Table 5

Factors Influencing Appropriateness of a Consult and Select Quotes

ThemeMajor subthemesFrequencyQuotations
Educational factorsLack of insight into other specialties, especially outside of medicine8/14“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 training6/14“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 year4/14“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 factorsGood consults must have a specific question14/14“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 opportunity13/14“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-up6/14“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 consult6/7 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 factorsAbility to manage a case7/14“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 case5/14“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 factorsAttendings consider liability and covering yourself legally in consult decision-making13/14“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 departments8/14“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 challenges6/14“[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 workload6/14“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)