Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, Professor of Emergency Medicine, The University of Arizona, Tucson, AZ
Introduction
Urgent care providers, as
much as or more than any
other specialist, must call
consultants to admit, refer,
appropriately treat, or obtain
follow-up for their patients.
At many urgent care centers,
physicians are also often on the
receiving end of calls from
providers.
Such physician-to-physician
communication, usually by
phone, can enhance patient
care but often takes an inordinate
amount of time and, if
done poorly, can undermine
collegial relationships.1-3 Advances
in communication technologies
have allowed some medical centers to show
some improvement in time management for non-urgent
consultations.4,5
Despite increased use of e-mail, instant messaging, fax,
web-based video conferencing, and radio systems for
communication in daily life, the telephone remains
the primary medium. Effective telephone consultations
with other physicians reflect on the urgent care
providers, their group, and their
center’s professionalism. More
importantly, they can facilitate
timely and efficacious patient
management. Poor physicianto-
physician telephone communications,
on the other hand,
may lead to inappropriate
responses from consultants, as
well as the urgent care provider
garnering the consultant’s distrust,
a poor professional reputation,
and difficulty obtaining
such consultations in the future.
At a time when many specialty
consultants and other primary
care providers are often
unwilling to see urgent care
patients, unprofessional telephone communication may damage the image physicians want to project. On the other hand, good interactions often lead to professional collegiality, the ability to shorten such interactions based on mutual confidence and respect, and a more efficient working environment—all of which benefit the patient.
With “interpersonal communications” being a core competency of graduate medical education, a simple
method to help teach this important skill would be
beneficial.
This paper describes such a model, specifying what to do
before the call is made, what to say during the call to conserve
time and to get the desired response, and the four
possible actions the caller could want from the consultant:
to see the patient, to admit the patient, to discuss aspects
of the case and to provide insight, and to see the patient in
follow-up. Two cases are used to illustrate suboptimal
and elegant physician-physician telephone consultations.
Educational Mandate
The Association of American Medical Colleges maintains
that a basic goal of medical education is to “develop a
base of skills and strategies for working with physician
colleagues and other members of the healthcare team.”6
Similarly, the Accreditation Council for Graduate Medical
Education (ACGME) recognizes the importance of
interprofessional communication, making it one of their
General Requirements applicable to residency programs
in all specialties. The requirement states: “The residency
program must ensure that its residents by the time they
graduate can develop appropriate interpersonal relationships
and communicate effectively with patients,
their patients’ families and professional colleagues.”7
This is similar to the ACGMR core competency task,
“interpersonal and communication skills,” to be adapted
to all residency programs.8 Emergency medicine academics
have recognized that “communicating with
members of the healthcare team is crucial for the emergency
physician” and intersects at many points with the
“Model of Clinical Practice of Emergency Medicine.”9,10
Studies have demonstrated that the great potential for
communication breakdown between practitioners can
have deleterious effects on patient care. Poor communication
may be due to lack of formal training, poor communication
skills, and time constraints.11-15
While some educational models have been used for
physician-patient telephone interactions, no formal
model has been adopted for consultations between urgent
care providers and consultants—a critical and common
part of our professional lives.16 Medical students and residents
learn telephone techniques from observation; this,
unfortunately, leaves a lot to be desired. The following
real-life cases illustrate, first, a typical negative encounter
and, second, the most elegant of telephone encounters.
Case 1
The senior medical student calls the pediatric surgeon
at 6 p.m. regarding a 9-year-old girl who probably
has appendicitis.
Med student: “I have a 9-year-old girl with abdominal
pain. She’s not pregnant, has a normal urinalysis, and is
on no meds….”
Surgeon: “Who is this???”
Med student: “I am Max Tern, a fourth-year student on
rotation at Sunrise Urgent Care. My patient lives with
her parents, has no allergies….”
Surgeon: “What do you want???”
Med student: “My patient has abdominal pain and
we’d like you to see her.”
Surgeon: “Does she have an acute abdomen? Has she
had any imaging? What are her labs?”
Med student: “Um, I’ll have to check.”
Surgeon: [Click.]
