Chapter 8. Appropriate and Effective Use of Consultants

1. The increasing complexity of modern medicine requires greater involvement of consultants and coordination of care across medical specialties.

2. Primary physicians and consultants should have clear, direct communication about the reason for consultation and the role of each provider.

3. Consultants should prioritize their recommendations, provide continuity of care perioperatively, and be sensitive to the content and delivery of their recommendations.

4. Preoperative evaluations should be evidence-based, coordinated with all involved physicians, and performed well before surgery to facilitate effective management of comorbidities or complex medical problems.

5. Consultants should facilitate the use of guidelines and consensus statements when recommending therapy and. where necessary, deviate from existing guidelines based on new knowledge.

6. Consultants should actively provide education to the physicians who consult them as well as to the patients on whom they consult (eg, healthy lifestyle interventions).

Recent evolution in the practice of medicine has increased the need for consultants and their role in the perioperative period. These changes arose in response to these situations:

• An aging patient population requiring more medical and surgical care
• The advent of same-day admission and outpatient surgery
• Better outcomes in sicker patients through technological and pharmacologic advances in surgery, anesthesiology, and medicine
• An appreciation that the complexity of care of sick people requires multiple specialties
• Increasing numbers of nonphysician providers who rely on physicians for medical advice
• Market pressures: the need to decrease costs by reducing errors and improving efficiency

The potential for consultation to have a positive impact on patient care and health care indices has never been greater. This chapter addresses the role of the consultant, the consultation process, factors influencing its effectiveness, and medicolegal considerations.

The consultant enters into a relationship with the patient at the request of the primary physician. The requesting physician should ensure that the patient understands the reason for the consultation prior to the referral and that the patient agrees to this relationship. The consultant should respect the existing professional relationship between the patient and the primary physician. If at any time confusion arises over the requested role of the consultant, this should be clarified with the referring physician. However, once involved with the patient, the consultant's responsibility is to put the patient's interest first.

Consultants should focus their attention on issues pertinent to the clinical question posed in the consult request. They should perform their own history and physical in addition to reviewing the medical record. Providing an estimated quantitative risk of both cardiac and noncardiac perioperative events for that patient and the proposed surgical procedure is ideal (Table 8-1), as well as proposing strategies to mitigate these risks. Evaluating medical versus surgical management; anticipating potential intra- and postoperative complications; and outlining a plan for postoperative care to prevent, detect, and treat complications is germane. Findings and recommendations should be clearly and concisely recorded in the chart and discussed directly with the primary physician. Unless the primary physician has given permission to the consultant to do so, the duty to convey important information to the patient remains with the primary physician.1

When making an assessment and recommendations, consultants should limit their direct discussion with the patient to their area of expertise (eg, management of diabetes) and should be careful to avoid direct discussion of issues within the domain of the surgeon or the anesthesiologist. The patient should understand that recommendations are simply that. The role of the referring physician is to decide which recommendations they wish to enact. An exception to this arrangement exists in a model of comanagement, in which the medical "consultant" has a set of clearly defined areas in which they may be actively managing as a "primary" physician and should make this role clear to the patient.

Consultants should avoid commenting on areas outside their scope of practice (eg, telling an anesthesiologist how to give an anesthetic or a surgeon how to operate). These comments are not authoritative and can cause animosity within the perioperative care team. Additionally, consultants should be sure to avoid trivial comments, such as "avoid hypotension," that are obvious to any physician and unlikely to improve patient care.2 When surgeons reviewed a series of medical consultations, 12% of the comments were rated as "insulting."3

Conflicts between primary physicians and consultants over medical or surgical decision making can be complex to resolve. A trilateral deliberative model has been proposed to deal with conflicts between the consultant(s) and referring physician. This model describes the ethical duties of the primary physician and consultant.4 It cautions against attempts to dominate each other and advocates minimizing differences of opinion over minor issues. Both the consultant and primary physician are obliged to maintain patient confidentiality separately if requested, except when relevant to immediate health care concerns. This model allows direct discussion between the consultant and patient over a difference of opinion with the referring physician. However, it also assumes that resolution between physicians was attempted and failed before the patient was alarmed by these discussions.

