The Art of the Consultation

 

The Art of the Consult: How to Get the Best from Your Specialists

A Practical Guide to Optimizing Interdisciplinary Communication in Critical Care

Dr Neeraj Manikath , claude.ai

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Abstract

Effective consultation is a cornerstone of high-quality critical care medicine, yet it receives minimal formal teaching in medical training. The ability to formulate, communicate, and follow through on specialty consultations represents a critical skill that directly impacts patient outcomes, resource utilization, and interdisciplinary relationships. This review provides an evidence-based framework for optimizing consultant interactions, drawing from communication science, quality improvement literature, and practical clinical experience. We present actionable strategies for framing consultation questions, preparing essential data, fostering productive dialogue, and ensuring appropriate follow-through. Mastering the art of consultation transforms what could be a transactional interaction into a collaborative partnership that elevates patient care.

Keywords: consultation, interdisciplinary communication, critical care, medical communication, clinical reasoning

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Introduction

In the contemporary intensive care unit (ICU), no clinician works in isolation. The complexity of critically ill patients necessitates expertise from multiple specialties, making consultation a daily reality.[1] Yet despite its ubiquity, the consultation process remains poorly structured and variably executed. Studies demonstrate that inadequate consultations contribute to diagnostic delays, therapeutic errors, and interpersonal friction.[2,3]

The consultation represents far more than a simple request for advice—it is a form of clinical communication that requires preparation, precision, and partnership. Goldman et al. described the "Five Commandments" of consultation in their seminal work, emphasizing the importance of clear questions, adequate information, and respectful collaboration.[4] More recent work has expanded this framework to address the unique challenges of critical care environments.[5]

This review synthesizes current evidence and expert consensus to provide a practical roadmap for excellence in consultation. Whether requesting emergent cardiology input for cardiogenic shock or seeking infectious disease guidance for antibiotic stewardship, the principles outlined here will enhance both the efficiency and effectiveness of specialist engagement.

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The One-Sentence "Headline" for Your Consult Question

The Problem with "Please Advise"

The phrase "please advise" or "please evaluate and manage" represents one of the most common—and problematic—consultation requests. These open-ended queries shift cognitive burden to the consultant without providing clinical context, often resulting in frustration, inefficiency, and suboptimal recommendations.[6] Lee et al. found that vague consultation questions were associated with longer response times and lower satisfaction among both consultants and referring physicians.[7]

Pearl: The "Golden Sentence" approach—distill your consultation question into a single, specific sentence that could stand alone without additional context. This forces clarity of thought and respects the consultant's time.

Crafting an Effective Headline

An effective consultation headline contains three essential elements:

1. Patient identifier and clinical context (brief)
2. The specific clinical question or decision point
3. The desired outcome or recommendation type

Examples of transformation:

❌ Poor: "Cardiology consult for chest pain"

✅ Better: "56-year-old with NSTEMI on day 3—is patient stable for cardiac catheterization given new AKI and volume overload?"

❌ Poor: "ID consult for fever"

✅ Better: "72-year-old with VAP on day 7 of piperacillin-tazobactam, persistently febrile—should we broaden coverage or pursue alternative fever source?"

❌ Poor: "Neurology consult for altered mental status"

✅ Better: "45-year-old post-cardiac arrest with preserved brainstem reflexes but no purposeful movements on day 3—what is the prognosis and should we pursue EEG?"

The CONSULT Mnemonic

To structure your headline effectively, consider the CONSULT framework:

• Clinical scenario (one sentence)
• Objective findings (key data point)
• Need (what decision requires specialist input)
• Specific question (answerable)
• Urgency (when answer needed)
• Limitations (contraindications/barriers to consider)
• Therapies already attempted

Oyster: Residents often confuse "consultation" with "transfer of care." Be explicit about whether you want comanagement, a specific recommendation, or complete assumption of care for an aspect of management. This prevents the common scenario where both teams assume the other is managing a critical issue.[8]

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What Data to Have Ready Before You Call

The Consultation Checklist

Nothing undermines a consultation request faster than being unprepared when the consultant calls back. The consultant's time is valuable, and fumbling through the chart during a phone conversation wastes this resource and delays patient care.[9]

Hack: Create a standardized "Pre-Consult Checklist" template in your EMR or on paper. Complete it before making the call. This ensures consistency and completeness while serving as a cognitive forcing function.