The surgeon then angrily calls the attending physician.
Case 2
The urgent care physician calls the cardiologist at 10
p.m. regarding a 70-year-old man with aortic stenosis
and true syncope.
Urgent care physician: “Bob, this is Jim at Sunrise
Urgent Care. I have a 70-year-old man with severe aortic
stenosis and true syncope. He’s stable now, normal
ECG, and has an IV and is on a monitor. The ambulance
should be here shortly.”
Cardiologist: “OK, can you fax the information to
admissions? I’ll arrange a CCU bed and, if nothing
unusual turns up, I’ll probably cath him in the morning.”
An Educational Model
The following method is similar to one that most experienced
physicians use naturally. In the format below, it
can be easily taught and learned by telephone-consultation
novices working in urgent care centers. It could also
be used to teach physicians whose practice will involve
calling into urgent care centers or to other consultants
with referrals or for advice.
To derive the most educational value from this
method, implement it just before a trainee makes such
a call or just after the preceptor listens to a telephone
consultation from a resident, student, or new primary
provider that fails in one or more of the key elements.
Using the model within moments of the less-than-optimal
phone interaction reinforces the learning process.
Before the Call
A. Know what you want from the consultant; i.e., why are
you calling? There are only four varieties of this
request (Table 1).
B. Know what you are going to say. If necessary, write
down the key points.
C. Have the chart, vital signs, and completed diagnostic
results available, since you may not remember all
the details.
During the Call
A. Be direct and concise. Writing down the points helps
beginners do this.
B. Speak clearly. Consciously slow your speech if you
are anxious or have an unfamiliar accent. (Do not get
annoyed if you have to repeat yourself.)
C. Start by saying the 3 “W”s:
1. Who you are.
2. Where you are calling from.
3. What you want (in a simple declarative statement).
This is the most important part of the call and, especially
when the consultant is involved in other activities
or is asleep, indicates the level of alertness they need
to handle your call. The options are described below.
D. Answer any questions—if you actually know the answer.
Don’t guess if you don’t know, even if you’re asked for
information that you should have obtained, but didn’t.
E. Be certain, in the end, to get an answer from the consultant
that addresses the reason you called. Responses
from the consultants might include:
1. They will admit the patient. Be certain to ask who
will contact the admitting office and whether the
consultant, a resident, a hospitalist, or someone else
will write the admitting orders. If the patient may
need surgery, ask if they should be kept “NPO.”
2. They will see the patient, either immediately or
at a specified time. If the time course seems too long
for the patient’s condition, explain that and try
to negotiate a more timely appointment.
3. The case you are describing is outside their area of
expertise. If they don’t make it clear, you should ask
who they think you should contact.
4. They are not on call. Hopefully, they can direct you
to the person who is on call for their group or
that specialty. (Of course, sometimes they actually
are on call, but misread the schedule. In those
cases, you will simply must call them again.)
5. They will not see the patient for any of a number of
reasons—insurance, too busy, etc. Often, these
patients must be referred to an emergency department
that has these specialists on call and available.
After the Call
A. Record whom you talked with, as well as the time
and date. If you must
call a number of consultants,
which is common
when referring to some
specialties, list them all.
B. List the consultant's recommendations:
appointment
place and time or place
and mode of transfer, as
well as anything the consultant
suggested be
done, such as imaging,
laboratory testing, or
clinical interventions.
Given a succinct and
meaningful interaction, the
consultant may simply (1)
say that they will see the
patient in their office
immediately, (2) accept the patient as an admission or say
that they will evaluate the patient in the local hospital
ED, (3) suggest the best course of action or further specific
evaluation so they can recommend the next step, or (4)
either accept the patient as a referral to their clinic or tell
you why they cannot accept the patient and suggest a
more appropriate referral.
Make a list of what the consultant wants done to
prepare the patient for a procedure, admission, or further
evaluation. Especially if you are requesting a STAT intervention,
try to expedite the requested diagnostic tests,
medication administrations, or procedures by calling
ahead or by sending along the appropriate lab work.
