MEDICAL

CONSULTATION

Achmad Rudijanto
Relationship
Introduction
 Little formal attention has been directed
to the role of the internist as a consultant

 Consultations are indicated

 “upon request”,
 in doubtful or difficult cases,
 or when they need to enhance the quality
of medical care

 Consultation are primarily for the

patient’s benefit
 Consultation and Referral
 A consultation is strictly defined as
requesting another physician to give
his/her opinion on problems
identification or management of the
problems.
 Referral means to request another
physician to take direct responsibility for
a portion or all of the patient’s care
 Delegation and referral
 Delegation involves asking a colleague to provide treatment
or care on your behalf. Although you will not be accountable
for the decisions and actions of those to whom you delegate,
you will still be responsible for the overall management of the
patient, and accountable for your decision to delegate
 Referral involves transferring some or all of the responsibility
for the patient’s care, usually temporarily and for a particular
purpose, such as additional investigation, care or treatment
that is outside your competence.
 You must be satisfied that any healthcare professional to
whom you refer a patient is accountable to a statutory
regulatory body or employed within a managed environment
TEN COMMANDMENTS of
CONSULTANT ROLE
1. To determine the question asked,
2. Establish the urgency of the consultation,
3. Gather primary data,
4. Communicate as briefly as appropriate,
5. Make specific recommendations,
6. Provide contingency plans,
7. Understand one’s role in the process,
8. Offer educational information,
9. Communicate recommendations directly to the
requesting physician,
10. Provide appropriate follow-up.
Goldman and colleagues, 1983
TEN COMMANDMENTS of CONSULTANT
ROLE

In which the consultant generally plays an

indirect role in patient management,
recommending rather than co-managing”.

Goldman and colleagues, 1983

AMA, ethical principles of
consultation
1. One physician should be in charge of the patient’s care
2. Overall responsibility of the attending physician for the
treatment of the patient
3. The consultant should not assume primary care of the patient
without consent of the referring physician
4. Punctually of the consultation
5. Discussion in consultation should be with the referring
physician and only with the patient with the prior consent of
the referring physician
6. Conflict opinion should be resolved by a second consultation
or withdrawal of the consultant; however the consultant has
the right to give his opinion to the patient in the presence of
the referring physician
7. A consultation should be differentiated from a referral
The expectations of the
referring physician differ by
specialty.

 Traditional relationships in which the

consultant provides advice regarding
a specific question and the referring
physician writes all orders
 To full management, including order
writing, of all internal medicine issues
by the consultant

Salerno SM, Arch Intern Med. 2007;167:271-275

Implement
clinical
process: Role of consultant
-History Once a consultation has been obtained,
taking the consultant should review available
-Physical data, obtain a history, and perform a
examination
-Review physical examination that includes a
available comprehensive cardiovascular
data (Lab, examination and elements pertinent to the
etc)
-Problem patient’s problem and proposed surgery
synthesis
-Identify the The consultant must not rely solely on the
risk question that he or she has been asked to
-Provide
suggestion
answer, but must provide a
comprehensive evaluation of the patient’s
risk
Medical Consultation
 In non-surgical patient consultation, clinical process
must be implemented to solve the problem and
make decision both for testing or management.
Identification of the risks and problems must be
doing based on the facts of the patients.
 Decision for solving the problems must be also
based on the patient’s need.
 DOCTOR PATIENT
RELATIONSHIP

Discussion about diagnosis and therapeutic

recommendations with the patient do after
obtaining the specific approval of the
referring physician

In case anything else fails to get agreement,

the consultant should indicate to the patient
his intention to withdraw from the case.

The patient has right to request from his

physician another opinion.
RISK ASSESSMENT
 RISK ASSESSMENT

 The most difficult aspect of the consultation process

arises in attempting to specifically assess the risk to
the patient of the proposed procedure
 This develops from unfamiliarity with the physiologic
stresses of anesthesia or specific surgical procedures,
and unpredictability of intra-operative complication
 All lead the internist to conclude his recommendation
with the gratuitous and superficial
 RISK
ASSESSMENT

Most consultation requests are really

asking the consultant to identify and
define significant medical problem,
to help to optimally manage them
preoperatively, during procedures
and to be follow-up post operatively
Risk Assessment

The most important contribution to

post-operative morbidity and
mortality are cardiac and
pulmonary complications

An assessment of cardiac &

pulmonary risk must be part of every
pre-operative medical evaluation
Risk analysis
Case

Consultant Referring
physician
Clinical process Clinical process

List of problems
? List of problems

Risk analysis

Intervention Intervention

Recommendation
to reduces the risks
CANCELATION OF SURGERY
PROCEDURE

 When feasible, elective surgery should be

delayed until metabolic control is acceptable
 Reasons to delay or cancel surgery differ
between elective and non-elective surgery.
 In elective surgery, there is more time to stabilize
medical conditions
 In non-elective surgery, the goal is often to
provide short-term stabilization with more
extensive workup deferred until after the
procedure
In serious medical condition
is unstable or untreated
 Conflict of Interest
Conflict on patient management may
happen between referring physician and
consultants.

Contributing factors to these disagreements

are differences in knowledge, the approach
to common problems, and the philosophy
about how closely the patient needs to be
followed or the urgency for surgery.
Conflict of Interest
The best way to prevent conflicts is
communication prior to the consultation in
verbal, as well as written, especially when
controversy is anticipated.

