How to Communicate in Medical Consultations: A Case Study

As a practicing or aspiring physician in a clinical setting, you understand the important role that medical consultations play in the everyday responsibilities of your job. Understanding how to manage a consultation and effectively communicate information can make all the difference.

Let’s carefully break down a theoretical case study to master what it means to effectively communicate during medical consultations.

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The Case

Initial Findings

It’s a typical shift for Jeff, an internal medicine PGY-1 finishing up his only month of Emergency Medicine of the year. It is late in his evening shift, and Jeff is on the way to see a new patient: “bed seven.”

He performs a history and physical on a 52-year-old female patient who reports leg pain. 

The patient states she fell while riding an electric scooter earlier that night, going about twenty miles per hour and landing awkwardly on her right leg.

Since then, she has had difficulty putting weight on her leg and has worsening pain. On exam, Jeff notices tenderness to palpation in the lower third of the tibia. 

Her initial set of basic labs from the ED are unremarkable, but she claims to be in severe pain. Her vitals are stable and Jeff suspects a possible closed tibial fracture but is still awaiting the X-ray results. 

Consulting with Another Department 

Jeff decides to consult orthopedic surgery for their evaluation and presents his patient over the phone. He casually states that the patient fell off a scooter and injured her leg. He suspects a fracture based on his exam but the patient’s X-ray results are pending. Ortho says it is not an emergency and that they will lay eyes in the morning once the results are out.

Around 6:00 a.m., Jeff receives the X-ray results for bed seven as he finishes his shift. The findings on the report show a displaced tibial shaft fracture.

He acknowledges this and informs the patient prior to signing out to the next EM intern, Cassie. He gives a brief one-liner on his patient and then begins the handoff using the I-PASS method. Jeff finishes by listing the remaining to-dos for the patient in bed seven, including following up with the orthopedics service.

Shift Change and Juggling Cases

Cassie acknowledges the sign-out and relieves Jeff. She pages orthopedics but moments later has to respond to a level one trauma case in shock room two—a pediatric patient who was accidentally shot by his older brother. As she manages this gunshot wound, orthopedics returns to her page. 

Hours later, Cassie goes to check on her patient in bed seven. She seems to be at baseline but screams in pain when Cassie examines her leg. The leg is clearly swollen, but Cassie assumes that is likely due to the fracture.

Cassie scrambles to her phone and pages for orthopedic surgery. The orthopedic team diagnoses the patient with compartment syndrome and prepares her for surgery. Afterward, the two teams discuss the case, miscommunication, and ways to improve.

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The Commentary  

The General Routine of Consultations

Consultation and collaboration among colleagues and specialists are unavoidable in the practice of medicine. Various practitioners work in a team to provide optimal patient-centered care. When multiple clinicians are involved, there are often challenges, especially with communication between the medical team. 

In this hypothetical scenario that is written to mimic a real ED case and consultation, the focus is on the effective and closed-loop communication that should be used when placing consults. In the hospital setting, residents should understand the process of consults.

Consultations are placed over a verbal phone conversation, typically between a primary physician and a specialist consultant. The physician ordering the consult should briefly present the patient in question, providing: 

• Relevant past medical history
• Medications
• A brief hospital course
• The reason for consultation, often in the form of a question

The consultant has an opportunity to ask any questions and offers recommendations after rounding on the patient. Please note that the consultant can also reject the consult or defer until a later time if they deem it inappropriate or if more urgent cases are present. 

Why This Specific Case Matters

This particular case demonstrates why communication and timely follow-up is essential when calling for a medical consultation. In the above scenario, Jeff did not convey the severity of the patient to Cassie, who did not follow up with the consultant. Perhaps with more information, such as a timely X-ray read, both parties would have seen this as a patient who is at risk for compartment syndrome.   

It did not help that this occurred during the night shift, with a skeleton crew of staff. Likely if more nurses were available to check up on the patient, or if more radiologists were on standby to read the X-ray and provide the report faster. Or, if Cassie did not have to deal with an emergency gun show wound. However, remember that in the ED—in this case, a level one trauma center—busy nights can happen. 

As a result of multiple communication issues, necessary care was delayed, and the patient deteriorated and had to undergo a potentially avoidable surgery.

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Tips to Strengthen Communication & Etiquette

To improve for the future, it is important to reiterate the etiquette for consults. In particular: 

1. The requesting physician should call with an appropriate and specific question in mind to be answered by the consultant, who should address the question asked. 
2. Introduce yourself and verify you are speaking to the correct consultation service.
   • Note: Though technology such as email, text messages, and electronic requests via EMRs are helpful, they should not replace verbal communication in the consultation process.
3. Speak clearly and start slowly, especially if you’ve woken a consultant from sleep.
4. State the patient’s name and medical record as well as the urgency of the consult. 
5. Keep in mind the time you place the consult. If a consultant finishes their shift at 4:00 p.m., avoid placing a 3:55 p.m. consult if you can.
   • Note: Most consults occur during business hours, but in the ED, some may occur in the middle of the night.
6. Be focused on your presentation and direct with your question.
7. Tailor the presentation to the specific service.
   • For instance, if you consult renal, you should have basic labs. To contrast, if you consult ortho, you should mention an x-ray or other imaging in your presentation.
8. Give your consultant time to ask questions about the patient, whether it’s labs, exam findings, imaging etc.
9. Be tactful in your conversations.
   • Telling a surgical consultant, “You need to take this patient to the operating room” vs. “I have a patient who I believe has an orthopedic emergency and needs to go to the operating room.” Hear the difference? One sounds better. 
10. Document the consultation. Your note can help the next team confirm that the consult was placed and the questions addressed. Be sure to include the consultant’s name, service, the time you spoke, and a brief note.
    • For example: “Time of discussion 1630, the case discussed with Dr. Johnson of infectious disease. His team will see the patient in the AM for osteomyelitis and offer antibiotic recs.”  

Teamwork between physicians and their consultants leads to improved outcomes for patients. We all have experienced a difficult interaction with a colleague, but keep in mind that situations can be helped along with clear communication and frustrations should not be taken personally. Treat everyone with respect and expect respect in return.

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The Bottom Line

Like with other aspects of medicine, there is an art to communication and consultation. Mastering this will not only strengthen your interactions with colleagues, but it will also improve patient care and your overall satisfaction on the job. 

Rehearse your presentations and remember to discuss pertinent information to communicate effectively. Learning how to handle professional interactions early in your training is a skill that yields dividends as you progress through your career.

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