Consult Commandments

Patrick:

Welcome back to Behind the Knife. This is Patrick Geoff, acute care surgeon at Duke University. Let's talk a bit about the surgical consult, shall we? Mastering the surgical consult is definitely a milestone in every young surgeon's career, but it's not easy. It is a difficult transition from the lowly data gatherer to the Mighty data synthesizer.

And it is in many ways an art form. Is there anything more beautiful than brachy down a complex, convoluted patient presentation into an immaculate assessment and plan? Something so bulletproof that the attending surgeon has been left speechless, no further questioning, no clarification of the patient's medical history, and no hemming or hawing about what to do.

And I'll tell you something. As an attending who staffs countless consults, a flawless presentation with a strong assessment and plan nearly brings a tear to my eye, and that is why today's episode. It's such an important one, and I'm joined by Dr. Joey Lev, a second year general surgery resident Duke, who is also a true gem of a human being and someone who just knocked

her consult rotation outta the park.

Joey recently put pen to paper and with the help of her colleagues, wrote an instant classic 10 consult commandments to dominate the day. Joey, welcome. Thank you. I'm excited to be here. Alright, Joey, so what are the 10 commandments that you and your classmates developed? Okay. One. Have a system. Two. Trust.

No one expect sabotage. Three, always ask at least one. Why? Four, always look at the imaging yourself. Five, don't worry alone. Six, don't bury the lead. Seven, never lie eight. Include a real assessment and plan in your note. Nine goals of care are important and individual and 10 over communicate. Gosh, they're all so juicy.

It's a strong list. So what prompted you to write these and to expand on that on each of them? Yeah. Co consults are really challenging. They require a whole range of different skill sets, triage, rapid synthesis of new information, the ability to piece together a narrative. And I found myself turning to these core principles every time

I wanted to write them down.

So the next set of folks coming through could have some guiding principles as they start to see consults. And they all come directly from mistakes I've made or patterns I've observed. Yeah, certainly agree. Consults really test the trainees metal, and that's why I like these commandments so much. So we're gonna start with number one, which is have a system. So what does your system look like, Joey? Yeah, the first thing I'm looking at is acuity. I'm checking vitals drips, making sure I have a second to spend at the computer, and don't need to immediately run over or walk over to the patient.

Then labs, micro imaging, major comorbidities, prior surgeries, blood thinners, immunosuppression, every time it's a long list, uh, but it has to happen. Then I'll check the ED note for their reported presentation, uh, and or they'll gimme that on the phone, uh, if it's an ED consult and if it's inpatient. I'll look at the h and p, look at the most recent note.

Just try to get a sense of why they're here and what's happened since they arrived. Yeah. How about you, doc? Yeah, I absolutely still have a system I use when seeing consults. And it's much like you said, I always take a moment to dig deep through the

charts, try to look at the old notes, especially operative reports and discharge summaries, which are easier to find nowadays in terms of, sifting through the old documents.

And if I'm not well versed on the pathology that I'm about to see, I'll take a minute, to read about it I also write stuff down, whether it's on my little sheet of paper, I carry around with me for consults or on a sticky note, which it happens more and more frequently because there's nothing worse than wasting a much of time digging through a chart and then having to re-engage with that exact same information later when, writing an attestation or a note.

And , I really like to ask patients some key questions to get a sense of their day-to-day activities. And really how robust they are. So I tend to ask , where do you live? Are you working? Do you drive? Do you take care of stuff around the house, walk with or without assistance?

Can you climb a flight of stairs. What's the most strenuous activity you do? And it really gives you a sense about, how robust that patient is, and especially if you're thinking about operating them, stratifying that risk. Alright Joey, next is trust no one and expect sabotage.

Is that a cynical

approach to what we do? No, I mean, I, I don't think so. And here's why. Generally speaking, every team's doing their best to provide excellent care to the patient. But not everybody knows what's important when it comes to a surgical consult. And physically examining the patient is more or less intrinsic to different specialties.

