Who Consults Us and Why? An Evaluation of Medicine Consult/Comanagement Services at Academic Medical Centers
Although general medicine consultation is an integral component of inpatient medical care and a requirement of internal medicine training, little is known about current consultative practice. We used a cross-sectional, prospective survey design to examine current practices at 11 academic medical centers over four 2-week periods from July 2014 through July 2015. Out of 11 consult services, 4 had comanagement agreements with surgical services, primarily with orthopedic surgery. We collected data regarding 1,264 consultation requests. Most requests (82.2%) originated from surgical services, with most requests originating from either orthopedic surgery (44.4%) or neurosurgery (11.6%). The most common reason for consultation at sites with a consult and comanagement service was medical management/comanagement (23.3%) and at sites with a consult-only service was preoperative evaluation (16.4%). On average, consultants addressed more than 2 reasons per encounter. Many of these reasons were unidentified by the consulting service. Learners on these services should perform comprehensive evaluations to identify potentially unidentified issues.
© 2018 Society of Hospital Medicine
The role of internists in consultation has considerably expanded over the past half century. Consulting general internists increasingly work across disciplines to coordinate complex care.1,2 Some internists assume a “comanagement” role with surgical specialties. This role requires sharing responsibility and accountability and involvement in admission/discharge processes.3-6 Internal medicine (IM) residents are required to serve as consultants.7 Yet, aside from observations collected 30 to 40 years ago, limited information is available for guiding educators in developing consultative curricula.2,8-10 We sought to assess current consultative practices across a sample of IM training programs. Specifically, we examined which services consult IM and their reasons for consultation (RFCs).
METHODS
We collected data on consultation requests at 11 US academic medical centers (AMCs). We applied a selective sampling approach that leveraged existing relationships and interest in consultative medicine to identify institutions across a variety of geographic locations. We collected data regarding the consult service structure at each site, including data on the presence or absence of comanagement services and consult requests received.
Data Collection Tool
Investigators at the University of Texas Health San Antonio (UTHSA) drafted the data collection tool. Iterative feedback on the data collection tool was obtained from the research consortium (final tool, Supplemental Figure). Data collected included service requesting consultation, RFC, time request was made (day/night), who first saw the patient (eg, resident, attending), whether requesting and consulting providers verbally communicated, and whether patients were transferred to medicine. Respondents also estimated how often RFCs were encountered during their general medicine services.
To streamline data collection, we used click boxes and drop-down lists that included diagnoses and symptoms. The use of these predetermined RFCs was based on prior studies and discussion with the research consortium on common RFCs in clinical practice. A write-in field was also included. Respondents could select multiple RFCs in the case of multiple questions. Respondents also provided data regarding clinical issues that were incidentally identified during their initial patient assessments. Incidentally identified issues are hereafter called “additional RFCs” for differentiation from stated RFCs. Prior to data collection, the tool was piloted at UTHSA.
Data Collection, Categorization, and Analysis
Participants submitted data using Survey Monkey (Palo Alto, California). Emails with the survey link were sent daily. Specific participants for each data collection period were chosen by each site. Days with no data entry were confirmed by the study coordinator. Each institution collected data for four 2-week periods from July 2014 to July 2015 for a total of 8 weeks. We did not track follow-up encounters. Repeat consultations for different reasons were considered new consults.
