The Consultative Process

Life is short, and the art long, the occasion fleeting, experience fallacious, and judgment difficult.

a Hippocrates (460–370 bc ) is considered to be the founder of European medicine. He lived in Greece during the Classic Period and was a contemporary of Socrates, Plato, Herodotus, and others. He is credited with three innovations in medicine: the separation of medicine as an art and science from magic, the development of the written detailed study of disease, and the promulgation of the highest of moral standards that characterize the profession. Descriptive bedside medicine was his forte. His writings showed him to be humble, containing frequent admissions of errors in his thinking in order that others might not stumble in the same manner. This timeless aphorism contains all the essential elements of clinical practice in a concise statement.

—Hippocrates ^a

As long as medicine is an art, its chief and characteristic instrument must be the human faculty. We come therefore to the very practical question of what aspects of human faculty it is necessary for the good doctor to cultivate. The first to be named must always be the power of attention, of giving one's whole mind to the patient without the interposition of oneself. It sounds simple but only the very greatest doctors ever fully attain it. It is an active process and not either mere resigned listening or even politely waiting until you can interrupt. Disease often tells its secret in the casual parentheses.

b Wilfred Batten Trotter (1872–1939) was an English sociologist and neurosurgeon who was very interested in the sociologic aspects of medicine. He is credited with originating the term herd instinct . He was also a surgeon to King George V. This quote (discussing what is currently referred to as presence ) is taken from the chapter entitled “The Art of Being a Physician” by Lloyd H. Smith, Jr., in the 19th edition of the Cecil Textbook of Medicine (W.B. Saunders, Philadelphia, 1992).

—Wilfred Trotter ^b

As a specialist, the hematologist is frequently asked to consult on a patient to clarify or solidify the diagnosis, prognosis, or treatment plan of another physician. Consultation is done in either the inpatient or the outpatient setting and can in turn be requested on a stat, urgent, subacute, or leisurely basis. By inference, the referring physician remains the physician in control of the patient's care, but the consultant's expertise, experience, judgment, wisdom, and even approval are sought to assist the referring physician's concept of the case in its entirety. In this era of cost containment and managed care, expert evaluation is cost effective because it may curtail the diagnostic process, limit unnecessary or even ill-directed testing, and shorten overall hospital time, as well as minimize patient suffering. A well-directed consultation is the best bargain for all stakeholders.

Several papers have discussed the mechanics, elements, and necessities to comprise a proper consult and have suggested that just so many items are necessary in the review of systems or family history to justify a certain billing code. This chapter does not attempt to address such impermanent or administrative matters, but focuses instead on immutable foundations allied with the precepts of internal medicine.

The diagnostic procedure is a fascinating exercise. It involves the most acute use of our senses and the accurate recording of our observations. It requires a logical synthesis of the central nervous system of the responsible doctor, of information from the patient and his family, from other doctors who have cared for the patient in the past, from colleagues in various specialties who are helping with the immediate problem, and from the laboratory. Prognosis and correct therapy depend upon the correct use of the diagnostic process.

c Eugene A. Stead, Jr. (1908–2005) was a primary pillar of American internal medicine. He was born and educated in Atlanta and then went to Harvard University in Boston, where he was strongly influenced by Soma Weiss. He was a pioneer in clinical investigation of the human circulatory system. At 34 years of age, he returned to Emory University as the Chairman of Medicine in 1943 but was recruited to the new Duke Medical School in Durham, North Carolina, in 1947, where he was Chairman for 20 years, founding and elevating that department of medicine to one of the greatest in the nation. He trained innumerable professors and chairs of medicine. Dr. Stead was a master of clinical thought and piercing observations and had a keen wit bettered by none. The two quotes are from E. A. Stead, Jr., What This Patient Needs Is a Doctor , edited by Wagner, Cebe, and Rozer (Carolina Academic Press, Durham, NC, 1978).