A further role of the consultant is as educator to the physician requesting the consult. This should be done tactfully and sensitively. Opinions should be concise and presented without condescension. Presentation of a differential diagnosis and selected references may help. Brevity is best because long treatises are unlikely to be read and consequently would be of no value.

Preoperative Assessment

Preoperative assessment clinics were created to streamline patient assessment and evaluation before surgery, and they appear to be effective. Preoperative evaluation has been shown to enhance management of existing conditions, diagnose new conditions, and help in arranging follow-up care.5-8 They can reduce costs by facilitating rational use of preoperative testing and consultation. Medical specialties have created consultation services to ensure appropriate physician specialists are available to respond to requests for consultations in a timely manner. Clinical guidelines such as the American College of Cardiology/American Heart Association (ACC/AHA) 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery have also been helpful in guiding appropriate preoperative evaluation and care.9

Consultation is usually performed by an anesthesiologist, internist, medical subspecialist, or a combination. Multiple studies have demonstrated improvement in surgical care from anesthesiologist-staffed preoperative clinics; less evidence has been generated from internist-staffed preoperative clinics.10-13 The surgical history and physical should be sufficiently detailed to identify the need for further workup. If indicated, the most appropriate specialist(s) should be consulted and specific clinical questions articulated. Internists and medical subspecialists are most appropriate for assessing and managing complex medical problems and for engaging in ongoing medical care. Anesthesiologists are best for assessing anesthetic risks, appropriate location for surgical care based on risk (eg, free-standing outpatient surgery center vs hospital), and whether patients are candidates for nurse sedation, monitored anesthesia care, or another type of anesthesia.

Multiple studies have indicated that the most important factors in effective consultation relate to communication. The reason for the consultation should be stated precisely and confirmed by the consultant with the referring physician. One study showed that 14% of consultants and consultees disagreed on the reason for consultation.14 Miscommunication such as this at least partially explains compliance rates with consultant recommendations of only 54% to 77%.3,15 "Please clear for surgery" is not a meaningful consult request.16 It is unrealistic for any patient to be "cleared" because no patient is entirely without some medical risk. Additionally, regulations governing consult reimbursements require that a medically appropriate question be asked of a consultant.1 The physician requesting a consult should be clear as to the type of intervention being sought: consult with recommendations only, consult and treat immediate problems, consult and comanage care, and so on.

Data suggest that in the preoperative period, patients are uniquely receptive to information on health and lifestyle. These educational opportunities should be exploited by all members of the health care team because these interventions can be especially effective for reinforcing other recommendations for a healthy lifestyle. Patients and their families should be counseled to stop smoking,17,18 limit alcohol intake19 and drug use, and improve diet and exercise. Referrals and supporting information should be provided whenever appropriate.

As with all types of medical intervention, perioperative consultations are subject to three basic types of medical errors: overuse in patients unlikely to benefit, underuse in patients with clear potential for benefit, and misuse.

Timing of the Preoperative Consultation

Requests for consultation should ideally be made sufficiently ahead of the scheduled procedure to allow time for necessary investigations and for appropriate medical interventions if warranted. The most commonly diagnosed unexpected morbidities are cardiac related. Allowing sufficient time for evaluation avoids last-minute delays in the event that the patient requires additional evaluation (eg, stress testing or echocardiogram), medication adjustment, or management of abnormal laboratory findings.

If a consultation is requested at the "last minute," the consultant should strive to fulfill their obligation to the patient and referring physician under the circumstances. It is appropriate to use these experiences as "teachable moments" for the referring service and to evaluate system issues that contribute to suboptimal timing.

Immediate Perioperative Period

The surgeon and anesthesiologist comanage patients in the recovery room. Consultation with other services in this setting is unusual. When it occurs, the consultant should be familiar with the normal range of physiologic changes in the recovery period when making their evaluations. More commonly, the consultant is requested de novo, or for follow-up after a preoperative consultation, after the patient returns to the ward or intensive care unit.

