Health Care Team (HCT)Health Care Team (HCT)

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Consultants

Consultants play a special role within the U.S. health care team model. In contrast to the medical systems of some countries, such as the United Kingdom, where the term “Consultant” is a title for a fully trained and certified medical specialist, in the U.S. medical system, the term “Consultant” refers to a particular role that a member of the health care team assumes.

In the U.S. medical system, a Consultant is someone with special expertise and/or experience who is called upon by a primary caregiver to advise on the diagnosis or management of a medical problem in the Consultant’s area of expertise or to assist in answering questions that are beyond the primary caregiver’s expertise. Most often, Consultants are physicians who are fully trained and certified in their specialties; however, non-physician members of the health care team may also serve as Consultants.

It is important to understand that when a Consultant is called to consult on a patient, the primary caregiver retains primary responsibility for the patient’s management. The Consultant provides expert advice, but it is up to the primary caregiver to take and implement that advice. In rare instances, the primary caregiver may choose not to accept the Consultant’s advice. Since the Consultant’s advice represents the highest level of expertise, the decision not to follow the Consultant’s recommendations should be discussed with senior residents, attending physicians, the Consultant, and, if appropriate, the patient or family, before proceeding (or not proceeding). Notations should also be entered into the medical record reflecting the rationale for rejecting the Consultant’s recommendations and documenting any conversations regarding the decision.

In most hospitals, Consultants are not permitted to directly write orders for patients on whom they are consulting. It is up to the primary caregiver to actually write the orders. However, in some hospitals or in certain situations, Consultants may be able to write orders directly, so it is important to learn local policy.

There may also be local protocols that automatically trigger a consultation in certain clinical situations. For example, in some hospitals stroke patients may be admitted to a general internal medicine service but routinely be consulted upon by a neurologist or speech-language pathologist.

Requests for consultations are usually made by completing and submitting an appropriate form, which should include the reason for the requested consultation and any specific questions needing answers. Such written requests should be followed up with or occur simultaneously with direct conversation between the primary caregiver and the Consultant. Direct conversation after the consultation has been provided is also highly desirable. Due to the busy schedules in most hospitals, it is wise to submit routine consultation requests and make phone calls to Consultants as early in the day as possible. Obviously, requests for emergency consultations can be made at any time.

Although the ultimate responsibility for consultation generally lies with the fully trained and certified specialist, it is common practice for initial consultations to be carried out by residents or fellows who are in training under the supervision of the specialist. The individual may be a resident or fellow specifically training in that specialty or, in some cases, a resident or fellow training primarily in another specialty but who is rotating through the specialty service being consulted. It is important to understand the experience level of the Consultant and his/her level of expertise (i.e., a fully trained and certified specialist, a resident or fellow in training in the specialty, or a resident or fellow rotating through the specialty service). If the primary caregiver is uncomfortable with the Consultant’s recommendations, it is entirely appropriate to request that the supervising Consultant review and endorse the junior Consultant’s recommendations or even come and see the patient. Before proceeding along these lines, however, it may be prudent to first consult with senior residents and attending physicians.

It is also critical that Consultants properly document their consultation and recommendations in the patient’s medical record. In emergency situations it may be necessary for the primary caregiver to verbally receive the Consultant’s recommendations and begin implementation, but it is important that such conversations be documented in the medical record and that the Consultant subsequently make his or her own entry into the medical record as well.

Although most Consultants will be physicians, consultations may also be requested and received from other members of the health care team who have particular expertise. Although most of the discussion above refers primarily to consultations on inpatients, outpatients may also be sent to Consultants. The same general principles and rules applicable to inpatient consultations by physicians also apply to outpatient settings and consultations by non-physician providers.

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