—Eugene A. Stead, Jr. ^c

[The] oldest and most effective act of doctors [is] touching. Some people don't like being handled by others, but not, or almost never, sick people. They need being touched, and part of the dismay in being very sick is the lack of close human contact. Ordinary people, even close friends, even family members, tend to stay away from the very sick, touching them as infrequently as possible for fear of interfering, or catching the illness, of just for fear of bad luck. The doctor's oldest skill in trade was to place his hands on the patient. Over the centuries, the skill became more specialized and refined, the hands learned other things to do beyond mere contact. They probed to feel the pulse at the wrist, the tip of the spleen, or the edge of the liver, thumped to elicit resonant or dull sounds over the lungs, spread ointments over the skin, nicked veins for bleeding, but the same time touched, caressed, and at the end held on to the patient's fingers. Touching with the naked ear was one of the great advances in the history of medicine. Once it was learned that the heart and lungs made sounds of their own, and that the sounds were sometimes useful for diagnosis, physicians placed an ear over the heart, and over areas on the front and back of the chest, and listened. It is hard to imagine a friendlier human gesture, a more intimate signal of personal concern and affection, than these close bowed heads affixed to the skin. The stethoscope was invented in the nineteenth century, vastly enhancing the acoustics of the thorax, but removing the physician a certain distance from his patient. It was the earliest device of many still to come, one new technology after another, designed to increase that distance.

d Lewis Thomas (1913–1993) was a native New Yorker and a graduate of Harvard Medical School. He was on the faculty of the University of Minnesota and then became Dean of New York University Medical Center, followed by his appointment as Dean at Yale Medical School. He became president of Memorial Sloan Kettering Cancer Center in New York City. He was a member of the National Academy of Sciences. His ability to translate with both clarity and intense interest things scientific, biologic, and medical into prose readable and enjoyable to the average reader was unparalleled. Three of his major works were The Lives of a Cell , The Medusa and the Snail , and The Youngest Science: Notes of Medicine Watcher , all of which received broad recognition and multiple prizes. The first citation comes from a short piece entitled “Leech Leech, et cetera,” and the second from “Housecalls.”

—Lewis Thomas ^d

There are many facets of the consultative process, ranging from the extent and reason for the consultation to the nature of recommendations and outcomes expected. These are listed in Box 1.1 . Several hints, hopefully helpful, are listed in Box 1.2 .

Box 1.1

The Consultative Process

Extent of the consultation
- Confirmatory consultation
- Brief consultation
- Comprehensive consultation
- Urgent consultation on a catastrophically ill patient
- “Undiagnosing” consultation
- Telemedicine consultation
- Curbside consultation
Reason for consultation
- Helping another physician
- Second opinion requested by the primary physician
- Second opinion requested by the patient
- Second opinion requested by a third-party payor
- Other third parties
- Disgruntled patient or family
- Inappropriate consultations
Consultant's point of view
Duties of the referring physician and consultant
Timing
How to do the consultation
Role of the clinical laboratory
Recommendations
Concerns
Outcomes
- Total agreement
- Supporting consultation
- Finding another physician for the patient
- Consultant assumes primary care of the patient
- Serious troubles
- Redirecting thrust of a workup
- Major disagreements between physicians
- Duration of consultation
- Noncompliant patients
- End-of-life issues
- Family members
- When a diagnosis is not forthcoming
When should a consultant request a consultation?

Box 1.2

Hints to Increase One's Consultative Diagnostic Acumen in Cases Refusing to Be Diagnosed

Most newly diagnosed “great cases” are not solved by a newly developed imaging technique, genetic screen, or esoteric referral laboratory test result; those have usually already been done by the time a new physician “cracks” a difficult case. Most of these Grand Rounds cases are solved by the consultative team that repeatedly digs and redigs into the baseline data selection that was either incomplete or inaccurate on admission and not followed up appropriately. Indeed, these errors tend to be erroneously perpetuated by new consultants accepting at face value admission electronic medical record (EMR) entries for past medical history, past surgical history, family history, social history, and occupational history. If these are labeled in the EMR as “not available” or “noncontributory” on admission yet neither completed when the patient has improved to the point where the intake data can be readdressed nor especially when family members or colleagues visit, one can nearly guarantee that any new consultants will assume they are still “noncontributory” in order to save time. One of the weaker aspects of the EMR is the ease of which disinformation or no information can be perpetuated using cut-and-paste shortcuts. Based on my consultative experience, I hereby offer 10 hints that, although admittedly are time consuming, have proven to be richly rewarding in beginning a new hunt for an elusive diagnosis. In Box 1.3 , I offer 10 of my own examples (one for each “hint”), hoping they might stimulate such interest in others' consultative diagnostic abilities.

