Why do consults “work” at private hospitals?
The order for consult is often placed by primary physician and called by either nurse or unit secretary. Sometimes primary physician will order the consult, but then communicate directly with consult attending physician to clarify reason for consult.
The consult attending physician is the first person to hear about the consult, improving efficiency.
The consult attending physician is held accountable for their consult. This sense of accountability occurs because the consult physician often relies on consult revenue to generate their income. Primary physicians have the choice of sub-specialty consult groups within the hospital and physicians within each group, thus it pays to perform well as a consultant. Consultants are often expected to place their own orders, coordinate further imaging / procedures, and communicate their recommendations to the patient and primary physician, thereby solidifying their responsibility for the patient as well as remaining competitive within the local marketplace. As a consultant, if you perform poorly, you will not be asked to see consults and your paycheck / reputation will suffer.
What is different about UAB?
UAB is a major academic center with multiple layers of attending physician “protection.” In order for residents and fellows to learn, they must be the first line of care; they accept and see consults before any attending physician hears about it. This allows attending physicians to remain detached from many of the duties expected of a consulting physician at a private hospital; this also creates a sense of detachment from the patient. In addition, their income / reputation / job security is not greatly affected by their performance as consultants. For service lines without designated consult teams, oftentimes the attending physician views consults as burdensome and time-consuming without significant reward or consequence for excellent or poor performance, respectively.
What is the issue?
As more-and-more sub-specialty service lines admit patients to general medicine as the primary service, the need for timely and high quality consulting services also increases. Primary physicians rely on consulting services to answer questions and perform procedures outside of their scope of training, thus are at the mercy of the consulting service. If consult attending physicians do not have a “stake in the game,” then they will be less inclined to “perform well.” This affects LOS, readmissions, and HCAHPS. In addition, longer LOS increases patient risks for complications, including HAI, deconditioning, pressure ulcers, etc.
What is the solution?
Change the consult process and culture at our institution. A sense of accountability must be instilled into consult attending physicians. This is no easy task and will likely require the combination of incentives and disciplinary action. All physicians involved in consulting services lines, no matter the value of their skill set, will be required to deliver high quality consulting recommendations (e.g. thorough recommendations communicated with patient and family) in a timely manner.
What are the means of accomplishing this?
Make quality consulting services a hospital-wide priority for 2017
Create consult-only service lines for the poorest performing subspecialty services, lead by proactive and responsible attending physicians; this is what has happened with the APP cardiology service.
Require that consulting teams see and write a note at least every 48 hours, unless they formally sign off (no more “following from a distance”)
Create a consult “rating system” (timeliness, thoroughness of recommendations, etc) with rewards and consequences that directly affect the attending physician of record
Develop a formal reporting system for any physician (resident, fellow, or attending) who attempts to inappropriately “block” a consult or is viewed as acting unprofessionally
Develop a reporting system for real-time issues (e.g. consult attending has not signed a note in 24 hours, etc)
I think we should list the anecdotal “worst offenders” and provide reasons. For example, orthopedics because their recommendations are often not updated with new information, plans for surgery are often not communicated with the primary team, attending physicians often do not see the patient or sign notes, etc.