tionsshowed100concordancewithrecommendationsfordiagnosticactionIncontrasttheservicesofgynecologyandgeneralsurgerywhichaccountedfor30ofallconsultsmanyofthempreoperativeassessmentsrespondedconcordan ID: 892923
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1 ___~~~~~~Features_I.NeilGrantConsultatio
___~~~~~~Features_I.NeilGrantConsultationPractice:CompetitionorCollaboration?SUMMARYConcordancewithrecommendations,andtwo-waycommunication,aretwoprimefactorsinconsultation.Theytendtodeterminewhethertheconsultationwillbecompetitiveorcollaborative.Theliteratureshowsthatprivatelyconsultedphysicianstendtorespondwithwrittenreportsfourtimesasfrequentlyasresidentsonhospitalservices,oranyteachingphysician.Theconsultationprocesshasthreeparts:preconsultation,consultation,andpostconsultation.Differentneedsandproblemsariseatdifferentstages.Onelargefactorisrespect,whichneedstobetaughtandencouraged.(CanFamPhysician1982;28:1279-1282).SOMMAIREEtred'accordaveclesrecommandationsetunecommunicationbi-directionnellesontdeuxfacteursimportantsdanslaconsultation.Ilstendentadeterminersilaconsultationenseraunedecompetitionoudecollaboration.Lalitt6raturedemontrequelesmedecinsconsultesprivementonttendancearepondrepardesrapportsecritsquatrefoisplussouventquelesresidentsdesdepartementshospitaliersoutoutmedecinenseignant.Leprocessusdeconsultationatroiscomposantes:lapre-consultation,laconsultationetlapost-consultation.Differentsbesoinsetproblemessurviennent'adiff6rentsstades.Unfacteurimportantestlerespect,quidoitetreenseigneetencourage.Dr.Grant,acertificantoftheCollege,isanassociateprofessorintheDepartmentofFamilyMedicineanddirectoroftheFamilyMedicineResidencyProgramatMcMasterUniversity.Reprintrequeststo:McMasterUniversity,DepartmentofFamilyMedicine,1200MainStreetWest,Hamilton,ON.L8N3Z5.THEPRACTICEofconsultationhasalwaysintriguedme.Atsomelevel,IknewIusedthisaspectofpa-tientcareaspartofmyowncontinuingeducation,yetIhavenotalwaysbeencomfortablewithwhatwasachievedformypatients.Inretrospect,myuseofconsultationshaschanged,andIhavebecomemorecomfortablewiththem.McWhinney'describedbothcomponentsmanyyearsago.Twoevents,outofmany,havestimulatedmetotranslatethatfascina-tionintopersonalunderstandingoftheprinciplesofconsultation.Thefirstinstanceconcernedayoungwomanwithfeelingsofunre-ality.Previouslyshehadsufferedablowtothehead,butneurologicalas-CAN.FAM.PHYSICIANVol.28:JULY1982sessmentrevealednoabnormality.Afteraboutsixmonths,afurtherneurologicalassessmentwassoughtasaresultofherreportingatypical"sei-zures",andbeingadmittedtohospi-tal.Ondischarge,herconsultationnotedescribedadiagnosticlabelandtreatment,neitherofwhichwaswithinmycomfortableexperience.Tele-phonediscussionwiththeconsultingneurologisthelpedfillthegapsinmycurrentknowledge.Thesecondillustrativeexperienceconcernedamiddle-agedparaplegicwomanwithneurogenicbladder.Isoughthelpbywritingtothespecialistpreviouslyinvolvedinhermanage-ment.Theletterinresponsedidnotmentionherdistressaboutherurinaryincontinence,orsuggestmanagementstrategies,butdescribedhercontinu-inglackofmotivationandcompli-ance.Myletterhadnotbeenre-ceived.Neitherspecialistwaswellknowntome,andbothsituationswereopentointerpretation,basedonerroneousassumptions.Firstly,aspecialistmadeassumptionsaboutmycurrentknowl-edge,andsecondly,Imadeassump-tionsaboutaspecialist'slackofre-sponsetomyrequestforhelp.Areconsultationscollaborativeac-tivities?Ihavereviewedpapersonphysicianconcordance,communica-tionandotherfactorsaffectingthepracticeofconsultationinanefforttoexaminethequestion.PhysicianConcordanceInaretrospectivestudy,MacKenzieetal.2examinedtheconcordancewithdiagnosticanddrugrecommendationsgivenasaresultofcardiologyconsul-tations.Drugrecommendationsweremademorefrequentlythandiagnostic,andwereassociatedwithahigherrateofconcordance(82%asopposedto64%).Recommendationstostartther-apywithadrug,especiallyinantihy-pertensiveorantianginalgroups,wereassociatedwithalowerconcordanceratethanrecommendationstocon-tinue,ordiscontinue,drugtherapy.Incontrast,diuretic,antiarrhythmic,andinotropicagentswereassociatedwith100%concordance.Theauthorsfeltthatapossibleexplanationlayinur-gencyofmanagement.Clinicalser-vices,whichaskedforfewconsulta-1279ONE tions,showed100%concordancewithrecommendationsfordiagnosticac-tion.Incontrast,theservicesofgyne-cologyandgeneralsurgery,whichac-countedfor30%ofallconsults,manyofthempreoperativeassessments,re-spondedconcordantlytoonly50%ofdiagnosticrecommendations.Calliesetal.3monitoredhospitaldischargesummariesonthosepatientswhohadhadapsychiatricconsulta-tion.Theyfoundthatpositiverepre-sentationsofpsychiatricconsultationsvariedstrikinglybyservice,from11.1%inthegeneralsurgerygroupto63%inthegeneralmedicinegroup.Popkinetal.,4alsoinaretrospec-tivestudy,foundthatconsultantpsy-chiatrists'recommendationstostartordiscontinuepsychotropicmedicationwereleastlikelytobefollowed.Spe-cificrecommendationsfortheuseofadrugforbriefperiodsweremorelikelytobecarriedout,aswasthecontinua-tionofanestablisheddrugregimen.Ofcourse,implementationofacon-sultingcolleague'srecommendations,withoutdiscrimination,wouldnotin-dicateeffectiveness:compliance,per-haps.Butthesestudiesdidnotdealonlywithactions,butwithpatientas-sessmentsandproblem
2 formulations.Consultingcolleaguesbearres
formulations.Consultingcolleaguesbearresponsi-bilityfortheirassessments,andfeelthatresponsibility.Theydonotactonlyasresources-theywanttoknowwhathappens;hencestudiesofcon-cordance.Ifphysiciansaskforconsultations,whywouldtheynotimplementorpayattentiontoacolleague'sthoughts?Ontheotherhand,perhapstheydointe-gratetheinformation,butdonotac-knowledgethatfact-orperhapsthereasongivenforconsultationisonlypartofthereason.CommunicationSaunders5describesatheoreticalmodelwhichwouldallowafamilyphysician,oranyotherphysicianforthatmatter,tobeclearaboutthenatureoftheserviceherequiresfromacon-sultingcolleague.Healsomentionsthattheconsultation-referralismorelikelytobeconcernedwiththesearchforsolutions.Herightlypointsoutthatinthefinalstageoftheconsultingprocess-followup-adelicatesitua-tionexists,involvingnotonlyphysi-cian/patientrelationshipsbutphysi-cian/physicianrelationships.Hismodeldealslargelywithpatientsandtheirproblems.1280HollisterandMiller6describeaphy-sician'spossiblemotivationsfortheseekingofconsultationas:1.lackofknowledge.2.lackofskill.3.lackofobjectivity.4.lackofconfidence.Inthe'lackofskill'categorytheystatethat"theconsulteeseestheproblembutnothowtodealwithit".Clearly,theyseephysiciansashavingdeficitsinbothcognitiveandpsychologicalspheres,inferringtheabilitytoapplyknowledgeappropriatelyinclinicalsituations.Thatisallverywell,intheory.BarnettandCollins,7inamodeloftheconsultationprocess,includedthreephases