Varun Phadke MD Profile picture
Feb 28, 2023 13 tweets 6 min read Read on X
1/
You staff a new consult w/ your team. You share pearls & make a plan.

Then:
🩻 You review the CT w/ radiology.
🤝 You chat w/ another consult service.
🗣️ You deliver your recs at the workroom.
📲 You call night float w/ an update.

So many opportunities to teach!

This week: Image
2/
Last week @JenniferSpicer4 kicked off our segment on "Teaching the Primary Team" by focusing on "The Why."



This week, for "The Who", I want to think beyond just the primary team to identify the many different learners we encounter as consultants.
3/
Why?

Even though the primary team is the obvious audience for teaching - their "ask" is what invited us into the case to begin with! - we usually interface with many other teams in the process of rendering our opinion.

All of these teams have learners we can impact!
4/
And, once we recognize the range of learners we are teaching - explicitly or implicitly - we must also acknowledge that the consult "ask" is just one domain of content about which we can/should teach.

This means we must tailor our teaching to both the learner & their team.
5/
For this 🧵, I'll discuss potential learners on the following teams:
📌 The primary team (who requested the consult)
📌 Other consulting teams seeing the same patient
📌 Teams providing diagnostic information for the case (e.g., radiology, pathology, microbiology, etc.)
6/
Let's start w/ the primary team.

A teacher-learner relationship is “built-in” to the consult interaction.

It can start off on the wrong foot when there are misunderstandings about “where” the learner is.

I previously shared strategies to avoid this:
7/
Intrinsic to that framework is the recognition that the “primary team” comprises a range of people to teach.

This includes:
🩺 Those directly caring for the patient
📋 Individuals covering for the patient
👩‍⚕️ The team leader

We must modify our teaching scripts accordingly! Image
8/
Now let’s turn to other consulting teams.

It’s pretty routine for multiple specialists to be “on board” a complex case.

Despite this, the inter-consultant interaction often gets neglected.

And the primary team ends up as the intermediary.
9/
It doesn’t have to be this way!

As consultants we need to be intentional about this interaction to make it productive.

Learners on other consult teams who are trying to build their own scripts, schemas, and decision thresholds benefit from the wisdom of other specialists! Image
10/
Finally, let’s recognize learners on teams that contribute diagnostic data.

Because radiology, pathology, & microbiology results are so often the trigger for consults, a consultant’s workflow often includes interfacing directly w/ the people that generate those results.
11/
There are two key teaching opportunities here:

1⃣ Sharing of clinical nuance that might shape their interpretation (beyond the limited “reason for exam”)
2⃣ Diagnostic feedback to help reinforce/hone their clinical skills

@StefanTigges @StewartGNeill - any others?
12/
Let's recap:

In this 🧵 we:

📌 Identified learners beyond the primary team that we also have the opportunity to teach
📌 Described the benefits of expanding our teaching efforts to include those learners
📌 Explored broad domains of teaching scripts for each of these teams Image
13/
Next week @JenniferSpicer4 will continue this series on “Teaching the Primary Team” focusing on “The When.”

Remember to check out #SubspecialtyTeaching @MedEdTwagTeam & follow @YihanYangMD @GStetsonMD @ChrisDJacksonMD to keep up with all our threads!

See you next week! Image

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More from @VarunPhadke2

Mar 14, 2023
1/
You’re starting a consult service block.

But this time is different.

-Maybe you don’t have a consult “team” to teach
-Maybe you want to showcase your specialty & recruit interested trainees
-Maybe you want to build ties to other service lines

What to do?

This week: Image
2/
@JenniferSpicer4 and I have spent the last few weeks exploring the "why", the "who", and the "when" of teaching the primary team in our role as consultants.

Now let's turn to the "what".

What repertoire of teaching scripts should we strive to develop as specialists?
3/
1⃣ Content knowledge

It's natural to gravitate toward teaching specialty-specific content - that's our expertise!

We've covered a lot of this territory in prior threads.

I'm going to highlight some of those pearls & point out specific strategies for teaching primary teams.
Read 16 tweets
Feb 14, 2023
1/
2pm. Usual day on ID consults.