So the resident that tells you the patient doesn't have pulses because they're not familiar with how to do a pulse exam, is not trying to sabotage you. But if you take their exam as the truth, you're off to a really bad start. So the more eyes on the patient looking at them fresh. Thinking through them completely, the better for the patient.

So do your due diligence and don't expect others to do it for you. Couldn't agree more. And this goes for all activities in the hospital. So dot your i's, cross your T's, take care of your, your own business every single time. Number three, always ask at least one. Why? So what do you mean by that? Why is the patient on Eliquis?

Why did this 30-year-old have a colonoscopy? Why does the patient take steroids? Does the patient with heart failure had a recent echo? And what did it show? You'll, you'll be presented with a lot of data when you first go to look at a consult and a little

bit of curiosity goes a long way. And to fully characterize the patient in terms that can be actually acted on, you have to go one step deeper than the one-liner the chart gives you.

But you also don't wanna get totally lost, in all the data. So while one Y is necessary, five might be counterproductive. Yeah, a little mental switch, right? Especially when you're really busy, you may just start plowing through things, collecting as much information as you can. You see that patient quickly, staff them quickly.

But to your point, asking that why will oftentimes get you to that next level and identify something really important about that patient. Number four, always look at the imaging yourself. It's really essential skill for surgeons.

And if reading CT scans overwhelm you, we do in fact have a video on behind the knife called How to Read a CT scan. So if you need some help reading CT scans, check it out. It is definitely the 1 0 1 approach, but gives you a good foundation for doing so.

Yeah, that's, that's a great video. I've watched it a few times. I think the advice I always get is, , look at the scan, then look at the read, then look at the scan again, because you wanna become well versed in interpreting your own imaging. But it's also important to remember, right,

that we have radiologists for a reason, and the radiologist is your friend.

So if it's, , your impression and their interpretation then aren't lining up, call them and talk it through. 'cause they don't have the clinical context that you have and you don't have their radiologic experience. But together, and over time, you'll, you'll start to figure it out. Teamwork does, in fact make the dreamer.

Next is number five. Don't worry alone. Amen. Joey, why is this so important? Yeah, I mean, our education is important and our growth is important, but the patient comes first always. So if people don't know, you're out of your depth, they can't help you. And the sooner you activate help, the sooner it comes and the right series of steps can happen for the patient.

And as a resident, what you can handle and what quakes your boots will change with experience. But as soon as you get the sense that this is not a you sized problem, you should get your senior, your fellow, your attending on tech. Yeah. Yes, yes, yes, yes and yes. So don't worry, alone, load the boat, call your senior or your staff right away.

And I think on that note as well, you should document what you do. So this goes for all providers, including attendings. If you evaluate a sick

patient, drop a quick note, just a few sentences we'll do. It shows that you were there, that you recognized the patient was sick, and that you developed. A plan.

Alright, number six, don't bury the lead. Yeah, I honestly didn't realize how important this was until I had interns calling me with consults. But it's much easier to follow a story if you know what you're listening for. So I'm a big fan of a framework. Dr. Chang, one of our chiefs, gave me, , clarify urgent or non-urgent.

Mm-hmm. And operative or non-operative. And then the consult question before diving into a one-liner. So for example, this is an urgent operative consult for pneumoperitoneum, or this is a non-urgent, non-operative consult for uncomplicated diverticulitis. That is such a good recommendation and

it's really, the only way to start a consult. By not bearing the lead, you appropriately frame the entire. A conversation, are we talking about an xap for dead gut or a sacral ulcer that matters when the patient has a medical history? That's five pages long.

And I'd also recommend anyone staffing, , depending on your system to share the patient's name, MRN and

location in addition to the reason for the consult at the very beginning. Number seven, never lie. Yeah, I think, everyone has their things that as an intern, they, miss for me personally, I most commonly missed simple vascular things.