:preconsultation,consul-tation,andpostconsultation.Theyem-phasizedtheimportanceoffeedbacktoconsultantsduringthepostconsultationphase.Incontrast,HinesandCurry8de-scribedtheuseofastandardreferralformintheirteachingpractice.Theformallowedthefamilyphysiciantoarticulateclearlytheexpectationsofhisorherconsultingcolleague,anddelineatedtherolesofbothincontinu-ingcare.Awrittenreportwasreceivedfromprivatelyconsultedphysiciansfourtimesasfrequentlyasfromresi-dentsinthesamespecialtyworkinginateachinghospital.Overtheperiodofthestudy,therewasadecreaseintherateofreferraltothatparticularteach-inghospitalservice(18%ofallrefer-ralsto6%overthreeyears).Itisnatu-raltoavoidabadservice,buthowandwhenwillaspecialtyresidentlearntheimportanceofcommunicationwithfamilyphysicians,orindeed,physi-ciansindisciplinesotherthanhisorherown?Afteraresidency?Cummins,SmithandInui9reportedonthereturnofinformationfromcon-sultingcolleagues.Theyexaminedtheresponsesfortimelinessandcompre-hensiveness.Theoverallrateofre-ceivingfollowupinformationwas62%.Privatespecialistsprovidedin-formationatarateof78%,comparedtoemergencyroomsoruniversitybasedspecialtyclinicswhichsentfol-lowupinformationatamuchlowerrate(48%and59%respectively).Theseauthorscomment:"substan-tialimprovementcouldtakeplaceatonceifconsultingphysiciansbecamemoreawareofthesimplefactthatthelocalmedicalphysicianisoftenacon-cerned,conscientiousperson,worthyofbettercommunication".Gold10examinedthelettersofrefer-ralandconsultationbetweenagroupofgeneralpractitionersandpsychia-tristsinVictoria.Hecommentedthatmoreskillinletterwritingmightavoidunnecessarytelephonecallsandlet-ters.ThecriteriaheusedforassessingtheeffectivenessofcommunicationhadbeenformulatedbyWilliamsandWallace11attheGeneralPracticeUnitoftheWelshNationalSchoolofMedi-cine.Theyhadsurveyedagroupofgeneralpractitionersandpsychiatrists,findingthattheleastimportantitemforthepsychiatristswasthegeneralpractitioner'sowndiagnosisofthepa-tientreferred.Wereallydohavealongwaytogo.Aretherolesofcollaboratingphysi-cianssoclearthatnonegotiationbyongoingcontactneedtakeplace?Whenonephysicianseesapatientorproblemdifferentlyfromanother,isthatacauseforjudgmentorinquiry?Itispossiblethatletterwritingmayhaveassumedaqualityotherthanameansofcommunication-amarkofrespect.Myguessisthatthisissue,respect,figureslargeinourcurrentchal-lenges.Butcommunicationtakesformsotherthanletterwriting,andrevealsasomewhatdifferentperspective.Perlsteinetal.12reportedontheim-pactofprovidingatelephone'hotline'consultationandreferralserviceforseveralcommunityhospitalnurseries,atthenewbornspecialcareunitinCin-cinnatiChildren'sHospital.Therewassignificantimprovementinthesur-vivalofinfantstransferredtothere-gionalfacility,butnoclaimthatthiswasasimplecauseandeffectmecha-nism.Reviewoftelephoneconversa-tionsduringthestudyperiodproduced"numerousexamplesofinformalandeffectiveteachingofpersonnelinthecommunityhospitals."Colemanetal.13inadescriptiveac-countofconsultationsbetweenpri-marycarephysiciansandmentalhealthclinicians,reportedthatconsul-tationswerelargely"unscheduled,takingplaceinavarietyofsettings,in-cludingtheparkinglot!"Greatercom-fortoftheprimarycarephysicianinhandlingawidevarietyofemotionalandpsychiatricproblemsresulted.Theliaisonwascontinuousandonsite.OtherFactorsReinkingetal.14studiedtheeffec-tivenessofthreedifferentconsultationCAN.FAM.PHYSICIANVol.28:JULY1982 stylesamongthestaffofahomeforthementallyretarded.Theconsulteeswerenursesinchargeofdifferentwards,andthee
