Consult Rejections as a Teaching Tool

An open letter to Consult-Liaison service heads on the importance of teaching residents how to reject consults responsibly

A page from the ED comes in. “32 y/o male, history of schizoaffective disorder, can you come see him?” I go down, ask the consulting provider what the question is. “Oh, he got into an argument with his payee, I think social work probably needs to see him in the morning.” Yeah, I ask, but what’s the psychiatric question? “Uh, well he has a history of schizoaffective disorder…” he trails off, and stares at me blankly. I inquire, did he make any threats? “No.” Did he say that he would hurt himself? “No.” So, what’s the question? “Uh, well he has a history of schizoaffective disorder…” The blank stare is back and has somehow found its way on to my face as well. Knowing I cannot refuse — I am a resident, and this is the rule of my service — I mumble that I’ll see the patient. He is sitting on the gurney, reading a book, and writing things down on a notepad. He says he got into an argument with his SSDI payee and wants to change it to someone else. He has no acute psychiatric symptoms and does not make any comments about wanting to harm himself or his payee. I also think he just needs to see social work in the morning.

An hour later I am greeted with another page from the ED. “Can you please reevaluate the patient in room 11?” (Our ED psych team team initially said that we thought his suicidal comments were for secondary gain and provided him with shelter resources.) My question: Has something changed, do you have new information? “No, he’s still saying the same things, we just want you to double check.” I see the patient. Nothing has changed. He is, indeed, still saying the same things. Shockingly, we recommend the same things.

These are typical for consults in our hospital, where we are never allowed to refuse a consult or a reevaluation. The best we can do is try and make it clear that we think this is inappropriate and hope that they feel a little embarrassed about themselves and withdraw the consult on their own. This is bad for patients, bad for residents (consultant and consulting service alike), and bad for the medical system as a whole.

I want to be clear that I am not arguing for a CL service that scrutinizes every consult for a reason to reject it, say like a zealous member of a zoning board in San Francisco looking for an excuse to deny a building permit for… literally anything. Medicine is complicated; we must remember that answers to questions that seem obvious to us from inside the bubble of our specialty may not be so clear from the outside, and our job as consultants is (to a degree!) to educate and assist our colleagues when they are uncertain about the proper course of action.

What, exactly, is the point of a consult?

I think it can be separated into two things, both in the furtherance of patient care. First, it is to bring to bear the expertise of the consultant team on a specific problem outside of their area of expertise and issue a recommendation about how to manage that problem. Second, it is to provide education to the consulting team about the basics of our specialty. This helps the primary team avoid easy mistakes (e.g. giving benzos to an agitated, delirious patient), develop their ability to manage straightforward situations without needing to request a consult (e.g. determining capacity¹ in a cognitively intact patient), and understand what is outside of a consultant’s purview.

It is worth pointing out some things that I think consults should not be used for: to save the primary team time², as an attempt to diffuse liability, to appease a patient or family member even without a consult question, to avoid having uncomfortable conversations with patients… the list goes on. These are all things that may be a secondary result of an appropriate consult, but they should never be the primary reason for a consult.

Ok, now that we have defined the contours of the argument, let’s talk about why consult services (and the residents that run them) need to be able to reject consults. Ultimately, these all come down to using rejections as a tool to set boundaries³.

The Rejection as An Educational Tool

Imagine you are a student who has been returned an exam with a failing grade, without any indication of what answers were wrong or why. Not only is this a nearly useless piece of feedback, it seems designed to belittle the student. However, when that test is returned with markup by the professor and office hours held afterwards, the test is transformed into a useful educational tool. It is worth recognizing that, together, the grade (i.e. the consequence) and the feedback augment one another, and that either alone would deprive the exam of its usefulness.

At first, rejecting a consult seems much like an exam without any markup, especially when the fundamental message is, essentially, “Figure it out yourself.” However, when delivered with an explanation of our reasoning (i.e. feedback), it becomes akin to our ideal exam above. As psychiatrists our job has always included learning how to deliver challenging messages to others in a constructive way – this is no different.

If we accept that rejections can be used a way to convey messages to the primary team, we must also acknowledge that the acceptance of a consult also conveys a message. Consider the schizoaffective patient I was asked to see above. What messages did I send in my agreement to see that patient? Here are some that come to mind:

1.     A patient having a history of a psychiatric condition is sufficient reason to issue a consult, even in the absence of a clear clinical request.

2.     Patients with schizoaffective disorder are, by their very nature, dangerous even without any signs of paranoia, anger, agitation, or verbalized intent to harm another.

- AND -

3.     Psychiatrists are uniquely able to determine the level of this danger.

There are others, but you get the point.

