by Ara Salibian, MD (@AraSalibianMD)
The scenario is all too familiar. It’s midnight after a long day in the OR, and shortly after getting home, your sleep is inevitably interrupted. After some quick self-motivation, you call back a page regarding a consult for a digital laceration. The resident on the line mentions a “young” patient who sustained an injury “probably a few hours ago” with what “looks like a deep lac” and “lots of bleeding”. Further inquiry yields little information; the mechanism is unknown, as is the patient’s hand dominance, occupation and smoking history. A vascular exam was not performed and unfortunately, lidocaine was used to block to digit for pain relief prior to obtaining a sensory exam.
This scenario, and many other similar situations, may commonly present to a consult resident. Beyond invoking frustration, they can lead to delays in treatment, and even worse, inefficient and suboptimal care. Understanding how to appropriately and efficiently manage consults is a critical skill that extends far beyond residency.
The field of plastic surgery encompasses an immensely diverse array of problems and solutions. Plastic surgeons care for many different types of disease processes and therefore inherently work closely with multiple other specialties. The large breadth of information across the field translates to a wide variety of different scenarios that can present to a consulting physician. Over the span of several hours, I have managed to field consults for complications of fat grafting in another country, a digit amputation, cellulitis, a comminuted mandible fracture, a decubitus ulcer, and a lower extremity open fracture, among other things; likely a humble list compared to experiences from more veteran residents. Plastic surgeons are the ultimate problem solvers, and must therefore be capable of handling the ultimate problems.
In academic settings, the junior resident is often relegated to the front lines of the consult service, functioning as the initial responder to consult requests. This can be a difficult and intimidating responsibility that not only requires the necessary fund of knowledge and skills to handle relevant problems, but also the appropriate demeanor and attitude to communicate with and assist referring services. The latter aspect can often be very challenging. Breaking down the process to basic principles offers a simpler method of navigating consults fluently.
The role of a consulting physician can be defined as the responsibility of offering expert advice or intervention for a particular problem. While residents at the forefront of this process may not be the experts, they have the foundation and resources to coordinate the necessary care. Treating consults in this manner, as requests for assistance in caring for a patient that lies within our area of expertise, allows for the development of an appropriate approach to managing these situations.
Within this overarching perspective, specific principles can be summarized by a well-known quotation:
A surgeon is judged by three A’s: ability, availability and affability
Paul Rexnikoff (1896–1984)1
The “three A’s” are likely recognized by every medical professional by time they graduate from at least medical school and surely residency training. Though they are relatively generalized terms, these characteristics offer concrete and directional guidelines for successfully working with referring teams and specialties.
Availability is likely the most important tenet of the three. Being timely to see a consult is critical for several reasons. Foremost, the nature of the problem, and therefore it’s urgency, is not always accurately conveyed or understood over a phone call. Consults that seem minor may be serious, and vice versa: potential replants have turned out to be papercuts and lacerations can become revascularizations. The only true way to confidently assess the gravity of a consult is to see the patient yourself. Increased wait times can affect treatment,2 and furthermore, a timely response is a courtesy to the requesting team as well as to the patient
Always being available, however, can be difficult. Multiple consults, more urgent issues, clinic responsibilities, operating, fatigue and many other factors can make the prompt evaluation of patients near impossible at times. Several strategies, however, can be used to circumvent this problem. Efficiency and time management play a large role in all aspects of residency and are acquired skills. Practice makes perfect, and with practice, evaluation and management of patients will become much faster. Along these lines, triage is also critical. Determining the patients that must be treated first and those that can wait streamlines the process and minimizes unforeseen errors. Finally, establishing contact early can be very helpful, even if you do not have time to complete treatment initially. Evaluate the patient quickly, and notify the referring team that you have seen their consult and will return to finish the process. This allows for appropriate triage, while closing the loop of communication and reassuring the referring providers and the patient.
One’s “ability”, can be defined as the skill, competency and capability needed to successfully execute a task. As residents (and even after residency) our ability will continuously be developing. However, many things can be done to maximize our ability at this point in training. Reading and continually learning to build knowledge is the core of any residency. Understanding and mastering the relevant background information for particular issues will help one ask the appropriate questions to a referring team, and subsequently improve efficiency and formulation of a plan.
Teaching is also a fundamental aspect of learning, and can importantly be used to help referring specialties optimize the management and workup of patients prior to requesting consults. In the appropriate situations, and if the respective parties are receptive, passing along relevant information can expedite patient care and improve patient safety. For example, obtaining the appropriate labs and imaging for decubitus ulcer patients or performing an accurate hand exam and avoiding compromising measures such as oversewing bleeding vessels or injecting local anesthetic prior to examination in hand trauma patients. These issues must be approached carefully, as to avoid seeming condescending, but when communicated appropriately, can improve efficiency and minimize unnecessary errors.
Lastly, the concept of affability ties all three tenets together. In the face of increasing pressure, stress and liability, frustration can seep into conversations and convey impatience, disinterest and disrespect. Not all consults will be appropriately managed or even appropriate. However, these issues can be correctly handled by maintaining professionalism and referring any problems to more senior personnel in a stepwise fashion. Communication is key, and personal frustration and disagreement can hinder patient care. Treating everyone with respect (attendings, residents, and medical students alike), whether they are correct or incorrect sets an appropriate benchmark for others and promotes a healthy relationship among healthcare teams to optimize the co-management of patients.
Becoming an efficient, effective and courteous consult resident does not happen overnight, and is only one aspect in the continuum of plastic surgery training. The same skills developed to appropriately handle consults in residency will apply to managing case referrals outside of training, regardless of one’s practice. Efficiently utilizing one’s knowledge base to solve problems in a timely manner while maintaining a respectful relationship with colleagues is a universal and highly useful skill set. Building upon these basic principles while continually advancing self-development and education will offer rewarding experiences, promote the development of gratifying professional relationships and allow for the opportunity to provide optimal patient care.
1. Schein M, editor. Aphorisms & Quotations for the Surgeon. Shrewsbury, United Kingdom: TFM Publishing; 20041. Schein M, editor. Aphorisms & Quotations for the Surgeon. Shrewsbury, United Kingdom: TFM Publishing; 2004
2. Mahmoudi E, Swiatek PR, Chung KC. Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter? Plast Reconstr Surg. 2017;139(2):444-454.