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- Figure Average Number of Questions Correct, by Specialty and Question Type
Statistically significant comparisons demonstrated with p < 0.05.
Tables
Phase 1 (n = 23) Phase 2 survey (n = 42) Internal medicine residents (internists) n = 10 (43.5%) n = 24 (57.1%) Neurology residents (neurologists) n = 13 (56.5%) n = 18 (42.9%) Male n = 14 (60.9%) n = 15 (35.7%) Female n = 9 (39.1%) n = 27 (64.3%) PGY-2 n = 0 (0%) IMR: n = 10 (41.7%)
NR: n = 7 (38.9%)PGY-3 Internists: n = 8 (80%)
Neurologists: n = 7 (53.8%)Internists: n = 14 (58.3%)
Neurologists: n = 5 (27.8%)PGY-4 Internists: n = 2 (20%)
Neurologists: n = 6 (46.2%)Internists: n = 0 (0%)
Neurologists: n = 6 (33.3%)Abbreviation: PGY = postgraduate year.
Internists
Mean (SD)Neurologists
Mean (SD)Absolute difference (CI) p Value Phase 1 Is this an appropriate neurology consult? 3.54 (1.16) 3.68 (0.95) 0.14 (−0.266 to 0.539) 0.501 Is this an appropriate internal medicine consult? 3.22 (1.13) 2.69 (1.12) 0.53 (0.108 to 0.947) 0.014 Phase 2 Is this an appropriate neurology consult? 3.38 (0.55) 3.67 (0.41) 0.29 (−0.087 to 2.921) 0.064 Is this an appropriate internal medicine consult? 2.58 (0.72) 2.19 (0.60) 0.39 (−0.122 to 3.983) 0.065 Internists should know the answer
Mean (SD)Internists would know the answer
Mean (SD)Absolute difference (CI) p Value Neurologists should know the answer
Mean (SD)Neurologists would know the answer
Mean (SD)Absolute difference (CI) p Value Neurology questions Internists 3.82 (0.73) 3.45 (0.94) 0.37 (0.167 to 0.568) 0.001a 4.48 (0.58) 4.28 (0.54) 0.20 (0.072 to 0.328) 0.003a Neurologists 3.17 (0.96) 3.02 (0.86) 0.15 (0.001 to 0.312) 0.049a 4.38 (0.63) 4.20 (0.62) 0.18 (0.088 to 0.282) <0.001a Medicine questions Internists 4.48 (0.61) 4.34 (0.56) 0.14 (−0.001 to 0.281) 0.051 3.60 (0.90) 3.48 (0.97) 0.12 (−0.067 to 0.307) 0.204 Neurologists 4.42 (0.56) 4.25 (0.62) 0.17 (0.058 to 0.286) 0.004a 3.83 (0.84) 3.69 (0.84) 0.014 (0.001 to 0.276) 0.049a ↵a Statistically significant at p < 0.05.
Internists should know the answer
Mean (SD)Internists would know the answer
Mean (SD)Absolute difference (CI) p Value Neurologists should know the answer
Mean (SD)Neurologists would know the answer
Mean (SD)Absolute difference (CI) p Value Neurology questions Internists 3.63 (0.41) 3.49 (0.35) 0.14 (−0.013 to 0.280) 0.073a 4.55 (0.38) 4.37 (0.40) 0.18 (0.057 to 0.310) 0.007a Neurologists 3.04 (0.52) 2.77 (0.52) 0.31 (0.009 to 0.547) 0.044a 4.42 (0.40) 4.30 (0.41) 0.12 (0.031 to 0.213) 0.012a Medicine questions Internists 4.64 (0.38) 4.53 (0.36) 0.11 (0.009 to 0.208) 0.034a 3.71 (0.50) 3.54 (0.41) 0.17 (−0.026 to 0.359) 0.086 Neurologists 4.60 (0.41) 4.58 (0.42) 0.02 (−0.025 to 0.069) 0.331 4.02 (0.57) 3.96 (0.61) 0.06 (−0.065 to 0.199) 0.302 ↵a Statistically significant at p < 0.05.