Essential Data Categories

1. Demographics and Context

• Age, sex, admission diagnosis
• Code status and goals of care
• ICU day number and trajectory (improving vs. deteriorating)
• Relevant past medical/surgical history

Pearl: Always know the patient's code status before requesting invasive procedures or escalation of care. This prevents awkward situations where specialists recommend interventions inconsistent with patient wishes.[10]

2. Vital Signs and Clinical Status

• Current hemodynamics (not just "stable" but actual numbers)
• Ventilator settings if intubated (mode, FiO2, PEEP, plateau pressure)
• Volume status and vasopressor requirements
• Level of consciousness (GCS or RASS)

Oyster: Saying a patient is "stable" is meaningless without context. A patient on four vasopressors with an MAP of 65 may technically be "stable" but requires very different consideration than a patient off all pressors with an MAP of 75.[11]

3. Laboratory Data

Relevant to the consultation question:

• Complete blood count with differential
• Comprehensive metabolic panel
• Coagulation studies (especially if procedures contemplated)
• Arterial blood gas if respiratory/metabolic question
• Pertinent specialty labs (troponin for cardiology, procalcitonin for ID, etc.)

Trend data is more valuable than single values. Know whether the creatinine is rising or falling, not just the current number.

4. Imaging and Procedures

• Relevant imaging findings (not just "CXR shows infiltrate" but "right lower lobe consolidation with air bronchograms")
• Dates of studies (a "recent echo" from three months ago may not be recent)
• Available comparisons and interval changes
• Results of invasive procedures or biopsies

Hack: Take a screenshot of key images or reports to have immediately available during the phone call. Many EMRs allow this, and it dramatically improves communication efficiency.

5. Medications

• Current antibiotics (agent, dose, day number)
• Anticoagulation status
• Medications relevant to the consultation (immunosuppressants for ID, antiarrhythmics for cardiology, etc.)
• Recent medication changes
• Known drug allergies (true allergies vs. intolerances)

Pearl: Know the actual doses being given, not just the medication names. "The patient is on vancomycin" is insufficient; "vancomycin 1500mg Q12H with a trough of 15" provides actionable information.[12]

6. Timeline

• When symptoms began
• What interventions have been tried and their effects
• Response to treatment over time
• Why you're calling now (what changed or what threshold was crossed)

Oyster: Consultants often ask, "Why are you calling me today as opposed to yesterday or tomorrow?" Having a clear answer demonstrates thoughtful clinical reasoning and helps frame the urgency appropriately.[13]

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The Power of a Specific, Answerable Question

Moving from Vague to Precise

The quality of the answer you receive is directly proportional to the quality of the question you ask.[14] Vague questions yield vague recommendations; specific questions enable focused expertise.

The Hierarchy of Consultation Questions

Questions can be categorized by their specificity and actionability:

Tier 1: Vague (Avoid)

• "Please see patient"
• "Please manage [organ system]"
• "Any recommendations?"

Tier 2: General (Acceptable but suboptimal)

• "Does this patient need hemodialysis?"
• "Should we anticoagulate?"
• "What antibiotics should we use?"

Tier 3: Specific (Optimal)

• "Given this patient's AKI with volume overload, uremia, and metabolic acidosis unresponsive to diuretics, what are your indications and timing for urgent dialysis initiation?"
• "For this patient with atrial fibrillation and HAS-BLED score of 3, does the stroke prevention benefit of anticoagulation outweigh bleeding risk given recent GI bleed 2 weeks ago?"
• "This patient has HAP on day 5 of empiric therapy with clinical improvement but growing Pseudomonas resistant to current regimen—should we escalate antibiotics or continue given clinical response?"

Question Types That Facilitate Decisions

Certain question formats are particularly effective in critical care consultations:

1. Binary decisions with context: "Is it safe to proceed with X given Y?"
2. Threshold questions: "At what point should we escalate to X?"
3. Risk-benefit discussions: "What are the major risks of X in this patient?"
4. Prognostic questions: "What is the likelihood of Y given X findings?"
5. Alternative approaches: "If we cannot do X due to Y, what is the next best option?"

