the best spot for a patient. But a big part of the challenge is to facilitate a useful conversation about, “Can you please help me take care of the patient right now? And can we leave the politics aside for a bit so we can do what’s right?”

      I think sometimes we get so mired in our own work politics that we forget that we need to do what’s right for that patient first…

      Do others have thoughts on similar problems?

    • Brent Thoma


      Thanks for the insights from the other side! I absolutely think we’re going to have to put together a MEdiC on receiving a challenging consult. I often wonder how well (or poor) EM docs do when the world flips around and we are asked for a consult from peripheral physicians,

      Regarding getting a consult from a “notoriously difficult individuals” – that’s a great question and I hope we get some tips. I’ve also been in that situation and it is not pleasant!

  • Michelle Gibson

    I work in a rehabilitation hospital, working in geriatric rehab, so I am on the side of calling acute care – ED and other. I teach my learners about this all the time. Why? Honestly, in addition to the “it’s essential for patient care”, I look to minimize the abuse they (med students and residents) receive, which is still a problem.

    If we have to call, we talk first about how to approach the call. I do this with the housestaff before we call.

    Step 1 – know your patient cold, and have the chart in front of you and/or EMR open and ready to view.

    Step 2 – Know your audience. Not to stereotype, but ortho doesn’t need to know much about anything other than “how they fell and what/how they broke”, and “are they ready for the OR” if needed to provide advice to us (which, yes, does mean we need to be ready to discuss PMHx, etc.) ED – more info, but very focussed – why this patient, right now, and why the ED. Internal medicine -have your story clear and straight. (And, the unwritten, hidden curriculum issue – that we discuss – what is the, ahem, personality of the person we’re calling…) Cardio – all the cardio imaging, etc. And the list goes on…

    Step 3 – like any good referral- have a clear question, which is actually your leading sentence. Amazing how far this goes!

    Step 4 – (Which is actually step 1 on the phone) – introduce yourself slowly, and clearly, and mention that you are working with me.

    (If needed, and time permitting, I sometimes get them to jot down the key info in point form before they start – helps my clerks especially.)

    If my housestaff can’t demonstrate they can do all of the above, I will often make the call myself, and have them listen in.

    At the time of the call, I am there, ready to jump in as needed. I tell them that if I’m taking over, it’s not personal, it’s usually about patient care and/or ensuring my learners don’t get abused on the phone.

    Then, we debrief. Much easier to debrief if you’ve, well, briefed.

    • Michelle

      So many things I love about this from Michelle (besides just having an awesome name!). By the way, I really appreciate all the non-EM faculty responding to this thread. I’m quickly realizing that this is a universal problem which involves the ED and beyond– with more commonalities than differences.

      I did indeed try this technique of “prepping” a medical student through how a consult might go — partly since it was a slow time in the ED and I knew the consulting resident was known for giving callers a hard time. I was going to phone in the consult myself until my student said that she was game for trying. So, we practiced once with my being the consultant. I purposely interrupted her trying to jar her thought process (it was actually quite fun!). We quickly debriefed and then when she called in the consult, things went incredibly smoothly. If there’s time available, this is definitely worth a try.

      Thanks for commenting!

      • Michelle Gibson

        Well, I can’t take credit for the name 🙂 , but I’ll note prepping/practicing falls under “time well spent” in my world. It saves time in the long run. Unless it’s REALLY urgent, 5 minute prepping tends to make everything run smoother.

        It probably helps that my inner introvert gets very anxious about calling, so I do this myself anyway – with my inside voice, anyway. (It fools the housestaff into thinking I’m relaxed about the call!)

        Found the link to this on Twitter, of course. All good things come from Twitter at this point, it seems!

        • Brent Thoma

          Agree, awesome tip! Effectively “priming” learners to make the consult and teaching them how to organize it at the same time.

  • Susan Shaw

    Hi Brent. Great topic. Definitely a recurring scenario that I think is unfortunately taught or modelled poorly by many.

    Its important to be able to work with consultants effectively so that your patient gets the best care possible. When working in the ICU I both ask for, and get asked for, several consults every day. Here are my thoughts.

