10 Commandments of Consultation

8/4/2019 10 Commandments of Consultation

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Medical ConsultationSteven Freer, MD

Mary Nettleman, MD, MS

A Basic Approach to Medical Consultation

The internist asked to “consult” on a patient istraditionally expected to assume the task of identifying and treating diseases outside theexpertise or capabilities of the consulting physician.This commonly encompasses the areas of perioperative medicine, as well as assistance tohealth care professionals in specialties such asrehabilitative medicine, psychiatry, or neurology,where the overriding acute or chronic conditions of the patient frequently supercede the medicalproblem for which consultation is sought. Often,however, the coincident problems are so integral tothe general health status of the patient that their separation is more of academic then practical value.Thus effective consultation requires cooperativecollaboration between members of differentspecialties.

In the early 1980’s, Goldman, Lee and Ruddpublished the often-cited “10 Commandments of Consultation”, which effectively defined a practicalstandard for internal medicine consultation.

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Consultants were advised to:

1) clarify the question

2) determine the urgency of the consultation

3) gather data independently rather than relyingon that previously obtained

4) be brief and succinct

5) state the differential diagnosis concisely andbe specific in recommendations

6) anticipate potential problems and provideoptions

7) honor the roles of other caregivers

8) teach with tact

9) maintain direct personal contact with the

consulting physicians10) follow up with periodic notes and, whereappropriate, recommendations.

These clear suggestions notwithstanding, thebenefits of consultative medicine in most settingshave not been rigorously studied. Assessing theeffectiveness of consultation has been based onmeasuring compliance with the recommendations of

the consultant rather than on patient outcomesStudies revealed that compliance was best whenrecommendations

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1) numbered 5 or less

2) focused on the specific question of the

consulting physician3) concerned medication rather than diagnostictests

4) required little additional work

5) were made in person and within 24 hours

6) were specific

7) involved consultant follow up.

Such findings have lead to conclusions tha“consultations are requested principally foassistance in management rather than diagnosis.”

and that “…recommendations peripheral to currenpatient care issues are unlikely to be implemented”.

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At least in the areas of perioperative riskstratification, significant measures have beencodified for predicting cardiovascular outcomes innoncardiac surgeries, but their usefulness is limitedby the need to extrapolate from one subgroup ofsurgical procedures to another.

3Others have begun

to assess the benefits of consultation on patientswith varying disease severity, on hospital lengths ostay, and on such indicators as adverse drug effectsand blood transfusion. Thus compliance alone as a

measure of the effectiveness of medical consultationis beginning to yield to true outcomes measures. Adisciplined investigation of the role and effect omedical consultation on patient outcomes deservesattention to improve both patient care and cost-effectiveness.

The Content of the ConsultationWhile all physicians have a duty to seek consultationwhen confronted with problems beyond theiexpertise, the acceptance of a consultation referraby the internist implies certain additional duties.

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The consultation and its documentation should becarefully constructed to meet these duties and to

avoid misunderstandings.

It should go without saying that the medicaconsultation begins with the history and physical. Inkeeping with the Goldman recommendations, oncethe clinical question and the purpose of theconsultation has been clearly defined a carefuassessment of the medical issues pertinent to thisquestion should be undertaken. Ascertain th



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urgency of the request and respond promptly. Same day service should be the standard. Acareful chart review and a focused history and

physical are fundamental expectations of amedical consultation. Depending on thecircumstances, the consultation might focus on riskstratification, management of a specific problem,diagnosis of a complex set of clinical parameters,continuity of care, or some combination of these.State your understanding of the purpose of theconsultation in the note. It is essential that theconsultant understand the expectations of therequesting physician so that time is not wasted inproviding the best possible service in theconsultation. If the consultant finds issues of importance distinct from the original request by theconsulting physician, these issues should bediscussed directly with the consulting physicianbefore being included in the consultation note. Thenote should not be regarded as a substitute for

