Thread by @VarunPhadke2

1/ “I’ve got a consult for you.”

A standard refrain for subspecialists, but one that often generates significant stress on both ends of the call.

Why?

Q: If you have ever felt anxiety about calling a consult, what was the cause of most of your stress?

2/ Consultation is an indispensable component of medical practice – the field is too vast and new science emerges too rapidly for any one specialty to stay current.

Thus, collegial and effective consultation is essential.

3/ Until recently, most ideas to improve ‘effectiveness’ of consultation focused on ‘mechanics’ & ‘culture’ – timeliness, communication, and professionalism – like the classic “10 Commandments of Effective Consultation”.

pubmed.ncbi.nlm.nih.gov/6615097/

This is the HOW of consultation.

4/ Make no mistake – these are essential skills.

In this context, past efforts to help learners prepare for consults fell into 2 categories:
1-Strategies to systematize REQUESTING of consults (5Cs, CONSULT, PAGE)
2-Strategies to systematize RESPONSE to consults (see last Tweet)

5/ There has been considerably less emphasis on the WHAT of consultation – the cognitive task(s) performed by the consultant.

Frameworks for ‘types’ of consultation do exist:

Kessler et al. 2013 – pubmed.ncbi.nlm.nih.gov/23017469/
Hale et al. 2019 – pubmed.ncbi.nlm.nih.gov/30768469/

6/ While helpful, these 'taxonomies' still center around communication.

As an educator interested in #TeachDx, I’ve been reflecting on how subspecialists contribute to a case from a reasoning perspective.

The goal? A universal conceptual framework for ‘subspecialty reasoning’.

7/ Such a framework could prove useful in many ways.

For instance, it could help us better define:
a) the way consults are requested and performed
b) how to assess and coach subspecialty trainees
c) metrics of high-quality subspecialty care

8/ In a recent perspective, @Denise_M_Connor S Durning @JRencic lay the groundwork for developing clinical reasoning as a core competency.

pubmed.ncbi.nlm.nih.gov/31577583/

It would be a natural next step to extend this focus to subspecialty training.

@MikeMeliaMD @EmilyBlumbergMD

9/ So what would this actually look like?

Let’s start with what we do – consults – & generate a paradigm for the 'phenotypes' of cognitive ‘asks’ we get.

This effectively transfers the burden of generating a ‘consult question’ from the consulting team *to the consultant.*

10/ New consults can be thought of as ‘diagnosis’ problems or ‘management’ problems. Both create reasoning dilemmas.

Dx problems are ‘what’ and ‘why’ questions.
Mgmt problems are ‘how/when’ and ‘who’ questions.

What does this mean? Read on for some ID examples…

11/ Dx problem #1 – ‘What’ Qs

These are cases without an established dx whose ultimate dx may/may not be within the consultant’s domain – i.e. non-specific abnormalities. The consultant must answer: WHAT is the dx?

In ID: Fever + ____. Unexplained eosinophilia. Leukocytosis.

12/ Dx problem #2 – ‘Why’ Qs

These are cases w/ an established dx in the consultant’s specialty – syndrome + confirmatory test – whose pathogenesis hasn't been fully defined. The consultant must answer: WHY this dx (or is there another dx)?

In ID: Bloodstream infxns. OIs.

13/ Mgmt problem #1 – ‘How/When’ Qs

Cases w/ established dx & pathogenesis but uncertain Rx plan. The consultant must consider 3Ts – time/test/treat – thresholds to guide best next step.

In ID: BSI in pt w/ ICD. Immunosuppression in pts w/ OIs. Infxn in tough to sample site.

14/ Mgmt problem #2 – ‘Who’ Qs

The issue is ownership. The consultant must ‘own’ short-term care of the pt b/c of unique access to an intervention (procedure, restricted drug, etc.) OR must 'own' the long-term care of the pt.

In ID: new dx of HIV, OPAT, undifferentiated FUO.

15/ Obviously few consults are just 1 type & usually comprise a blend of Qs.

So what’s the point?

Being meta about consults in this way can help us:
1-be explicit about a subspecialist’s cognitive input
2-assess/coach subspecialty trainees
3-reimagine how to request consults

16/ The cognitive/reasoning contribution for...

Dx Probs #1 – domain-specific schemas/illness scripts
Dx Probs #2 – metacognition (what else is going on?)
Mgmt Probs #1 – navigating test/treat thresholds
Mgmt Probs #2 – metacognition (communicating uncertainty/commitment to f/u)

17/ Assessment/coaching of learners for...

Dx Probs #1 – refining problem representation & DDx
Dx Probs #2 – avoiding bias (anchoring, premature closure, etc.)
Mgmt Probs #1 – developing test/treatment thresholds
Mgmt Probs #2 – communication skills

18/ Re-imagining consult requests for...

Dx Probs #1 – I’ve got sick pt & need help making a dx
Dx Probs #2 – I’ve got dx but want to ensure I'm not missing something
Mgmt Probs #1 – I’ve got dx & need help w/ best next step
Mgmt Probs #2 – I’ve got dx & need you to own the case

19/ Here’s a summary table of this conceptual framework.

Within each cognitive ‘phenotype’ of consult I have provided examples of the associated consult question and the cognitive role of the subspecialist.

One could easily imagine milestones within each domain.

20/ Curious to know your thoughts and how to develop this further #medtwitter #IDTwitter #TeachDx!

@ImproveDx @IMreasoning @rabihmgeha @DxRxEdu @tony_breu @sargsyanz @andrewolsonmd @thecurbsiders @JenniferSpicer4 @Amstrw @CarlosdelRio7 @gradydoctor @EmilyAbdoler @MDdreamchaser