Preparation Before the Consult
- Prepare adequately but not obsessively; consider
- Preparing the discharge
- Everything is up to date
- Patient information is in front of you including med charts, letters, and every investigation
- Know what your team wants
- What your team’s question is
- Whether you want phone or in-person consult
- Urgency of the consult
- Have at hand the relevant history, examination, investigations and management
- Consider if you were the consulted registrar, what you would like to know
- Find any external documents
- Investigations/procedures in hospital
- Echos/angiograms often in the department and not uploaded until post discharge
- ECGs often in the paper file
- Insulin charts often at the bedside
- Scopes often in clinical notes only under endoscopy reports
- External investigations/procedures → Call for pretty much everything
- Ask the patient if these have been done and if they have it in a folder
- Investigations/procedures in hospital
- Do a practice run of the consult in your head making sure the opening is good
- Prep a discharge for the consult; at least the issue relating to the consult
- You can avoid notes and results trawling and realise any holes in your current assessment
- Always better to refer early with a poorer presentation
- https://litfl.com/wp-content/uploads/2020/01/Referral-cheat-sheet.pdf
- Also see Consult Reference
Common Questions by Specialty
| Specialty | Common Questions |
|---|---|
| Cardiology | What does their 12 lead ECG look like? When was their most recent echo? Have they ever had an angiogram? What was their weight on admission and has it changed? Have they had troponins? Has it peaked? Have they had fasting lipids and glucose? |
| Gastroenterology | Weight loss? Scope history? Family history? Alcohol consumption? If severe vomiting/diarrhoea, what are their UECs? Haemodynamic stability? If IBD → surgical history? If liver disease → outcome of liver screen? If hepatitis → viral load? genotype? |
| Renal | UECs? Iron studies? Urinary sodium, albumin to creatinine ratio, protein to reatinine ratio or electrophoresis? Have they had a renal tract ultrasound? Are they making urine? Are they on dialysis or would they be considered for it? |
| Surgery | When was their last meals? Are they anticoagulated? Are they bariatric Surgical history? If they’re bleeding → have they been cross matched? Have you done a PR? |
| Intensive care | Indication for ICU review? Have they breached MET criteria? Do they have advanced life directives? |
| Anaesthetics | Have they had an anaesthetic before? Do they have a cardiac condition? Are they bariatric? Do they have dentures? When was their last meal? Are they anticoagulated? |
| Orthopaedic | As above for surgical referral plus: Is the fracture open? Are they neurovascularly intact? |
| Rehabilitation | What will be their goals? Are they completely stable? What is their follow-up plan with the home team? |
| Neurology | What are their examination findings (the more specific the better)? What does their imaging show? |
| Respiratory | Have you done an ABG? What are their saturations? What does their CXR show? Do they have recent spirometry or RFTs? What is their smoking history? Have you done thoracocentesis (if an effusion)? What are their occupational exposures |
Finding the Consult Number
- Often consulting a team takes a while for the other consulted team to respond
- Always have paperwork or something you can do while waiting for the consulted team to respond (e.g. discharges, pathology orders (although do not lock yourself out of eMR), your own overtime sheet)
- Start by trying to page the consulted team
- Text/Whatsapp/Teams the reg
- Text/page the team JMO
- Switch to transfer to mobile
- Document simply ‘paged XXX reg XXX times, will try again’
The Actual Consult
- Introduce yourself: ‘I am one of the new interns on (ward/specialty)’
- Correct reg: ‘Are you on for Consults?’ (also get their name)
- Question - Specialty Specific: Always start with the Question
- Keep it short; usually on sentence e.g. This is a consult regarding XXX, are you able to help me with this where XXX can be optimal antibiotic regime for XXX infection or optimisation of CCF management or drainage of pleural effusion for XXX
- Keep the question clear: Know exactly what you want from the Consulted Team (i.e. what you want them to do; ‘see the patient’ is not enough)
- If your team has no question in particular, just ask for optimisation of the management of (medical condition) or diagnostic dilemma of (something related to the Consulted Team’s system)
- Keep it relevant
- Patient Name/Patient Record Number/Identifier
- Spiel
- Typically better to follow the long case format (HxPc, PMHx etc.) and keep it relevant to the consulted specialty
- Start your spiel only for that specialty e.g. ‘This is a (age) old female/male presenting with/who has (condition) ± complicated by (condition), on a background of (two or three major comorbidities) with (any other extra important information)’
- HxPC: one sentence on why the patient’s in hospital, then talk in detail about the consulted problem
- PMHx: Generally include everything but mention matters that are related to the consulted system first
- Also include the relevant consultant if the patient is already known to someone in the consulted specialty
- Medications: tailor to specialty and name the important ones first
- Other history: e.g. social history, mobility status, ADLs and home supports for Geris
- Examination findings: Examine and usually just generally saying that there are no relevant findings is sufficient (if there is indeed none)
- Investigations: Include those supportive of your diagnosis and/or relevant to the consulted specialty and include any special tests performed to investigate for the issue consulting about. Also mention if you’ve chased letters and outpatient investigations
- Management: go into very precise detail about what management has been instituted as the consulted team will be highly alive to those matters
- When will you see the patient?
- Plan/advice currently: investigations, management and follow up
- Document as the registrar sspeaks about additional investigations and management
- If they aren’t seeing the patient, ask if any follow up is required and what the final plan is (especially how medications are stepped down/ceased)
- If they see the patient, they should document
- If you’re not calling again, ask for a comprehesnive plan all the way down to the GP handover (e.g. when lines can come out, oral stepdowns, contingency plans)
- Obtain an easier way to get hold of them (e.g. mobile number)
- Can say that it is to send investigations results to them or give your number to them
Example
- Hi, my name is
[Your Name]. I am the intern on General Medicine A.- Are you the Cardiology registrar on for external referrals today?
- Do you have time to receive a referral?
- I have with me Mr John Smith, a 55-year-old gentleman with unstable triple vessel disease that requires transfer for inpatient coronary bypass. He initially presented with severe, central chest pain radiating to his left arm and was diagnosed with an NSTEMI. His ECG shows new ischaemic changes in comparison with a graph from January and he is currently awaiting a transthoracic echo.
- My consultant is concerned about his welfare if left untreated, and we were hoping to have him transferred to Large Metropolitan Hospital for inpatient bypass.
- Would you be willing to accept this patient? Do you have a bed available?
- Thank you for your time – if you need any more information I am holding pager #123.
After the Consult
- Document, especially if they’re coming or their phone advice and their plan
- Can just use a simple template:
[Your Specialty] JMO [Your Name]
Discussed with [Consulted Specialty] Registrar Dr [Reg Name]
Happy to review pt. today [or another time]
Recommendations:
– [the details]