II. Approach: Relationship
- Maintain a friendly, collegial relationship with consultants and hospitalists
- Approach as a longterm relationship
- Socially converse when time and situations allow
- Follow-up on shared patients
- Learn from their expertise
- Treat as partners working for the best interest of the patients (as opposed to adversarial relationships)
- Assist consultants when they need help from the emergency department or other consulting services
- Assist with order placement, procedure set-up, consent process
- Connect them with nursing staff or technicians who can assist them
- Acknowledge when "dumping on admitting or consulting services"
- Thank them for their help in particularly difficult situations
III. Approach: Consultation (example)
- Introduction
- Introduce yourself
- Write down their name and the time of the phone call
- Thank the consultant for their involvement
- Frame the Consultation (brief overview)
- Subjective
- 65 year old female with a history of diabetes and coronary disease
- Presents with a 5 day history of progressive exertional Chest Pain
- Assessment
- I suspect Unstable Angina and
- Plan
- I would like to transfer this patient to you for further evaluation
- Subjective
- Details (pertinent)
- Subjective
- Anterior, substernal Chest Pain with radiation to both arms, jaw
- Associated Shortness of Breath and Nausea. resolved prior to presentation
- History
- S/p PTCA with DES x2 to LAD in 2012, last echo 1/2013 with 45% EF, no WMA
- On Metoprolol, Aspirin, Plavix, Atorvastatin
- Objective
- Last BP 110/60, HR 95, O2 Sats 93% RA and unremarkable exam
- Normal Troponin, unchanged ekg, Chest XRay
- Plan
- Subjective
- Listen, clarify history and answer questions
- Ask specific questions when seeking consultant advice
- Summarize your understanding of next steps
- We will await RN report and will then obtain Ambulance transport to your facility
- I estimate one hour from that time to arrival at your facility
- Are there any other measures you recommend prior to transport
- Closing
- Thank you for your assistance with this patient's care
IV. Precautions
- Tribalism (or the specialty clique)
- Avoid using team cohesiveness (e.g. Emergency providers) to isolate other groups or consultants
- Avoid labeling other specialties with negative characteristics
- Encourage collaboration and mutual respect
- References
- Lin and Brazil in Herbert (2015) EM:Rap 15(12): 6-7
- Consultation Advice with which you feel uncomfortable
- Examples
- Delayed evaluation by a consultant (e.g. Acute Coronary Syndrome, Ectopic Pregnancy, surgical Abdomen)
- Potentially unsafe disposition (e.g. discharge home versus hospital observation or admission)
- Present your reservations to the consultant
- Lay out specific and objective reasons for concern, and their potential complications
- Offer alternative options (e.g. keeping the patient in the emergency department until consultant evaluation)
- Consider alternative consultants
- Does the call schedule change in a few hours?
- Is there another consultant available with whom you have a good working relationship?
- Consult other colleagues
- Confer with your partners on shift or with department head
- Always follow what you believe to be in the best interest of the patient (best practice, safety)
- Employ Shared Decision Making when the best path is not clear
- References
- Mason and Swaminathan in Herbert (2021) EM:Rap 21(7):1-2
- Examples
V. References
- Sacchetti and Herbert in Herbert (2013) EM: Rap 13(9): 4