3 ffectivenessofconsul-tationwasassessedby
ffectivenessofconsul-tationwasassessedbythenumberofprogramsinitiatedbythenurses.Theconsultantstyleswere'expert','resource',and'process'.Theexpertconsultantprescribedsolutionstosolveimmediateproblems.There-sourceconsultantprovidedinforma-tionwithwhichthenursecouldsolvetheproblemherself.Theprocesscon-sultanthelpedthenurseformulatenotonlythenatureoftheproblem,butalsoplansforitssolution,andofferedreinforcement.Acontrolgroupcon-sistedofwardsstaffedbynursesineverywaycomparabletotheothers,butwithoutconsultantresources.Dur-ingtheperiodofstudy,andinfollowup,theprocessconsultantmodelwasfoundtobeclearlymoreeffectivethaneithertheexpertorresource.Cherniss15describedanattempttohelpconsultantsinspecialeducationidentifyaconsultee'slevelofreadi-nessforproductiveconsultation.Thepaperseemedtodescribeinrelation-shiptermsmanycognitivedeficienciesamongtheconsultees.Whatisimpor-tant,however,isthataconsultantwasthinkingaboutthepeopleaskingforhelpwithstudents'educationalprob-lems.RudyandWilliams16describedsomepotentialpitfallsfortheprimarycarephysicianinthepracticeofcon-sultation.Theymentionedthatfamilyphysiciansresistreferralbecausetheyfearlosingpatientstoconsultants.Theyalsomentionedthattheremaybeconcernaboutexposingoneselftocrit-icalevaluationbythatprocess.Isug-gestthatthisislesslikelytobeafactorinthecontextofacontinuingrelation-shipbetweenphysicians.BaizermanandHall17highlightphysicianproblemsasopposedtopa-tientproblems.Theydrawattentiontotheconceptofproblemsbeingdiscom-fortsproducedbyinterpretationofdata.Inotherwords,patientshaveproblemsassignedbyphysicians'in-terpretiveskills,andifonephysicianfindsdifficultyinclassifyingaprob-lem,he/shemayseekhelpfroman-other,withadifferentgroupofclassi-fications.Werner,ZellerandWilliams18de-scribedthreecriteriafortheconsultingpathologist:interpretationofdata,rec-ommendationforactionandpresenta-tionofrationale.Theyfoundthattheconsultantrecommendedactionasofteninthefactofuncertaininterpre-tationofdata,aswithdefinitiveinter-pretation(whichisreallynottoosur-prising).Theyhaveaddedadimensiontotheliteraturehowever,byformaliz-ingexpectationsoftheconsultingpathologistasadiscriminatingandcriticalphysician.Morethanthat,thestudyindicatesthatconsultingpathol-ogistsareconcernedaboutpatients,andrespondtothesameforces,de-spitetheirapparentisolationfrompa-tientcare.DiscussionObviously,consultationsaresoughtforaspectrumofreasons.Inbroadterms,thereasonsarephysicianandpatientbased,andinclude,forthephysician,amixofpsychologicalandcognitivereasons.Theliteratureap-pearstodealwithphysicians,orpa-tients;letters,orlackofthem.Inprac-tice,eachconsultationincludespatientandphysiciancomponents,tovaryingdegrees,andservedbyavarietyofcontacts.Ihaveattemptedtopointoutthattheoreticalmodelsexist,andarebeingused,inthepracticeofconsultationbetweenphysicians.Therearepoten-tialhazardsandrealdifficulties,butonefactseemstoemerge.Privatelyconsultingspecialistsandfamilyphy-siciansseemtocommunicateandcol-laboratewellinpatientcare.Why?Ibelievethatitisonthebasisofthephysician-physicianrelationship.Whatarethecriteria?Isuggest1.acommonphilosophy,2.continuityofrelationship,3.communication,and4.complementaryroles.1.Firstofall,physiciansinthecommunityshareacommonprimaryobjective-patientcare.Thatisnottosaythatthisisnotthecaseinteachingcentres,butthelatterhaveanaddi-tionalobjective-education.Ifeelitispossibleforthetwotoexistinhar-mony,butalsothepotentialexistsforcompetition.Ifpossessionofknowl-edgepersistsintopracticeasthepri-maryaimofprofessionallife,ratherthanasameanstohelpingpatientsaspeople,thenwearemorelikelytoseecompetitive,ratherthancollaborative,relationships.2.Physiciansinthecommunityhaveongoingrelationships,thatallowthemtofindoutabouteachother'sprofessionalstrengthsandweak-nesses,knowledgeandskills,experi-ence,judgmentanddiscrimination.Thisknowledgearisesthroughdiscus-sionofsharedproblemsaboutpa-tients.3.Throughsucceedingconsulta-tions,'hot'issuesintherelationshipareresolved,forexample,expecta-tionsincommunication(timingandcontent),expectationsinbehaviorwithpatients,methodsofresolvingandrecognizingconflicts.Themethodofcommunicationislessimportantthanthestyle.Relationshipsovertimeappeartobethefactorinthedevelopmentofmu-tualrespect.Isitperhapsnecessaryforusalltoexperienceeachother'sdisci-plineinordertoappreciateadifferentperspective?Idonotknowtheanswertothatquestion.ButIwouldliketothinkthatwecouldact,evenintui-tively,withinourcurrentresidencyprograms,tofosterlearningtheprac-ticeofconsultation.Thismighttakeseveralforms-interdisciplinarytu-torialgroups,primarycareexperi-encesforallspecialtyresidents,tonamebuttwo.4.Asaresultofsharedexperiences,physicianslearntosupporteachother.This,Iamsure,islargelyunspoken,butwillbereflectedbyconsultationpracticesandcommunications,inbothdirections.Iamsurethatallfamilyphysicianshavesaidtothemselves'I'mtheconsultantinthiscase'.Isuggestthefollowinginitiatives:1.ThattheCFPC
4 'sSectionofTeach-ersextenditsskillandexp
'sSectionofTeach-ersextenditsskillandexperiencetoourcolleaguesintheRoyalColleges,toformagrouptoexaminethiscom-montheme.2.Thatthefacultyoffamilymedicineresidencyprogramsextendtheirskillandexperiencetoourcolleaguesinotherdisciplinestoexaminetheteach-ingofprinciples,practice,andevalua-tionofconsultationskills.Ideally,inmyview,interdisciplinarygroupsofresidentsshouldlearntogetherovertime,aboutconsultation,andarealef-fortbemadetoseekhelpfromourcol-leagueswhosecareersarenottotallyboundtoteachingestablishments.Ifeelthatitistimetorecognize,andex-plore,anddescribethecriticalnatureofexperienceinthefield.Ithasgreatimpactformedicaleducation.3.AresearchthrustbeundertakenbytheCollegeofFamilyPhysiciansinthisarea.Let'sexplorethisparticular1281 boundarybyfindingoutwhatreallyhappensbetweenphysicians.Wemightthenbeabletodescribeskillsandattitudesthatwecanteach.Firstofall,weneedself-respecttomountsuchinitiatives.References1.McWhinnevIR:Thefoundationsoffam-il/medicine.CanFamPhysician1969Apr;15:13-27.2.McKenzieTB,PopkinMK,CalliesAL,etal:Theeffectivenessofcardiologycon-sultation.Chest1981;79:16-22.3.CalliesAL,PopkinMK,MacKenzieTB,etal:Consulteesrepresentationsofcon-sultantspsx'chiatricdiagnoses.AmJPsy-chiatrv1980;137:1250-1253.4.PopkinMK,MacKenzieTB,HallRCW,etal:Consulteesconcordancewithcon-sultantspsychotropicdrugrecoinmenda-tions.ArchGenPsvchiatry1980;37:1017-1021.5.SaundersTC:Consultation-refer-ralamongphysicians:Practiceandprocess.JFamPract1978;6:123-128.6.HollisterWG,MillerFT:Problem-solb-ingstrategiesincon.sultation.AmJOr-thopsvchiatry1977;