Section 3: Perioperative Risk Assessment and Management

Role of the Medical Consultant

INTRODUCTION

Medical consultation has become an important component of Hospital Medicine. These consultations include preoperative evaluation, perioperative management, and medical care of patients on various nonmedical services. Previous surveys found that many primary care physicians and hospitalists felt inadequately trained in perioperative medicine, and as a result, this area received additional emphasis as part of the core competencies for Hospital Medicine. With the growth of the hospitalist movement, the role of the consultant has evolved from providing evaluation and advice to include comanagement of the patient in certain settings. The goal of this chapter is to review the role and responsibilities of the medical consultant, focusing on the principles of consultation and techniques to improve effectiveness.

GENERAL PRINCIPLES OF CONSULTATION

More than 25 years ago, Goldman and colleagues described the concepts for performing medical consultations. His “Ten Commandments” for effective consultation included the following:

1. Determine the question.

2. Establish urgency.

3. Look for yourself.

4. Be as brief as appropriate.

5. Be specific and concise.

6. Provide contingency plans.

7. Honor thy turf.

8. Teach with tact.

9. Talk is cheap and effective.

10. Follow-up.

These concepts, which incorporated many of the ethical principles described by the American Medical Association (AMA), are important and remain valid for the traditional consultation. However, some modifications are necessary to cover the new role of hospitalists as comanagers.

TYPES OF CONSULTATION

The traditional or standard medical consultation consisted of a formal request from the requesting physician to evaluate a patient and answer a specific question (Table 49-1). The consultant was expected to address the question and to provide advice and recommendations, but not to write orders or bring in other consultants; the requesting physician remained in control and responsible for the patient’s overall care and treatment. The consultant also focused on the specific problem rather than looking for and addressing other issues. Consultations were requested only when necessary and not for routine management. The follow-up period was usually brief and did not involve daily visits for the duration of hospitalization.

This traditional role of the consultant has been changing over the past 5 to 10 years. A survey by Salerno and colleagues revealed that many surgeons wanted the medical consultant to assume ...