To resolve the conflict a case conference in

academic setting or utilizing persuasion by
other consultants/a second formal
consultation in private practice settings can
be helpful1 .
 RELATIONSHIP TO
OTHER

The general internists are commonly in a

position of being one of a number of medical
consultants
Conflicts may include different advice for the
same problem, recommendations for therapy
which may adversely affect another problem
or interfere with another consultant’s
recommendations
 Medical consultation
Medical Non Surgery Surgery
consultation
Emergency Emergency
Elective Elective
REPORT OF CONSULTATION

 Summary of the history and hospital course should be stated

briefly.

 The aspects of physical examination important to the problems for

which the consultation was obtained should be detailed,
especially any differences from those recorded by the primary
physician.

 Only pertinent laboratory data should be listed.

 Identified problems should be stated clearly.

 The recommendations should be as specific as possible

 The consultant should provide the surgeon with a clear, concise

evaluation of medical risks, measures to improve or stabilize the
patient pre-operatively, post-operative medical considerations,
and he/she role in the overall care of the patient.
REPORT OF CONSULTATION

 The frequency of or need for continued

follow-up should be questioned if the
consultant does not feel that follow-up
not need to be made or more than
occasional visit.
 A written note should document when
the consultant will no longer follow the
patient and consultation is complete
Area of Medical Consultation
Medical Surgery
consultation
- Elective Surgery +
Non
- Emergency Surgery
Clinical Non
Process Surgery
-Problems analysis
-Impact Analysis of the problem to procedures
-Decision making to reduce the risk
-Clear report
 Medical Consultation Steps
Analysis of the Planning of
Problems Intervention

? ?
RISK ANALYSIS
?
RECOMMENDATION

Recommendation :
-Solve the problems in your areas
-Reduce intervention Risk for your colleagues
Summary

 Consultations are indicated

“upon request”, in doubtful or difficult cases,
or when they need to enhance the quality of medical care
 Consultation are primarily for the patient’s benefit
 A consultation is strictly defined as giving his/her
opinion on problems identification or management of
the problems
 A consultation is not giving clearance
 In surgery cases, the consultant must analyze risks and
give some suggestion to solve/minimize risks
 In any conflict of interest, communication is the best
way to solve
 Sharing information
with colleagues
 Sharing information with other healthcare professionals is
important for safe and effective patient care.
 When you refera patient, you should provide all relevant
information about the patient, including their medical history
and current condition.
 If you providetreatment or advice for a patient, but are not
the patient’s general practitioner, you should tell the general
practitioner the results of the investigations, the treatment
provided and any other information necessary for the
continuing care of the patient, unless the patient objects.
Medical consultation
 a procedure whereby, on request by one
physician, another physician reviews a
patient's medical history, examines the
patient, and makes recommendations as to
care and treatment. The medical consultant
often is a specialist with expertise in a
particular field of medicine.
 Mosby's Medical Dictionary, 8th edition. ©
2009, Elsevier.
Role of consultant

 The performance of a consultation

involves the phases of initial contact,
completion of the consultation report,
follow up
 A case summary should be sent to the
consulting physician, although a verbal
description of the case has been given
 The role of medical
consultation of the
surgical patient

 The role of medical consultant of the

surgical patient is to determine the
presence of known or unrecognized
co-morbid disease or other factors that
may increase risk or morbidity and
mortality from baseline and to
recommend strategies to reduce the
risk and optimize the patient’s
condition before surgery procedures5
Medical Consultation
 In patient with low risk of complication,
a careful screening history and physical
examination are the most important parts of the
preoperative assessment of patient.
 The history should focus on symptoms that suggest
the possibility of occult cardiac or pulmonary
disease
 Should not routinely obtain laboratory testing before
surgery. There is no difference in morbidity and
mortality between patients who undergo routine
preoperative testing and those who don’t undergo
such testing
Summary
 The expectations of the referring physician differ by specialty
 A consultation should be differentiated from a referral activity.
Consultation is strictly defined as requesting another physician to
give his/her opinion on diagnosis or management of the patient.
 Identified problems should be stated clearly based on patient’s
data.
 The recommendations should be as specific as possible.
 The consultant should provide the surgeon with a clear, concise
evaluation of medical risks, measures to improve or stabilize the
patient pre-operatively, post-operative medical considerations,
and he/she role in the overall care of the patient.
Introduction
society demands the highest standards of
professional competence and ethical conduct
from doctors. The working population expect no
less, and insists on equally high standards of
proficiency in car and conduct from occupational
physicians
Koh D. Occup Environ Med, 2003 60:1-2

In recent years there has been increasing

publicity about errors and malpractice of
doctors, both hospital physicians and general
practitioners
Manus. Quality in Health Care, 2009 9:14-22
The science and art of medicine
 Medicine is both a science and art
 Science deals with what can be observed and
measured, and a competent physician recognizes
the sign of illness and disease and knows how to
restore good health
 But scientific medicine has its , limits, particularly in
regard to human individuality, culture, religion,
freedom, right and responsibilities.
 The art of medicine involves the application of
medical science and technology to individual
patients, families and communities, no two of
which are identical