directly and clearly communicating with therequesting physician. Potentially controversialissues should be discussed directly prior to anyinclusion in the consultation note. Managementdisagreements should be discussed privately.Notes should never be critical or inflammatory.While notes should be very specific in their recommendations, phrases like “patient is clearedfor surgery”, or “medically cleared” should beavoided, as should “patient is not suitable for surgery”. Only surgeons and anesthesiologistsdecide if a patient is ready for surgery. The medicalconsultant’s task is to risk stratify and make

recommendations to minimize perioperativecomplications, and it is important that he or sheunderstand the limitations of data available toaccomplish this. Assigning numerical values to riskor other potential outcomes is to be avoided. Thedata are insufficiently precise to warrant this, and itmay be seen more literally than was intended.Notes should make no implicit or explicit guarantees. Follow up should be consistent and allencounters documented. When you are certain your services are no longer needed, clearly sign off thecase, but always provide an invitation for re-consultation. Include a beeper or phone number.

Brevity is essential in consultation notes. It is notnecessary to document every detail of anappropriate history and physical examination in mostcases. Obviously, it is important to document thepresence or absence of things pertinent to thequestion prompting consultation. Factors known toconfer risk in the case of perioperative assessments(signs or symptoms suggestive of angina, aorticstenosis, congestive heart failure, etc.) should

always be noted. Consulting physicians are mostinterested in your recommendations, and will lookthere first when reading consultation notes. Theseshould be listed in the beginning of the note, jusafter an opening statement defining the purpose othe consultation. Any written discussion should beclear, concise, and organized, but brief . Alwayskeep a copy of your original consultation notesfor your own records.

Evidence-based guidelinesWhenever possible, consultative opinions should bebased on scientific evidence from well conductedpublished studies. Examples of such studies includethose that support prophylactic antimicrobials prioto certain types of procedures

5and prophylaxis fo

deep venous thrombosis.6

In areas where clinicatrials do not exist, consensus-based guidelinesbased on expert opinion may be used. An example

would be management of exacerbations of chronicobstructive pulmonary disease.

7. The American

College of Cardiology and the American HearAssociation have published an excellent generaguideline for the perioperative cardiovasculaevaluation in patients undergoing noncardiacsurgery.

3Finally, there are many conditions and

patient populations that are not encompassed byclinical trials or guidelines. This is not surprisingsince internal medicine consultation is a very broadfield. The medical conditions that must beaddressed cover virtually the entire scope of practiceand much of the value of the consultation depends

on the skill of the consultant.

When to request that surgery be delayedThe decision to delay or cancel surgery rests withthe surgeon and the patient. If the consultant feelsthat surgery ought not to proceed, he or she shouldspeak directly with the surgeon. Verbacommunication is the key to ensuring an optimaoutcome for the patient. At times, the surgeon mayagree that the procedure should be cancelled. Inother instances, the surgeon may have informationthat the consultant does not have and which justifiesimmediate surgery.

Reasons to delay or cancel surgery differ betweenelective and non-elective surgery. In electivesurgery, there is more time to stabilize medicaconditions and to “fine-tune” medications. In nonelective surgery, the goal is often to provide short-term stabilization with more extensive workupdeferred until after the procedure. An exampleserves to illustrate this point. For elective hipreplacement, the consultant may recommend



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complete pulmonary function testing in a patient withchronic obstructive pulmonary disease andshortness of breath. The goal would be todetermine the extent of the lung disease, identifyreversible components, and motivate the patient tostop smoking. However, if that same patient had afractured hip it would be inappropriate to delaysurgery for complete pulmonary function testing andthe results would likely be influenced by the patient’spain and immobility. In this instance, an arterialblood gas and a good physical examination maydetermine the immediate need for oxygen andbronchodilators.

Elective surgery should be delayed when a seriousmedical condition is unstable or untreated.Infections, heart failure, and many other conditionsfall into these categories. The consultant shouldalso look for undiagnosed medical problems.Pregnancy should be ruled out in all women of

childbearing age, either by history or testing. Acareful history will sometimes elicit symptoms of angina that have previously been overlooked. Abreast examination should be performed in womenwho are scheduled to undergo elective surgery sincebreast cancer is common and would preemptelective surgery. Mammograms should beappropriately up to date for age.