The first time this happens, it might not be so bad. We see the patient anyway, but gently educate the consulting provider that this is something that they can handle on their own. We feel like we helped to educate, and the primary team feels a little bit less anxious. The trouble comes when those consults continue despite education, because we become complicit in undermining our own teaching! Thus, primary teams become unsure about:

1.     What they can manage on their own

2.     The contours of our expertise (e.g. the line between psychiatry and neurology)

3.     What we are able to offer a patient (e.g. the line between psych and social work)

4.     What information they need to have obtained to determine whether or not a consult is warranted.

Without the tool of rejection, there is no incentive for primary teams to learn the answers to any of these questions, because there are no consequences for an inappropriate consult. Of course, there are individuals who will try to learn the answers to these questions regardless of whether we reject consults, but they are not spared the confusing signaling either.

The Rejection as Part of Resident Education

Rejections, if trainees are taught to treat use them carefully, are a powerful tool for teaching residents. Discussing a possible rejection allows attendings to teach residents:

1.     The limits of the CL service’s expertise. i.e. what questions they can and cannot answer.

2.     What information the primary team vs. the consulting service is responsible for obtaining.

3.     How to ask probing questions of a primary team to clarify ambiguous questions.

4.     What a primary team can safely manage on their own, and when our expertise is necessary even if the primary team does not recognize that in the moment.

Without the ability to reject a consult, the average trainee’s desire to learn these things is severely attenuated. Why learn what information the primary team is responsible for if you end up collecting it yourself because you cannot enforce those requirements? Why learn what a primary team should be able to manage alone if you’re going to manage it anyway? Furthermore, a service head’s insistence that all consults are seen sends mixed messages to trainees in the same way it does to the primary team – when everything needs to be seen it becomes more difficult to identify the mundane from the critical.

Training programs have an obligation to teach residents the tools available to an attending level physician. Rejections are part of that toolbox. Service heads need to acknowledge that - regardless of their personal attitude towards rejections – residents deserve to learn how to learn how to wield them in a responsible manner. To not do so runs the risk of producing physicians who will leave training and put patients and themselves at risk by using rejections to ignore legitimate consults and failing to recognize when it is critical that they become involved in care.

The Rejection as Training in Professional Development and Communication

Another practical aspect of rejecting consults is that it is an exercise in establishing professional boundaries. Learning how to set boundaries with our peers is an essential skill to ensure that we maintain a sustainable professional life post-residency and is a skill that should be taught and developed in residency training. Residents must learn to understand what their responsibilities are and where they end, lest they develop a distorted, unrealistic sense that they are ultimately responsible (and the only ones capable of managing!) every aspect of every patient they see.

Not rejecting consults teaches the opposite. It suggests that there are no professional boundaries that others need to respect. That the consultant is ultimately responsible for the failings of other services or the administration. That our input is so essential in every situation that it would be irresponsible for us to not share our wisdom. Ask yourself, what sort of opinion of other services does this foster? Certainly not one of competence. What opinion of the consultant in their own eyes? Certainly not one of humility.

The Rejection as Resource Stewardship

I think, somewhere in our ACGME training requirements, there’s something about teaching residents to consider the costs of treatment, so let’s talk about the costs of a consult. The most obvious one is the monetary cost of a consult, though there is an obvious counterargument that the expertise offered may reduce other costs (e.g. length of stay). I admit to not being familiar with the literature (if there is any) on this topic, but I do not think it would be controversial to hypothesize that seeing every consult is not particularly cost-effective. This is especially true for time-sensitive settings, such as emergency departments, where a consult can easily add an additional 2-3 hours of wait time to a discharge.

Indeed, this is probably the cost that we should scrutinize the most because we stand the benefit the most from ignoring it, while the patient and the rest of society (who subsidize healthcare costs either through public or private insurance) pay for it.

Time is another significant cost – even the most straightforward consult takes time to do properly. Speaking to the consulting team, reviewing the chart, speaking to the patient, thinking about a plan, writing the note, staffing the patient, relaying the recommendations to the primary team, and then follow up visits and notes if needed. For a busy service, every consult represents time taken away from other patients, some of whom could genuinely use the extra time devoted to reading their charts, reviewing the literature, or discussing the case with a colleague.

In Closing, Please Teach Your Residents How to Properly Reject Consults

That’s all, really.

---

Epilogue

I wrote this essay when I was in the midst of my 2nd year of training, on the heels of many very silly consults from the ED that woke me up at 3am when I was on-call and a lot of very silly capacity consults while I was on my C/L rotation. I wrote it in an attempt to convince my service chief to change the department policy. It didn’t work, for those of you wondering, but it did result in a very interesting conversation between the two of us that made me more sympathetic to her point of view.⁴

I still think I’m right though.

I was going to publish this as I originally wrote it, but I just finished my first two days of moonlighting covering an inpatient unit plus a C/L and ED consult service and I think I gained some additional perspective that augments the original piece.

