Calling a consultant or admitting doctor may be very stressful. When they question your decision making it may make you feel dumb or inadequate. Most of the time there is a failure to communicate the case effectively and that leads to confusion or push back. Remember, you are the only one who has physically evaluated the patient and therefore you have the most clinical knowledge about this specific case. The consultant/admitting doctor on the phone has only evaluated the patient's electronic chart and this is NOT enough for a complete clinical encounter (otherwise all of medicine would be telemedicine and we would never need to see patients in person). It is your job to narrate a story and communicate your concerns using evidence-based medicine. In this lecture, we review tips to help make the process more comfortable and streamlined.
- Hello I have an admission/consult for a pt with <insert diagnosis> who needs to be admitted/consulted on based on <insert criteria>
- Give the patient’s name and medical record number
- Brief pertinent history
- Focused physical exam
- Pertinent labs
- Pertinent imaging
- Interventions performed
- Admission information
When starting the conversation, it is important to be clear why you are admitting to or consulting the doctor on the other end of the phone. Don’t make this ambiguous. Tell them the diagnosis and the criteria the patient meets for admission or consult. For example “ I have an admission for syncope that meets ACC/AHA criteria for admission.” “I have a consult for a CT confirmed appendicitis.” This is not like inpatient rounds where you are presenting the case from the beginning and slowly working your way to the diagnosis. You give the punch line upfront.
Be very precise when it comes to what you present in the history and physical exam. You want to emphasize pertinent positives and negatives only (you can skip irrelevant portions of the exam). For example, be sure to emphasize the wild cards that may be present (for more info on wild cards check out our lecture on the topic. Wild Card Lecture). If you are consulting ophthalmology for acute angle glaucoma, be sure to mention the visual acuity and the IOP when presenting the vital signs. You can omit the GU exam on this patient.
When you present the labs think about what labs are truly important. Surgeons will want to hear the white count, hemoglobin, platelets, and INR. An Infectious disease doctor will want to know culture results. You do not have to recite the results of every lab you ordered.
Be sure to emphasize the interventions you performed. You are not just triaging the patient. You helped turn an undifferentiated patient into a differentiated patient. You gathered all of the data, trimmed the fat, and provided the next doctor with a concise tightly packaged patient for them to manage. All the while, you actively resuscitated your patient and the hard work you have put into caring for the patient should be highlighted.
When I first started working in the ED I would write down my sign-outs. That way I could read my sign-out instead of trying to present from memory. This kept me organized and ensured that I did not miss important information. If I was interrupted I would know exactly where to resume my presentation. Side note: if you are getting repeatedly interrupted, it is ok to tell your consultant in a nice way “Hold on, let me finish my sign-out and then I’ll be happy to answer a few of questions at the end of my presentation.” Remember you do not have to answer every question as if you are being drilled in morning rounds. This is a handoff of patient care.
Finally, always take a second to think about what questions the admitting/consulting physician may ask BEFORE you call and be ready with an appropriate answer. At my hospital, the residents will often try to shuffle patients between the cardiology, gmed, and pcu services. Have an ironclad answer as to why the patient needs to be admitted to a particular service.
You are not trying to lie or dupe the other doctor into taking your patient. You are the only one who has seen the patient and you want to relay the data you gathered from the real world to a provider who only has electronic data. You have performed a full assessment and determined with the best of your ability that the patient needs an admission or consult. As long as you are able to express that information, you will should not have issues.
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