    When requesting a consult:
    1. Prepare your question or “reason for consult” BEFORE you page the consultant.
    2. Introduce yourself by name, role, and rotation. Example: “My name is Susan Shaw. I’m the attending physician working today in the Intensive Care Unit.” Don’t assume anyone knows who you are and never misrepresent yourself. (Personal preference: drop the “Dr” title when making this contact.)
    2. Make sure you are familiar with the patient’s story including relevant vitals, key physical findings and lab results. Keep the chart close at hand or at least a structured note that summarizes the pertinent details.
    3. Use a structured communication method to quickly get across your need for assistance. I personally use SBAR (Situation, Background, Assessment and Recommendation).
    4. Make sure you make it absolutely clear to the consultant what is being asked of them.
    5. Keep it professional: Avoid colloquialisms. Never disparage other colleagues or professions. And never ever use less than kind terms to describe the patient.
    6. Close the loop: confirm the consultant is now on the patient’s team, determine an estimated time frame for his or her arrival, and thank your new partner for his or her assistance.

    If you feel like you are being barraged by questions, try to keep calm and answer to the best of your ability. Its ok to say “I don’t know but I will find out for you.” Remember when the consultant is asking you for vitals or other such details its most likely because he or she is trying to create a picture in his or her head of the patient, trying to clarify the situation, and likely trying to make some triage decisions.

    And you didn’t ask, but here are a few things I try to keep in mind when asked to see a patient in consult.
    1. Introduce yourself when you answer your page. Again, don’t assume anyone knows who you are. *This is Susan Shaw returning a page. I’m on call for the ICU. How can I help?”
    2. Remember that you are being contacted because someone believes a patient needs your assistance.
    3. Try to listen without interrupting.
    4. Above all, keep in mind that you are being asked to help because a patient needs your help.

    This is a tough skill but it is definitely teachable and definitely gets easier with practice. I look forward to reading your MedEd experts’ thoughts.


    • Brent Thoma

      Thanks for the great tips!

      Complete introductions seem to be something that are often missed and, as you note, extremely important. I also like the structured prep/communication devices because it can be difficult to provide a concise, organized story when stressed.

      In general, I think our ICU attendings do a spectacular job of gracefully answering consults.

      Thanks for weighing in.

  • Dina Wallin

    What a great topic to discuss– this is an untaught, yet crucial, skill to have as an emergency physician. My thoughts…

    1) When speaking with a difficult consultant, I make an extra effort to take a deep breath and keep a cheery, calm voice before I speak. I listen carefully to the consultant, to see if I can figure out why he or she is being so snarky (tired? Hungry? In the ICU and too busy to hear my presentation? Lacking medical knowledge about this topic and too embarrassed to disclose it?), acknowledge that I hear them and their problem must be difficult, and explain my perspective. If I still get pushback, then I say something along the lines of, “Well, you’re certainly being very thoughtful and detail-oriented about this patient. How about you come on down to the ED and we can discuss this case at the bedside, to figure out what’s best for the patient?” It always comes down to the patient, not my ego or feelings.

    2) My advice to the learners would be what I said above, and also to try to see the case from the consultant’s perspective– overworked, underpaid, undersupported, and may have an attending who yells at him no matter what he does. It’s vital not to make a bad phone interaction personal, and, especially for more junior trainees who will be around and working together for several more years, meeting and discussing a case in person helps smooth things over. Lastly, if a consultant is being frankly unprofessional, to the detriment of patient care, don’t be afraid to put this in writing and let her program director or chief resident know; everyone is still learning and she needs to cultivate her communication skills.

    3) I would speak with the consultant in person once he arrived in the ED, say something like, “Wow, it seemed as if you and Melanie had a rough conversation. Can you tell me about it?” and go from there, based on his response. It would be nice to turn the poor encounter into a teaching moment. I would also talk with Melanie to hear her perspective and work on the abovementioned skills with her, maybe even have her listen in on how I communicate with a consult.

    4) I think I’ve expounded enough on my minute wisdom… some people are naturally better communicators than others, but I think to guarantee a productive interaction with a consultant, one needs to prepare himself with relevant patient data, take a deep breath before speaking, and empathize with his colleague in order to not lose his temper.