It’s important that I mention that I am paid per consult, since I’m sure that this bears on my decision making. New consults are paid significantly more than follow-up consults (2.25x more), but follow-ups are generally much faster (e.g. 1-2h vs. 15-30 minutes).

Bad Consults Were Less Annoying Than Expected

To a large degree, I think this is because of the learned helplessness I have developed as a resident. I used to get myself really worked-up about inappropriate consults, and would try to be just confrontational enough with the consulting service in the hopes that they would feel badly enough about their decision that they would cancel it or maybe would be a little bit better in the future. This seemed to exclusively result in me spending more time awake in the middle of the night going back-and-forth with the ED prior to seeing the consult, and then an additional 30-45 minutes trying to fall asleep while dealing with my sympathetic nervous system’s unreasonably strong reaction to interpersonal conflict. Now I just go, see the patient, jokingly⁵ give the ED a hard time about some of the more ridiculous cases, and get back to sleep. Oddly, this seems to actually make the ED feel badly about silly consults⁶, though I can’t say that has translated into fewer of them.

Obviously, knowing that you are going to get paid to see a consult, no matter how dumb, takes away some of the sting. I find it really distasteful that this factors into the equation for me (I think it should matter approximately 0%) and I am going to try and pay more attention to it.

Rejections Outside of an Academic Environment Serve Different Purposes

Taking residents out of the equation I think focuses the reasons for rejecting a consult down to two personal concerns - protecting your time and avoiding unnecessary liability - in addition to the systemic resource stewardship

Avoiding unnecessary liability is basically just saying “uh, this isn’t my job.” In my experience, psychiatrists run into this the most with consults for capacity in which the primary team hasn’t actually assessed capacity themselves, but hey you know grandpa seemed a little disoriented when we went to do the consent and psychiatrists can adequately explain the risks/benefits of this hip arthroplasty as well as the risks/benefits of the alternatives, right? Definitely no liability there, no sir.

In terms of protecting your time, there’s always just a little more you can do for any given consult. Additional history to collect, another call to collateral, more time spent on making documentation clear, etc. etc. In theory, this stuff is marginal, but sometimes that second collateral call gives you a ton of information that totally changes your management.

In this sense, protecting your time dovetails with avoiding unnecessary liability. The more time you can spend on consults that legitimately require your expertise, the better you can argue that you did what was reasonably expected of you in caring for the patient if shit does hit the fan.

Unfortunately, that weekend has left me a bit cynical (prematurely, I admit) about the educational utility of rejections outside of a teaching hospital. There just doesn’t seem to be the same amount of interest from the doctors I worked with in expanding their knowledge. One didn’t seem to understand that being alert and oriented was not the same thing as having capacity - despite a few attempts to explain that there is more than that. Another IM doc, who I consulted to evaluate a patient for ear pain, told me “I don’t look at ears, I just let ENT do that. I’ll just order some Augmentin.”

This might also just be me still feeling like a trainee who “shouldn’t” be in the business of trying educate attending-level physicians. I hope I feel different about this with time.

1. For the non-physician readers (assuming any of you are left). Capacity is a determination as to whether or not an individual is able to make a particular decision about their medical care. There are lots of ways to conceptualize it (see: Appelbaum & Grisso). I break it down like this:

1. Does the patient have an understanding of their present situation? (e.g. that they have a kidney infection)
2. Does the patient understand the intervention/treatment that is being proposed, and the risks/benefits of that treatment? (e.g. that we would like to treat with antibiotics which may cause particular side-effects)
3. Does the patient understand the alternatives to the proposed intervention/treatment (including no treatment) and the risks/benefits of the alternatives? (e.g. that other treatments may be less effective, increasing their risk for more serious complications, etc.)
4. Can the patient give a reasoned explanation about why they chose one option over another? (e.g. They choose no treatment, but can explain that it is because they do not wish to undergo a painful and risky surgery)
5. Are they consistent about this decision over time? (note: this doesn’t always apply)

2. After having rotated through medicine and the ED and seeing how overworked and time-crunched services can get, I think this is the one where I could grant some leeway. Sometimes, a service is so full of acute patients and situations that need to be addressed right now, that the primary team just doesn’t have enough time to do a good job addressing problems that are important but not critical. As long as the primary team makes it clear that this is the case, and doesn’t try and use this as an excuse for everything, I think it’s fine.

3. And psychiatrists love boundaries, let me tell you. Need to keep one occupied at a dinner party? Ask ‘em about boundaries.

4. I have been informed by some of my juniors that this has, in-fact, changed. Credit where credit is due.

5. …mostly

6. I get way more comments from the PAs like, “sorry, I tried not to consult you, but my attending wants it” or “I know this is really stupid, sorry.”