47:445-450.7.BarnettBL,CollinsJJ:Anewlookattheconsultationcontinuum.JFamPract1977;5:665-666.8.HinesRM,CurryDJ:Theconsultationiprocessandphysiciansatisfaction.CanMedAssocJ1978;118:1065-1073.9.CumminsRO,SmithRW,lnuiTS:Coin-inunicationfailureinprimarycare.CanMedAssocJ1978;243:1650-1652.10.GoldN.Psvchiatricconsultation.AustFainPhysician1978;7:827-833.11.Per/steinPH,EdwardsNK,SutherlandJM:Neonatalhotli/etelephonenetwork.Pediatrics1979;64:419-424.12.WilliamsP,WallaceBB:Generalpractitionersandpsychiatrists-Dotheycommunicate?BrMedJ1974;1:505-507.13.ColemanJV,PatrickDL,EagleJ,etal:Collaboration,consultationandrefer-ralinanintegratedhealth-mentalprogramatanHMO.SocWorkHealthCare1979;5:83-97.14.ReintkingRH,LivesayG,KohlM:Theeffectsofconsultationstyleonconsulteeproductivity.AmJCommunityPs'chol/978;6:283-290.15.ChernissC:Theconsultationreadinessscale:Anattempttoimproveconsultationpractice.AmJCommunityPsychol1978;6:15-2/.16.RudyDR,WilliamsT:Theconsultationprocessanditseffectsontherapeuticout-comee.JFaimPract1977;4:361-363.17.Baizermc7nM,HallWT:Consultationasapoliticalprocess.ComMentalHealthJ1977;13:142-149.18.WernerM,ZellerJA,WilliamsD:Consultationinthecoagulationlabora-tory.AmJClinPathol1981;75:504-508.VerdictDelayedDiagnosis:DidthePlaintiffsHaveaCase?DESPITETHEdifficultiesencoun-teredbecausethedoctorinthelawsuitdescribedonpage1271wasnotpresenttotestifyinhisownde-fense,alloftheallegationsmadebytheplaintiffweresuccessfullyrefuted.However,thecourtfoundthedoctor'sworkhadbeennegligentinonere-spect;hehadfailedtoreadthenurses'notesandtohaveknowledgeofrele-vantinformationinthem-informa-tionwhichmighthavepreventedthecomplicationsoratleastmitigatedtheireffects.Inthecourseofthetrialtheexpertswhogaveevidenceacknowledgedthatbytakingrectaltemperaturesinthepostoperativeperiod,thenursingstaffmayhavecontributedsignificantlytotheanastomoticbreakdownandthesubsequentseriesofevents.Thedoc-torhadbeenawarethattraumatotheanastomosisbyarectalthermometershouldbeavoidedandwroteaveryspecificorderthatrectaltemperaturesshouldnotbetaken.Theorderwasun-derlinedinred.Despitethisorderthenurses'notesindicatedclearlythatrec-talthermometershadbeenusedoveraperiodofseveraldays.Thecourtfeltthathadthedoctorreadthesenotationseachdayhewouldhaveknownaboutthenurses'errorsandcorrectedthem.Thenurseswerejudgednegligentinfailingtofollowwrittenorders,butthehospitalanditsnurseswerenotapartytothelawsuit.Becauseofthesurgeon'snegligence,thecourtawardedsubstantialdamagesandalargeamountofprejudgmentin-terest.Clearlythereisalegalobligationondoctorstoreadnurses'notes;iftheyfailtofulfillthisobligationtheydosoattheirperil.Perhapsthisobligationwasmostaptlysummarizedbyajudgemorethanadecadeagowhenhestated"...adoctorreceivesnoticeofwhat-everhasbeenwrittenintherecordwhenhereadsit,andifheneglectstoreadithecannotbeheardtocomplainthathedidnotknowwhathadbeenen-teredthereinforhimtoread'.3*References1.AresVV[1970]S.C.R.608atp.626.2.AresVV.JludgemenitofMr.JusticeO'BvrneAlber-taSupremeCourt.3.BadgerVS(1970)16D.L.R.(3d)146(SaskQ.B.)atp.169.Foodforthought?Doyouhaveanyquestionsorcommentsaboutsuchequivocalmedicolegalissues?Sendyourqueriesto:MedicineatLaw,CANADIANFAMILYPHYSICIAN,4000LeslieSt.,Willowdale,ON.M2K2R9.We'llattempttohavethemansweredinupcomingissues.Queriesshouldbesigned,butanonymitywillbeprotected.1282CAN.FAM.PHYSICIANVol.28:JULY1982