1.
If a patient has been admitted several times and improved during each hospitalization only to relapse following discharge, one should strongly consider that something in his home, environment, or work may be the cause.
2.
For a patient with long-term chronic nonspecific weakness, fatigue, or adult “failure to thrive,” ask when the patient last felt well and ask the patient to be as specific as possible.
3.
Ask who filled out or helped the patient fill out the multipage health questionnaire before an appointment and was this task taken seriously or perfunctorily executed. Would you trust your life on it?
4.
Is the family history really noncontributory?
5.
If notes from the referring hospital document that a biopsy was made, did anyone tell the patient or family the results?
6.
Did “pending results” from the referring hospital ever get resolved?
7.
For recently acquired acute illnesses that not only are undiagnosed but are worsening, ask the patient and/or the family or friends each and everything done in the previous month to include such things as trips, vacation, new medication, a new hobby, a new pet, a new home or a new roommate, or even a new job. You are looking for clues while trying to joggle everyone's memory.
8.
If you are quite certain that your tentative diagnosis is correct, yet your patient avoids or denies a key decisive fact, explore any reasons the patient may have for doing so.
9.
Just because an expert in another field excluded your diagnosis that actually falls more into that expert's field does not mean that you are wrong and the other expert is correct. One must sometimes display one's mettle even if it is within someone else's field.
10.
Never fail to consider factitious illness; if this is never considered, it is never diagnosed.