  • Rob Bryant

    Great post,
    The 2 techniques I find the most helpful with consults are 1, to get your question / request in early (especially with surgeons) and 2, to then also suggest a course of action. i.e., the 0200 appy call:
    “Dr Surgeon, I have a 22 yo who needs to come in for an appy, they have appendicitis by history, exam and CT, and have received iv invanz and can probably go to the OR in the am, would you like to talk to a nurse now for orders or hear from the floor?”.
    The suggested course of action technique (ala, Mel Herberts ‘you need to know what you need to know, and you need to know the next step’) has worked well for me, and also allows me to realize when I am calling for help / advice, vs a simple disposition.
    The suggested course of action needs to be phrased in a way that shows you know what evidence based course of action needs to occur, while magically not giving the impression that you are telling your consultant what to do. (“it is my understanding that this patient would benefit from going to the OR to have their large abscess I & D’d as part of source control in the early goal directed therapy of their sepsis’.)

    The never-ending circuitous H and P at 0200 to someone you woke from a dead sleep is never going to be a pleasant conversation!.

    The ‘sorry to bug you so late’ line also seems to encourage better listening skills from my consultants. This is preferable to the ‘I am glad I was able to screen the other 20 people who presented tonight with potential surgical pathology and only have to call you about this one patient’ line.

    • Seth Trueger

      Rob- great point about the “request up front” — I find it really helpful, particularly with the surgical specialties. Usually that’s how I start the conversation (i.e. while they’re still finding their pen, and of course after an appropriate salutation & introduction) e.g. “I have a chest pain admit for you…”

      • I actually, now start with…. ‘I have a consult… Do you have pen/paper? The name of the patient (spell name), the patient is in bed (___)… Reason for referral is….” and so on!

        I have found that it has increased the amount of attention the listeners have… You focus them, and make the patient ‘real’ (i.e. give them a name…)

      • TChanMD

        I like to call that ‘Leading with the Headline’.
        I heard in Journalism school they teach ppl to write in a reverse-pyramid of importance (most import first, then least important/details last)

        That way, if ppl stop reading (or paying attention) they got the big parts.

        I think this is paramount for both Consults and Case Presentations in the ED. We often get interrupted (or phones cut off, or pagers go off) and don’t have time for the whole spiel. If you lead with Name/Age/Location/Reason for referral… the rest is easier to figure out… even if you get cut off!

    • I often even actually try to talk to consultants I often interact with at the beginning of a night shift to chat with them about how the want me to run the night (e.g. Surgery resident – you want consults one at a time? Or do you need a break from 0200-0400?)

      I try to acknowledge that unless someone is sick, well, I can probably wait and work with you. Many people want them as they go…

      I also, try the above ‘name, spelling, location, case’ technique now (see above)… buys me time to make sure they’re awake and paying attention! 😀

    • TChanMD

      I often even actually try to talk to consultants I often interact
      with at the beginning of a night shift to chat with them about how the
      want me to run the night (e.g. Surgery resident – you want consults one
      at a time? Or do you need a break from 0200-0400?)

      I try to acknowledge that unless someone is sick, well, I can
      probably wait and work with you. Many people want them as they go…

      I also, try the above ‘name, spelling, location, case’ technique now
      (see above)… buys me time to make sure they’re awake and paying

  • Seth Trueger

    Great post & discussion! Before I forget, Chad Kessler has written a bunch about the “science” of consults, in both peer-reviewed & grey literature (e.g. (disclaimers: I am paid to tweet for EPM; and, Chad was my small group preceptor in my 2nd-year med school clinical skills class).

    I had mentioned a bunch of this on twitter; Teresa asked for more detail so here you go:

    When I was in residency, the ED attending had complete discretion to admit anyone, anywhere, by official hospital board policy. That being said, the policy was hampered by a number of factors:

    -most of the specialist residents didn’t know this

    -the admitting residents still needed to write all the orders

    -the bed board staff didn’t know the policy so at 3am if the resident didn’t write orders, no bed would be given

    -admitting to an unwelcoming service was terrible for relationships

    -just because the ED could admit anyone anywhere didn’t mean the chair wouldn’t hear about it in the morning.

    As a resident, I tried to convince the consultants to admit who I wanted without bringing up the policy; I only actually had to once in 4 years — and in that case, the attending came down and discharged the patient (that was one of the “escape valves” they had).

    Ultimately I don’t think a hard & fast policy makes a big difference as there will always be ways to drag feet, and at the bare minimum, admitting over someone’s objections will be bad for relationships and future patients, and my goal is always to do what’s best for our patientS (plural emphasized).