And you know, the temptation to say you felt for a popliteal when you didn't, or you took that dressing down and you didn't, , is real. It's a real temptation, but you can't do it. You'll ruin your credibility, you'll hurt patient care, and you'll become a part of the problem explicitly. . So it'll feel bad to have missed something.

I've certainly felt bad, but we're not born knowing what to look for for every consult. We're in training, so the goal is to learn from it and to remember next time. Yeah, I agree. The attendee almost always knows, so don't lie. It's a really bad look. Just say, I don't know, and I'll get back to you as soon as possible.

All right. Moving on to number eight. Include a real assessment and plan in your note. Yeah. General surgery to follow is not a plan. If the team understands your thought process, you form a good relationship with your consulting

teams. You're a united front for the patient and you're less likely to suffer the consequences of mixed messages.

Also, you're not turfing the consult down the road to be redone by whoever you hand the patient off to because somebody is gonna have to come up with and document a real assessment and plan, and that should be you. I will also say the more I walk folks through my thought process and notes, , and when I call them, et cetera, the fewer re-engagement I get when primary teams turn over Uhhuh 'cause their team change over more than yours does.

Yeah, . There are just so many reasons to write a robust, thoughtful, and thoroughly explanatory assessment and plan in your notes. So it shows that you care. It shows you have been thoughtful, as you mentioned, it provides the consulting team with a rationale for why you made that recommendation and improves communication.

It increases the consulting team satisfaction in regards to interacting with the surgery team, and it helps you by making you actually think. So writing a robust, thoughtful, and thoroughly explanatory assessment plan in your note also hones your own clinical acumen. It's also really helpful in the future

when you, , or anyone else on your team goes digging through the chart to see that patient again.

Alright, number nine. Goals of care are important and individual, especially when a problem is really high acuity.

You wanna know the patient's code status. You wanna know if surgery is within their goals. You wanna know what kind of life would be tolerable for them. , Shared decision making for patients that are incapacitated is really hard. , And that's where calling on family, the DPOA guardian, et cetera, really comes into play.

But the bottom line is we're treating the person not the problem. And we can't do that without knowing what the person would want. Yeah. Understanding goals of care is as important as knowing the patient's ejection fraction or INR or CT scan findings. And all too often the primary team will not have sussed this out in advance of placing a surgical consult.

And unfortunately then that falls on you as the consulting. Resin, which really stinks. , , it's often not ideal for consulting service to, be having this type of conversation at midnight, after meeting the patient and their family for five minutes,

and when the alternatives that are

being discussed is some sort of often disaster hot mess type surgery, which, , has huge implications. , Alas. This is the reality of consult life. And so last but not least, we're gonna do number 10, which is over communicate.

There are so many touchpoint that really should happen when you see a consult. You see them, you staff them with your senior and or attending. You call back the primary team or chart, chat them with the plan and document it and you tell the patient or make sure that the primary team does, and you circle back and close loop with whichever service the patient is going to, to make sure that their resident team also understands and is on board with the plan.

I mean, over-communicate as a phrase makes it sound like it's redundant work. But the reality is that keeping everyone on the same page actually streamlines communication and improves patient care because you don't have a bunch of conflicting narratives floating around in the ether that require repetitive reengagement or delay actually implementing the plan.

Well said Joey, thank you so much for doing this. Now, are you able to send us out with a poem from your debut collection in sensible

losses? I would love to. This poem is called Non Maleficence Plain Woman with Growling Voice, whose breathing was the clanging of out of tune violin strings pulled together in last ditch calibration I brought for you Dickinson and Shaka and Levine.

Whose Amulets against nothing. Were still better than nothing and did not tell you that I stopped the poems before the end. Cut out the sad parts. Brought you only to flowering places. Beautiful. So for more of Joey's really exceptional poetry, check out the link in the show notes. And Joey, send us out.

Until next time, dominate the day.