The Challenges of Consultations By Neal E. Flomenbaum, MD, Editor-in-Chief

Among the many factors that keep patients in emergency departments longer is the occasional need to summon consultants to help diagnose and treat their problems. Unless the consultant happens to be in the emergency department seeing another patient, some time will pass before he or she arrives. When called, a consultant may be treating a more seriously ill patient elsewhere or be scrubbed in the operating room. But it is important to remember that when a consultant is asked to come to the emergency department, two patients are usually waiting for that consultation to take place—the patient on the stretcher and the patient in the waiting room waiting to get onto that stretcher.

Consultations provided by house officers in teaching hospitals present additional challenges. In the October 22 Archives of Internal Medicine, an Agency for Healthcare Research on Quality study on medical errors involving trainees picks up where the Institute of Medicine’s explosive 2000 study on medical errors leaves off. Although not specifically noting how many, if any, of the cases involved consultations, the new findings contain some unsettling implications for patient care in outpatient settings such as emergency departments.

A random sample of 889 closed malpractice claims from 2002 to 2004 considered four categories responsible for 80% of all such claims: obstetrics, surgery, missed and delayed diagnoses, and medications. The study revealed that 240 (27%) of the errors (occurring between 1979 and 2001) involved trainees whose role in those errors was judged to be at least moderately important. Residents were involved in 87% of those cases, 72% involved judgment and communication errors, and 70% involved what the authors refer to as “teamwork factors"—especially lack of supervision and inadequate or improper handoffs.

As the ACEP publication Foresight noted in 2002, EMTALA requires physicians on call to emergency departments to respond within a reasonable period of time, and the Center for Medicine and Medicare Services defines that further as 30 minutes for true emergencies in large cities. Both of these rules appear to apply mostly to out-of-hospital physicians as opposed to physicians-in-training who are physically present in the hospital.

There are virtually no national standards for resident consultations that address response time, level of training, and the nature and degree of supervision. The difficulty of factoring in concerns about patient care and safety, resident education, work-hour restrictions, and attending physician responsibility and then trying to apply all of this to reasonable standards in the outpatient setting perhaps explains why none exist.

Although resident education is an important goal in teaching hospitals, most emergency physicians request a consultation (especially during off hours) when a problem is beyond their expertise and scope of practice. In such cases, clearly defined responsibility, supervision, and follow-up—either in person or via telephone—from an attending physician on the consulting service are important.

At the same time, the overall responsibility of the emergency physician for managing the patient does not automatically end when the consultant appears. There are many times when a physician who is not capable of performing a specialized procedure is nevertheless aware that it needs to be done—and even when and sometimes how. When the proposed plan of care does not include that procedure or when it appears that the patient will require additional care afterward, the emergency physician is still at least partially responsible for doing everything possible to provide it. n

Emerg Med 39(11):8, 2007