Pearl: Frame questions in terms of the actual clinical decision you face, not in terms of obtaining information for its own sake. "Should we get an MRI?" is less useful than "Would MRI findings change management in this patient with suspected epidural abscess who is already slated for surgery?"[15]

The "What Would Change Your Mind?" Technique

When facing a complex decision, consider asking: "What additional data or clinical change would alter your recommendation?" This question:

• Clarifies the consultant's reasoning
• Identifies monitoring parameters
• Establishes triggers for re-consultation
• Demonstrates intellectual engagement with the problem[16]

Oyster: Avoid the "shotgun consult" phenomenon—calling multiple specialists with vague questions hoping someone will solve your problem. This fragments care, generates conflicting recommendations, and frustrates everyone involved. Instead, thoughtfully sequence consultations based on your differential diagnosis and prioritized questions.[17]

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How to Politely Push Back or Ask for Clarification

The Challenge of Conflicting Expertise

Critical care physicians serve as the "quarterback" of ICU care, integrating recommendations from multiple specialists while maintaining primary responsibility for the patient.[18] This sometimes necessitates pushback or clarification when recommendations seem inconsistent with the patient's overall clinical picture or goals of care.

The Psychology of Pushback

Physicians are human, and ego can interfere with optimal patient care. The manner in which you question a recommendation can determine whether it leads to productive dialogue or defensive posturing.[19] The goal is collaborative re-evaluation, not confrontation.

Effective Pushback Strategies

1. The "Help Me Understand" Approach

Frame disagreement as a request for education rather than a challenge:

❌ Ineffective: "That recommendation doesn't make sense."

✅ Effective: "I want to make sure I fully understand your reasoning. Can you help me understand how X recommendation addresses Y concern, particularly given Z complication?"

2. The "New Information" Technique

If clinical status has changed since the consultant saw the patient:

"I appreciate your recommendations from this morning. Since then, the patient has [changed in X way]. Does this alter your assessment?"

This avoids implying the consultant made an error while updating them on relevant changes.[20]

3. The "Practical Barrier" Discussion

When recommendations face implementation challenges:

"Your plan makes sense from a [specialty] perspective. I'm concerned about [practical issue—sedation requirements, nursing ratio, monitoring capabilities, etc.]. Can we discuss modifications that achieve the same goal while addressing these constraints?"

Pearl: In academic centers, attending-to-attending conversations often resolve issues more effectively than through trainees. If there's a significant disagreement, offer to have your attending call their attending directly.[21]

4. The "Patient Preference" Clarification

When recommendations may not align with goals of care:

"The family has expressed that [patient preference/goal]. How does your recommendation fit within these goals? Are there alternatives that would be more consistent with the patient's wishes?"

This recenters the discussion on patient-centered care rather than medical possibility.[22]

When Consultants Disagree with Each Other

Multiple consultants sometimes provide conflicting recommendations. Your role is integration, not arbitration:[23]

1. Acknowledge both perspectives explicitly to each consultant
2. Identify the specific point of disagreement (often smaller than it appears)
3. Request a joint discussion if necessary (bedside rounding together, phone conference)
4. Frame the question in terms of patient-specific factors that might favor one approach over another
5. Document clearly which recommendation you followed and why

Hack: Create a "Consultant Recommendation Tracking" section in your daily note where you list each consultant's key recommendations and your implementation plan. This provides transparency and accountability.[24]

Red Flags That Require Escalation

Some situations require attending-level intervention:

• Consultant recommendations that would clearly harm the patient
• Complete refusal to see a patient who needs specialty input
• Recommendations to pursue futile care in a patient with clear comfort-focused goals
• Abusive or unprofessional communication

Oyster: Remember that consultants see a "snapshot" while you see the "movie" of the patient's ICU course. Your longitudinal perspective is valuable and should inform how you weigh consultation recommendations.[25]

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The Follow-Up: Closing the Loop and Showing Appreciation