A multimodal fast-track surgical care model to promote healing, earlier discharge and return to function, and fewer complications is being advocated.20,21 This approach requires carefully coordinated team-based care involving surgeons, anesthesiologists, nurses, and other clinicians. Consultants should be aware of this model and facilitate its use as indicated by the clinical situation. Most major postoperative complications occur in the first 72 hours; therefore, the consultant should be available to assist during this interval, and longer if their expertise is indicated in the management of subsequent complications.22 Further, the primary physician has an obligation to inform the consultant of any subsequent developments that may be relevant to the consultant's expertise.23,24 Increasingly, surgeons are engaging internists or others to assist or provide perioperative medical care while they focus on surgical management, so such engagement will likely be more common in the future.

Postoperative Care

Increasingly, models of comanagement between surgeons and various medical specialists, including anesthesiologists, have been developed to enable more expedient and skilled medical care to be provided on the wards and to enable surgeons to concentrate their efforts on busier operative workloads. In one study, the frequency of comanagement by medicine-trained physicians for patients undergoing 15 common inpatient operations increased 11.4% annually from 2001 to 2006.25 Proposed models of comanagement have emphasized more efficient and cost-effective preoperative testing, shorter lengths of stay, and the potential for improved medical outcomes (all these are consistent with the fast-track approach described earlier). To date, studies of comanagement have not clearly demonstrated statistical benefits in outcomes beyond minor medical improvements such as decreased urinary tract infections and electrolyte abnormalities and improved staff satisfaction. Separate studies showed varying results in terms of outcomes such as cost of care, length of stay, time to surgery, and major medical complications.26-29

Another role that is increasingly appropriate for consultants involves the need for effective communication at the time of patient transition out of the hospital. Literature focused on effective "handoff of care" and the medical errors occurring at the time of patient transition to home or to rehabilitation settings has shown the need for greater attention to this area.30 Traditionally, consultants have not always played a major role in this area, but their skills and experience suggest they could be valuable contributors, and the opportunity is consistent with their commitment to strive for the patient's best interests. They should be aware of the service they can provide for the patient by ensuring that issues related to their area of expertise are well communicated to the health care provider who will be responsible for the patient after discharge from the hospital. Checklists and "readback" are effective strategies to enhance transfer of information.30

Rapid response systems or rapid response teams have also developed as a strategy for early identification of hospitalized patients with potentially unstable or deteriorating conditions. Depending on the medical center, these systems may or may not involve physicians on the team of emergency providers. If present on this team, internists (often hospitalists), intensivists, or anesthesiologists may practice in either a consultative or comanagement role. Literature to date remains inconsistent regarding the statistical benefits of these systems.31-34

Consultations can be useful in diagnosis, management of existing conditions, triage to a new service, and in delaying or even cancelling surgery on occasion.5-7,35 Yet half of all recommendations are ignored.15 This could reflect lack of relevance of the consultant's comments, failure to communicate reasoning or urgency, or a decision to ignore relevant information.

Communication is essential if a consultation is to be relevant to the requester. The clinical question must be clearly stated and understood. This is achieved by direct and precise communication between requester and provider, both written and orally (Table 8-2).36

Fewer than 6 recommendations should be made if possible. Data show that compliance decreases with increasing numbers of recommendations.37,38 This is true regardless of the severity or complexity of the patient's medical condition. Therefore, recommendations should be carefully selected and prioritized. Annotating recommendations as "crucial" may help focus the requesting service on highly important items requiring immediate attention and improve compliance.36 Recommendations should be written concisely and also communicated to the requesting service directly so that any understanding can be clarified. It is wise to avoid insulting, unhelpful, or redundant advice (eg, avoid hypoxia).

