Mastering The Inpatient Consult Service

Every few months I have the pleasure of teaming up with one of my fellows (and often a resident, and sometimes a medical student), to evaluate hospitalized patients with known or suspected rheumatic diseases as part of the inpatient consult service. This is quite a change from my typical day as a rheumatologist, where I see patients in an outpatient clinic.

On occasion, patients with known rheumatic diseases land in the hospital—the patient with lupus and worsening kidney disease, the patient with gout and a severe flare, the patient with vasculitis experiencing a relapse. At the same time, many patients are admitted for workup of unexplained symptoms—joint pain, fevers, rash—or develop these while being treated other conditions. For these patients, we are asked to evaluate for the presence of rheumatic diseases.

Having just finished covering the inpatient rheumatology consult service, I am reflecting on my week and have identified 15 factors that help you achieve a successful week.

Hausmann’s Rule of Rheumatology: always question the original rheumatic diagnosis.Rheumatology is a challenging field in which many diseases don’t have specific diagnostic tests. Instead, rheumatic disorders are diagnosed based on the pattern of the history, physical exam, and laboratory tests. It really is an art and a science. As a result, those unfamiliar with the intricacies of rheumatic diseases may misdiagnose patients solely based on bloodwork (e.g., diagnosing “lupus” in a patient with only a positive ANA and joint pain). Over time, these diagnoses may get perpetuated in the medical record, and you end up having patients with concurrent diagnoses of lupus, rheumatoid arthritis, vasculitis, and fibromyalgia, who may have none of those conditions.It is essential to understand how patients were initially diagnosed….Were uric acid crystals found in a swollen joint? Were history and laboratory features consistent with diagnostic criteria? Was a biopsy done that confirmed the disease? What were the findings from the bone marrow? You may be surprised by what you find out.
Take every opportunity to learn about the patientWilliam Osler said, “listen to your patient; he is telling you the diagnosis.” In addition to talking with the patient, you should also ask family members and friends who know the patient well to contribute to the history, (“What have you noticed?” “When did things get worse?”) as they may have important insights to share…but only if you ask them.It is also important to perform a comprehensive “chart biopsy”. from the medical records, as things may surprise you. A patient I saw had a red, swollen ear, which may have been caused by relapsing polychondritis, a rare immune-mediated inflammatory condition of cartilage. However, in examining her records, it turns out that two years prior she had presented with “cellulitis” of the nose that was treated with antibiotics (she had forgotten about this). The finding of chondritis in more than one area is more suggestive of relapsing polychondritis and makes me want to be more aggressive about her treatment.
Learn about the medical problemStudies have shown that physicians regularly identify gaps in their knowledge during patient encounters, yet they don’t always pursue the answers. During this week in the consult service, I learned about the potential side effects of propylthiouracil, manifestations of sarcoid in the gastrointestinal tract, causes for small-vessel vasculitis, management of familial Mediterranean fever during pregnancy, treatment of rheumatoid arthritis in the setting of heart failure, dysphagia in Sjogren’s syndrome… Clearly, I’m a young attending and still feel like I have a lot to learn. But perhaps it is this feeling that makes young doctors provide better medical care.
Question your assumptionsWorking with trainees is a wonderful way to question your assumptions. For instance, when I mentioned to my fellow that TNF inhibitors are contraindicated in CHF, she knew the primary literature on this topic and explained to me how this conclusion was made. Initially, TNF inhibitors were tested in patients with CHF–not RA–and it led to worse cardiovascular outcomes. In RA, however, the data doesn’t support TNF inhibitors as a cause of CHF. In fact, the practice of questioning may be an effective way to improve medical care and medical education
Generate a generous differential diagnosisIn evaluating a patient that seems to have a slam-dunk diagnosis, also consider all the potential alternatives that could explain the patient’s symptoms, and document what argues for or against the alternative diagnoses. This cognitive bias, called anchoring, causes us to fail to change our minds about a diagnosis, even when new information argues against it. For instance, we were consulted on a patient with abdominal obstruction and initially anchored our diagnosis to a rheumatic cause. However, we failed to consider the possibility that it could have been cancer…which now seems to be the leading diagnosis.
Take every opportunity to teachTeaching during the consult service is a unique opportunity for learning at the point of care…where others (the inpatient team) have already identified gaps in their knowledge that you can easily fill. Take the time to seek out the inpatient team and have a face-to-face discussion with them about the problem, your approach, and recommendations. Avoid just giving them a to-do list. Get in the habit of teaching at every opportunity, even in your notes. And don’t forget to teach the patient as well!
