As we usher in a new academic year, students take their first steps as medical interns, and interns transition into senior roles. For many, it is also time for that first job as an attending. Amidst the excitement of a new beginning, it’s important to remember that this is a period marked by a steep learning curve for all of us. I remember dreading calling in consultations as a new intern, and 10 years later I distinctly recall being berated by a consultant hematologist when I placed my very first consult during my first week on the wards. I remember his anger over the phone as he raged that I “did not have all the information he needed” and that my “question is idiotic.” He asked me to “have your senior resident call me” and then told me that I was “unlikely to make it through intern year” before abruptly hanging up. I remember my senior resident later laughing about this and telling me that it was a “rite of passage” to be yelled at by this consultant and that I “should toughen up.”
A decade later, I take this experience with me during each and every encounter with my peers and especially my trainees. The medical culture unfortunately often skips over incidents like this, chalking them up as acts of “tough love” and “part of the learning process.” In a high-stakes hierarchical culture, toxic behavior and bullying incidents are spoken of in hushed tones and rarely addressed in real time. We must do better to promote a respectful and safe learning and working environment.
Over the years, I have incorporated much of the feedback I have received into constantly striving towards professional growth. There has been a lot of trial and error, and a steep learning curve of attempts to do better. Here are a few thoughts on how to foster a collegial culture as a consultant.
- Clarify the consult question.
Many of us are not taught how to effectively formulate a consult question and a lot of conversations start with “I guess I just wanted to let you know about the patient” or “my attending asked me to call you.” This often gives rise to frustration on both ends. Rather than coming across as pushing back on the consult, it’s important to employ an even-keeled curiosity regarding the case presented. Ask the caller, “How can I best help in the care of this patient?” and whether there is a specific question you can answer for their team. This can prevent a lot of frustration stemming from consultants not addressing the actual problem, to learners overwhelmed at being grilled on details they may not perceive as relevant. Utilize this as an opportunity to educate on what information is needed so that they can have it on hand next time they call you.
- Determine the urgency of the consultation.
Some days you will be called in for your 15th consult at 6 PM on a Friday. Systemic issues giving rise to being short-staffed and over-worked can perpetuate the cycle of toxicity in medicine. However, this exhaustion and frustration should not be misdirected towards the other end of the phone. Take a step back and establish when/if the patient needs to be seen. Is the team reaching out to assist in ensuring a close outpatient follow-up? Is this a sick patient that needs to be seen urgently, or are there preliminary recommendations you can provide through chart review before you round on the patient the next day? Formulate a plan together to ensure that the patient is seen within an appropriate timeframe based on the current resources.
- Always remember that the person calling you is asking for help.
What seems straightforward to you may not be for someone who has not practiced within your field. It is best to give a brief recommendation and reassurance rather than condescendingly brushing off a question. Evaluate whether specific educational topics need to be provided to clarify certain misconceptions. Every conversation is an opportunity to teach and to positively contribute to a patient’s care plan.
- Adopt best communication practices.
Is this an urgent and complex situation requiring a phone call or is this something that can be relayed through documentation? Keep the recommendations simple and specific since others don’t have the same knowledge of your subspecialty. For certain niche labs and imaging, you may need to discuss directly with the learner to ensure that they are ordered correctly. Remember that your recommendations may or may not be followed by the primary team for various reasons. Refrain from passive aggressive chart documentation and simply reach out to clarify concerns and other issues you may not be aware of.
- Provide clear contingency plans.
Let people know when you need to be contacted and what to watch for. Clear if/then scenarios will save a lot of back and forth and provide appropriate guidance. This is especially relevant in the care of sicker patients, who are at a high likelihood of clinical decompensation. Make sure that people can reach you for follow-up, especially after hours, and always close the loop prior to patient discharge or signing off.
- Explain your role as a consultant to the patient.
Ensure that your recommendations pertain to your specific role in the care team and are reviewed in a timely fashion with the primary team. There is a lot of angst that arises when patients receive contradictory messages regarding discharge plans, for example.
- Apologize when you make a mistake.
Inevitably, communication may not be what you intended or hoped for. If tempers flare or miscommunication occurs, take a step back and apologize. Establishing a reputation of humility, collegiality, and kindness ensures that people can seek you out earlier than later, which can prevent many complications and delays in care.
- Speak up when you witness mistreatment.
It is our collective responsibility to address unprofessional behavior in real time and to speak up when witnessing incidents of bullying and misconduct. If you are in the position to do so, leverage your privilege to stand up for others and to call out inappropriate behavior. Be the advocate that you wish you had.
In conclusion, setting a professional and collegial standard on communicating with peers and learners as part of a multidisciplinary patient care team is imperative. Fostering a safe learning environment where people are encouraged to ask for help when needed and can clarify expert recommendations without fear of backlash translates into safer patient care and a better work culture.
What are some of your best practices?