Requesting consultations that are unnecessary is not only common but is repeatedly cited by consultants as a leading concern of theirs. Many specialists feel they are being asked to see patients unnecessarily and without adequate evaluation prior to the request. These consult requests without a high-value medical need decrease our consultants’ available time and resources to deal with “real” problems. Their consultation services become more strained and less functional, leading to frustration and workflow and satisfaction problems.

 Ironically many PCP’s and hospitalists are frustrated when non-physician providers (NPP’s) are seeing patients instead of the requested consultant, without realizing how excessive consultation requests have been a major factor in creating and perpetuating  that work model. There are many benefits to consultants, patients, hospitalists, lengths of stay, and resource consumption that will result from reducing unnecessary consultations.

 Several types of consultation requests and consultation request practices have been identified as potential problems by consultants.

  1. A consultation in which there is no diagnostic question or therapeutic intervention needed that has not already been assessed or addressed by the admitting attending physician or the PCP.
  2. “Courtesy” consultations where the consultant is called because of having seen the patient on an outpatient basis even when there is no active issue that needs to be addressed on an inpatient basis.
  3. Consultations requested by NPP that would not have been requested by a physician attending hospitalist.
  4. Consultations that duplicate work and evaluations already performed on an outpatient basis by the PCP or a consultant.
  5. Consultations requested before physically examining the patient and taking an appropriate history and determining any prior outpatient workups that may have been performed to see if a consultation is actually needed. (Major complaint from consultants in every field)
  6. Consultations performed without discussion with or other direct notification of consultant to review the reason for consultation as well as the urgency and priority of the requested evaluation. Although this is poor practice, most consultants say they receive most of their consultation requests from secretaries and nursing staffs via a “notification” process rather than direct contact from the provider requesting the consultation.
  7. Consultations requested for diagnosis and/or management that are within the expected knowledge and experience of the attending physician and should not require subspecialty consultation. Board-certified physician hospitalists have expected knowledge bases and skill sets such that consultation requests reflect services that they are not capable of performing without specialized assistance.
  8. Consultations where important information exists outside of the inpatient record that has not been obtained.

Suggestions to improve Length of Stay and avoid unnecessary hospital stays caused by inappropriate consultation requests:

  1. Make sure all relevant and appropriate information has been obtained before the consultation is requested.
  2. When NPP (such as NP or PA or night coverage, etc) has requested a consultation the attending physician realizes is not needed, cancel the consultation rather than tie up the consultant with an unnecessary consultation.
  3. When NPP’s are allowed by their supervising physician to order consultations independently, it is the responsibility of that physician or physician group to provide appropriate feedback and education to their NPP colleagues. Continuous quality improvement must take place so that the same standard of care exists whichever provider is seeing the patient with respect to making sure consultation requests are ordered appropriately. The attending remains responsible for all the consultations ordered by NPP’s who work with their patients so they need to review, assure, monitor, train, and/or establish appropriate guidelines such that the process functions to their level of satisfaction and inappropriate consultations are not requested. 
  4. For most consultations, call and discuss the case with the consultant. This will serve to avoid a number of consultations, help the consultant appropriately triage the urgency with which the patient should be seen, identify steps you should take before he/she sees the patient, and appropriately identify the issues of concern to make sure the consultation is effective and useful. This usually results in more timely evaluations and a much shorter length of stay.
  5. Where a direct conversation may not be needed in some situations, secure text messaging (STM) to the consultant should be done most other times a consultation is requested. General rule: if it is important enough to have the patient seen by s specialist/subspecialist during a very intense and focused hospital stay, then it is just as important to have a discussion at the time that such decision is made.
  6. When discussing the case directly with the consultant is not needed (there will be some such situations) or the request is being made “after hours” and calling at that time is not appropriate for the situation, then the preferred way to deliver the information and request to the consultant is via secure text messaging.

Certain common diagnoses – syncope, non-cardiac chest pain, congestive heart failure, COPD, pneumonia – would typically be within the scope of practice of the admitting physician and consultations would not be expected unless there are complications or complexity where subspecialty evaluation is needed. Since inpatient providers are knowledgeable about and skilled in treating patients with these diagnoses and do it virtually all the time, it would be an exception or special circumstance when help from another physician would typically be requested. When that does occur, it is essential to document in the chart and to the consultant exactly why such a consultation is requested.