Wednesday, October 10, 2012

Sweating Bullets and Killing 'em With Kindness - Calling a Consult

The Gist:  Although it's not an exciting or popular topic, communicating with consultants is vital in the emergency department (ED).  Trainees are often less than stellar at communicating with consultants (as evidenced by the Henn paper below), but there are resources available to combat this problem, distilled in this free EM:RAP EE podcast.

Before my third year of medical school, I would have balked at the idea of receiving training for telephone consultations and it wasn't a part of our curriculum.  In fact, I recall skimming through an EM: RAP Educators Edition podcast on communicating with consultants during a road trip after I had exhausted my other podcasts.  Could it really be that difficult?

Over the past several months, rotating at several different institutions in the United States, I noticed that the relationships between emergency physicians and consultants varies widely.  In some institutions, I watch residents sweat profusely at the prospect of calling surgery, postpone the consult as long as possible, or have an inpatient team balk when asked to admit a patient with a concerning story for ACS and an unequivocally positive delta troponin (that was 11 only a couple of hours later).  When I experienced my first difficult consult from the ED, my solid presentation transformed into a fragmented stutter.  I realized that I needed help.  I listened to my attendings and other residents discuss patients with the consultants and began modeling my calls after what I overheard.  Then, I read an article that made me realize I was not alone (and motivated me to find other resources to improve myself).

The paper:  Henn et al A metric-based analysis of structure and content of telephone consultations of final-year medical students in a high-fidelity emergency medicine simulation BMJ Open 2:e001298 

  • 113 final year medical students completing an emergency medicine clerkship conducted simulated phone calls to consultants after receiving education on telephone calls throughout their medical school curriculum.  They were told how to introduce themselves and told they would be evaluated on communication skills.  61% of phone conversations included in study (n=69)
  • 72% (n=50) did not identify expectations from their supervisor
  • 97% did not write down and repeat the recommendations of the consultant 
    • This is failing to "close-the-loop" and may lead to differences in expectation, errors, or frustration
  • 29% did not identify their role and 31% did not give full name and title
    • Some doctors demand to talk to attendings or superiors, so it may be tempting to skip this step; however, it's an absolutely necessary component.
So, perhaps many of the issues I faced in calling a consultant revolved around my own lack of clarity.  

Once again, I turned to FOAM to improve my skills and was not disappointed by a closer listen to the free EM: RAP podcast.

Life In The Fast Lane (LITFL) does a superb job summarizing key points for communicating with consultants.

  • Be nice 
  • Anticipate the preferences and personalities of the consultants.
  • Again, be nice but hold your ground on the actual issues.  

Emergency Physicians Monthly ran an article by Dr. Chad Kessler on learning to call consultants.  In the article, Dr. Kessler cites the "5 C" model that he and others coined and developed, published in an article in the Journal of Emergency Medicine:
  • Contact - Say precisely who you are and ask with whom you are speaking.
  • Communicate - Be very clear, very nice.
  • Core Question - Ask a specific question and say precisely what you want.
  • Collaborate - Allow consultant to respond and be flexible with what they want.
  • Close the Loop - Repeat your understanding of the consultants recommendations to ensure all parties are on the same page. has some great talks on the subject.

Give Dr. Kessler's talk a listen:
  • Ensure you have a purpose and a very specific question.  What do you want?
  • Prepare.  Gather your information so you're ready to go.
  • Kill them with kindness without cutting corners on the issues.
    • Respect their view.
  • Use a standardized framework -the 5 C's.  
  • Record the conversation.  Write down the name of the individual you spoke with, the time, and the recommendations.
  • Practice calling consults (just don't actually dial them with fake consults on a slow night shift).  Go through what you're going to say in your head, jot notes down on a piece of paper, or run things by your resident/attending.
Dr. Peter Rosen shares his perspective on difficult consultants in the first portion of this talk:
  • Sometimes you have to be unpopular.  If someone's sick - hold your ground!
  • Treat them the way they want to be treated (the platinum rule).
  • Recognize the consultant's situation.  
    • At 0300 or in the midst of a child's violin recital, it may be necessary/prudent to adapt your communication (less jokes, more forgiving for grumpiness)
    • Sometimes people do admit patient's because it's the easier option.  Do what's right for the patient.
  • Make decisions and commit to them (if you don't want to - go into another specialty).
The SBAR format is another popular format for presentations and hand-offs that may improve performance with consults when presenting the patient to the consultant (1).  The Southampton Emergency Medicine Education Project blog has a great review of SBAR in this role. 
Situation - Who (you and your patient), Why (you're calling)
Background - What (is going on with the patient), where (they are and where they've been...CTs/labs, pertinent history)
Assessment - Assessment of the patient
Recommendations - How (you want to proceed) and what you expect out of the consultant

1.  Matthew C. Tews, J. Marc Liu, and Robert Treat (2012Situation-Background-Assessment-Recommendation (SBAR) and Emergency Medicine Residents' Learning of Case Presentation Skills. Journal of Graduate Medical Education: September 2012, Vol. 4, No. 3, pp. 370-373.

No comments:

Post a Comment