division of hospital medicine perioperative medicine · a medical consultation is a deliberation...

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SESSION OUTLINE

A medical consultation is a deliberation between physicians regarding the diagnosis or management of a

particular patient

making consultation medicine an important aspect of the practice of internal medicine.

Because of busy schedules, the volume of consultations and the advances in communication technology,

the interaction has evolved from a meeting of physicians at the bedside to independent patient

interactions separated in time and space. Internists are often asked to assist surgeons in caring for

patients in the perioperative period (co-management) providing risk stratification, optimizing medical

conditions, and initiating interventions intended to reduce risk. Despite the considerable time spent in

performing consultations formal training in the art and science of consultation medicine has been felt to

be inadequate. Additionally, among the various functions traditionally performed by the consulting

internist (preoperative evaluations, postoperative care, coordination of care) demands of modern day

practice have called on the internist to acquire or refine new knowledge and skills. More options,

however, can lead to more opportunities to mishandle consultations, which can worsen outcomes, lead to

dissatisfaction for the patient and the referring physician, and place the consultant at medico legal risk.

Internists must therefore understand their roles and responsibilities when consulted and be able to

communicate effectively.

The overall goal of this session is to educate students and residents about the evolving role of the

medical consultant and to improve patient care by improving the consultant’s ability to communicate with

and understand the needs of referring physicians.

DIVISION OF HOSPITAL MEDICINE

PERIOPERATIVE MEDICINE

Principles of Medical Consultation

and Perioperative Care

INTRODUCTION

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PRINCIPLES OF MEDCIAL CONSULATION AND PERIOPERATIVE CARE

Author: E Gurza Date: 4/1/13

Learning objectives from GIM Core Curriculum: At the conclusion of this session the participant will be able to:

# 1 Know & apply the principles of an effective consultation process

# 2 Understand the norms of behavior in professional relationships specific to the role of the consultant

# 3 Know what constitutes a comprehensive preoperative assessment

# 4 Understand what separates comanagement from the standard consultation

#10 Demonstrate the incorporation of cost awareness principles into complex clinical scenarios

Objectives specific to this session: TEACHING METHODS ASSESSMENT METHIODS

1

Know the principles of effective consultation

Readings Case vignettes

Written exam

2

Compare the different responsibilities and expectations of the medical consultant when performing co-management or the traditional consultation

Readings Case vignettes

Written exam

3

Describe & employ the strategies to improve consult process and improve compliance with consultant recommendations

Readings Case vignettes Experiential

Written exam Multisource feedback Attending

4 Propose & employ methods that promote more effective communication through verbal discussion


Multisource feedback Attending eval

5 Model the accepted ideal consultation behaviors

Experiential Multisource feedback Attending eval

6 Identify the components of a complete perioperative evaluation

Readings Written exam

7 Demonstrate the ability to work effectively as team member

Role Model Experiential


8 Describe the general measures of clinical stability for safe care transitions

Readings Written exam

9 Demonstrate the ability to help coordinate the care of patients being managed by multiple services



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Integrate the principles of cost-effective care & resource allocation that does not compromise quality of care & is based on valid & reliable research


Chart review

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Routinely incorporate valid & reliable protocols/guidelines as appropriate to ensure consistent quality of care & reduce variability


Chart review

12 Understand the basic principles of reimbursement (coding) for the care of the consult patient

Readings

Chart review

LEARNING OUTCOMES

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This session describes the different roles that internists can perform as medical consultants and provides

strategies for improving the effectiveness of the consult process. It will also introduce the participant to

the knowledge and skills required to manage complex medical patients undergoing surgery.

1. Provide an overview the goals and objectives of the rotation 2. Teaching to the curruricuar milesestones that describe the principles of medical consultation

and perioperative medicine 3. Review of the evidence for how to improve the consultative proves 4. Review the norms of behavior that should govern the consultative process

TEACHING METHODS TIME DESCRIPTION OF CONTENT 15 min Written pretest (elective content) Self-study 60 min Readings General principles Types of consultation The process of consultation Optimizing the process

The preoperative assessment: What is wrong with “clearing” a patient for surgery?

Introduction 15 min Structure/Components/expectations of rotation Small groups 55 min Develop an understanding of what is

expected of a medical consultant by interactive review of case vignettes

The importance of consult medicine Expectations & responsibilities Strategies to improve the process

Methods for more effective communication Professional behavior of the consultant

Post test 5 min Session content

AGENDA & METHODS

SESSION CONTENT (Teaching outcomes)

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Small conference room

1. Description of Elective 2. Faculty materials

The assessment procedures are aligned with the competency-based learning objectives. At the completion of this session participants will be assessed by and receive formative feedback on data acquired form the following:

1. Faculty as well as other members of the health care team will provide competency-based assessment which includes direct observation of patient management and chart review

2. Written exam of core content Long-term outcomes from your session would you like to see measured?

1. Satisfaction 2.

Please provide at least 3 content questions which will be used for the end-of-rotation content exam

A 64 year old lady with longstanding diabetes mellitus and hypertension was admitted because of acute

decompensation of her longstanding systolic heart failure. The etiology of her heart failure was felt to be

hypertensive heart disease and that of the acute decompensation from dietary indiscretion and suboptimal

compliance with taking her medications. She responded well to intermittent does of IV furosemide with

improvement in her dyspnea, the noted JVD and disappearance of the S3. Because of a slight rise in the serum

creatinine, felt to be from overdiuresis, the heart failure service was consulted. Recommendations were left in

the medical record to initiate a furosemide drip. The following day when the fellow conveyed to the attending

that the drip had not as yet been started; the fellow was told to sign off.

