How to Consult Infectious Disease

As an infectious disease specialist I often help in difficult medical and surgical cases. I am the Gregory House, M.D. of medicine, the expert diagnostician who knows the nuances of various antibiotic treatments and the varied processes of infection. My skill is a cognitive one. Unlike House, real infectious disease specialists do not tend to do the procedures themselves be it drainage of an empyema (lung space infection) or resection of a brain abscess, nor do we primarily read the images.  Like House though, we do have a differential diagnosis as long as our arm and are not afraid to move various diagnoses up and down that list while we await our recommended work-up to prove or disprove them.

That said, most of our business comes from other physicians inviting us to partake in the care of their patient. While we welcome the work, there’s something to be said in the HOW and WHY of obtaining a consultation from us. I just came across an amusing xtranormal video on YouTube that raised a few points.

DO introduce yourself. Even if you end up giving us a shitty consult, we might not be too harsh on you if we realize you are an intern in June or a medical student.

DO know your patients details such as age, medical history, setting of hospitalization, and course to date. Don’t, for the love of God, tell us that you are “just cross-covering”, or that “you just picked up the patient”.

DO have a question and be clear of your expectations of us. We love to answer questions. The medical world already thinks us verbose in our consultations; and I did state above that we generate very wide differential diagnoses, so do yourself a favour and ask us a specific question or two. “My attending said to call” is never acceptable. “I don’t know what’s going on and I was hoping you could take a look and see” though poor form is OK as at least you realize that your patient is sick and you are being an advocate for them. Also, we do know that patients who receive an ID consultation for staphylococcal bacteremia at least do better.

After all, an infectious disease physician does have a secret weapon. It is called asking patients about antibiotics taken before coming to the hospital, asking them if they have an exotic pet/fad diet/foreign travel/unconventional sexual activity, calling the microbiology lab at the hospital from which they transferred for results obtained there.

I once asked a frail married 70-odd year old man with unexplained fevers what he did on his frequent solo vacations to the Caribbean after eliciting that he went to the Caribbean alone regularly. He admitted that he frequented prostitutes which of course led to the diagnosis of acute retroviral syndrome (early HIV infection). I also once asked a widowed 90-odd year old woman, well-functioning considering, newly placed in a nursing home and having recurrent urinary tract infections that were new to her whether she was sexually active. It didn’t pan out to be anything, and she did look at me as if I was crazy, but hey, it had to be asked.

DO ask for help sooner than later. Please, and don’t consult us on the day of the patient’s discharge home.

DON’T (for heaven’s sake) consult us on the date of discharge…and then have the nurse page us throughout the day asking when we will see the patient because the family has come from 2 hours away and want to leave before the blizzard hits, or the ambulance is coming to take them to the nursing home at 1 pm. Poor planning on your part does not a medical emergency for us make, especially when the patient has been hospitalized for more than a day.  This is probably the rudest behaviour ever.

DON’T expect us to provide the basis for your discharge summary. It’s medical folklore that if you want to know what happened to a patient during the hospital course you read the Infectious Disease consultation note because everything will be in there in a chronological order…because of our tendency to be comprehensive and verbose.  I’m honoured. However, I guess I can be particularly spiteful in that regard because if I suspect that’s the real intention behind the request for consultation (eg. an isolated low-grade fever 2 days earlier in a surgical patient who has been in the hospital 2 months and is planned for discharge to a nursing home soon) I will ask you to define your question(s), review the chart in its entirety as I owe the patient my full evaluation, talk to the patient, then summarize the hospital course in as few sentences as possible while still answering your question(s).

DON’T expect me to be your pharmacist or home health nurse. I say “me” because I’m not sure other ID physicians share this qualm with me. The scenario usually goes hand in hand with the last-minute consultation. It’s usually from a surgical service. Usually, evidence for infection is low, but the surgeon has arranged for a PICC  (a long term intravenous access), has started vancomycin IV and writes for an “ID consultation for management” in the same set of orders as the “discharge home with IV antibiotics”. Seeing how I do not run an infusion center (an ambulatory center where one may receive intravenous medications, fluids, and blood products), this is poor form and disrespectful.

I am a physician as well, a diagnostician at that. Invite me early in the case to evaluate the patient and I may agree with you in the end that the patient is better off on intravenous antibiotics and will gladly make arrangements for home intravenous antibiotics and will assume management of any complications with the PICC or the antibiotics. It does not matter how long it took to convince the patient they needed the PICC or how many hoops were jumped through to get it placed, if after my evaluation I decide the patient does not need antibiotics or that oral antibiotics are just as effective, I’m going to recommend that the PICC comes out! That should serve as another reason you should consult earlier than later in a patient’s hospital course because no-one is happy in the scenario just described.

DO tell the patient that you have asked us to see them and for what purpose. Nothing irks me more than patients who are rude to me because yet another doctor has come to see them and can’t we just read the chart?

DO assess the patient before you call for help. I’m a consultant. My note should not be the first note in the medical record.

DO at least attempt a workup. If you are the neurology teaching service and you have a patient with a headache and fever and suspect an infection, do attempt a lumbar puncture for spinal fluid for routine cultures (…and save a bit if you think we will ask for more studies) before you write an order for a consultation for meningitis. #JustSaying.

DO talk to us. Sometimes, it’s easier to pick up the phone and just talk to us. Communicating via the medical chart is poor form. But I realize in some community hospitals, the requesting physician is not really asking for ID recommendations but rather is asking for ID to take over a part of the patient’s care. At one such hospital, I would call the requesting physician with my impression and recommendations and would invariably be told not to bother calling them and just do whatever I felt was necessary in terms of medication switches or imaging studies or consultations to other services.

DON’T consult us (via an order) on a patient we have already been consulted and for whom we have written daily notes. We already suspect that you know little about the patient, just don’t prove us right.

Whew!

That said, I have a few hints for any budding infectious disease specialists out there as to how to be an effective consultant.