“Stop. STOP! Hold on. I’m a pea brained surgeon. Let’s go back for a minute.”
Pictured: Surgery resident receiving a consult – A dramatic rendition.
I never thought I would be an angry person. I never thought I would enjoy lobster. I thought wrong on both accounts. Residency has this way of changing you in ways you never thought possible. Although the eat-nothing surgery diet is a great way to lose 30 lbs, it’s more than that. It’s hard to see how it happens…a person gets put in a high-pressure, unfamiliar situation where patients’ well being and occasionally lives are on the line, gets deprived of sleep, is often hangry, given a workload that only increases, surrounded by hundreds of employees with their own stresses and problems, with people above you and below on the totem pole asking questions, and do this for 12+ hours a day, 6/7 days, for years. Oh wait…that sounds exactly like it could cause dramatic personal changes. After two years of residency, my patience gets worn down much more easily. When I was an intern, I didn’t know enough to know when to be upset or irritated. Not that I’m a seasoned resident, but two years of experience has at the very least taught me when to be annoyed by how a consult is presented. I’m still what I’d like to think is a tolerant, level-headed person (see: person who fights people outside of work to not fight people at work) . Despite a range of emotions that sometimes includes negative ones (see: anger that I thought was only reproducible by lag in an online video game) over the past two years, I’ve managed to at least make the nurses not hate me and defuse a number of pretty tense situations, caused by me or otherwise.
The above quote was something that I said to a medicine intern last week. It has been 11 months into residency for the interns; there are a few things they should be proficient at. However, I spent 60 seconds listening to his story about a patient….and still had no idea what was going on. Or if he was even calling a consult. My Sherlock Holmes-like powers of deductive reasoning figured he probably was. While I almost resorted to my usual habit when I get annoyed – which is cutting off the person mid-story and saying “okay great we’ll see them” and hanging up, I took this moment to do a little education. If you’re a chief resident, fresh intern-to be, MS3, or anything in-between, I’m going to lay out how to call a well-packaged consult. This is an essential skill for almost any (pathologists, you’re off the hook on this one) medical resident to have. So few people do it well that I consider it a failure of medical education; it can’t be a failure of the individual with how widespread it is. I’m here to set that straight. This is also an exercise in self-reflection for how I have received (and called) consults. Those on the receiving end are not exempt. The remainder of this article is a long-winded explanation of how to succeed at consults. If you want the abridged version, here it is:
- Introduce yourself and your service
- Confirm the other person is the correct consultant. Ask if it is a good time for a consult.
- Give patient information
- State in one sentence what the consult is for, for example “acute cholecystitis”. This is the most important part of the whole presentation. This helps focus the consultant.
- Give brief (<60 second) presentation involving pertinent history, physical exam, labs, and imaging findings.
- State what you have already done to treat the patient
- Ask if the consultant would like any further workup or treatment prior to seeing the patient.
- Thank them for their help
How to be proficient at receiving consults:
- Don’t be an asshat
- Introduce yourself and your service when you answer the page, i.e. “Hi, this is Brandon with Surgery”
- Confirm you are the correct consultant, ask for patient information
- Listen to the presentation without interrupting
- Ask for any additional treatment or workup prior to you evaluating the patient
- Notify the person calling you if there will be a limitation in seeing the patient, such as needing to finish a two hour surgery before seeing the patient, your attending being scrubbed into the OR, etc.
- State you will see the patient and thank them for calling the consult.
- See the patient in a timely fashion.
- Staff the patient and provide further management to the team calling the consult.
That is as long as the book “First Aid for Calling Consults” would be. Read on if you want more detail on the subject.
Consider the following two phone calls about the same patient. I’ve had similar renditions of these presentations at some point. This is real life. This is what I hear the moment I say “Hi, this is Brandon with surgery” (FYI, that’s the appropriate way to return a page. It is friendly, identifies your name and service you are with, and takes less than 5 seconds. Answering a page as “SURGERY!”, or “Hello” is inappropriate. One of our orthopedic residents says that if he responds to a consult page and they say “Hello.” He just keeps saying “Hello” in responds until they actually introduce themselves or ask a question. Inappropriate? Maybe a little. Deserved? Definitely. Use proper phone etiquette):
“Hi I’ve got a guy who had two days of nausea and vomiting when he ate a cheeseburger. It seems to radiate down his right abdomen and sometimes to his back stabbing pain, rated 7/10 and sometimes 5/10 It’s never happened before but says that he had left sided pain a month ago when he got punched so he hasn’t been able to keep food down and he came in he’s got diabetes and hypertension, gout, had his appendix out when he was 12, and I think he had a colonoscopy once which was normal he’s here and admitted on the floor, currently NPO says he smokes about a half pack of cigarettes per day, drinks 5-6 beers once a week otherwise denies any chest pain or dyspnea, no weakness, numbness or tingling on exam he’s got no scleral icterus, his trachea is midline, his heart has no murmurs, gallops, or rubs with a normal S1/S2, lungs have some crackles at the bases, he’s a little tender in his abdomen bilirubin is 10 and he’s down here now with his sister who is asking questions….”
