When to call consults for your patient

This is a big headache for hospitalists – when to call consults. I have seen crazy practices such as calling consults for every single issue the patient has, oh you have COPD and p/w SOB, let’s call pulmonary. But what is more common in the daily clinical practice is that the consults will tear you apart if they think you are calling unnecessary consults and if you somehow miss something and the consult will also come to tear you apart – why you didn’t call me earlier? Leave some safety margin and smell the smoke before it becomes a fire.

Now people think you should call consult only when it is necessary. Is it true? The judgment of when it is necessary solely depends on your understanding of the case and you are only a generalist and you may not even have the knowledge to tell when it is necessary. This fundamental paradox seemingly cannot be overcome and is the root cause of the conflicts between generalists and specialists – the best solution I have seen is to trigger a consult automatically when the case meets certain criteria and these criteria can be discussed beforehand with the specialists. Or you can curbside.

Curbside vs. Formal consult: do not trust a curbside consult fully – things can go wrong in many ways. The information you give to the consult might not be sufficient for him/her to make the best clinical judgment – the way you describe the case might not be right due to your own blindspot BECAUSE you are not as educated as the consult with the issue at hand.

Sometimes, the person you curbside might be only a fellow/PA/NP instead of the attending on the service, would you trust that clinical opinion? I would not. (I had a case with low baseline cortisol level and normal cosyntropin response and the endocrine fellow let the patient go).  Last but not least, if their name if not on the chart, they care less than when their name is on the chart. Some good ones may tell you hey this is s tricky case do you mind putting in a formal consult and I will see the patient later; but sometimes it just happens that everyone is busy.

Last caveat: if you feel like once you call a consult and they come to see your patient, your job is done, then you are totally wrong. Consults miss things all the time. There was one time I had a patient with bacteremia and asked ID consult where is the source (twice!) – he documented in the note that the patient had some IV a few weeks ago and likely has phlebitis. On the day of discharge, patient said he had neck pain and steroid injection to his neck a few days before he was admitted! Of course, I rushed him to the MRI for a scan.

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