Make sure stuff gets done rightAs a consultant, you are not directing the care of the patient, but rather offering management suggestions to the inpatient team. This has its benefits, in that you can focus on the big problem (and can defer the management of constipation or repleting of electrolytes to the team), but it also has its drawbacks in that you don’t always get what you ask for. For instance, you may ask for a beta 2 glycoprotein antibody but a beta 2 microglobulin is ordered instead. You may ask for a CT scan of the sinuses, but the team instead prefers a CT scan of the chest. Also, be sure to keep a list of all pending labs and check them regularly. Attention to detail is often what distinguishes a great physician from a good one.
Know the guidelines, but be flexible in their interpretationGuidelines are usually written by really smart people based on the available evidence. For the most part, their recommendations are better than whatever you can come up with on the back of your team census list. The variation in health care quality throughout the country could be improved if more physicians followed established guidelines more often. However, there may be times when following the guidelines may not be the right thing to do for your patient, maybe because of their comorbidities, wishes, or other circumstances. In these cases, by all means, deviate from the guidelines and discuss why you’re doing so. As in writing, you need to learn grammar to be a great writer, but you don’t always have to follow the rules.
Manage your time wiselyIt is extremely challenging to serve the inpatient consult service while continuing to do everything else you’re supposed to be doing (seeing patients in clinic, conducting research, teaching, spending time with family…). As a result, you have to be strategic about when you want to see new patients, which other patients may need to be seen, and in what order. Good fellows should see all (or most) of the patients on the service every day, seeing which patients are doing well and which may need a change in management. Having seen the patients, fellows should play the lead role in organizing rounds.
Don’t refuse consultsIf the primary team asks for your help, it’s usually because they’re at a loss and think you may be able to assist. They probably don’t know any better. If the problem is not rheumatologic, take the opportunity to teach the team how to differentiate rheumatic illnesses from other etiologies. For instance, reviewing how inflammatory joint pain differs from those of mechanical causes can greatly aid their clinical care and perhaps prevent future consults. Unfortunately, most physicians have had very little exposure to rheumatology throughout their training, and many are intimidated by the field.
Try to get your consults done on the day they are requestedThe inpatient team may try to “ease” the consult request by saying: “it’s not urgent…you can see them today or tomorrow.” If you can, try to see them the same day the consult was asked. You never know what “tomorrow” will look like, whether you will have ten consults, have to trudge through a snowstorm, or whether you will be ill. If you can see the patient on the same day, do it! You may also expedite the workup and management of the patient, reduce costs, and may even help to get the patient home earlier!
Ask for and provide feedbackLet your team members know what they’re doing well and what they could be doing better. Ask them what they enjoyed about the week and what you could have improved. It’s the only way to get better. In many professions that seek expert performance (sports, music, even business), coaching has become a routine part of the culture. Yet most physicians are hesitant about receiving feedback from anyone: If I managed to graduate med school, pass all my exams, and sweat day and night for years during my residency, who are you to tell me how to improve? However, the evidence of coaching to improve performance cannot be ignored.
Care for the patientReally.
Let the trainee takes the leadIn addition to the care of the patient, part of the role of the consult service is the education of medical trainees. This can only happen when the trainee independently interviews and examines the patient, reviews their medical records, and comes up with an assessment and management plan on their own. Trainees should take the lead in discussions with the patient and the medical team. Trainees should dictate management…of course, not if it would harm clinical care. Unless you have clear evidence that your steroid tapering regimen is better, why not allow them to dictate the dose and duration of the taper, even if it’s not what you would have done?
Reflect on your experienceReflection is a metacognitive process that allows you to process and understand your experiences—what worked, what didn’t work—and in doing so, become better in events. In order to become an expert, it is not sufficient to acquire knowledge and skills; you must also employ a deliberate process of reflection to improve your performance.