Box 1.3

Some Personal Examples of 10 Hints to Increase One's Diagnostic Acumen

1.
A patient repeatedly had weakness, tiredness, and headaches while at home, only to quickly improve with admission, yet relapsed when returning to his environment. These symptoms were noted each winter, and we became suspicious that this may have been chronic carbon monoxide poisoning. Indeed, an examination of his home heating system showed exhaust leakage. Repair resolved all the problems. Other cases that have fallen under this same category include poisoning by exposure to rodenticide (so-called superwarfarin) with repeated bouts of hemorrhage.
2.
A patient had seen several hematologists for mild normocytic, normochromic anemia, and weakness that had defied an explanation for 10 years. I was shocked when I asked the patient when she last felt perfectly well, and she stated “It was October 4, 1998.” I asked her to explain such precision. She said that all mothers knew the date of her children's birth, and that was the date of birth of her fourth child. I inquired how that delivery went, and she replied she didn't remember much but she was very ill, that she was in shock and bleeding from postpartum hemorrhage. I then inquired whether she had nursed all of her babies; she replied that she had breastfed her first three babies, but her “milk never came in” for the fourth baby. She confirmed that she had had no periods since that delivery, thinking it was just because she was getting older. I suspected she might have Sheehan syndrome, and indeed testing showed that she did have significantly impaired pituitary function with secondary hypothyroidism and hypoadrenalism. When she was appropriately treated, her anemia resolved and her energy improved. Other responses to this question have included one was well until a trip to the desert Southwest and apparently contracted coccydiomycosis. Others began to feel bad since they were started on a new medicine, with β-blockers being high on that list.
3.
We were asked to consult on a patient entering the third trimester of her fourth pregnancy who had just moved to this area from a distant city. This pregnancy was 10 years after her previous pregnancies. Her referring obstetrician was new to her, and her office staff asked questions of this patient regarding her intake medical history. The new obstetrician was curious as to whether the patient's swollen left leg might indicate a pregnancy-related DVT, yet in part discounted that idea because her intake form had noted a negative response to the question as to whether she had had any prior “thromboses.” We were quite convinced this was a DVT and asked the patient to confirm whether she had had any previous “thromboses,” and she confirmed that she never had but did admit to having “blood clots in my leg” with the third pregnancy. We then ascertained that the person helping her fill out the form was essentially a clerical employee with minimal medical knowledge, evidenced by the fact she did not know that a “thrombosis” is the same as a “blood clot.” Sometimes personnel with the least knowledge are given such a task, often at the patient's peril.
4.
I was sent a patient diagnosed with ITP for consideration for a splenectomy. The referring hematologist's notes stated that the “family history is noncontributory.” The patient said that she had been resistant to all manner of drug treatment for ITP to include rituximab. We also noted that the patient had had some nephritis and that her platelets were enlarged with an MPV of 15. As our doubts that she actually had ITP were formulating, we discussed the possible role of splenectomy, and she said, “You know, my identical twin had similar problems, and her splenectomy did not help.” At that time it became blatantly clear that the patient had hereditary macrothrombocytopenia and did not have ITP; at least this twin was spared splenectomy.
5.
We saw a patient for anemia who was transferred to our hospital for fever of unknown origin following coronary artery bypass surgery. During the history we found that the patient had undergone a bone marrow biopsy at the referring hospital. Both the referring physician and my fellow had read the final biopsy report as nonspecifically abnormal. Despite the “family history is noncontributory” EMR entry, we got a history of heavy exposure to mycobacterial infection because his mother was confined to a sanitorium during his childhood. The official print-out of the bone marrow biopsy from the referring hospital was a three-page document, in which it was mentioned that “the edge of the biopsy appeared to show extensive granuloma formation,” yet that information was not contained on the three-line summary. It was only by reading the entire document we discovered that a granuloma had been seen. We deduced his latest atypical mycobacterial infection had been reactivated by stresses from his heart surgery.
6.
A patient had had a fever of unknown origin in a referring hospital and was transferred following a 1-month evaluation. She had had innumerable tests done for what appeared to be a pneumonitic process for her fever of unknown origin. My fellow recognized that there were some “pending” tests, specifically bronchoscopy cultures for slow-growing organisms. He called the referring hospital's microbiology laboratory, and the pleasantly surprised laboratory technician explained that the cultures were just growing out luxuriant Nocardia . One wonders how long it may have taken this information to reach the patient's health care providers had we not pursued that line of evidence.
7.
A healthy young man had been admitted to our hospital for delirium, confusion, and fever several days prior, and a diagnosis had not yet been established. Near the end of the first week he developed thrombocytopenia, so we as hematologists were consulted. Not only was he not getting better but was getting worse and becoming more delirious. He had been very healthy. We asked what had happened in the past 2 to 3 weeks. We centered on his bride's explanation that following their wedding in June they had gone camping for the latter part of that month and early July in North Carolina. Having a fever of unknown origin that was quite atypical and now with multisystem deterioration to include thrombocytopenia and having been in North Carolina, I asked her if she recalled if they had had any tick exposure. Her forceful enthusiasm in affirming that question led us to promptly diagnose Rocky Mountain spotted fever, which is endemic in North Carolina in the summer months. He and his thrombocytopenia rapidly responded to the correct antibiotics.
8.
A 70-year-old woman was found to have an abdominal aortic aneurysm (AAA) and came to our hospital for an endovascular repair, following which she was referred back to her local vascular surgeon. Within a few weeks he noted a significant decline in her platelet count and abnormal coagulation tests. She was urgently referred back to us, and we were the initial physicians to examine her in our institution. Indeed she did have mild thrombocytopenia and prolonged partial thromboplastin time but on examination also had an enormous pulsatile mass in the area of the endovascular repair. We asked her time and again whether something had gone wrong, and she time and again denied it. As a day or two more went by, she continued to deny that anything had happened. We became increasingly convinced that some accident had occurred, and finally after days of our inquiring, she admitted she had tripped over her granddaughter's toys and fallen across a stool, striking her abdomen quite forcefully, which explained the avulsion of her AAA repair. When asked why she had withheld this information, she said she was afraid Medicare would cease taking care of her because of her own actions, and also she didn't want her grandchild to get in trouble. The endovascular device was repaired, and she returned to normal health.
9.
A young woman was referred to hematology by her attending neurologist for a “hypercoagulable workup” following a stroke. She was not a smoker and denied any use of cocaine or similar drugs. I asked her what was going on prior to this strokelike event, the symptoms of which had by now largely disappeared. She stated that a week before, while on her honeymoon, her husband insisted they go skydiving. Apparently she had some difficulty jumping out of the plane and remembers “twisting my neck so that my head almost spun off” owing to the force of the wind. I immediately thought that she might have had a cervical artery dissection and the exposed endothelium may have attracted a conglomeration of platelets that embolized a few days later, causing her stroke symptoms. The referring neurologist told me she had had appropriate imaging of her cranial vessels. I recall getting the nerve up to call the neuroradiologist who had read her vascular studies as normal. I asked him to look again very closely at the films because I was quite convinced it was far more likely she had had a cervical artery dissection than any “hypercoagulability” that I was asked to evaluate. He resisted but promised to do it. I received a phone call an hour later that indeed there was a flap that they had initially missed. One's diagnostic certainty cannot be simply negated by the fact that the true diagnosis was arguably in someone else's domain.
10.
A 22-year-old woman had been repeatedly seen by numerous hematologists for “recurring purpura” that was quite remarkable sometimes but totally absent other times. Innumerable coagulation tests were done, which were all negative. When we saw her, she had a fresh crop of large purpuric lesions, which had the peculiar distribution of being in the skin only over both biceps and triceps. There was a hint of linearity to these lesions. She seemed to enjoy talking about the sudden onset of these lesions and how painful they were but did admit she was happy when they seemed to spontaneously resolve. We did not repeat any laboratory tests because these had all been done ad nauseum and all had returned normal. Our diagnosis was that these lesions were factitiously induced. On questioning, she finally admitted to placing large binder clips used to hold approximately an inch of paper on these areas and leaving them on for several hours despite the pain. It was uncertain what her secondary gain might be, but we did consult the psychiatric team, who noted that she was rather histrionic. Although she was being readied for further therapy, she was found to have “escaped” from the hospital during the night.