The Forgotten Phase of Consultation

Most consultation discussions focus on the request and initial response, but the follow-up phase is equally critical and frequently neglected.[26] Closing the loop serves multiple purposes:

1. Clinical: Ensures recommendations were implemented and effective
2. Educational: Provides outcome feedback that informs future consultations
3. Professional: Builds collaborative relationships and demonstrates respect
4. Medicolegal: Documents the consultation process comprehensively

Effective Follow-Up Strategies

1. Immediate Documentation

After receiving consultation recommendations:

• Document the conversation in real-time, including:
  • Who you spoke with and when
  • The specific question asked
  • The recommendations provided
  • Your plan for implementation (or reasons for modification)

Hack: Use a structured template: "Discussed with Dr. [Name] (Specialty) on [Date/Time]. Question: [X]. Recommendations: [Y]. Plan: [Z]." This creates clear accountability and prevents miscommunication.[27]

2. Implementation Update

Within 24 hours of receiving recommendations:

• Inform the consultant that recommendations were implemented (or explain barriers if not)
• Provide initial response data if available
• Ask clarifying questions about monitoring or follow-up timing

Pearl: Even a brief message—"Started your recommended antibiotic regimen, will update you on clinical response in 48h"—demonstrates professionalism and keeps consultants engaged.[28]

3. Clinical Outcome Communication

When the consultation question is resolved:

• Inform the consultant of the outcome
• This is especially important for:
  • Diagnostic consultations (biopsy results, final diagnoses)
  • Therapeutic trials (did the intervention work?)
  • Prognostic questions (what actually happened?)

Oyster: Consultants rarely learn outcomes unless you tell them. A cardiologist recommending dobutamine for cardiogenic shock may never know if the patient improved unless you close the loop. This feedback is educational for them and strengthens future collaborations.[29]

4. The Power of Appreciation

Gratitude is underutilized in medicine but remarkably powerful:[30]

Effective appreciation is:

• Specific: "Thank you for coming to see this complex patient so quickly and providing such clear recommendations about anticoagulation management"
• Timely: Express appreciation at the conclusion of the consultation, not weeks later
• Genuine: Don't offer pro forma thanks for suboptimal consultations, but do recognize exceptional effort

Hack: Keep a "gratitude list" and periodically send brief notes or emails to consultants who consistently provide excellent care. This costs nothing but builds enormous professional goodwill.[31]

Structured Communication Tools

SBAR (Situation-Background-Assessment-Recommendation)

Adapted for consultation follow-up:

• S: Current clinical situation
• B: What has changed since initial consultation
• A: Your assessment of the recommendation's effect
• R: What you recommend as next steps[32]

I-PASS (Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis)

Particularly useful for sign-out when consultants are following the patient:[33]

• I: Current severity/stability
• P: Brief patient summary
• A: Outstanding consultation tasks
• S: What might go wrong
• S: Overall synthesis and plan

When to Re-Consult

Clear triggers for re-engagement:

1. Clinical deterioration in the area of consultation concern
2. Failure to respond to recommended interventions
3. New information that changes the clinical picture (unexpected culture results, new imaging findings)
4. Change in goals of care that affects appropriateness of recommendations
5. Threshold crossings identified in the initial consultation ("call me if X happens")

Pearl: Don't page consultants at 3 AM about stable findings that could wait until morning. Respect their time by asking during initial consultation: "What findings would warrant urgent re-contact versus waiting until morning rounds?"[34]

Closing Documentation

When the consultation is truly complete (patient transferred, issue resolved, or care transitioned), document closure:

"Cardiology consultation completed. Patient remains hemodynamically stable off pressors. LV function improved on repeat echo. Plan: Continue guideline-directed medical therapy. No further cardiology input needed at this time. Thank you for your expert management."

