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 ...