However, the hospital environment presents additional barriers to effective consultation. Academic medical centers, where consult interactions frequently occur between trainees, are particularly affected. Consult barriers between trainees include frequent handovers, high resident and fellow workload, differences between resident and fellow rounding structures and work incentives, as well as inexperience, which affects both the quality of consult requests and fellows’ ability to deliver timely care and teach in the setting of consultation.
A recent study conducted by our group demonstrated that hospitalists report better consult interactions when they work directly with attending consultants rather than with fellows.2 Further, our previous work has demonstrated that both residents and fellows may have perceptions that inhibit the consult interaction.1 Residents may perceive fellows as too busy or not interested in teaching. Fellows have have similar views about residents as learners. In addition, fellow pushback on consult requests (the perceived reluctance to perform the consultation) is relatively frequent and can have a significant negative effect on subsequent teaching interactions.1,2
Given that consult interactions within academic medical centers have an impact on knowledge, skills and, perhaps, career choice of future physicians and future faculty, how can these interactions be improved? We believe the following five concepts hold the key to unlocking the full potential of consult interactions.
1. Enhance Communication Around Consult Requests
Because the consult request itself can set the tone for subsequent interactions, positive exchanges in this initial stage are critical. A specific consult question communicated clearly and concisely facilitates not only the ability of the consultant to help the team and the patient, but also subsequent interactions, in part through minimizing the perception of pushback. Several models have been developed that can be used to train residents and medical students to request consultation effectively.6,7 Consultants can limit the perception of pushback on the part of the requesting physicians by agreeing to help right away. Saying “yes” to the consult changes the interaction from one of negotiation over whether the consult will be performed to one of collaboration in which the two parties are working together to deliver patient care.
2. Encourage In-Person Communication & Teaching Between the Consultant & the Primary Team
In-person communication is strongly preferred by physicians requesting consultation, and consult notes posted in the electronic medical record or pages containing recommendations are the least valued.1,2,8 At the hospital and program levels, incentives to communicate consult recommendations directly can have a far-reaching impact. On an individual level, physicians requesting consultation can encourage communication and teaching simply by expressing their interest. We have found that fellow consultants often direct their teaching at those who demonstrate an interest in learning.1