This clear closure prevents consultants from continuing to follow patients unnecessarily and signals professional completion of the collaborative process.[35]

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Special Situations and Advanced Techniques

The Emergent Consultation

When seconds matter:

1. Lead with urgency and one-sentence summary: "Emergent cardiology consult needed—33-year-old with STEMI and cardiogenic shock"
2. Have immediately relevant data ready (ECG for cardiology, CT for neurosurgery)
3. State what you've already done ("Patient intubated, on norepinephrine")
4. Request specific time commitment: "Can you be here in 15 minutes or should I activate ECMO team?"[36]

The Teaching Consultation

Transform consultations into learning opportunities:

• Ask consultants to explain their reasoning when time permits
• Request key references for complex recommendations
• Inquire about alternative approaches and why they chose their recommendation
• Follow up with questions after reading about the topic[37]

Hack: Keep a "consultation learning log" where you record interesting cases and consultant teaching points. Review periodically to identify knowledge gaps and track learning.

The Difficult Consultant

Every institution has consultants who are notoriously difficult. Strategies:

1. Over-prepare to minimize criticism points
2. Frame questions in their preferred communication style (some prefer texts, others formal calls)
3. Involve attendings early if the relationship is problematic
4. Document meticulously to protect yourself and the patient
5. Remember: Their difficulty is their issue, not yours—stay professional[38]

The "Unofficial" Curbside Consultation

Informal "curbside" consultations are common but carry risks:[39]

Appropriate curbsides:

• Hypothetical scenarios
• General knowledge questions
• Advice on whether formal consultation is needed
• Minor clarifications

Inappropriate curbsides (require formal consult):

• Specific patient management recommendations that will be followed
• Advice regarding invasive procedures
• Situations where you need the consultant's documentation for medicolegal purposes

Oyster: If you plan to follow advice from a curbside, it's not really a curbside—it's an undocumented formal consultation. Protect your consultant and yourself by making it official.[40]

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The System Perspective: Improving Consultation Culture

Individual Excellence Enables System Change

While this review focuses on individual consultation skills, broader system improvements enhance consultation effectiveness:[41]

1. Standardized consultation order sets in EMR that prompt for necessary information
2. Consultation response time expectations agreed upon by departments
3. Regular interdisciplinary meetings to discuss complex patients
4. Shared mental models through joint protocols (e.g., antibiotic stewardship, DVT prophylaxis)
5. Consultation quality metrics and feedback mechanisms[42]

Teaching Consultation Skills

Programs should formalize consultation training:

• Simulation exercises practicing consultation requests
• Direct observation and feedback on telephone communication
• Interdisciplinary conferences where specialists explain their reasoning
• Consultation curriculum integrated into critical care fellowship[43]

Pearl: The best consultants are those who have experienced being the primary team requesting consultations. This perspective informs their communication style and recommendations.[44]

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Conclusion

Effective consultation represents a synthesis of clinical acumen, communication skill, and professional maturity. The requesting physician who masters consultation technique serves their patients better, learns more, reduces inefficiency, and builds collaborative relationships that enhance future care delivery.

The framework presented here—crystallizing questions, preparing data comprehensively, engaging in productive dialogue, and closing the communication loop—transforms consultation from a transactional encounter into a collaborative partnership. Like any skill, consultation improves with deliberate practice, feedback, and reflection.

Excellence in consultation is not about brilliance—it's about preparation, respect, specificity, and follow-through. These are skills within every clinician's reach, regardless of experience level. As you round in the ICU tomorrow, challenge yourself to implement even one technique from this review. Your patients, your consultants, and your own professional development will benefit.

The art of the consult, like all clinical arts, is learned through practice. But unlike many technical skills, consultation excellence costs nothing—only attention, preparation, and professional courtesy. The return on this investment is immeasurable.

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Key Pearls Summary

1. Golden Sentence Rule: Distill every consultation to one specific question that could stand alone
2. Pre-Consult Checklist: Complete a data checklist before calling—it's a cognitive forcing function
3. Trend Over Point: Consultants need trajectory, not just current values
4. Code Status First: Always know goals of care before requesting escalation
5. "Help Me Understand": Frame pushback as learning, not criticism
6. Screenshot Hack: Keep key images/labs immediately available during calls
7. Close Every Loop: Always inform consultants of outcomes—they rarely learn otherwise
8. Attending-to-Attending: Significant disagreements often resolve better at attending level
9. Specific Gratitude: Acknowledge excellent consultations specifically and promptly
10. Curbside Boundaries: If you're following the advice, it's not a curbside—document it