That hurts me to continue typing. I hope it hurt your eyeballs just to read. This suffers from so many sins that you’d have to drench it in acid, light it on fire, and send it to the Pope to have an exorcism performed. This is the type of consult that a nervous medical student calls. Let’s improve a little bit.
“Hi I have Mr. Smith he’s a 56 year old male with two days of nausea and vomiting, postprandial. Relieved when laying down, radiates to his back. Inciting event was eating a cheeseburger. States it is 6/10 and sharp, crampy pain. Relieved in 30 minutes after eating. Past medical history is significant for coronary artery disease, hypertension, atrial fibrillation, and gout. Had an open appendectomy performed years ago, no other surgeries. Family medical history is significant for colon cancer. He came into the ED and his temperature was 101, blood pressure normal. We got an ultrasound but it hasn’t come back yet. CT is ordered. We gave him some fluids and antibiotics, can you come see him?”
This one hurts markedly less. This is the type of consult that interns call. This has many less problems with the one before. This one also generally has too much information in it, but I got tired of trying to make up more things to type. Here is the last example:
“Hi, is this surgery? This is Jack in the ED. I’ve got a new consult for you. Is now a good time? Okay, consult is on a Mr. John Smith, bed 29 in the emergency department. Medical record number 17246922. The consult is for acute cholecystitis. This is a 56 year old male who presented with 2 days of right upper quadrant pain, nausea, and vomiting after eating a cheeseburger. It was sharp, unrelieved by tums, and so he presented to the ED. On arrival his temperature was 101 and he was tachycardic to 110. Labs showed a WBC of 15 with a left shift, creatinine of 1.5. Bilirubin is 3.0 with AST/ALT of 180/300. CT showed gallbladder wall thickening and pericholecystic fluid. He’s got CAD and afib, history of an appendectomy as a kid. We have made him NPO and started him on Zosyn. Is there anything else you’d like us to do?”
This is the type of consult report that we all dream of. I’m sure you can see the key differences between these examples, but one last example. This is how the consult gets translated and packaged into surgical language for a (good) presentation to a chief resident.
“I’ve got a new consult. Smith, bed 29 in the ED for acute cholecystitis. Came in with 2 days of RUQ pain, nausea, emesis. Febrile to 101, WBC 15, bilirubin of 3.0 from a baseline of 0.5, Cr 1.5 from 1.4 baseline, elevated AST/ALT to 180/300. They got a CT showing pericholecystic fluid and fat stranding, ultrasound showed cholelithiasis, 9mm gallbladder wall and a 1.1cm common bile duct. He’s was lethargic at first but is now responsive and alert after the fluid, he’s got RUQ tenderness with a positive murphy’s sign and he’s not peritonitic. Has trace bilateral lower extremity edema. Has coronary artery disease s/p CABG in 2016, echo 6 months ago was normal and has no chest pain or dyspnea on exertion. Has afib on xarelto, which he took this morning. He’s had an open appendectomy and no other abdominal surgeries. Last ate at 8am this morning. He’s a Jehova’s witness. He got 2L of fluid in the ED and Zosyn, they haven’t called GI or medicine yet.”
That’s how each of those three examples of a consult call gets packaged to a surgical presentation. While it’s different for each specialty, medicine versus surgery versus gastroenterology, there are some defining features of a good consult. We are going to start with the don’t’s (I’m honestly not sure how many apostrophes that is supposed to have.)
- This should go without saying…but the first step before you can even call a consult is to have actually seen the patient. While you can learn quite a bit about a patient from their chart, there is a reason why the H&P is history and physical. If the person has calling the consult has not seen the patient, that is a travesty to the practice of medicine. It is completely inappropriate, and will likely make the consultant very angry if they find out. I ask questions about exam findings to anyone who calls me for a consult, and it is very easy to figure out they haven’t seen the patient.
- Launch into the presentation with no proceeding introduction. If you blindside me by immediately talking about a patient with no preceding greeting or identifying information, I understand you have no idea how a consult works, will be unlikely to want to listen to you for longer than 10 seconds, and will not believe anything you say. I am surgeon. Me surgeon. Me surgeon cut things. I am a simple human cutter of things. I need simplicity, direction, and focus. I can barely concentrate long enough to count to ten square knots I tie before they are cut, I need every edge I can to concentrate for a consult. Also it helps to be friendly. If I recognize the name of a resident who is calling me and I’ve seen them around the hospital, it helps to build those relationships. We are all in this together.
- Start off by making sure you have the right service. A simple, “Hi, is this general surgery?” ensures you paged the right person, or makes sure the person on the other end is who they are supposed to be.
- Identify yourself by name and service. I like to know your name and where I’m getting a call from. My pages come from all across the hospital.
- Make sure it is a good time for me to take a consult. Occasionally I will need 10 seconds to find my pen and paper or 30 seconds to log into the EMR so I can review the chart while you’re talking
- Start with the patient’s name, medical record number/birthday, and room number. I need to know what human being you are about to tell me about.
- Launch directly into the story after you have told me the appropriate identifying information. You still aren’t done making sure my simple surgeon brain doesn’t explode
- Tell me in the VERY NEXT SENTENCE WHAT THE CONSULT IS FOR. This is the most important part of the consult. This sentence should go: “this is a consult for __________” where that blank represents words like “mesenteric ischemia”, “ischemic colitis”, “small bowel obstruction”, “necrotizing soft tissue infection” or other similarly surgical sounding words. This is the most missed part of the whole process. The reason for its omission is one of three things: the person on the other end forgot to say it, wasn’t trained how to call consults, or has no idea what they are actually calling for. This is especially true for medical students, but often residents (or even their attendings) as well. Often times the top of the totem pole yells down “call surgery!” to the underlings, and it either gets misunderstood, not fully understood, or flat out doesn’t make sense.
- If don’t know what you’re calling for, it is okay to say that out loud. We surgeons are (mostly) human. We want to take of patients and we want to help you. We understand that lots of dark and scary things that go bump in the night tend to be surgical problems. Surgery exists at the limits of medicine when medical management is either ineffective, partially effective, or flat out doesn’t exist. You can’t put a femur fracture back together with medication any more than you can cut out high blood pressure (for those of you that are saying, “but but but pheochromocytomas!”…please stop ruining my examples with zebras.”). If you need help because your patient is Sick and you don’t know what to do, and there might be a surgical solution to their problem, we are happy to help.
- Spend more than 60 seconds talking about your patient if you can help it. Our attention spans are short. You can aid in this by telling us what the consult is about as mentioned above. This helps us focus on information to pick out of your presentation
- Give us information that isn’t immediately pertinent. The patient’s father having diabetes, while a part of the family history, is not at all pertinent to the issue at hand. Neither is their gout or hyperlipidemia. A history of heart failure or that they have had 3 heart attacks this year, however, is. We don’t enjoy patients dying on our table.
- Include relevant information. For surgery, this first and foremost includes things that mean they are Sick instead of sick. WBC of 14, hemoglobin of 10, bilirubin of 4? These things are pertinent and great to include. However, things such as hypotension, a hemoglobin of 5, a lactic acid of 10, altered mental status, needing intubation….these are the things that scream Sick with a capital S. Recognizing patients that are Sick is an incredibly important skill. Time is paramount here, and a Sick patient is one that we know we will go see no matter what we are doing. These are the patients we have a limited window to turn around before the rolling boulder of death picks up too much momentum. On the contrary, a stable, sick patient might wait until our next case is done before we see them.
- Include a physical exam. While, generally speaking, we don’t believe anything until we perform it ourselves, it lets us know that you have actually seen the patient (It is worrisome how often this is not the case), and taken the time to examine what you think is pertinent.
That concludes what it takes to present a good consult. While some of this has to do with general communication skills, there is underlying medical knowledge that is necessary to perform this well. However, I believe a beginning third year medical student could present a cohesive, brief consult. They might not be able to answer any ensuing questions, but they could present better than most residents if they followed those steps.
I understand there are likely many residents out there that have gotten yelled at by a surgery resident about a consult. This is not to forgive anyone who does that, but realize that every consult called creates a variable amount of work for us. Intrinsically, nobody likes someone giving them work on a very visceral level. It’s why the emergency department is hated simply (and unjustly, but I can’t say I haven’t cursed the number of the ED every time it comes across my pager) for doing their job: every phone call they make creates work for someone else. We appreciate efficiency among all else, because getting 20+ consults/traumas in a 24 hour period (as frequently happens to us at the 1,000+ bed private hospital we rotate at), if each one of those calls takes 5 minutes of our time instead of 60 second, that’s almost over an hour of wasted time.
Do not be insulted if you get cut off abruptly, as long as it is done in a polite manner. I’ll say, “thanks, we’ll see them” and quickly hang up if I know that I have 15 seconds before my team moves on to the next room, my patient rolls to the OR, or if I really, really have to use the bathroom. Frequently, our own chart review will be more pertinent and give us the exact information we need. As long as we have a name, room number, and reason for consult, that’s the bare minimum. That said, any consultant should out of courtesy allow you to tell your story. If it gets too long or full of extraneous information, at a certain point it comes down to our efficiency versus courtesy; value for our time will always win.