    • Hi Seth:

      1) That’s great! Thanks for getting on the blog to interact with us more here! The details of your community are so interesting, as many people do not have similar policies, but it’s for sure of interest to explore/understand the different ways to function.

      2) Ahhh, the six-degrees of Chad Kessler. @M_Lin will know – it’s amazing how small our community is! Chad is a friend/collaborator of mine as well. 😀 I tried to get him to chime in as an expert on this case, but alas, he is very busy at his new job. In the future, we hope to draw him in more… (He’s already said he’s up for a MEdIC round, but maybe not right now…) I will email him your comment to see if he’ll engage us on the blog… he is twitter-free, alas (we should change this!).

      3) How do you think policy, culture and practice interchanges? In Canada, many small communities, the ED doc has to admit pts and assumes care overnight….


    • TChanMD

      Thanks for sharing your thoughts/references Seth!

      Hi Seth:

      1) That’s great! Thanks for getting on the blog to interact with us more here! The details of your community are so interesting, as many people do not have similar policies, but it’s for sure of interest to explore/understand the different ways to function.

      2) Ahhh, the six-degrees of Chad Kessler. @M_Lin will know – it’s amazing how small our community is! Chad is a friend/collaborator of mine as well. 😀 I tried to get him to chime in as an expert on this case, but alas, he is very busy at his new job. In the future, we hope to draw him in more… (He’s already said he’s up for a MEdIC round, but maybe not right now…) I will email him your comment to see if he’ll engage us on the blog… he is twitter-free, alas (we should change this!).

      3) How do you think policy, culture and practice interchanges? In Canada, many small communities, the ED doc has to admit pts and assumes care overnight….

      Some other thoughts:
      I actually, now start with…. ‘I have a consult… Do you have
      pen/paper? The name of the patient (spell name), the patient is in bed
      (___)… Reason for referral is….” and so on!

      I have found that it has increased the amount of attention the
      listeners have… You focus them, and make the patient ‘real’ (i.e. give
      them a name…)

  • George F

    A few stats I found online around this topic.. maybe you can all spot the familiar name!

    Understanding communication between emergency and
    consulting physicians: A qualitative study that defines the essential
    elements of a referral–consultation

    T. Chan, D. Orlich, K. Kulasegaram, J. Sherbino

    McMaster University, Hamilton, Ont.

    Effectively communicating with consultants is a key skill for
    emergency physicians. Our objective was to define the essential elements
    of an effective referral–consultation between emergency and consulting
    physicians. From March to September 2010, 61 physicians (31 residents
    and 30 attending physicians; 21 Emergency Medicine physicians [EM], 20
    General Surgery physicians [GS], 20 Internal Medicine physicians [IM])
    were interviewed by a single interviewer. Two investigators
    independently reviewed 100% of the transcripts using grounded theory to
    generate a code of categories until saturation was reached. Coding
    disagreements were resolved by consensus, yielding a single inventory of
    themes, sub-themes and qualifiers. All of the transcripts were coded
    using the common code. Thirty percent of the transcripts were coded by a
    second investigator to determine inter-rater agreement. Two hundred and
    forty-five themes and qualifiers were identified. Inter-rater agreement
    was 77%. Shared themes (> 60% endorsement) in the
    referral–consultation process were as follows: initial preparation
    (overall endorsement 87% [ranging from 70% to 100% in different
    groups]), basic communication (i.e., identify the physician by name)
    (100%), hypothesis of patient’s presentation (75% [62%–83%]), clinical
    question for consultant (70% [55%–95%]), urgency (100%) and patient
    stability (74% [62%–80%]), clarifiying questions (100%), follow-up
    communication (98% [95%–100%]) and feedback (98% [95%–100%]). Each
    clinical specialty significantly contributed to the model (chi-square =
    7.879; p = 0.019); however, each of the groups contributed
    different amounts (EM 57%, GS 41%, IM 64%). In conclusion, we define the
    essential elements of a referral–consultation with input from emergency
    and consultant physicians. These findings may inform the development of
    a referral–consultation model for junior learners.

    • Brent Thoma

      Yep! That paper is what we figured made her qualify as one of our experts 🙂 I think it ate a good chunk of her free time during residency!
      Some great expert replies and references will be posted on Friday – stay tuned.

