Patient Presentation
“You’ll want to look at this new patient who was added to your schedule this afternoon,” the nurse said to a pediatrician. It was a referral from an outside optometrist who had noted an optic nerve problem in an otherwise healthy school age child during a routine examination. The optometrist referred the patient for further medical evaluation including possible imaging. It was unclear if additional ophthalmological care had also been requested for the patient. The patient had not been seen within the health system and no additional information was available. The pediatrician contacted the on-call ophthalmologist who agreed that this was an eye problem first and potential medical problem second. The ophthalmologist contacted his colleagues in neuroophthalmology who worked the patient in that day.

Discussion
Most physicians go into medicine because they like people and want to help them and their families. Clinical patient care can also be fun, interesting, intellectually challenging and provide a creative outlet. All physicians will never know everything and need help with patient care problems that arise. That is when a patient should be referred for a consultation. Effective consultations have several important components which can be overlooked. When clear questions with background information are asked and the consultant provides specific clear recommendations answering the question but also planning for contingencies, the patient will get excellent care and both the requesting physician and the consultant will both learn from the consultation.

Patients and families should understand why the consultation is being requested so they can help the consultant and understand the consultant’s recommendations.

Learning Point
Some tips for effective consultations include:

• What is the Question?
  • As the requesting physician (RP) actually phrase your question in the form of a question just like the television show Jeopardy! Don’t make the consultant guess what you want to know. Help the consultant to help you.
    • Ask “What antibiotics should be started and for how long should the treatment be? or What else should be considered in the differential diagnosis at this time and what additional evaluations should be considered? “
  • Give the consultant enough background information so they have a context with which to understand the question. Provide this in the consultation request in a letter, fax or the electronic medical record. Urgent or emergent requests should be done verbally.
    • “Rule out fracture” without saying where the pain is doesn’t help the radiologist who has to guess. Add the location, mechanism of injury etc.
    • Similarly, new cough and fever for 3 days is different than increasing cough and new fever after recent pneumonia for the radiologist and the infectious disease specialist.
• What is the Timing?
  • When do you need to know the answer?
  • Is it emergent, urgent or elective?
  • Elective consultations can go through the usual request channels but urgent and especially emergent ones need to be verbally communicated directly.
  • Again tell the consultant directly what your expectations are. You may see it as emergent when the consultant sees it as urgent and decreases its priority in his/her workload.
  • The urgent consultation can become emergent too if the patient’s clinical situation changes.
• Is It the Right Consultant?
  • It maybe unclear who would be the right consultant
    • A patient with a problem cough could see the allergist or the pulmonologist
    • A hand issue could be a hand surgeon, plastic surgeon or orthopaedic surgeon
  • As the RP ask if this is the right consultant, and the consultant should ask themselves if they are the right person too to answer the question.
  • RP and other providers who usually work outside a specific health system may not “know the system” and patients should be re-referred to the appropriate service if needed.
• Who “Owns” the Patient or Problem after the Consultation?
  • The RP should be clear about if they still want to continue to be the “owner” of the patient and provide the overall management or if they would like the consultant to take over the care. “Owner” of the specific problem is similar. This should also be clearly stated in the consultation request.
  • Consultants should also be clear about who “owns” the patient or problem and not “steal” the patient or “ignore” the patient. “Stealing” or “ignoring” can be the RP’s viewpoint if “ownership” is not clear.
  • “Ownership” is fluid and may change as the patient’s clinical status changes too.
  • “Ownership” should be expressed to the patient so they understand who they should be communicating with regarding the “final say” in their care.
  • Whether the consultant “owns” the patient or problem, there should be appropriate periodic follow-up based on the patient’s clinical status.
• What are the Recommendations?
  • As the RP, check the chart for elective recommendations. This is time efficient for the consultant and yourself.
  • Emergent and urgent matters should usually be discussed between the different people.
  • Communication between the RP and consultant is cheap and effective. It can provide information quickly, clarify questions and develop rapport and trust between the individuals.
  • Both the PP and consultant should be willing to say they don’t know the answer or only have part of the answer and seek additional help as needed.
• Recommendations Should Be Brief and Specific
  • The consultant shouldn’t rewrite the entire medical record but should recap the salient points for the consultation and why the question is being asked.
  • The recommendations should be clear and specific so the recommendations can be understood and additional time isn’t needed for clarification. Reasons for the recommendations should be clear. The RPs are asking for help and therefore they do not have that expertise, so providing them with specific information will allow them to take great care of the patient and also learn at the same time.
• Provide Contingency Plans
  • Patient’s clinical status changes and therefore provide information for when to talk with you again or a second line of care if the initial one doesn’t work for the patient.
  • Anticipating potential problems and communicating a plan is good for everyone.
• Learning Goes Both Ways
  • Consultations are a great way to provide education to the RP about the problem. The RP usually will be interested in learning more, but they also will probably never be an expert in this problem like the consultant is. The RP will hopefully learn, and gain confidence in their clinical skills for the next time they face a similar problem. The RP should also be gracious in learning about their lack of knowledge for a problem. The consultant too can learn from the RP about their scope of practice, and their own clinical care expertise, and can use this for improving the specific recommendations they put into the consultation and their verbal discussions with RPs.
• Use Your Manners and Be Gracious
  It should go unsaid that both the RP and the consultant are courteous, cordial and professional in their verbal and written communication.
  Legitimate disagreements occur and should be discussed verbally. The patient medical record is not the place for this type of discourse.
  “Pleases” and “Thank yous” go a long way to express your appreciation for the expertise and clinical skills of all the physicians involved.

Questions for Further Discussion
1. What other tips do you have for an effective consultation?

Related Cases

Disease: Consultation and Referral | Communication

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: General Pediatrics | Ophthalmology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143(9):1753-1755.

Wilkie V, Ralphs A. The pressures on general practice. BMJ. 2016;353:i2580. doi:10.1136/bmj.i2580.

Kneebone R. Dissecting the consultation. The Lancet. 2019;393(10183):1795. doi:10.1016/S0140-6736(19)30898-0

Scaioli G, Schafer WLA, Boerma WGW, Spreeuwenberg PMM, Schellevis FG, Groenewegen PP. Communication between general practitioners and medical specialists in the referral process: a cross-sectional survey in 34 countries. BMC Fam Pract. 2020;21(1):54. doi:10.1186/s12875-020-01124-x

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa