This study confirms many elements of effective consultation and provides several new insights. Some findings have implications for evolution in the approach to consultations as the penetration of EMRs in US medicine continues to increase and as practice patterns evolve in different specialties.5,6
Our results reinforce that the first priority for a consultation request is that it state clearly the question or reason for consultation.2,5,7,10,11
In a previous study in which both requestor and consultant were interviewed after consultations, disagreement about the consultation question occurred in 21%.2
Our results supported and extended other tenets of effective consultation, including that requests indicate urgency, and that consultants should keep notes and recommendations concise.1–3,5,7,10
This study added new insights. Our respondents emphasized the need for consultants to clearly indicate when they will no longer follow a patient, often referred to as a “sign-off note.” Previous authors have emphasized that consultants should follow up after recommendations are made,7
but to our knowledge none has emphasized that the consultant should let the requestor know when the consultant is no longer following the patient. Without a sign-off note, absence of a comment or a note may be interpreted by the requester as agreement or acquiescence with the current patient management or lack of need to test further or change course. This ambiguity can be avoided with a note specifying that the consultant will no longer be involved in a case. If a consultant has signed off, and there are further questions, the requestor will know to contact the consultant again.
Our respondents answered that consultants who recommend new drug therapy should specify dosage and duration of new drugs. Requesters placed greater value on details of duration than did consultants. Inclusion of specific details has been associated with greater likelihood that drug therapy recommendations will be heeded.1,4
Generic drug names were much preferred over brand names, which may signal lessening of the influence of pharmaceutical industry marketing compared with non-commercial sources of information on drug effectiveness and costs or may reflect the academic nature of study hospitals.
The numbers of physicians involved in inpatient care has steadily increased, and immediate responsibility for care changes multiple times during typical hospitalizations, which necessitates what are frequently called “handoffs.”12
Respondents seemed to have this in mind when they answered that a consultation request should clearly specify the person that the consultant should contact and how the contact should occur.
The preference among consultants for use of an EMR alert to notify a requester that a consultation has been completed may reflect difficulty in knowing whom to contact. The efficiency of the Veterans Affairs EMR may have been one reason why MVAMC practitioners preferred that requests for routine consultation be made through the EMR. Interestingly, alphanumeric text messaging was least popular and considered by many respondents to be unreliable because of lack of verification that messages were received or understood.
Legibility has long been an issue,3
becoming less so as EMRs replace paper charts with handwritten notes. But legibility does not guarantee comprehensibility.13
Our respondents placed great value on consultation responses that were written clearly and concisely, listed specific recommendations, and outlined the rationale for the recommendations. Large majorities preferred assessments and recommendations in numbered or bulleted lists rather than in paragraphs.
While the EMR facilitates communication, 67 percent of respondents ranked verbal communication of the essence of the consultation response best or second best. Many previous reports have emphasized the importance of verbal communication between consultant and requestor.3,5,7,14
An alternative view was posed by a study of outpatient consultations in which the content of the communication was more important that the mode of communication.15
The evidence suggests that the advantage of verbal communication between consultant and requester is that it increases the likelihood that communication will be accurate, comprehensive, and understood and that the consultant will be available for questions or further discussion.
Respondents preferred consultations that recommend a specific follow-up plan and decisions for future management based on results of more proximate steps. While such plans and decisions may be intuitive for consultants, primary physicians felt these elements should be included in the consultation response. A sign-off note would be a good place to recommend follow-up and future management plans because it would be easily identifiable later on. Previous studies found a positive association between the number of “follow-up” notes written by consultants and the likelihood that the recommendations would be followed.1,7
Some authorities have recommended that contingency plans be provided,7
but we are unaware of empirical data on whether better outcomes are associated with follow-up notes or contingency plans.
Respondents wanted consultants to state the rationale supporting recommendations, but they did not care much about references to support the recommendations. Some authorities have suggested that references be supplied judiciously,7
but a recent survey found that only 27% of physicians felt that literature references are useful as part of the consult.5
It may be that physicians in large, metropolitan hospitals have easy, quick access to secondary and tertiary sources for guidelines and review articles and may not have interest or time in reading articles cited in consultation responses.
This survey had both strengths and weaknesses. The 50% response rate, good for surveys of this type, was a limitation, and surgeons and surgical-subspecialists made up only 3.7% of respondents. Seventy-eight percent practiced in internal medicine and/or pediatrics, and the results are most likely reflective of these disciplines. Some questions allowed respondents to rate many consultation elements positively rather than constraining them to prioritize. It was difficult in some cases to discern the elements that were truly critical in the minds of respondents. The study was done in four independent hospitals with individual affiliations with a single medical school and was limited to inpatient consultations, and the results may not be fully applicable to other settings. A strength was that many questions asked about specific details that have practical importance in daily work. Another was that we were able to compare responses of physicians who usually requested consultations with responses of physicians who were usually consultants. This was an opinion survey, and we did not measure the impact of respondents’ preferences on patient outcomes.
Our results have implications for development of consultation guidelines and policies, education, and possible incorporation into service level agreements between requestors and consultants.5,6
Physicians in training have been involved in the consultation process for decades,9,16
and the most recent Accreditation Council for Graduate Medical Education (ACGME) education requirements state that internal medicine residents must have a structured clinical experience to act, under supervision, as consultants to physicians in other specialties.17
Until recently research on how to educate physicians on how to most effectively request or respond to consultations has been meager.8,16
EMRs provide powerful opportunities to improve the consultation process. Templates should be developed for both requesters and consultants to encourage adoption of the specific characteristics this and previous studies have found are desired or associated with improved adherence to recommendations or better patient outcomes. A provider who requests a consultation may not be on duty when the consultation is completed. EMRs should enable a requester to designate one or more surrogates who would be alerted if a consultation is completed when the requester is off duty. EMRs should have a separate template and note title for consultation sign-off notes so that others are able to easily locate and understand the recommended plan. By standardizing consultations, EMR templates could facilitate research that would determine which of the popular elements of consultation requests or responses are associated with improved outcomes.
Other changes in delivery of care and practice patterns will also influence how consultations should be done. These changes include demands for surgeons to spend more of their time in operations, increased prevalence of co-management involving requesters and consultants, and an increasing percentage of consultations performed by medical subspecialists as opposed to general internists.5
Consultation tools within EMR systems should be designed to reflect these changes. Several previous studies have shown that a portion of consultant recommendations are not followed.3,4,18
While there may be valid reasons for some of this lack of conformance with consultant recommendations, non-conformance often reflects failures of communication or follow-through or lack of familiarity with how to carry out recommendations.3–5,18
A recent study showed that an EMR tool that allowed referring providers to review and implement electronic recommendations from consultants improved the percentage of recommendations that were implemented.19
This and previous studies have documented elements considered important for effective consultations. The recent studies show how consultations can be most effective with current practice patterns and technology. The evidence should guide efforts to improve the consultation process through policy, service level agreements, and EMR design.