Consultants and consultations, part 1

What exactly are we looking for, as general pediatricians, when we request a consultation with a pediatric subspecialist?

When recently asked to describe the expectations inherent in a consultation, it quickly became clear to me that there is rarely a typical consultation — at least from my seat. For the specialist, the patient may fall into a common pattern (eg, the 16-month-old with recurrent otitis media for an otolaryngologist). But to me, that referred patient and family reflects a very specific set of circumstances. The specialist almost certainly weighs many of the same circumstances — but how well have I informed him or her of the context of my ongoing deliberations with the family? Do I rely on the family explaining the situation, do I write a referral letter or email, do I call the consultant, or has the specialist already, after many years, understood my referral patterns and expectations?

Details for consultation

Obviously, the better practice model would define an exchange of ideas directly with the subspecialist (in a case of critical illness, this goes unsaid). However for most routine consultations, each of our practice days is full of priorities, many of which are going unmet, and the ability — or even the desirability— of immediate direct contact is lacking. Email will likely take over as the mode of communication of choice, but linking the specific email with the patient visit does challenge even the best of electronic record systems. Confidentiality is always a concern. Even more troublesome is how to express in print the intricacies of certain patient/family/physician dynamics, particularly those that involve the psychological state of the family. How best to describe the issues of the hypothetical 16-month-old above that puts in context the degree of family stress that accompanies each of the episodes of otitis media — the amount of pain and discomfort, days of missed work, maternal guilt, potential parental over-concern, etc.

For most of these issues, we have to be open in our conversations with families and acknowledge the multitude of factors that go into the consideration of a management option that is only available through a specific consultant — pressure equalization tubes in this case — and guiding appropriately. And perhaps we try to match the specific consultant to our hopes for the outcome, referring to the procedurally inclined specialist for the child we believe needs tubes and to the less procedurally inclined specialist for those patients and families who require reassurance.

For many consultations, there is neither complex nor numerous overlays onto the specific medical problem of concern, or even multiple office visits for a common recurrent pediatric problem. Among these are consultations for an issue for which I am sure that I do not know the diagnosis — the known unknowns. These types of cases, of course, can cross any subspecialty and typically require direct contact with the consultant so that I can pronounce my ignorance in advance, thus saving the consultant from developing a referral note that politely spares my feelings. I also tell the patient and family that I do not know the answer and am hoping for a more expert opinion.

There are also those situations when I can at least narrow the differential to several items. For these situations, I once again need to let the consultant and the patient/family know about my differential list so they are aware of some level of knowledge on my part. I am always glad in this situation if one of the potential diagnoses is in Latin or is eponymous.

Of course, the unknown unknowns are potentially present in any patient encounter, hopefully lessened by our involvement in maintenance of certification.

Difficult referrals

Some referrals are just difficult. Humbling may be the better term. These often involve a finding that I have been following that clearly no longer appears to be what I thought it was — like an innocent heart murmur sometimes falls into this category. Or at least it was innocent before I became aware of the click of a bicuspid aortic valve. For example, my effort not to concern the family, or have them worry even after being appropriately reassured by the pediatric cardiologist of an underlying heart defect when I believed the murmur to be innocent, turns into a delay in the diagnosis of a serious medical condition.

In some ways, the issue of consultation is a systems issue. Those of you who practice in an HMO, or a specialty group practice, or what will in the future be an accountable care organization (ACO), have tackled some of these issues and have likely come up with some helpful practices. Others might practice in areas where pediatric subspecialty care is available from competing sources — some of which may offer 48-hour referrals to capture care, or glossy advertising exhorting their expertise. Some consultants utilize physician extenders such as nurse practitioners or physician assistants to facilitate quick access to their clinics.

In every case, however, the fundamentals remain the same. I am seeing a patient I need help with and I need to be able to make an appropriate referral. Often I will undertake a portion of the diagnostic evaluation on my own, before seeking consultation. Some of the evaluation I will have learned from the specialist by previous consultation or in more formal didactic sessions.

Practice management guidelines can also be very helpful, particularly if developed locally or adapted to local needs and conscientiously updated. In many cases, the consultation will prove longitudinal, ongoing care for chronic diseases, or ongoing functional complaints. In all cases, the success of the consultation requires a successful relationship between all parties involved. Being able to communicate effectively across distance and platforms is critical. If health care system reform and integrated electronic medical records help this along, more power to them.

Next month, I will discuss the infectious disease consultant and the general pediatrician.

William T. Gerson, MD, is clinical professor of pediatrics at the University of Vermont College and a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Gerson reports no relevant financial disclosures.

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