The Case

A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and fevers. Her laboratory studies were notable for a markedly elevated white blood cell count of 121,000 (normal is 5,000–10,000, and routine infections virtually never raise the count above 25,000, making this level highly suspicious for a hematologic malignancy). The ED physician contacted the hematologist on call regarding the abnormal complete blood count (CBC). The hematologist informed him that she would follow up the labs and see the patient the following day.

Later that afternoon, the patient was admitted to the hospital by the primary medical team and continued to worsen through the night. She became progressively tachypneic with an increasing oxygen requirement, ultimately requiring intubation and transfer to the intensive care unit. The primary team did not attempt to contact the hematologist again overnight, assuming that the information about the patient's tenuous clinical status and markedly elevated white blood cell count had been adequately conveyed by the ED provider and that no acute intervention was required overnight, which is why the hematologist had decided to see the patient the following day. In fact, the hematologist had been told only that the patient had an "abnormal CBC with a pending differential" and that her input might be helpful. She was unaware of the urgent nature of the consult.

The following day, the hematologist confirmed the diagnosis of leukostasis as the result of acute myeloid leukemia—an oncologic emergency for which treatment should have been initiated immediately. Although leukapheresis and induction chemotherapy were ordered, the patient had already developed multi-organ system failure as a result of the delay. She was transitioned to comfort measures and died shortly thereafter.

The Commentary

by Steven L. Cohn, MD

Communication failures are a major safety problem in health care. The 2016 National Patient Safety Goals listed improving the effectiveness of communication among caregivers (NPSG.02.03.01) and relaying critical test results to the correct provider in a timely fashion as important priorities.(1) This case illustrates why clear communication is essential when calling for a medical consultation. In the scenario described above, the referring ED physician did not appropriately communicate the specific reason for consultation and urgent nature of the clinical situation to the consultant, who in turn, also failed to recognize that this was a patient who might rapidly deteriorate. To make matters worse, the admitting physician mistakenly assumed that the ED physician had formally consulted the hematologist and that the hematologist was fully aware of the patient's clinical presentation. As a result of multiple communication failures, necessary care was delayed, and the patient rapidly deteriorated and ultimately died.

A consultation is a formal request made from one provider to another to give their opinion on the diagnosis and management of a particular patient. The requesting clinician may seek consultation for any number of reasons ranging from advice on diagnosis or management issues, confirmation of a treatment plan, risk assessment and reassurance, or documentation for medical-legal reasons. The referring physician must communicate clearly with the consultant so that the consultant understands the reason for consultation and what role he or she is serving with regard to the patient's care.

More than 30 years ago, Goldman and colleagues published "The 10 Commandments for Effective Consultation," to highlight the general principles to be followed by a consultant.(2) In the case described here, the first three principles were not followed. The central reason for the consultation request needs to be clearly stated and understood in order for it to be addressed appropriately.(3) The ED physician did not convey the specific nature of the CBC abnormalities and either did not comprehend the urgency of the situation or incorrectly assumed that the hematologist would determine the level of urgency and the appropriate time course for follow-up. The consultant in turn should have responded in a timely fashion (4) and would have realized the emergent nature of the patient's condition if she had reviewed the primary data—the CBC—herself upon being contacted.

Urgent consultations should be seen promptly, whereas elective consultations can be seen within 24 hours, although ideally on the same day as requested. The manner in which the question or information is conveyed can have a tremendous influence on the consultant's response. A request for a routine or general consult will generate a different response than one asking for specific advice on the management of a particular medical problem. In this case, the referring physician did not emphasize the extreme leukocytosis in a previously healthy pregnant patient, and the hematology consultant approached the problem as a routine one for an abnormal CBC, thereby delaying it until the following day.

Direct verbal communication between the consultant and the referring physician is preferable to communicating via the chart.(3,5) The requesting physician should clearly state the questions to be answered by the consultant, and the consultant's response should specifically address the questions asked. Unfortunately, this is often not the case. One study showed that the referring physician and the consultant disagreed about the primary reason for consultation in 14% of cases.(3) Because of the high frequency of misunderstanding between consultants and referring physicians, direct verbal communication is important to prevent misinterpretation. Ideally, this should be done in person or via phone, creating an opportunity for further clarification and discussion. Clear communication is sometimes particularly challenging in academic settings where, in addition to the referring and consulting physicians, house officers, nurse practitioners, physician assistants, and students often become involved in the consultation process and may not fully understand the clinical question at hand or the response of the consultant. It may be advisable for hospitals to mandate communication between attending physician and attending physician for consultations.

In the era of the electronic medical record (EMR), verbal communication is often lacking. Consultation requests are often made through the EMR, or by email or text message to consulting physicians. The lack of verbal communication may result in inadequate information being provided to a consultant or even worse, failure of a consultant to receive the request altogether. With the advent of telemedicine, consults can now be performed remotely. Telemedicine has the ability to improve clinical quality by expanding access to specialists and services that might otherwise be unavailable in certain locations. Although it is performed remotely, telemedicine consultation still requires direct communication between the referring and consulting physicians to ensure that the clinical question and consultant recommendations are clearly understood.

Clear communication has been linked to strong safety cultures and positive workplace relationships. Standardizing communication between referring physicians and consultants will help ensure that important information is conveyed promptly and that the needs of the patient are appropriately addressed.

Take-Home Points

• The referring physician is responsible for clearly stating the reason for the consultation and describing the level of urgency.
• The consultant must be sure to understand the question being asked and confirm the urgency.
• Direct verbal communication between the referring and consulting physicians eliminates misunderstandings and ensures more effective consultation.
• Overreliance on modern technology (email, text messages, and electronic requests via EMRs) should not replace verbal communication in the consultation process.

Steven L. Cohn, MD Medical Director, UHealth Preoperative Assessment Center Director, Medical Consultation Services University of Miami Hospital & Jackson Memorial Hospital Professor of Clinical Medicine University of Miami Miller School of Medicine Miami, FL

References

1. Oakbrook Terrace, IL: The Joint Commission. National Patient Safety Goals: Hospital Accreditation Program. January 2016. [Available at]

2. Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143:1753. [go to PubMed]

3. Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74:106. [go to PubMed]

4. Horwitz RI, Henes CG, Horwitz SM. Developing strategies for improving the diagnostic and management efficacy of medical consultations. J Chronic Dis. 1983;36:213. [go to PubMed]

5. Pupa LE Jr, Coventry JA, Hanley JF, Carpenter JL. Factors affecting compliance for general medicine consultations to non-internists. Am J Med. 1986;81:508. [go to PubMed]

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