    • TChanMD

      You made my day, George. 😀

      Someone has read my abstract. And cited back to me! 😀

      I’m a big geek when it comes to good communication, but this project taught me a lot about qualitative stuff in general. This one was, admittedly, a bit more descriptive (re: stats) and more ‘mixed methods’.

      Our little research group subsequently went deeper into the depths of qualitative research looking at issues around Trust, Familiarity, and Conflict. Working on the Conflict paper now… and the Trust/Familiarity paper has been slated for December 2013’s edition of the Journal of Graduate Medical Education (JGME).

      Stay tuned for more!

  • Richard van Wylick

    As a consultant pediatrician, I am always amazed to read cases like this. I have always thought it flattering for a colleague to ask for my opinion on a case. Is that not why we chose a consulting specialty? If nobody trusted and honoured me with a request for consultation, how would I make an income? I guess that I have just been naive all these years!

    • Brent Thoma

      You sound like the kind of consultant that a resident would enjoy talking to! The juxtaposition with this case demonstrates a broad spectrum of consultant attitudes. At worst, the consultant is “doing you a favor” by seeing a patient. At best, the consultant feeling honoured to offer their expertise. Thanks!

  • Gus M. Garmel, MD

    My first comment submitted to ALiEM blog, which is a wonderful site. I’ve been reading the conversation related to difficult consultations and communication. Unfortunately, this one of the many challenges we face in our specialty. Several thoughts come to mind. First, no one needs to allow others to behave unprofessionally. Get what you need for the patient, but do not accept or allow unprofessional attacks. These need to be taken to a higher level (by you or by someone on your behalf). Each hospital has HR, chiefs of EM and/or other services, administrators, etc. You must always be professional (mentioned in other comments), but FOCUS ON WHAT’S BEST FOR THE PATIENT (how can anyone truly argue with that logic?). No need to “apologize” for needing assistance or asking someone to do their job (it’s not your fault someone has appendicitis and needs a surgeon). Try to frame your “need” (for the patient) as a “request for consultation” rather than an “order” (“you NEED to do this”). No one likes being told what to do (you NEED to take this patient to the OR…); they can decide on their own if given the right information or if asked what you think. This is similar to when a patient comes from the clinic to the ED “for an LP” (you can decide whether or not this is needed). Better if the patient is sent to the ED for “further evaluation.” When consultants behave poorly, it is possible that something is triggering their bad behavior or response. Don’t take it personally, do your best job possible (having all the data, concise communication, etc.). Be glad that you don’t “live” with that person or have to deal with him or her every day! And focus on the patient, improving your own communication skills, and not worrying too much about the communication skills of others. Easy to say, much more difficult to do (especially in the heat of the moment). So one final “tip” is to practice, and to get to know your colleagues and consultants outside of the ED (staff parties, committees, cafeteria, etc.) or in the ED when time pressures might be less critical. Good luck to everyone, Gus

    • Michelle

      Hi Gus: Welcome to the world of blogs! We’re honored to have you comment.

      The mantra of “I’m doing what’s right for the patient” is a tip to always remember when addressing challenging situations and people in the hospital. Great tip.

  • Tanju Taşyürek

    In such situations I used to think by the principles of game theory which I’ve lerned deeply from the book”Thinking Strategically, The Competitive Edge in Bussiness, Politics and Everday Life”-Avinash K. Dixit and Barry J. Nalebuff
    1. I try to think the way the consultant think and understand the “dominant strategy” he or she has. This may be avoiding to take the patients care, to make you do more test for more time or to push the risk of the patient on your side, etc. The main conflict is around not receiving the work load or not accepting the risk of the situation. Mostly they try to push over the work load and risk on your side.
    2. Then I try to analize what could be the equilibrium in this situation. (By using game theory term – the Nash equilibrium.,)
    3. I omit the passive strategies
    4. I make plan for my goals and prepare a strategy for it.

    Game theory is exciting and very helpfull for conflict management and has its own therminology and principles like every scientific discipline have. Starting by understanding the principles for example minimax theory-Nash equilibrium, the extensive form games, normal form games etc. may open a new (and scientific) way of desicion making process.

    And last word; Yes Nash is John Nash from the movie “A Beautiful Mind”.