For emergency physicians, consultations are an integral part of our specialty. Whether to provide hospitalization, provide assistance with challenging procedures, obtain follow-up appointments, or provide specialty-specific opinions, consultants are involved in 20 percent to 60 percent of all emergency department visits—and that number is growing annually.^1,2 Surprisingly, formal training during emergency medicine residency to communicate with consultants is varied and can be sparse. As a result, poor communication occurs in 14 percent to 24 percent of inpatient consultations and leads to increased cost to patients and health systems, decreased patient experience of care, and suboptimal patient care.^3,4

There is recognition and an effort in the medical community to ameliorate the situation through effective communication.^5,6 However, there are still difficulties with consultants that may not be addressed easily by these systems. An audit of a London hospital identified “personality clashes” as key causes of conflict during consultation.⁷ Conversely, establishing a personal relationship with a consultant is found to mitigate conflict.⁸

The focus of this article is twofold. First, general etiquette is the cornerstone of a great relationship and can set the stage for a fruitful discussion with a consultant. Second, while there may always be difficult consultants, it is wise for emergency physicians to communicate in a way to not only advocate for their patients but to actively promote healthy working relationships.⁵ These strategies detailed in Dale Carnegie’s 1936 classic, How to Win Friends and Influence People, will provide the framework for the following discussion.⁹

Mind Your Manners

Don’t criticize or complain but understand first. It is often easy to find fault in consultants when they are slow to see the patient or ask for an add-on test prior to a bedside evaluation. Before jumping to conclusions, it is important to understand the consultants’ viewpoint. There may be legitimate or unforeseen reasons for their delays or actions that are beyond their control or are in the best interest of the patient. For example, a consultant could be determining what suture, split, scope, or other materials to bring based on that additional workup. Upon further understanding, materials could be made readily available in the emergency department. Complaining and criticizing before understanding destroys the possibility of working together.

Give honest and sincere appreciation. Consultants provide follow-up to patients, assist (as needed) with ED procedures, provide longitudinal care in the hospital, and offer specialty opinions. Saying “Thank you” or “I appreciate it” demonstrates a respect and appreciation for their work and dedication to patients. This is not intended to flatter consultants but to show genuine gratitude. There are also other subtle ways to show appreciation. For example, following up with an general surgery consultant about the outcome of an operation for an ED patient shows recognition of the craft. If a patient’s primary care physician has already provided a thorough outpatient work-up for a chronic complaint, mention it. This effort makes care delivery more efficient and effective.

Try to greet consultants. The emergency department is familiar to its emergency medicine staff but not necessarily to consultants. The emergency department provides access to equipment, supplies, and personnel. Emergency physicians should see themselves as hosts and see consultants as guests. For guests, a quick welcome or introduction can go a long way. Making an effort to meet your consultants when they arrive or leave the emergency department can foster a good relationship for future consultations and mitigate potential conflict.^8,10 Imagine yourself visiting the medical floors for assistance with a difficult intubation without anyone to help orientate you to where the patient is or what equipment/personnel are available.

Talk in terms of the consultant’s language. Every specialty, by nature, has its focus and medical terminology. Honing an understanding of the consultants’ specialty can facilitate strong communication. When discussing an eye complaint, visual acuity, pupillary size, and intraocular pressures are the vital signs of ophthalmology. Obstetricians start conversations in terms of Gs (gravida), Ps (parity), and LMPs (last menstrual period). Engaging consultants on their terms helps both you and the consultants provide timely and coordinated efforts for the patient.

The Difficult Consultant

Begin friendly. Some consultants have a reputation for being more difficult. Regardless of a consultant’s initial demeanor or any previous encounters, every conversation should begin with a welcoming tone. It will help set a stage for a solution that makes everyone is happy and can help “disarm” the most disgruntled of souls.

Avoid arguments, if possible. Arguing may yield a quick win for an admission, but it will never win a consultant’s good will. The next time that consultant is called, there will be further difficulty. Remember that every consultation is about two relationships: the relationship you have with the patient and the one you have with the consultant. The patient should always come first, but our relationships with consultants often outlast those we have with our patients. Providers don’t have to agree on every aspect of a patient’s care, but by demonstrating professional conduct, you can foster the same in others.

