Article:

Pavitt S, Bogetz A, Blankenburg R. What Makes the "Perfect" Inpatient Consultation? A Qualitative Analysis of Resident and Fellow Perspectives. Acad Med. 2020 Jan;95(1):104-110.

Summary:

Consultative care is a frequent component of inpatient medicine, and an opportunity for both teaching and learning. As hospital technology and electronic medical records become more complex there are increasing options for methods of communication between consultants and learners requesting consultation. Utilizing qualitative research methods, this group explored the graduate medical education experience of communication surrounding the requesting and provision of consultative care in a pediatric hospital in California. Themes that emerged indicated that the method of communication used by a resident physician to request the initial consultation affected how a fellow physician communicated with the requesting learner.  Megan Conroy interviewed first author Sara Pavitt.

Interview:

MC: The use of qualitative research methods may be foreign to many readers. Can you discuss how and why your questions were best answered using qualitative methods and briefly explain grounded theory?

SP: The origin of this study came from reflecting on my own consult experiences: some were the best educational experiences that I had during residency and others made me feel uncertain and insecure. I set off to understand what creates the “magic” behind those empowering consults. To answer this question, we needed to fully understand the perspectives of the individuals completing consults at our institution, both residents and fellows. We therefore conducted focus groups, which allowed for free flowing, dynamic ideas to be discussed. Qualitative methods are typically used to analyze focus group data. We determined to utilize methods based on grounded theory.  Grounded theory is a rigorous qualitative methodology which allows theories to be generated directly from the data, without a preconceived hypothesis. Data from each focus group was analyzed to develop codes. The codes are grouped into categories from which themes emerged. Throughout analysis, focus group transcripts were constantly compared to assess for surfacing of new codes and ideas. We chose this methodology to limit preconceived hypotheses from the research team so we could fully understand resident and fellow perspectives and allow emergence of innovative concepts.  

MC: Your study suggests that trainees in your institution prefer in-person communication of consultative care requests and recommendations to improve teaching, learning, and patient care. Have your findings informed or changed standard practice of consultative care within your institution?

SP: We used the results from this study as a rigorous needs assessment to inform an intervention to improve consult communication. The essential consult elements identified in the ‘perfect consult’ were incorporated into a communication framework aimed at standardizing the initial consult request. We implemented this tool throughout our hospital using quality improvement methodology and were able to improve consult question clarity, communication, and satisfaction. Be on the lookout for the manuscript detailing that portion of the study! 

MC: While the focus of consultation is improvement in patient care, what are some methods that can be used to enhance opportunities for teaching and learning?

SP: We discovered that teaching and learning starts during the initial consult request. If the consultee states their thoughts about the case’s differential diagnosis and their own proposed plan, it allows the consultant to immediately identify the global understanding of the consultee and potential gaps in their knowledge. This allows for targeted teaching to occur during that initial conversation. Furthermore, fellows proposed that engagement at the beginning of the consult would lead to greater commitment to the entire process including enthusiasm about providing formalized teaching while delivering final recommendations. Both residents and fellows agreed that teaching and learning can occur with any communication modality, but in-person communication was preferred when delivering final recommendations. Our focus groups identified multiple logistical barriers to in-person communication, many of which could be easily addressed. For example, at our institution, many fellows expressed that they were unaware of the physical work locations of residents. This information is now included in orientation for all incoming fellows. I would encourage institutions to ask fellows about barriers to in-person communication as many may have low-resource solutions.

MC: You found that the framing a resident physician gives to an initial consult, at the time of request, impacted the downstream teaching relationship—how can other institutions apply this finding to optimize consultative care?

SP: Trainees often lack formal training on consult communication. They often feel unprepared and unsure of what information to include within the consult request or uneasy when a consult lacks a specific question. By standardizing the initial consult request with essential consult elements, it gives trainees a framework to feel comfortable and empowers critical thinking while engaging the consultant. From these conclusions, we were able to successfully develop and implement a communication tool to standardize the initial consult request. This intervention required minimal resources and could be easily implemented at other institutions. I would be happy to discuss this intervention with anyone interested!

 

Blog post author

Megan Conroy, MD is Chief Pulmonary and Critical Care Medicine Fellow at The Ohio State University in Columbus, Ohio. She completed residency training at MedStar Georgetown University Hospital and served as the Chief Resident in Quality and Patient Safety at the Washington, DC VA Medical Center. She is completing a Masters of Arts in Educational Studies specializing in biomedical education with interests in entrustment, remediation and quality improvement. She is active in the American College of CHEST Physicians, serving as the fellow-in-training on the Airways Disorders NetWork Steering Committee, a member of the Trainee Work Group, and as a member of the CHEST Physician Editorial Board. Twitter Handle: @DrMeganConroy

 

 

Article author

Dr. Sara Pavitt is chief resident and completing her final year of child neurology residency at Stanford Children’s Health. During residency, she found her passion for medical education and quality improvement research. Specifically, she is interested in the development of innovative educational practices and improving communication in our busy, complex healthcare systems. Next year, she will begin her pediatric headache fellowship at University of California – San Francisco. She enjoys traveling the world, running, and spending time with her family. Twitter handle: @PavittSara