Extent of the Consultation

It is essential that both the referring physician and the consultant have in mind the extent of consultation requested, which will in turn govern the aim and comprehensiveness of the consultation.

Confirmatory Consultation

In the situation of a confirmatory consultation the referring physician is quite comfortable with the diagnosis, prognosis, and treatment. He or she generally wishes the consultant to focus on efforts already made and to corroborate those findings. This type is frequent in the second-opinion consultation or one in which the referring physician needs encouragement, as well as perhaps some advice garnered from the consultant's experience. These consultations are therefore focused, often brief, yet may involve reviewing substantial previously collected data. In general, the consultant does not need to request extra tests.

A subtype of the confirmatory consultation exists when the referring physician does not think the services of the consultant are indicated but, because of uncertainty or pressure from family members, wishes the consultant to document such in the chart. The most common reason for not using specific services is severe illness in the patient, which would make the consultant's services worthless, futile, or even contraindicated by unnecessarily extending the dying process. Examples in hematology might include evaluation for mild thrombocytopenia in an intensive care unit (ICU) patient with multiorgan dysfunction syndrome (MODS) or determination of whether a “hypercoagulability workup” is indicated in an elderly patient who is dying of carcinomatosis yet has developed new deep vein thrombosis (DVT). In such cases the referring physician should indicate to the consultant that the consultant's opinion is more important than services. The consultant should not be reluctant to see such patients, yet brevity is in order.

Brief Consultation

In a brief consultation, the questions are more broad based and in a patient who has received appropriate diagnosis and treatment commonly involve long-term issues, such as length of therapy with glucocorticosteroids in a patient with immune thrombocytopenia purpura before one proceeds to splenectomy or the duration of anticoagulant therapy in a patient with hypercoagulability who has developed a major thrombosis. The consultant's long-term experience with many similar patients and knowledge of the literature are often more important than his or her diagnostic or therapeutic acumen.

Comprehensive Consultation

In a comprehensive consultation the referring practitioner may not be a subspecialist but an internist or possibly another physician who needs comprehensive assistance regarding the diagnosis, prognosis, and therapy. This consultation often is generated by surgeons or obstetricians/gynecologists attending a patient with thrombosis who needs thorough evaluation for hypercoagulability. In these situations the consultant more often than not is the manager of laboratory testing and can do this in a cost-effective manner based on his or her expertise. Key decisions are often made by the consultant with the approval of the referring physician. Occasionally, the referring physician will ask the consultant to manage entirely the hematologic aspects of the patient's care, which can be easily done conjointly with the referring physician; if so, this must be clearly understood between the treating parties. A common example is consulting with an obstetrician attending a woman with antiphospholipid syndrome (APLS). Together the physicians can discuss preconception issues, anticoagulant therapy throughout gestation, and anticoagulant management during and after delivery of the child, with the patient and her family.

Urgent Consultation on a Catastrophically Ill Patient

Catastrophically ill patients are often hospitalized in an ICU and may be seen by multiple experts attempting to assist the attending physician in determining a diagnosis. These consultations require subspecialty expertise and a solid knowledge of general internal medicine. Anyone may make the single unifying diagnosis that underpins all manifestations in such extremely ill patients. The consultant hematologist may be the first to recognize that thrombocytopenia in a febrile, confused, azotemic patient supports an overall diagnosis of Rocky Mountain spotted fever, thus corroborating all findings made by all previous consultants.

