Welcome to the FMG Doc Blog. Today we will cover a topic that is relevant for junior residents but may offer some good tips for senior residents and fellows. I will provide a framework that should make this process smoother for you. It is very relevant for FMGs, because again, it is an opportunity to shine in your hospital, get to know providers in other specialties, get to be the “go to person” for the ER (primary care, etc), and an opportunity to shine with the senior residents/attendings that may influence your fate in the program or write a strong recommendation letter for you. When I completed my non designated prelim year, one of my first rotations as a second year was the general surgery consult resident at one of our community hospitals. Thankfully I left a good impression on several attendings and senior residents that eventually led to me securing a categorical PGY-3 position.
Before we get started. Let me share a few general rules that I have lived by that have been very helpful:
- There are NO curbside consults.
- Be nice.
- It’s OK to ask your referring doctor to complete additional studies that may be pertinent.
- Review all the patient data yourself.
- See the patient.
- Call the senior/chief/attending with a concise statement of the consult and what the patient needs.
- Discuss the plan with the referring physician AND the patient.
- Complete your note ASAP.
When I started seeing consults, one of my main fears was that I was going to forget to ask something. Well, eventually it happened – I forgot to ask the patient when they last ate. Rookie mistake! Had to go back and ask the question after the staff started getting the Operating Room ready. I promised myself I would not do that again. I took Dr. Atul Gawande’s advice and created a checklist so I would not miss any important details. It looked like this.
- Patient name, date of birth, medical record number, location
- Physician requesting consult
- Reason for consult
- H&P data – all the usual stuff: chief complaint, history of present illness, review of systems, past medical/surgical history, family history, social history, allergies, medications, last meal (if surgery patient)
- Laboratory studies
- Imaging studies
For surgical patients, I also included this:
- Case booked in OR
- Orders placed
- Consent obtained
- Type and cross ordered
This framework helped me a lot, because it helped keep me on track. I printed out several sheets and carried them around with me. Over time and with practice, I realized I did not need this all the time. However, the discipline of having a system and sticking to it, helped me become a very efficient consult resident.
Before seeing the patient, review all the data available in the chart. Even though you work with very good ER doctors, internal medicine physicians, they are also seeing a lot of other patients. Occasionally they will report something that is not entirely accurate. Therefore, review each lab, look at each imaging study, and review prior notes yourself. Otherwise you can get burned or be led down the wrong path.
After seeing the patient, gather your thoughts and come up with a short statement for your senior/chief/attending. It should include the age and gender of the patient, your diagnosis and plan. If unsure of the diagnosis just say: “I think the patient has …” and recount the remainder of the findings that support your differential diagnosis. Type your note quickly and then calling your attending, that way you can put in the definitive plan immediately. This makes everyone’s life a lot easier.
Once you discuss the case with your attending and come up with a final game plan call back the consulting physician, or better yet, go down and talk to them directly and discuss the plan. If your plan was different from the one you discussed with the patient, then update them as well. Afterwards make sure you put the patient “on the list” and sign them out in the morning (or whichever way it works with your team).
One of the rules I also mentioned was the “curbside” consult. Many times, other practitioners will want to “run things by you” without a formal consult. Beware! Often, they will put on the chart that the case was discussed with “insert your specialty here” and that YOU recommended doing this or that. This can hurt you from a medicolegal standpoint. It’s important that you tell the person calling that if they have a clinical question that you would rather do a formal consult.
It is extremely important that you master the art of seeing a consult. The reason is that you will be doing this for the rest of your professional life. The key is to make sure your referring physician feels supported when they are calling you for help. Furthermore, how you interact with your referring physicians WILL undoubtedly affect YOUR bottom line. Remember, the success of a physician is based on the tenets of ability, affability and availability. Guess what? All these apply when you are seeing consults. So good luck and remember to be nice!