In a cold march morning in 2021 a big city urban “academic” hospital, the “consult” phone rings. A Nephrology attending answers “ Renal consult, can I help you?”. The “Hospitalist” on the other end says, “ Yes, I have a creatinine of 1.5mg/dl, AKI, please see.”. The Nephrologist replies, “ Yes, we shall, please send me details of the location and will take care of it.” The Hospitalist says, “ thank you, and please don’t ask you fellow to see, I want an “Attending only” consult. The Nephrology attending politely agrees. He nods to the “renal fellow” next to him and says, “ Don’t worry, this one is for me only”. The Hospitalist continues “One more thing, I am done for the day, it’s 4PM, can you call the consult recommendations to my resident in house, thanks!” and hangs up.
Not too long ago, we trained as residents and fellows to see patients and get the “ nuts and bolts” of medicine and the field you were choosing. You wanted to see more patients to get the experience; perhaps not all of us but most of us wanted to get the “full and complete “ experience. Attendings saw patients with us and we learnt from their clinical wisdom. While fellows/residents were work horses, most academic centers had educational missions as well to counterbalance the workload. Things have changed in the last decade. The above conversation reflects some of those changes.
What is wrong with the above conversation? What has bought us to this stage or might get us to this stage? Why is it “okay” for the “team” calling the consult to have trainees see their patients and “consult” team has to be “attending only”? While a fellow might have less experience, their vision is not tunneled and they might bring an amazing differential diagnosis to the forefront. While the fellow might be seeing many patients, seeing more patients might make them more efficient and learn to prioritize. There is lot of learning even when the volume of patients is high. Is it the fear of “patient satisfaction” or is it a fear of “litigation”? Not really sure. I have heard it’s “communication” and many subspecialty fellows “don’t want to see more patients.” Is that really true? Maybe once in a while, we all get tired and want to “go home”. But we most of us went into medicine to “see patients” and provide optimal patient care. I can say proudly that sometimes my patients ask “ Where is the fellow?, you are alone today? We miss the fellow..” You form a team and a “team” always brings more to patient care than a “single person”.
In addition, “consult” team cannot ask any questions. “ Yes sir, I shall see the patient”. Questions are asked to see the urgency of situation, to assess workup and to get a sense of what can be done quickly before we get there. “Asking questions on the phone” does not equate “avoiding” a consult. A good consultant will ask pertinent 1-2 questions and see the patient. “Fellows” ask too many questions.. perhaps they are avoiding the consult. Fellows ask questions to learn about the patient- it’s simple. Most fellows are nervous and want to make sure that when they present to their “attending”, they have a complete story. Unfortunately, this is sometimes mistaken as “ avoiding consults”. How quickly many attendings forget—“ I was once a trainee and did the same!”.
In the era of corporate medicine, where “academia” is blending with “private practice”, there is soon going to be no difference. “Pan-consultemia” will drive these consults that will increase medical costs even more. “Attending only” services are good to help off load the fellows burden in many academic centers and creating such services is an excellent idea for that reason. When a surgical team calls a “attending only renal consult” and I don’t even get to speak to an “attending” on the other end-let alone a fellow or resident- it boggles my mind.
Double standards in medicine!
Academic programs have a training responsibility to prepare the future generations of doctors. Therefore I would argue that trainees should never be excluded from seeing a case except based on training program reasons to project the interests of the trainee (duty hours, patient loads, better learning opportunities, etc.). Essentially, "attending only renal consults" should not happen except if it is to benefit trainees.ReplyDelete
Consultation is not a matter of seeing a patient and "dropping" a note. It is a collegial and ideally educational interaction between all-members involved. Patients, consultants, and primary team members. Therefore, we must always ask questions and strive to understand what a primary team is thinking and what they need our help for.
We are consultant providers improving the care of this patient and the next through our work with each primary team. While this may seem idealistic it is a noble goal to be sure.
Rob R, CA