“Undiagnosing” Consultation

Sometimes the patient's condition may be incorrectly diagnosed and perhaps the patient inappropriately sent to the hematologist. In these situations one must be rather careful to exclude explicitly the diagnosis that the referring physician made. It is both professional and cost effective to rule out the diagnosis that was being entertained. One must carefully garner laboratory data that justify the negation of the working diagnosis and compile corroborating evidence, such as historical and physical examination findings, that may be incompatible with that diagnosis. It is easier to diagnose a patient's condition incorrectly than to undo a diagnosis. One could argue that higher standards are required for undiagnosing an illness than diagnosing that illness. An example is when a physician seeks the hematologist's endorsement of his or her diagnosis of protein C deficiency only to learn that the protein C level was low because of concurrent warfarin therapy. The incorrect diagnosis not only is wrong but has financial, familial, and insurability ramifications. A forthright consultation will steer the referring physician away from the incorrect diagnosis so that the diagnostic process may be redirected.

Telemedicine Consultations

In an increasingly electronic world, telemedicine (telephone, video, electronic transmissions [e-mail] of medical information) is a reality. The accelerating use of telemedicine has left in its wake numerous unanswered administrative, legal, ethical, and financial questions, yet surprisingly few questions regarding the actual practice of medicine. Telemedicine use lags far behind industry, commerce, and even entertainment in this area.

It is clear that such modern modalities are useful if for no other reason than the rapidity of correspondence and the availability of consultative expertise in more remote and/or underserved areas. Because of uncertainty of the standing of telemedicine consultation, one must be cautious and expect rapid changes and resolutions of these questions from government, professional societies, and insurance carriers. Legal issues will arise, and precedence will be established.

Differing from typical “curbside” consultation (see later) a durable, retrievable, and probably discoverable written record exists, which could impact questions regarding establishment of a doctor-patient relationship. Traditional medicine requires face-to-face interactions and appropriate examination and testing prior to diagnostic and therapeutic consideration. If there exists a previous doctor-patient relationship, then the traditional face-to-face evaluation has been established so that this issue may be moot in such cases.

Perhaps not surprisingly, many physicians are eager to expand in this area. Others have explored barriers and motives in this area, finding that most barriers are actually administrative (licensing or legal) and/or financial (billing and reimbursement).

In 2002 the American Medical Association (AMA) officially endorsed online consultation and billing for these services. A CPT code, 0074T, has been established. In a 2003 policy paper the American College of Physicians (ACP) further urged the Center for Medicare and Medicaid Services to reimburse such services. This subject is beyond both the scope of this chapter and the expertise of this author. The ACP has published an outstanding Policy Paper in 2015 giving thoughtful review and advice in this area. Their 13-point Physician Statement is strongly suggested for the interested reader.

Curbside Consultation

Although some groups quickly condemn “curbside consultations,” they are a fact of professional life. Central to these arguments regarding condemnation versus continuance are two competing horns of this dilemma: perceived increased liability for one's unofficial advice versus enhancing and streamlining daily medical practice. Of course, another possible third point is the absence of official (yet time-consuming) professional consultative fees.

These consults may occur serendipitously in the doctors' lounge, in the hallway, or occasionally by telephone. They are unofficial, and both the “consultant” and the requesting physician must realize that any suggestions arising from this act are not based on a true doctor-patient relationship because there is no traditional history, physical examination, or counseling of the patient; accordingly, no fee is generated. The fact that a true doctor-patient relationship is not established seems to many to relieve the curbside consulting physician of owing a duty to that patient he has not seen.

Liability for injury arising from one's unofficial advice can always be claimed. Considerable case law exists supporting that failure to have an established doctor-patient relationship is key to defending against this alleged liability. One search of medicolegal literature and judicial opinions found minimal, if any, risk.

However, courts have determined in at least two situations a physician who has never encountered the patient does owe that patient a duty. The first is that if a physician is on call for an emergency room, owing that emergency room patient is a duty that is implied by the Emergency Medical Treatment and Active Labor Act (EMTALA). In the second situation a physician on call for his group and/or “covering” for another physician owes a duty to even an unseen patient as he is officially covering for a group or colleague.

A federal case ( Newborn v United States of America ) supported that even considerable and repetitious e-mail consultation between a Walter Reed Medical Center hematologist and pediatricians at a US Army medical facility in Germany did not establish “close management and control” in a disputed wrongful death case. The deciding judge noted that encroachment on such informal consultation would negatively impact accessibility of practitioners to consultation, resulting in grave public policy implications. That decision was upheld in the US Court of Appeals.

