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Need a consult? Be sure to ask the right questions

From the January 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Christine Kuehn Kelly

Bring up the subject of specialty consults, and Harvey J. Murff, ACP-ASIM Member, becomes embarrassed. "I can remember the abysmal consults I wrote in my first year," recalled Dr. Murff, a third-year resident at Mt. Sinai Medical School in New York. "Fortunately, in three years we learn how to manage the situation better."

As medical knowledge expands and the availability of specialty procedures increases, specialist consults are an increasingly important part of medical practice. Already, experts estimate that there are more than 15 million specialty consultations each year in the United States.

Yet educators say that for many physicians in training, learning how and when to refer patients for a consult is difficult. "Residents often provide referral data that is only partially useful," said Stanley Reichman, FACP, an associate professor of medicine at Mt. Sinai. "They don't always clearly ask what they want to know, and they don't always provide the evidence they have already gathered." Dr. Reichman estimated that because of this type of miscommunication, residents' questions go unanswered in about 15% of all consults.

Part of the problem is that most residents receive little instruction. "The referral process is only picked up by osmosis, from observing the behavior of attendings and other physicians," said Paul W. Ladenson, FACP, director of endocrinology and metabolism at Johns Hopkins University and editor of the "The Consultation Guide," a book that offers tips to help primary care physicians manage their specialty referrals.

Residents benefit from a learning environment in which the referral process is stressed, housestaff point out. For example, internal medicine residents at New York's Mt. Sinai present referrals selected from patients they see in the school's ambulatory service clinic. And at the Sepulveda Campus of the Veterans Hospital of Greater Los Angeles, residents and attendings get together at weekly utilization meetings to review and approve referrals for nonurgent conditions.

"Doing referrals helps me get a better sense of how to pursue the workup," said Meredith F. Lash-Dardia, MD, a first-year internal medicine resident at Mt. Sinai. She recalled a patient with increasing shortness of breath whom she eventually referred to a pulmonologist after consulting with attendings in the department. "The next time I'll know when to order chest X-rays and a CT scan for shortness of breath," she said.

Here are some tips to make the most of your specialty consults:

  • Think it through. Formulating specific questions is the single most important thing you can do when making a referral. What is it you want a consultant to do that you can't do yourself? Do you want advice about diagnosis or treatment or a procedure to be performed? Do you simply want reassurance for your patient or for yourself? Finally, is there anything more you can do before referring the patient?

    "First, conceptualize the help your patient requires," said Tariq K. Malik, FACP, director of internal medicine associates at Mt. Sinai Medical School. "Then ask yourself where to find the answer to the problem. Next, decide who is the best person to send the referral to. You need to use the appropriate subspecialist for time efficiency and cost-effectiveness."

    If you don't, said Dr. Malik, the results can be akin to what can happen if you take your car to a muffler shop when it has a starter problem: "You'll still get a new muffler because that's their specialty."

  • Talk to your preceptor. Once you've thought out the questions, use preceptors and attendings as first-line consultants before making a referral. They may suggest additional action you can take before going to a consultant.
  • Get all appropriate testing done before the consult. Sending a patient with a hypercalcemia to an endocrinologist without the results of a serum parathyroid hormone assay, for example, wastes both the patient's and the specialist's time. Remember, though, that excessive pre-consultative testing can delay the delivery of care, increase the risk of adverse reactions and raise costs.
  • Communicate your intent. Once you know what you're looking for from a consult, phrase your questions accurately. For example, do you want the patient to be returned to you, or are you referring him for complete care? Avoid generic phrases such as "please evaluate" or "needs follow-up."

    Communications between resident and consultant can fail as a result of poor use of language. When investigators at Nottingham University in Great Britain analyzed written communication between general practitioners and orthopedic surgeons, they found that the questions asked in referral letters were rarely answered. Researchers concluded that referrals were not successful because of careless writing, poor word choice or confusing sentence structure.

  • Provide sufficient documentation. Even when residents order the right tests, they often send their patients to specialists with insufficient information. Provide the consultant with lab or other diagnostic details you have gathered plus relevant history.
  • Know your comfort level. Although the number of in-house consults may drop as you become more experienced, referrals are often a matter of how comfortable you feel managing certain diseases, rather than the severity of the patient's condition.

    "Some general practitioners may feel more confident in treating patients with severe and complex anemia," said Dr. Ladenson from Johns Hopkins, "while others may need to refer cases of even mild anemia if they do not understand the cause."

  • Use guidelines. Organizations like the Agency for Health Care Policy and Research provide algorithms for diagnosing clinical conditions, but few provide advice about how to handle referrals. Dr. Ladenson's "The Consultation Guide" provides referral indications and recommended tests for about 500 of the most common clinical problems that require consultation in ambulatory patients. The book, which is based on contributions from more than 100 experts in both primary care and specialty medicine, also provides a directory of relevant clinical practice guidelines and supporting references. (For more information on the book, see the Lippincott Williams & Wilkins Web site at www.wwilkins.com/.)

    The book's guidelines and recommendations can help determine how urgently a consultation is required. "Timing is important in referrals," Dr. Ladenson explained. "There is an optimal time to get the specialist involved. Does the patient require an immediate, urgent or routine consultation? Sometimes patients get referred too late in the decision-making process."

  • Consider costs. Primary care physicians are under pressure to limit referrals, so you might want to monitor how much your specialty consults are costing. As a rule of thumb, two dollars are spent on specialty care for every dollar spent on primary care.
  • Learn from your referrals. When you receive recommendations from a consultant, it's important to understand what you're expected to do. One of the purposes of the consultation is to learn something, so if you don't understand a consultant's recommendations—or don't agree with them—talk to the specialist.

    There are other important points to consider when making referrals. Patients have a significant role in the referral process and can be emphatic about seeing a specialist. If the referral is not necessary, try to learn what is driving your patients' wish to see a specialist, said Dr. Murff from Mt. Sinai. Ask, for example, why they are so interested in seeing a particular physician.

    When strong-willed and/or sophisticated patients want a referral, it can be difficult for residents to deny the request. If the request is totally inappropriate and the patient doesn't accept your explanation, however, don't feel uncomfortable about calling in attendings who have familiarized themselves with the case.

    You also shouldn't feel uncomfortable if you aren't referring enough "interesting" cases to other housestaff. In training institutions, fellows naturally want to be given cases that will expand their learning opportunities. But if a patient is being appropriately referred for a common problem, expect the specialist to consider the patient worthy of his efforts.

    "That's the way it is in practice," pointed out Michael Greenberg, MD, an Illinois dermatologist. "You'll mostly be taking care of mundane things, but each patient deserves being considered the most interesting case in the world." Fellows should have the same attitude.

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

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