Theme Major subthemes Frequency Quotations Educational factors Lack of insight into other specialties, especially outside of medicine 8/14 “No one truly knows what anyone else does. No one knows what it means to be in other specialties.” (INT 9)
“As an internist, there are lots of areas we know something about, but we know exactly what we don't know… we see the big picture.” (INT 1)
“I'm interested to learn, but we often get absorbed in our own things. There's no ownership or investment… they're not our patients.” (INT 8)Distance from common medical school training 6/14 “If everybody could remember what they learned from med school that would be dramatically helpful.” (INT 14)
“In IM, you're continuing to practice what you learned in medical school, but for some specialties it might have been a while since touching those other areas.” (INT 1)Medical intern year 4/14 “Neuro does the same thing though—they often don't need our help—they did a full year of medicine, so they should know! They have a basic level of medicine.” (INT 5)
“We took 1 year of medicine, so we know a little bit of their training, and the least they can do is do their part. It's frustrating that they don't do this most of the time. Other services are not trained in neuro exams. It's not right.” (INT 9)Communication factors Good consults must have a specific question 14/14 “Focus on what you need help with. If you're specific, you will get something specific in return.” (INT 1)
“Consults should be a back-and-forth dialogue. There should be a clear, specific question and pertinent information. You should share your idea of what's going on and why you need help.” (INT 2)Consults should also be an educational opportunity 13/14 “Some consulting physicians provide recommendations, which serve as an opportunity to learn their thought process. It's important though to make the time and space, but that's difficult when we have so many patients.” (INT 1) Importance of follow-up 6/14 “The best consultants call after to follow-up and make sure thoughts and plans are conveyed in a conversation. But this requires initiative and is often not done, especially because doing the note in the chart is the bare minimum.” (INT 1)
“More often, specialties are asking medicine for help with their question, but they won't follow-up. They just assume we'll take care of the patient and they can be done with everything.” (INT 7)Prior workup or perceived effort before calling a consult 6/7 Neurologists “The team should have done some of the legwork on their own before the call. It's so frustrating when they haven't done anything and expect you to do it all.” (INT 6)
“There is no reason why medicine can't do a history, a workup, a differential, and start things like understanding metabolics and possible infections. The majority of our consults are inappropriate as a result because they don't do their part.” (INT 9)Clinical factors Ability to manage a case 7/14 “Half the time, the person calling a consult is simply not confident in their abilities to perform, say, a neuro exam. And it may in fact be appropriate for them to not be so confident.” (INT 6)
“It can be frustrating to find out how little people know. You don't know the true emergencies until you see the patient yourself.” (INT 9)
“The expectation is that ER [emergency room] sees dizziness multiple times a day and calls for difficult cases. Sometimes I find that they just call for every patient because it's easier to have neuro do it for them or don't want to be held responsible.” (INT 13)Complexity of case 5/14 “So [it's] better to have both sides' input. In complex cases, it's not bad to consult. It is harder to keep track of and more work, but it should be done.” (INT 13)
“Now I understand why I get some of the consults that I get—this ambiguity can be troubling if you don't know the area.” (INT 9)Administrative factors Attendings consider liability and covering yourself legally in consult decision-making 13/14 “When attendings tell you to call, you do it… probably to cover your [self]… and for legal/liability reasons. They want to be sure and don't want to miss things, even if they know what's going on.” (INT 5)
“Liability is not what we're thinking about, but it's what senior people are thinking about. They want to cover their bases…” (INT 1)Cultural and incentive differences between institutions or departments 8/14 “We're also guilty in medicine—we need to communicate better. These different standards among specialties also create barriers and present missed educational opportunities…” (INT 3)
“[A]ll the educational pushes haven't addressed the fact that different departments have different cultures, so we need to be sensitive to that when working together.” (INT 4)
“All-department [interdepartmental] M&M meetings should occur when something bad happens… We need to talk with each other to make things move forward and so we can learn.” (INT 7)
“Turf wars are a major part of this—people do not see consults due to perceived boundaries of their specialties.” (INT 5)Workflow challenges 6/14 “[W]e get consulted for things that are not an inpatient problem. Leaving this unaddressed will not affect patient care and is not important now. It can be dealt with after discharge, but we delay discharge, order extra tests, and call consults.” (INT 2)
“I don't like the transfer to medicine service consults. It's not a medical consult but a management issue—it's about dumping patients.” (INT 5)Stress and workload 6/14 “Everyone is equally overworked and underpaid.” (INT 9)
“It's harder to provide optimal patient care and a great learning environment when there is a lack of reimbursement and payment for consults and such high workloads.” (INT 2)
“Some services are simply busier, so they will be more resistant.” (INT 1)
“Attendings would never reject consults, but residents and fellows would. Probably because we are not incentivized for workload. It all stems from aggravation from being overworked.” (INT 5)Theme Major subthemes Frequency Select quotes Technological solutions Leveraging the electronic medical record (EMR) 12/14 “It's hard to gather… who is the consulting physician—what if there was a line in Epic [EMR] that showed the multiple teams involved and the contact information for the consultant?” (INT 8)
“We need systematic protocols for consults… maybe putting it in writing, maybe even all in the EMR. These would prompt specific questions and enforce closure so you hear back on the plan.” (INT 5)Enhance how teams communicate through telecommunication and cell phone service improvement 5/14 “Some services don't respond and are hard to page. Sometimes, a person has the direct cell number of a surgeon, it makes a big difference.” (INT 8)
“There has to be a better way to relay information to each other than paging them… [it] is archaic and inefficient.” (INT 7)Educational solutions Enhance rotations on other services to emphasize interdisciplinary collaboration 9/14 “The calls after consults to explain the notes and recs provide an important avenue for education—what if we had the medicine rotators who are on neuro for a few weeks actually learn what information is helpful for both parties involved?” (INT 9)
“I know neurosurgeons spent a month with neuro—endless training of 7 years. But the attendings that did this saw the relationships between departments—less adversarial and more collegial… residents [should be] changing shoes for learning experiences. Colleagues do not have to be at odds with each other.” (INT 11)Administrative solutions Streamline workflows and protocols with regard to particular clinical scenarios 8/14 “We have 2 separate consults services for stroke and other consults—for other departments it seems so disjointed… Let's streamline consults within our own departments.” (INT 9)
“It's also confusing how there are so many different subservices, so this should be streamlined.” (INT 6)Attending-directed services for noneducational consults 3/14 “Pulm[onology] does non-teaching consults. The attending triages all and does [consults] him/herself if [they are] not educational.” (INT 9)
“Have a neurologist in the ER to triage and teach.” (INT 13)Frequency: number of participants who reflected corresponding subthemes, of the 14 participants who were interviewed.
Name Location Contribution Charles Sanky, MD, MPH Department of Emergency Medicine, and Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; and analysis or interpretation of data Caroline Gentile, MD Department of Neurology, University of Pennsylvania, Philadelphia Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; and analysis or interpretation of data Jennifer Ren, BA Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY Drafting/revision of the manuscript for content, including medical writing for content, and analysis or interpretation of data Eric Bortnick, MD Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; and study concept or design Stephen Krieger, MD Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; and analysis or interpretation of data
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