In some instances, even non-elective or emergentsurgery may need to be delayed for unstableconditions. In fact, the entire history and physicalexamination should be geared to the discovery of

these conditions. Diabetic ketoacidosis, sepsis,pheochromocytoma, a new myocardial infarction,and other such conditions would certainly requiretreatment prior to surgery. Consultants arefrequently called for hypertension in patients on theday of surgery. While there are no absoluteguidelines for when to delay surgery, diastolic bloodpressures over 110 mm have been associated withadverse outcomes and are generally accepted as areason for delaying urgent surgery.

4. It is important

to remember that blood pressure goes up with painand stress. Overtreating mild hypertension on theday of surgery may result in intraoperative

hypotension.

Laboratory and Imagining Tests: BasicPrinciplesThe basic principle of clinical testing is the same asthat of the physical examination and history: toidentify conditions that should be stabilized prior tosurgery or conditions that might require surgery tobe delayed or cancelled. There is no menu of tests

that applies to all patients. A healthy sixteen yearold boy with a broken leg probably does not requiretesting. In general, known conditions should beinvestigated and stabilized. For example, bloodglucose testing and measurement of serumcreatinine would be appropriate in a diabeticSpecific examples are cited in the chapters that deawith each condition.

A complete blood count is the most commonlyabnormal test and is routinely recommended inpatients with cardiac disease, renal diseasemalignancy, diabetes, in those on medications thamight predispose to bleeding, and when significanintraoperative blood loss is possible.

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surgery is rarely delayed unless anemia is extremeElectrolytes and creatinine should be obtained inpatients with hypertension, diabetes, renal diseaseand in those who are on medications affecting thesevalues. Liver function testing and enzymes should

be performed in persons who drink alcohol at leasmoderately, in those on medications which affect theliver, in patients with abdominal complaints, and inpatients with known liver disease. In absence ohistory of clotting or anticoagulation, a protime israrely abnormal. A recent electrocardiogram isrecommended in persons with cardiac disease, buis not a good way of screening for occult cardiacdisease in patients without this diagnosis. Howeverpatients with risk factors for heart disease mayexperience post-operative chest pain and it is usefuto have a baseline electrocardiogram for comparisonpurposes. Chest radiographs are performed when

there is suspicion of pulmonary pathology. Othestudies, such as cardiac imaging studies, arecovered in their appropriate chapters.

Whenever possible, records of testing from otheclinics, hospitals, or physicians should be obtainedIf available in a timely fashion, these results maypreclude repeat testing or allow the consultant toevaluate the chronicity of a condition.

References:

1. Goldman L, Lee T, Rudd P. Ten commandments

for effective consultation. Arch Intern Med1983;153:1753-5.

2. Pupa LE Jr, Coventry JA, Hanley JF, CarpenterJL. Factors affecting compliance for generamedicine consultations to non-internists. Am J Med1986;81:508-14

3. Eagle KA, Brundage BH, Chaitman BR, Ewy GAFleisher LA, Hertzer NR, Leppo JA, Ryan T, Schlant



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RC, Spencer WH 3rd, Spittell JA Jr, Twiss RDGuidelines for perioperative cardiovascular evaluation for noncardiac surgery: An abridgedversion of the Report of the American College of Cardiology/American Heart Association Task Forceon Practice Guidelines. Mayo Clin Proc 72:524,1997.

4. Goldmann, Brown and Guarnieri: PerioperativeMedicine, 2

ndEdition McGraw-Hill, 1994

5. Antimicrobial prophylaxis in surgery. Med LettDrugs Ther. 2001;43:92-7.

6. Geerts WH, Heit JA, Clagett GP, Pineo GF,Colwell CW, Anderson FA Jr, Wheeler HB.Prevention of venous thromboembolism. Chest.2001;119(1 Suppl):132S-175S.

7. Bach PB, Brown C, Gelfand SE, McCrory DC.Management of acute exacerbations of chronicobstructive pulmonary disease: a summary and

appraisal of published evidence. Ann Intern Med.2001;134:600-20.

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10 Commandments of Consultation