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
DISCUSSION
Our study provides insights into the consultative landscape of AMCs and identified who consults IMs and their RFCs. Thus, our study has implications for resident consultative education. The consult services included in our study presented varied structures, including those that require medicine consultation as a resident rotation and those with comanagement agreements. Consistent with the results of prior studies, surgical services requested the majority of consults, with orthopedic surgery generating the highest number of requests. Consultation requests from neurosurgery were higher than previously reported.2,8,9
Our study reveals that comanagement and preoperative evaluation are the most common RFCs and are the least commonly encountered RFCs in IM inpatient services. The broad nature of these RFCs speaks to an increasing need for comprehensive consultative care. Consultants addressed a wide range of clinical issues, including rare entities that defy easy categorization (eg, Moyamoya disease). This broad landscape presents challenges in focusing curricular content areas outside of comanagement and preoperative evaluation but does provide evidence “to expect the unexpected” in IM consultation, as has been previously noted.8
In over a third of encounters, consultants addressed an issue that was not stated in the initial RFC. Consultants also addressed more than 2 RFCs per encounter. These observations suggest that medicine consult services may be essentially comanaging some patients even when a comanagement care model is not formally in place. These findings provide rationale for the continued expansion of comanagement services.11
Our study provides further evidence that, in modern consultative practice, “determining your customer” is more important than “determining the question.”12-14 We work in an era in which comanagement services are increasingly prevalent but are not ubiquitous and in which IM consultants routinely address multiple issues. Prior studies indicated that most surgeons do not believe that consults should be limited to specific questions and instead prefer comanagement.13 Understanding the expectations of the requesting physician is therefore important and highlights the importance of verbal communication at the time of initial consultation. Ongoing interprofessional communication is a vital skill that residents should acquire.
Our study has several limitations. Although our sites represented a varied sample, we focused on AMCs. Therefore, our study may not reflect consultative experiences in nonacademic hospitals or sites without dedicated consult services. Trade-offs exist in our data collection approach, which provided predetermined RFCs. We selected our methodology to facilitate data entry and to aid RFC categorization. Nevertheless, it may have lessened the clinical nuance of submitted data. The provision of predetermined RFCs may have influenced issue selection by the respondents. However, in 473 encounters (37.4%), the survey respondents provided free-text entries for the stated RFC, and 944 additional RFCs were written in as responses. These results demonstrated that respondents did not limit themselves to the predetermined list. We did not perform chart reviews to validate data. Finally, our data were a cross-section of initial consultations. We lack information on subsequent diagnoses or additional clinical issues that developed later.
In conclusion, we found varied consultative experiences across AMCs. However, preoperative evaluation and perioperative comanagement – particularly of orthopedic and neurosurgical patients – were common and should be included in curricula. Faculty should recognize the unique nature of IM consultation to prepare residents. Specifically, faculty should prepare residents to expect to identify and address unstated medical issues and to provide comprehensive assessments regardless of whether the consultative structure has a comanagement component. Given the unique nature of consultative IM work and the possibility of discordant expectations between consulting and requesting physicians, perhaps the most valuable skill to impart to residents is effective and regular communication.