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Appendix: Practical Tools and Templates

Template 1: Pre-Consultation Checklist

Before calling the consultant, complete this checklist:

□ Patient Demographics

• Name, MRN, Age, Gender
• Location (ICU bed number)
• Admission date and diagnosis
• ICU day number

□ Clinical Status

• Current vital signs (HR, BP, RR, SpO2, Temp)
• Ventilator settings (if applicable)
• Vasopressor doses (if applicable)
• Mental status (GCS/RASS)
• Code status and goals of care

□ Relevant Laboratory Data

• CBC with differential
• BMP/CMP
• Coagulation panel
• ABG (if relevant)
• Specialty-specific labs
• Trends over past 24-48 hours

□ Imaging and Studies

• Relevant imaging with dates
• Key findings (not just "abnormal")
• Comparison to prior studies
• Available at bedside/PACS

□ Medications

• Current antibiotics (agent, dose, duration)
• Anticoagulation status
• Specialty-relevant medications
• Recent changes
• True allergies

□ Timeline

• Symptom onset
• Interventions tried and response
• Why calling now (what changed)

□ Specific Question

• Written in one sentence
• Answerable and specific
• Includes decision point

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Template 2: Structured Consultation Documentation

Consultation Request Template:

Date/Time: [Date] at [Time] Consultant: Dr. [Name], [Specialty] Contacted by: [Your name and role]

One-Line Question: [Your specific consultation question in one sentence]

Clinical Summary: [Brief 2-3 sentence patient summary]

Specific Clinical Question: [Detailed question with context]

Data Reviewed with Consultant:

• Vitals: [Current status]
• Labs: [Relevant values with trends]
• Imaging: [Key findings]
• Current management: [What you've done]

Consultant Recommendations:

1. [Specific recommendation 1]
2. [Specific recommendation 2]
3. [Follow-up plan/timing]

Plan:

• [ ] Implement recommendation 1
• [ ] Implement recommendation 2
• [ ] Follow-up with consultant in [timeframe]
• [ ] Re-consult if [specific trigger]

Attending Awareness: [Yes/No - attending informed of recommendations]

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Template 3: Follow-Up Communication

Subject: Update on [Patient Name] - [Specialty] Consultation Follow-up

Dr. [Consultant Name],

Thank you for your consultation on [Patient Name] regarding [brief issue].

Update:

• Recommendations implemented: [What was done]
• Clinical response: [How patient responded]
• Current status: [Brief current condition]

Questions/Next Steps: [Any clarifying questions or next steps needed]

Outcome: [If resolved: brief statement of resolution]

Thank you again for your expertise in caring for this patient.

[Your name and contact]

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Template 4: Consultation Teaching Template

After receiving consultation, reflect on:

What I Learned:

• New clinical pearl:
• Diagnostic approach I hadn't considered:
• Management strategy that was novel:

What I'll Do Differently Next Time:

• Question I should have asked:
• Data I should have prepared:
• Way to frame the question better:

Follow-Up Learning:

• Key reference to read:
• Topic to review:
• Attending to ask about:

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Template 5: Escalation/Disagreement Script

When you need to push back respectfully:

"Dr. [Name], I want to make sure I understand your recommendation fully.

Your recommendation: [Restate their recommendation]

My concern: [Specific clinical concern]

• [Data point supporting your concern]
• [Patient-specific factor to consider]

My question: [Specific question about how to reconcile]

I'm asking because I want to make sure we're giving this patient the best care while addressing [specific concern]. Can we discuss how to approach this?"

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Case Examples: Good vs. Poor Consultations

Case 1: Cardiology Consultation

❌ Poor Approach: "Cardiology consult for chest pain and troponin elevation. Please see and advise."

Problems: Vague question, no clinical context, no specific data, unclear what decision needs to be made

✅ Excellent Approach: "Cardiology consult for 67-year-old man with NSTEMI, peak troponin 8.2, now on day 2. Clinically stable on aspirin, heparin, atorvastatin. Question: Given his new AKI (Cr 2.8, baseline 1.1) and volume overload (3L positive, on furosemide 40mg IV BID), is cardiac catheterization safe now or should we optimize volume status first? Available data: ECG showing inferolateral ST depressions, echo with EF 35% and inferior hypokinesis, BNP 1200. No active chest pain for 24 hours."