Rather, the requesting physician is inquiring in an unofficial broad manner about generalities that may well apply for a group of patients (e.g., those with mild thrombocytopenia undergoing colonoscopy) yet might not apply to any specific patient (e.g., as above but assuming the patient is a Jehovah's Witness). Giving one's professional advice, even without compensation, is central to our professionalism. Practitioners should not abuse this precept either by repeatedly taking advantage of this courtesy or by using the general unofficial advice in a specific official capacity.

In a study of telephonic consultation in pediatric practice, Wegner and associates demonstrated that such communication decreased hospital admissions and visits to the emergency department in that the referring physicians' questions were sufficiently addressed so as to negate the perception that a visit or admission was needed. By studying Medicaid data, for this study alone, nearly a half million dollars was found to be saved, yielding a ratio of $39 saved for each $1 spent funding the Medicaid consultation.

Others correctly state that information provided by the physician to the unofficial consultant can be and often is incomplete, such that the question actually being asked by the physician to the consultant may not actually be the true issue at hand. One study found this to be true in half of their “curbside consultations.” When and if a consultant perceives this may be the situation, a formal consultation request is in order. This same study found that should a more formal consultation be generated, that advice is entirely different from the initial informal consultation curbside request in 60% of such cases.

A name provides an illusion of clarity where there was mystery and gives illness a tangibility which makes it seem more likely to be overcome. This applies not only to the patient but also to the doctor.

e Richard Asher (1911–1969) was a keen English clinician and consummate wordsmith. His writings and lecture style clearly showed that he liked what he did. He excelled especially at the interface of internal medicine and psychiatry. He coined the terms Munchausen syndrome and myxedema madness . His writings and lectures demonstrate that he made cogent observations from the simplest of medical situations and wrote about them in an economic style. This quote comes from a collection of his best essays on how doctors should use words, Talking Sense (University Park Press, Baltimore, 1972).

—Richard Asher ^e

While a doctor's knowledge may be extraordinarily precise for predicting what would happen to a thousand patients with a given condition, as the denominator becomes smaller, accuracy in prediction attenuates exponentially. It nearly disappears when the sample size recedes to unity, namely, when the doctor is called to prophesy outcome for a single individual. It is difficult to apply statistics to an individual patient. The unique challenge in doctoring is to determine where, if anywhere, a particular patient fits on the Gaussian distribution curve derived from a larger population. The decisive factor is the physician's breadth of clinical experience.

f Bernard Lown (b. 1921) graduated from Johns Hopkins Medical School in 1942 and spent his clinical years in Boston. He was a cardiologist of the old school, giving most of his credit as a clinician to Dr. Samuel Levine. Dr. Lown taught a whole generation of clinical cardiologists not only cardiology but also the art of being a physician, with particular reference to listening to the patient and making a strong, empathetic connection. Dr. Lown's contributions are numerous and include seminal observations on digitalis intoxication, use of lidocaine in arrhythmias, the establishment of DC cardioversion, and the establishment of what would become the modern coronary care unit. He won the Nobel Peace Prize in 1985 for his work in prevention of nuclear war. These quotations are taken from his 1996 book The Lost Art of Healing (Houghton, Mifflin, Boston, 1996), which is highly recommended to any physician cherishing aspects we may well be losing as the burden of the technologic approach to medicine increases.

—Bernard Lown ^f

Reason for Consultation

At first glance it seems intuitive that the reason to consult is to help another physician's management of a patient. Although this view is fundamental and time honored, it is not all inclusive. Several reasons exist for the consultation and cover the entire spectrum of the consultant-patient interaction.

Helping Another Physician

This is still the most common reason for the consult to be requested. In these situations the primary physician requests assistance in the patient's diagnosis, prognosis, or treatment while he or she maintains overall care of the patient.

Second Opinion Requested by the Primary Physician

In this situation the primary physician has made a diagnosis and plan, but because of his or her unfamiliarity with the process or because of the seriousness of the illness, he or she requests a second corroborating opinion. In nearly all cases the patient's care remains with the referring physician.

Second Opinion Requested by the Patient

In this situation the patient either has pressed for a second opinion or may have secured the consultation without informing the primary physician. This circumstance should be elucidated early in the consultative process and is probably best done by asking to whom the report should be sent. The patient and family may vary in reasons for pursuing a second opinion, but more often than not it is the result of a benign motivation. They generally wish the report to go back to the referring physician. That should be done with an opening sentence in the consultation letter stating that the patient sought the second opinion and that your information is being transmitted to the primary physician.

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