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The gentle art of the consult

“Your family doc is very clever,” said the Cardiologist that I was seeing.

“Yes, I know she is,” I said, “but why do you say so?”

“Well, because she sent me this excellent letter about you, outlining her concerns and asking very clear and pertinent questions. I really like this, it recognizes my expertise and it doesn’t feel like a dump. Usually, all I get is “chest pain, please assess.” It makes me feel like I have to do all the work.” I nodded, understanding her point.

I then ran from the Cardiologist’s office to my clinic, where I saw my patient, who is twenty weeks pregnant and has four giant fibroids that I anticipate will give us a lot of trouble as her pregnancy progresses. I am sharing her care with one of my trusted Obstetrics High-Risk colleagues. The Ob let me know earlier in the week that the patient was in the ER with abdominal pain. I called the patient in and was able to reassess, explain and add to the treatment.

As a primary care physician, I am always working with consultants. I send them patients in order to ask their opinions, get procedures done, transfer for surgery or complex management. At the best of times, it is a fruitful relationship of mutual aid with the patient at the center. Both docs then feel that they have been heard, understood, and doing their best work. At the worst, it is an exercise in cross-cultural blindness.

One of the worst consults I ever got was many years ago. I sent my patient, a young woman with an anal fissure that kept recurring, despite conservative management. I sent her to a colorectal surgeon. I had worked the patient up as best I could but thought now she needed a scope. When the patient returned to me (there was no letter), the surgeon had simply prescribed the same conservative treatments that I had already tried. When I called, he was too busy to talk. Frustrated, I re-sent her to the surgeon I had initially wanted to send her to. This surgeon, my classmate, read my letter, scoped the patient expeditiously and diagnosed her HPV related anal cancer. I remember this story because I have a lithograph self-portrait of the patient with her radiation markings on my wall. It always reminds me to be sure to get the answer I need. Now fifteen years later, she is still alive and well and creating beautiful artwork.

The best consults I remember from my early years in practice were from an endocrinologist. I started my practice with next to no experience in outpatient medicine (don’t ask). In those early days, I covered my ignorance by consulting very, very, liberally. This endocrinologist would send me back beautiful letters, each one a gem of CME. He always couched his invaluable teaching with “as you know…”. He let me know what I could and should do next time without making me feel my own incompetence. I kept those letters in a file, which I would consult as needed. 

On the other hand, there is the sloppy primary care consult. “Headache, please assess.” This is an example of the worst type of primary care consultation. There is no information, nothing that indicates the thought process, anxieties, or workup that the family doc has undertaken. It does not even ask a question. It smacks of McMedicine. In this day and age, where provincial governments are pressuring frontline physicians to increase quantity over quality, the temptation is real! We must resist it for the good of our patients and for the system.

What works best, I believe, is when primary care docs and their consultants know and trust each other. We are not random interchangeable roles. As everywhere in primary care, it is the relationship that heals.

That afternoon I was supervising the family medicine residents in their, mostly online, clinics. We discussed many kinds of consults: the “patient known to you” consult, the “I need a procedure/surgery done” consult, the “this patient is insisting on seeing a specialist” consult, and the “I have done all I know how to do, and things are still bad, please help me” consult. I tried to pass on what I have learned of this gentle art. I hope that this will make things better for my residents, the consultants and most importantly, for my patients.