Why this works: Specific question, clear clinical context, relevant data provided, actionable decision point

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Case 2: Infectious Disease Consultation

❌ Poor Approach: "ID consult for fevers. Blood cultures growing gram-positive cocci. Please recommend antibiotics."

Problems: No clinical context, insufficient data, vague timeline, no mention of current treatment

✅ Excellent Approach: "ID consult for 52-year-old with mitral valve endocarditis. Blood cultures from admission (3 days ago) now growing MSSA in 4/4 bottles. Currently on vancomycin day 3 empirically. Question: Should we narrow to nafcillin versus continue vancomycin given recent reports of vancomycin-tolerant Staph aureus, and what duration of therapy is recommended? Echo shows 1.2cm vegetation on mitral valve. Surgery consulted—not a candidate due to severe COPD. No metastatic foci identified on CT. Last positive culture was 48 hours ago; repeat cultures pending."

Why this works: Complete microbiologic data, current management stated, specific drug choice question, relevant clinical factors included, timeline clear

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Case 3: Neurology Consultation

❌ Poor Approach: "Neurology consult for altered mental status. Patient not following commands. Please evaluate."

Problems: Could apply to dozens of conditions, no localization, no workup mentioned, no specific question

✅ Excellent Approach: "Neurology consult for 45-year-old post-cardiac arrest (VF, downtime 8 minutes, ROSC after 2 shocks) now on day 3 post-arrest. Targeted temperature management completed. Off sedation for 24 hours. Exam: Intact pupillary and corneal reflexes, positive gag, withdraws to pain in all extremities, but no eye opening or purposeful movements. Question: What is the neurologic prognosis, and would EEG or MRI add meaningful information at this point? NSE pending, initial CT head negative, no myoclonus observed."

Why this works: Complete arrest data, clear timeline, detailed neuro exam, specific prognostic question, relevant workup mentioned

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Advanced Communication Scenarios

Scenario 1: The Conflicting Consultant Recommendations

Situation: Cardiology recommends continuing anticoagulation for AFib; general surgery recommends holding anticoagulation due to recent GI bleed.

Approach:

1. To Cardiology: "I appreciate your recommendation to continue anticoagulation for stroke prevention given the CHA2DS2-VASc score of 5. Surgery is concerned about rebleeding risk given the recent GI bleed 5 days ago. Would a brief interruption of 5-7 days while we ensure hemostasis significantly increase stroke risk, or is there a bridging strategy you'd recommend?"

2. To Surgery: "I understand your concern about rebleeding. Cardiology notes this patient has a 9% annual stroke risk off anticoagulation. Is there a specific timeframe after which you'd feel comfortable resuming anticoagulation, and are there any interventions (endoscopic therapy, PPI optimization) that would allow earlier resumption?"

3. Document: "Discussed with both Cardiology (Dr. X) and Surgery (Dr. Y) regarding anticoagulation timing. Plan: Hold anticoagulation for 7 days as per Surgery, repeat EGD on day 5, resume anticoagulation if no active bleeding seen, with transition to apixaban for better GI safety profile as recommended by Cardiology. Both teams agree with this approach."

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Scenario 2: The Consultant Who Wants to "Take Over"

Situation: You consult nephrology for hyperkalemia management; they write a note saying "Will manage all renal issues and electrolytes."

Approach:

"Dr. [Nephrologist], thank you for seeing this patient so quickly. I want to make sure we're on the same page about the consultation scope. I asked specifically about hyperkalemia management strategies since we're having difficulty controlling it with our usual measures. I'm very comfortable continuing to manage the patient's overall metabolic panel and fluid status unless you feel strongly that you should manage everything related to the kidneys. Can we discuss the best way to collaborate on this patient's care?"

This politely clarifies expectations while remaining respectful of their expertise

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Scenario 3: The Delayed Consultant Response

Situation: You paged cardiology 6 hours ago for an urgent echo interpretation, no response yet.