Learner: “So the patient had [complex multi-stage procedure w/ prosthetic material] yesterday. Turns out they were bacteremic.”

You: "and...?"

Learner: "They want antibiotic recs...I'm not sure how to approach that..."

You: 🤷

This week:
2/
Consultants are often called upon for input on management.

Typically, this means helping with a clinical decision (which test? which treatment?).

Management reasoning refers to the cognitive processes by which clinicians make those decisions.

pubmed.ncbi.nlm.nih.gov/29800012/
3/
Teaching & assessing clinical decision-making skills is HARD.

Without a framework for the cognitive processes involved, it can be challenging to isolate the specific skills a learner needs to work on.

This leads to unhelpful feedback like "lacks confidence" (which = 🤷).
Read 20 tweets
Feb 8, 2023
1/
You’re staffing a complex patient w/ a learner on your consult team.

As they present it's clear the case was challenging for them.

They get to their assessment & take a breath.

You hit ⏸️ & say…”You know what? Let’s think through this dx together.”

What next?

This week:
2/
Consultants are often asked to assist with diagnosis.

What do we bring to the table?

An easy answer is deeper knowledge of a specific subset of presenting problems & diseases.

Focused clinical exposure means that we develop a unique & rich library of schemas & scripts.
3/
Though specialty-specific knowledge is essential to effective diagnostic reasoning for consultants, it is not enough.

Our unique 'invited' role in cases means we also need to have specific (meta)cognitive skills & habits.

Those skills/habits are part of a teachable process.
Read 18 tweets
Jan 17, 2023
1/
9am. Consults.

Them: “We want you on board because ____ is 'refusing' to do this procedure but ____ says it's needed. You're the tiebreaker.”

You: [sigh] “OK.”

⌛️

Patient: “Ah! ____ said YOU'RE the one holding up my discharge!”

You: 🙄

Feeling triggered yet?

This week: Image
2/
Conflict is inevitable when working within a system.

What do I mean when I say “conflict”? 🤔 For the purposes of this 🧵 let me paraphrase a huge body of literature w/ the following definition:

Conflict is “disagreement” that causes (or has the potential to cause) “harm”.
3/
Let's unpack this a bit more w/ a focus on conflict in consultative care.

"Disagreement" is a broad term.

It can stem from...
↪️ real OR perceived differences in opinion
↪️ about diagnosis OR management
↪️ between the primary team & the consultant OR between consultants
Read 19 tweets
Dec 20, 2022
1/
5pm. ID consults.

On 📞 giving recs re: culture growing Serratia.

Them: TY for seeing our patient!

You: Of course! BTW do you know the hx of Serratia? No? Well let me tell you about Operation Sea-Spray…

⌛️

Them: ...So should we start abx? Which one?

You: 😳

This week: Image
2/
So far @JenniferSpicer4 & I have explored consultant skills pertaining to the consult "ask".

We'll now focus on how to respond to the ask, verbally & through notes.

Let's start w/ a poll of those of you who CALL consults:

What is your PREFERRED way to receive consult recs?
3/
Previous studies suggest that verbal communication of consultant recs – especially initial recs - is preferred by most clinicians.

Additionally, lack of in-person interaction w/ consultants is one factor hospitalists identify as negatively impacting learning & patient care. Image
Read 17 tweets
Dec 7, 2022
1/
Fri. 4PM. You just got consult #8.

Then, a call: "We have a new consult. This patient's been here for 2 weeks. We’re not sure what’s going on & wanted you on board.”

😱

You: "…so, what’s the question…?"

How do we improve this interaction?

This week: Receiving Consults
2/
About 3 yrs ago on a thread about the cognitive aspects of consults I posted this poll:


Nearly 2/3 of >1100 respondents said “anticipated pushback” was the biggest anxiety-inducing factor when calling a consult.

This is a problem.
3/
"Pushback" can be intentional or perceived. Either way it is not a desirable component of consultation (for EITHER side).

This week our focus is the consult request interaction, including its goals & downstream consequences, and strategies to make it more productive.
Read 18 tweets

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