A final disclaimer is this: we do not expect you to know all about our field. That’s the reason you are calling us – because you either don’t know the next step or don’t have the resources or training necessary to perform what the patient needs. No more can I manage dialysis on a patient than a nephrologist can perform a nephrectomy. Emergency department physicians don’t have credentials for the OR, nor do surgeons have credential for the cardiac cath lab. We all need to work together. It’s the kind of teamwork necessary to take the best care of our patients.
It is unreasonable if I expect a medicine team to know the criteria for making pancreatic cancer resectable, or if I expect an emergency department physician to know the criteria for surgical intervention on a superior mesenteric vein thrombosis, or for when perform an exploratory laparotomy for pneumatosis of the colon. It is also unreasonable to expect a medicine team to know what type of workup is necessary for liver transplant, or what type of CT scan is needed for pancreatic cancer. There is a reason that my specialty is just that….a specialty.
However, it is reasonable to expect that the person calling a consult has physically seen and evaluated the patient. It is usually reasonable to expect some basic laboratory work and imaging for that condition (if indicated). It is also reasonable to expect a differential diagnosis at least, or a confirmed diagnosis if possible. That’s the whole point of going to medical school and having a broad base of training. While I might not be an OB/GYN, you can bet that if I suspect a patient has an ectopic pregnancy instead of an appendicitis, I would try to get information to support that claim.
A consult for “abdominal pain” on a patient that the person calling the consult hasn’t even seen will make my blood boil. A consult for “concern for acute mesenteric ischemia” with a description of the abdominal exam with CT scan will not. While the work-up is often adequate, it is okay to not have the entirety of the work-up that we want. But there needs to at least be some information for us to go on besides the history.
Above all else, it is 99/100 times reasonable to expect that the patient will be NPO if there is concern this patient will need any type of surgical intervention. Do not feed a patient if calling a surgical consult. This should be one of those snap associations for people who call surgical consults. Call surgeryandmakepatientNPO. That’s how that word goes.
A quick aside here: for emergency department residents, signing patients out to the next resident is a common practice. Unfortunately, sometimes the surgical consult was not called prior to this sign out. We then get the call of “I’ve got this patient from sign out and was told to call surgery”, and this includes the physician having physically seen the patient <50% of the time. Not only is that a poor continuity of care, but if that patient hasn’t been seen in several hours, there can be a relevant change in clinical status over that time frame. Bottom line…it is wrong to call a consult without having physically seen the patient.
This topic has the potential to be fairly charged. Anyone has called a consult can attest to having had an unreasonable response from their consultant. That includes me, I’ve definitely been unreasonably angry or received a less-than-nice response from a consultant I’ve called. I am aware that there are problems on both sides. The tips above are to help your lives go smoothly when calling a consult – especially for the new interns. But let’s fix both sides here. If you realize you’ve been a rude recipient, call them back and apologize once you have cooled off later. I’ve done that more than a number of times to both other residents and nurses. Therefore, for those of you receiving consults, here is some etiquette:
- Answer the page with your name and service
- LISTEN to the consult. Go the duration of their presentation without interrupting.
- Take down the patient’s information appropriately
- Ask appropriate questions
- Request any further labs or imaging you would like prior to seeing the patient
- Give them a timeframe of when you will be able to see the patient
- Explain any limitations in your capabilities at that moment (about to scrub into a case, your attending is operating doing an 8 hour procedure, it won’t be able to be seen by an attending til the following morning, etc.).
- See the consult and perform time-sensitive things in an appropriate manner. You don’t wait 4 hours to see a necrotizing fasciitis consult.
- Take down the contact information of the person calling you, in order to contact them promptly after.
- Provide additional recommendations for labs/imaging/treatment after you have seen the patient.
- Notify the requesting team if there were any changes to the plan after discussing the plan with your chief/attending/etc.
- Be an asshat. The person calling you is a human being and needs your help.
- Expect the person calling you to know the answers to all of your questions. Their focus is different from yours. There is a line between basic questions versus specialty specific.
- Blow up or become angry if they don’t have a specific part of information you need
- Interrupt them during their presentation (unless it drags on too long)
Last, but not least, there will be moments when someone higher on the totem pole tells you to call a consult that you may not agree with, may not have all the information on, or may be inappropriate for that service. We all have been put in that situation where we know the consultant will be less than enthused with the content of our phone call. The disarming phrase you should use in that case is universal, and it is simply, “My _____ wanted me to call you about…” Where the blank is the word “attending”, “chief”, etc. This is universal code for “I’m sorry about this consult. I understand it may be unnecessary or not indicated. I have been told to do this by my superiors and I am obliging”. If you hear this from someone calling you, do not take out any of your frustration or anger on them, as it is out of their control. That said, I remember using this phrase when in fact, it was a very appropriate consult and I was wrong. Trust in those above you, but there will still be moments for that phrase.
Happy consult calling, and as always leave a comment or email me if you so desire.