Alternatively, recommendations can be prioritized as preoperative and postoperative courses of action. For example, a patient's medical condition may require many interventions, but only a few may be necessary to prepare a patient for surgery and anesthesia22; the remainder can be implemented postoperatively. This information, too, must be clearly stated both in writing and verbally. The presence of the consultant after surgery is important to facilitate the implementation of postoperative recommendations.

Recommendations should be specific and concise. For example, when recommending a drug regimen, the drug name, dose, schedule, duration of therapy, and therapeutic goals should be clearly stated. This precision facilitates compliance and reduces errors in interpretation.39 Providing reasons for further testing is always helpful and educational to the consultee and others. Continued presence and follow-up by the consultant with visits noted in the medical record and ongoing communication with the requesting service to reiterate recommendations also improves compliance. Nonurgent recommendations that can be pursued as an outpatient should be communicated clearly.

Many of these principles of consultation are summarized well in Goldman and Lee's Ten Commandments for Effective Consultations (Table 8-3).41 The issue of contingency plans is controversial, as stated by Caplan et al.42 In general, contingency plans should not be provided in lieu of timely reevaluation of the patient and are best used for nonurgent issues or to clarify what foreseeable scenarios should prompt notification of the consultant.

Primary providers should seek consultation when a clinical problem is outside their scope of practice or exceeds their level of expertise.23 Consultants should be used to enhance care, not be used defensively to "cover one's back." The requesting provider should inform the patient why the consultation is requested because the patient must give consent to see the consultant.24 It is the job of the consultant from a medicolegal perspective to appropriately document his or her independent assessment of the patient's condition and to review and interpret all data independently (ie, laboratory results, diagnostic studies) appropriate to their medical specialty. The consultant should confirm, ideally verbally, that the primary physician receives his or her written assessment and recommendations, comprehends the reason for these recommendations, and has the opportunity to ask questions. In doing so, effectiveness of communication between providers is enhanced, but it is also important from a legal perspective that a consultant ensures that his or her input is understood. The primary physician in a traditional model has ultimate responsibility for medical decision making, which should be made clear to patients when a consultant is involved. This becomes more complicated when "consult and treat" is the model requested or in comanagement scenarios where dual responsibility is involved. Both primary physicians and consultants should avoid informal "curbside consultations" as a general rule, for they can be inadequate medically and convoluted legally.43 When in doubt, consultants should see the patient formally if he or she feels a complex question is being asked.44

Consultants and primary physicians may both be responsible for the adequate and accurate "handoff" of information and plan of care when patients transition between levels of care, such as from the intensive care unit to ward or from hospital to rehabilitation or home.45

The work of the consultant has increased due to shorter planned inpatient treatment, greater numbers of sicker patients able to benefit from surgery and other invasive procedures, and increased use of physician extenders whose supervising service lacks the necessary medical expertise to manage various and complex medical problems. The role of the consultant in many settings has evolved from the traditional information-only model to one of more engagement in care of the patient and education of the consultee.

All parties should ensure effective verbal and written communication. Primary providers should know when consultations are needed and be precise in their clinical requests. Consultants should respond in a timely manner with brief, clear, and focused recommendations. The doctor–patient relationship that exists with the requesting provider should be respected. The consultant should remain engaged throughout the perioperative period and be available for assistance with postoperative care. When comanagement is requested, it is essential that everyone's role be clearly understood, including by the patient. Consultants should facilitate the use of guidelines and consensus statements when recommending therapy but, where necessary, deviate from existing guidelines based on new evidence.46,47

• Emanuel LL, Richter J. The consultant and the patient-physician relationship: a trilateral deliberative model. Arch Intern Med. 1994;154:1785.
• Fischer SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology. 1996;85:196-206.
• Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143:1753.
• Kleinman B, Czinn E, Shah K, et al. The value to the anesthesia-surgery care team of the preoperative cardiac consultation. J Cardiothoracic Anesth. 1989;3:682.
• Lubarsky D, Candiotti K. Giving anesthesiologists what they want: how to write a useful preoperative consult. Cleve Clin J Med. 2009;76:S32-S36.