You are asked to see a 73 year-old woman for a preoperative assessment before a cervical fusion. Her

electrocardiogram shows an old inferior myocardial infarction. You feel the patient is stable but you want to

LEARNER EVALUATION

HAND OUTS and ON-LINE INSTRUCTION MATERIALS

FACILITIES & EQUIPMENT

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contact the patient’s PCP and determine if there has been a cardiac history and if any evaluation has been

performed. When you come in the next day you find that the patient was taken for surgery.

For each of these cases briefly describe alternative behaviors that might improve the consult process.

Participants will evaluate the faculty and the clinical experience by means of: 1. the evaluation methods as established by SSOM and the Internal Medicine residency program 2.

1. Role of the Medical Consultant. Chapter 1. Steven L Cohn. Perioperative Medicine. Steven Cohn (ed). Springer 2011

2. Overview of the principles of medical consultation and perioperative medicine. Cohn S, Macpherson D. UpToDate (accessed 5/21/13)

Other sources: The Role of the Medical Consultant. Consultative & Perioperative Medicine essentials for

Hospitalists. http://www.shmconsults.com

The Role of the Medical Consultant Session outline_5-20-13

COURSE EVALUATION

READINGS

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CASE VIGNETTES

1. You have been formally consulted to assess cardiac risk for a patient with coronary artery disease undergoing elective spine surgery. After interviewing and examining the patient, you are concerned about the presence of a recently placed coronary stent. You recommend delaying surgery for several months. The surgeon disagrees with you and plans to proceed with the operation. In this situation, what is the MOST appropriate action for you to take?

A. Consult a cardiologist for a second opinion about the safety of the operation B. Write a consultation report that supports the surgeon’s plan to proceed with

surgery C. Withdraw from the case after discussing your opinion with the patient in the

presence of the surgeon D. Do not leave a consult report in the chart

2. You are co-managing a 59 year-old patient with diabetes on the general surgery service

who underwent a hemicolectomy. Upon chart review, you note a newly elevated creatinine of 4.1 mg/dL. The patient is receiving enalapril and metformin. In a comanagement model, which if the following actions is MOST appropriate:

A. Recommend to the surgeon to consult nephrology B. Order the discontinuation of the enalapril and metformin yourself C. Recommend to the surgeon that further tests be ordered to evaluate the elevated

creatinine D. Request permission from the surgeon to investigate this unexpected finding

3. You are asked to perform a traditional consultation a neurosurgical patient with a

postoperative fever. You intern wants to know the best way to get the surgeon to follow through with your recommendations. Which strategy is MOST likely to improve compliance by the consulting physician?

A. Page your recommendation to the surgeon B. Include multiple recommendations for diagnostic testing C. Withhold recommendations unrelated to the consultation question D. Perform the consult within 72 hours

4. You just performed a traditional consult on a 72 year-old woman on the orthopedic

service who complained of chest pain after her cervical spine fusion. Her electrocardiogram reveals possible new T-wave inversions in V1-V4. Although her symptoms are atypical, you think she should be ruled out for a myocardial infarction with serial enzymes. Which is the BEST next step?

A. Write your recommendations in the chart and see your next patient B. Page the physician in charge of her care to discuss each recommendation and

its urgency C. Send a text page to the physician extender for the orthopedic service that you

are consulting cardiology for them. D. Write orders in the chart to check cardiac enzymes and to place the patient on

telemetry.

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5. You are called to evaluate and help manage delirium in a 75-year-old man who underwent thoracic surgery 4 days ago. Another hospitalist in your group had previously seen him for a preoperative evaluation. You feel that the patient is stable and does not need pharmacologic treatment for delirium. When writing your consultation report, which of the following is MOST important?

A. Describe in detail the patient’s medical history which led up to the operation. B. List and discuss a complete differential diagnosis for the patient’s symptoms. C. Leave contingency recommendations for medical management if the patient

worsens. D. Leave no more than 5 recommendations.

6. A 64-year-old woman with end-stage renal disease and uncontrolled hypertension is

scheduled for the repair of a hip fracture. You are consulted for preoperative evaluation. The orthopedist also requested a nephrology consult. Which of the following communication strategies is MOST appropriate?

A. You should not confer with the other consultant on the case. B. You do not need to review data concerning the patient’s renal disease. C. You must keep abreast of the other consultant’s recommendations. D. You should communicate the nephrologists’ recommendations to the surgeon.

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FACULTY MATERIALS

The following is taken from the Society of Hospital Medicine’s Consultative & Periopertaive Medicine Essential for Hospitalists at shmconsults.com

Comments on Question 1

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Comments on question # 2

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division of hospital medicine perioperative medicine · a medical consultation is a deliberation...

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