One caveat when calling a teaching institution: If the
consultant asks for every lab test to be back and every
piece of unnecessary historical information to be gathered,
e.g., "standing stool velocity," before he or she will see the
patient, you know that you are probably dealing with a
junior resident who lacks knowledge and confidence. If
the situation is urgent, simply call their attending. If
not, live with it. Even in private practice, you occasionally
run into this sort of physician.
Discussion
It takes time to develop the rapport necessary for the
shorthand conversation portrayed in Case 2. However,
using the basic telephone etiquette for urgent care
provider-consultant interactions (including consulting
with emergency physicians) would have avoided the disastrous
results described in Case 1. Consultants say that
their trust in a specific caller helps them determine the
validity of the information
being given and that "junior
practitioners may benefit
from training in telephone
consultations or
from guidelines to make
the process less haphazard."
17
The method for telephone
interactions with
consultants as described
above parallels in many
respects "contextual" clinical
case presentations, i.e.,
"a flexible means of communication
and a method
for constructing the details
of a case into a diagnostic
or therapeutic plan."18
This educational model, whether posted as a reminder
near the telephones, put on pocket cards or into an
electronic file for reference, or taught didactically, is
simple to incorporate and leads to our ultimate goal: elegant
medical practice and excellent patient care.
References
1. Chatterjee A, Lackey SJ. Prospective study of telephone consultation and communication
in pediatric infectious diseases. Pediatr Infect Dis J. 2001;20(10):968-972.
2. Cotton MF. Telephone calls to an infectious diseases fellow. Pediatrics. 1995 May;95(5):753-754.
3. Smego RA, Khakoo RA, Burnside CA, et al. The benefits of telphone-access medical consultation.
J Rural Health. 1993;9(3):240-245.
4. Abbott KC, Mann S, DeWitt D, et al. Physician-to-physician consultation via electronic mail:
the Walter Reed Army Medical Center Ask a Doc system. Mil Med. 2002;167(3):200-204.
5. Rushakoff RJ, Woeber KA. Evaluation of a "formal" endocrinology curbside consult service:
advice by means of internet, fax, and telephone. Endocr Pract. 2003;9(2):124-127.
6. Association of American Medical Colleges: Contemporary Issues in Medicine: Communication
in Medicine.Washington, DC:AAMC, p 17, 1999.
7. Accreditation Council for Graduate Medical Education: General Requirements: 3.E.3 Interpersonal
skills and communication. http://www.acgme.org/RRC_PreDocs/Quad101400.pdf
.
8. Website: http://www.acgme.org.
9. Chapman DM, Hayden S, Sanders AB, et al. Integrating the Accreditation Council for Graduate
Medical Education Core competencies into the model of the clinical practice of emergency
medicine. Ann Emerg Med. 2004 Jun;43(6):756-769.
10. Hockberger RS, Binder LS, Graber MA, et al. The model of the clinical practice of emergency
medicine. Ann Emerg Med. 2001;37:745-770.
11. Williams PT, Peet G. Differences in the value of clinical information: Referring physicians
versus consulting specialists. J Amer Board Fam Prac. 1994;7:292-302.
12. Lee T, Pappius E, Goldman L. Impact of inter-physician communication on the effectiveness
of medical consultations. Am J Med. 1983;74:106-112.
13. Bourguet C, Gilchrist V, McCord G. The consultation and referral process. A report from
NEON. J Fam Prac. 1998;46:47-53.
14. Epstein R. Communication between primary care physicians and consultants. Arch
Fam Med. 1995;4:403-409.
15. Saunders T. Consultation-referral among physicians: Practice and process. J Fam Prac.
1978;6:123-128.
16. Larsen J-H, Risor O. Telephone consultations at the emergency service, Copenhagen County:
analysis of doctor-patient communication patterns. Fam Prac. 1997; 14(5):387-393.
17. Hollins J, Veitch C, Hays R. Interpractitioner communication: telephone consultations
between rural general practitioners and specialists. Aust J Rural Health. 2000; 8:227-231.
18. Haber RJ, Lingard LA. Learning oral presentation skills: a rhetorical analysis with pedagogical
and professional implications. J Gen Intern Med. 2001 May;16(5): 308-314.