Dramatize the presentation. Showmanship is a skill worth practicing to help better sell your thoughts. To convince a consultant to come evaluate a patient, focus on the more serious details of the patient’s case. If the patient has significant labs or imaging abnormalities that may be of interest to your consultant, stress those points. If the patient physically looks unwell but that is otherwise not reflected in the diagnostic evaluation, describe the patient. For example, in a previously healthy patient with pneumonia, you could say, “The patient presented diaphoretic, febrile with bouts of severe rigors, needing the assistance of two staff members just to help her walk into the emergency department.”

Appeal to the higher motive. As health care providers, we have an extrinsic responsibility to provide care, as outlined in hospital bylaws and contracts. However, an often more powerful incentive to see a patient is the intrinsic responsibility felt by most physicians to help others. A tactful reminder to the consultant of the goal to care for the patient can be useful. For example, say, “I know it’s late at night, but this patient has a need for your expertise.”

Be mindful of the consultant’s schedule. On-call schedules can be useful in some mindful planning of when to call for consultation. Calling consultants before they leave the hospital or waiting for a short time until consultants are in the hospital (without detriment to the patient) and mentioning this courtesy helps.

If all fails, challenge your consultant. For the most part, successful people respond to competition and will work to surmount a challenge when given. Appealing to one’s intellectual curiosity can be useful. A few examples that appeal to this side of consultants might be, “This is an interesting case that will need a keen doctor to work him up more,” or, “I think there’s something potentially serious going on with this patient, and I just can’t pinpoint what it is.”

Conclusions

Conflict with consultants is inevitable. However, there are factors that we can control to help mitigate or prevent negative interactions. Cognizance of our demeanor and perspective without jumping to hasty conclusions can help begin a cooperative discussion. Fostering relationships with our consultants builds a foundation of trust. Finally, employing specific strategies to deal with difficult consultants may be necessary. However, it is important to remember that we are not motivated by pride to “get what we want” but by the overarching goal of providing the best care for our patients together.

Disclaimer: The views expressed are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense or the US Government.

References

1. Sanders JL, Raja AS, Hasegawa K, et al. Decline in consultant availability in Massachusetts emergency departments: 2005 to 2014. Ann Emerg Med. 2016;68(4):461-466.
2. On-call specialist coverage in US emergency department: ACEP Survey of emergency department directors. American College of Emergency Physicians; 2006. American College of Emergency Physicians website. Available at: acep.org/content.aspx?id=36752. Accessed Sept. 11, 2017.
3. Lee RS, Woods R, Bullard M, et al. Consultations in the emergency department: a systematic review of the literature. Emerg Med J. 2008;25(1):4-9.
4. Chan T, Sabir K, Sanhan S, et al. Understanding the impact of residents’ interpersonal relationships during emergency department referrals and consultation. J Grad Med Educ. 2013;5(4):576-581.
5. Salerno SM, Hurst FP, Halvorson S, et al. Principles of effective consultation: an update for the 21^st-century consultant. Arch Intern Med. 2007;167(3):271-275.
6. Kessler CS, Tadisina KK, Saks M, et al. The 5Cs of consultation: training medical students to communicate effectively in the emergency department. J Emerg Med. 2015;49(5):713-721.
7. Reid C, Moorthy C, Forshaw K. Referral patterns: an audit into referral practice among doctor in emergency medicine. Emerg Med J. 2005;22(5):355-358.
8. Chan T, Bakewell F, Orlich D, et al. Conflict prevention, conflict mitigation, and manifestations of conflict during emergency department consultations. Acad Emerg Med. 2014;21(3):308-313.
9. Carnegie D. How to Win Friends and Influence People. New York: Simon and Schuster; 1981.
10. Kessler C, Asrow A, Beach C, et al. The taxonomy of emergency department consultations—results of an expert consensus panel. Ann Emerg Med. 2013;61(2):161-166.

Dr. Koo is a PGY-3 resident at the Madigan Army Medical Center emergency medicine residency program in Tacoma, Washington, and a captain in the United States Army.

Dr. Bothwell is faculty in the Madigan Army Medical Center emergency medicine residency program in Tacoma, Washington, and a lieutenant colonel in the United States Army.