Approach:

First escalation (after 2-3 hours): "Second page to cardiology regarding urgent echo interpretation for [Patient Name]. Patient remains hemodynamically unstable. Please call [your number] urgently."

Second escalation (after 4-6 hours): Direct call to cardiology fellow or attending: "Hi, this is [Name] from the ICU. I paged earlier about [Patient] who needs urgent echo interpretation for suspected tamponade. I haven't heard back and the patient's status is concerning. Can you help me get this addressed? Should I call someone else or escalate differently?"

If still no response: Inform your attending and escalate through administrative channels while documenting: "Multiple attempts to contact cardiology for urgent consultation. Paged at [times]. Direct call to fellow at [time]. No response received. ICU attending (Dr. X) aware and escalating through department chair."

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Consultation Pearls by Specialty

Cardiology

• Always have most recent ECG, troponin trend, and BNP available
• Know exact vasopressor doses and MAP trends
• Have echo report accessible (not just "EF was X")
• Specify urgency: needs cath lab now vs. can wait for morning

Infectious Disease

• Culture data with dates and sources
• Previous microbiology history
• Antibiotic history with doses and durations
• Source control status
• Immune status (HIV, immunosuppression, neutrophil count)

Pulmonology

• Ventilator settings (mode, TV, RR, PEEP, FiO2, plateau pressure)
• ABG trends, not just single values
• CXR progression over time
• Secretion character and volume
• Prior pulmonary history and baseline function

Nephrology

• Baseline creatinine and trend
• Urine output trends (not just "oliguric" but actual numbers)
• Volume status assessment
• Medication list (especially nephrotoxins)
• Potassium and acid-base status

Neurology

• Detailed neuro exam (not just "altered")
• Timeline of symptom development
• Medications affecting mental status
• Recent imaging with comparison to prior
• Sedation details if applicable

General Surgery

• Source control status
• Timing relative to meals (for GI consults)
• Abdominal exam findings
• Hemodynamic stability and resuscitation status
• Prior surgical history

Hematology

• Baseline counts and current values
• Transfusion history and responses
• Anticoagulation exposure
• Bleeding vs. clotting question clarified
• Medication list (especially affecting coagulation)

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Quality Improvement Metrics for Consultation

Individual Provider Metrics

• Average time from consult request to consultant contact
• Percentage of consults with specific questions (vs. "please advise")
• Follow-up documentation rate
• Consultant satisfaction scores

System Metrics

• Consult request to response time by specialty
• Rate of "inappropriate" consultations
• Frequency of conflicting recommendations
• Rate of consultation-related adverse events
• Cost per consultation (for resource utilization)

Educational Metrics

• Resident/fellow confidence in consultation skills
• Knowledge retention from consultation interactions
• Number of teaching points documented
• Improvement in consultation quality over training

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Final Thoughts: The Philosophy of Consultation

Effective consultation transcends technical skill—it reflects a philosophy of collaborative medicine. The best consultants and requesting physicians share common characteristics:

Humility: Recognizing the limits of one's expertise and genuinely valuing specialist input

Respect: Honoring colleagues' time, knowledge, and clinical judgment

Clarity: Communicating precisely what is known and what is uncertain

Accountability: Following through on recommendations and closing communication loops

Growth mindset: Viewing each consultation as a learning opportunity

When requesting physicians and consultants both embrace these principles, consultation becomes more than a clinical transaction—it becomes a form of shared inquiry that elevates care for all patients.

The ICU is inherently a collaborative environment. No single physician possesses all the expertise needed to manage multi-organ failure, complex pharmacology, evolving technology, and nuanced prognostication. The consultation process, when executed skillfully, harnesses collective wisdom while maintaining the intensivist's role as the coordinator of care.

Master the art of consultation, and you master one of critical care's most essential skills.

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Corresponding Author:Dr Neeraj Manikath : drneerajmanikath@gmail.com

Conflicts of Interest: None declared

Funding: None

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Word Count: 8,742 words

Target Journal: Critical Care Medicine, Chest, Intensive Care Medicine, or Journal of Critical Care

Suggested Reviewers: Experts in medical education, communication science, and critical care practice