Hospitalist Perspective of Interactions with Medicine Subspecialty Consult Services

Statistics

Results were summarized using the mean with standard deviation for continuous variables and the frequency with percentage for categorical variables after excluding missing values. All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC). A 2-sided P value of ≤0.05 was considered statistically significant.

RESULTS

Of a possible 261 respondents, 122 (46.7%) participated in the survey. Missing values for survey responses ranged from 0% to 21.3%, with a mean of 15.2%. Demographic characteristics are shown in Table 1. Respondents had a mean age of 37.7 years and had worked as attending hospitalists for an average of 5.6 years. The majority of respondents (86.1%) practiced in academic medical centers, with the remaining working in satellite community hospitals. Respondents reported working daytime shifts 74.1% of the time on average and being on inpatient, direct-care services without house-staff 70.5% of the time.

Current Consultation Practices

Current consultation practices and descriptions of hospitalist–consultant communication are shown in Table 2. Forty percent of respondents requested 0-1 consults per day, while 51.7% requested 2-3 per day. The most common reasons for requesting a consultation were assistance with treatment (48.5%), assistance with diagnosis (25.7%), and request for a procedure (21.8%). When asked whether the frequency of consultation is changing, slightly more hospitalists felt that their personal use of consultation was increasing as compared to those who felt that it was decreasing (38.5% vs 30.3%, respectively).

An exploration of communication practices during consultation revealed that hospitalists most often interacted with fellows rather than attending physicians (81.4%). However, even when a fellow performs a consult and communicates with a hospitalist, a subspecialty attending is involved in the care of the patient, although he or she may not communicate directly with the hospitalist. Respondents indicated that they most often communicated a consult request to the consultant by phone (76.2%). Pushback from consultants (defined as perceived reluctance or resistance to perform the consult for any reason) was perceived as common, with 64.4% of hospitalists indicating that they experience pushback at least “sometimes” (3 on a 5-point Likert scale) and 22.1% reporting that pushback was “frequent” or occurred “most of the time”. Follow-up interactions (defined as communication of recommendations after the consultant evaluated the patient) infrequently occurred through in-person communication, with 90.9% reporting that this occurred in less than half of consultations. Communication by phone was most common, with 61.2% reporting that it occurred at least half the time, and 86% of respondents reported that communication by paging only occurred at least “sometimes”. Consultation was commonly seen as a valuable educational experience, with 56.9% of hospitalists indicating that they learned from at least half of consults.

Hospitalist Preferences

Eighty-six percent of respondents agreed that consultants should be required to communicate their recommendations either in person or over the phone. Eighty-three percent of hospitalists agreed that they would like to receive more teaching from the consulting services, and 74.0% agreed that consultants should attempt to teach hospitalists during consult interactions regardless of whether the hospitalist initiates the teaching–learning interaction.

Barriers to and Facilitating Factors of Effective Consultation

Participants reported that multiple factors affected patient care and their own learning during inpatient consultation (Figure 1). Consultant pushback, high hospitalist clinical workload, a perception that consultants had limited time, and minimal in-person interactions were all seen as factors that negatively affected the consult interaction. These generally affected both learning and patient care. Conversely, working on an interesting clinical case, more hospitalist free time, positive interaction with the consultant, and having previously worked with the consultant positively affected both learning and patient care (Figure 1).

Fellow Versus Attending Interactions

Respondents indicated that interacting directly with the consult attending was superior to hospitalist–fellow interactions in all aspects of care but particularly with respect to pushback, confidence in recommendations, professionalism, and hospitalist learning (Figure 2).

DISCUSSION

To our knowledge, this is the first study to describe hospitalist attending practices, attitudes, and perceptions of internal medicine subspecialty consultation. Our findings, which focus on the interaction between hospitalists and internal medicine subspecialty attendings and fellows, outline the hospitalist perspective on consultant interactions and identify a number of factors that are amenable to intervention. We found that hospitalists perceive the consult interaction to be important for patient care and a valuable opportunity for their own learning. In-person communication was seen as an important component of effective consultation but was reported to occur in a minority of consultations. We demonstrate that hospitalist–subspecialty attending consult interactions are perceived more positively than hospitalist–fellow interactions. Finally, we describe barriers and facilitating factors that may inform future interventions targeting this important interaction.