Some tips for effective infectious disease consultations
DO be courteous and appreciative no matter how ridiculous you think the consultation is. Consults are your lifeline.
DO identify the question(s) asked of you.
DO answer the question(s) asked of you.
DO try to change a curbside into a formal consultation. You’ll be amazed at what was left out or misconstrued when you actually talk to the patient and review the chart yourself.
DO communicate verbally with the primary service or other pertinent consultants on the case. You will always uncover hidden questions or concerns.
DO gather data from all sources. No, no-one else is calling Hospital B and C’s microbiology department for
cultures done there in X time-frame.
DO ask the patient what their explanatory model for their illness is. I admit this is a strange one. The patient might shoot back “you are the physician aren’t you?”, and might automatically think you clueless so be selective in whom you pose this question to. But more often than not, patients tend to reveal a historical point they’ve told no-one else that might be helpful in your evaluation.
DON’T be shy in being intrusive in the patient’s life. Assuming that old people do not have sexual intercourse will not help you diagnose an STD in an octogenarian.
DON’T assume the reason for consultation is all there is to the case. “Cellulitis – not responding to antibiotics”, may not be cellulitis at all but rather sarcoidosis in which simply broadening the antibiotic coverage or switching antibiotics is not going to help. I sometimes evaluate a patient from the standpoint that the diagnosis to date is wrong. Pompous I know, but I figure “if they knew what they were doing, they wouldn’t be asking my opinion”. Which is why I plough through with rude patients who don’t want to talk to “yet another doctor because everything is in the chart”. No, patients, everything is not in the chart!
DON’T be verbose in your consultation. Honestly. Be comprehensive but concise.
DO be reasonable and cost/resource-conscious in workup. Just because you’ve generated a broad differential does not mean that you now order every single test and study known to man and start multiple antimicrobial agents to cover everything. The primary service could have done that. Knowing when to pursue certain tests and what antibiotics to start and when to start is part of the nuances of our art.
DO have a contingency plan verbalized or charted. After all, you are human and your first diagnosis or treatment plan may be wrong or inadequate. Like Gregory House, MD you DO want to keep re-evaluating your list of differential diagnoses especially if the patient is not responding the way you expect them to.
DON’T be afraid to just observe the patient…even off antibiotics. This in itself is a plan of
action. It’s not “doing nothing”. This is another nuance in the art of being an infectious disease specialist.
Internists, particularly infectious disease specialists, are often called “fleas” (as in “the last one to jump off a dying dog”)…I suppose this is derogatory but don’t let that deter you, DO keep patients on your radar (at the very least) as a simple issue early in the hospitalization may turn out to be a more complex one (related or not) later down the line… Besides, the primary service today who is covering the patient that was picked up as a transfer from a different floor or different service is ignoring the upward trending leukocytosis because “ID is on the case” or “per ID” as eloquently copied/pasted day after day after day…
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