Blog | Wednesday, September 28, 2016

The problem of too many consultants


Recently I communicated with a patient's mother in another state. She had great angst when a series of subspecialists gave her different opinions on the ongoing plan for her grown son.

This problem happens too often in 2016. Each subspecialist seems to see the patient solely through the prism of their expertise. We have seen 1 consultant call 3 or 4 other consultants.

Many hospitalists will tell you this story. At many community hospitals the consultants do not just provide an opinion, but rather they write orders. This practice leads to confusion and sometimes conflict amongst the subspecialties.

Several years ago, I watched a video in Canada about this problem. The video discussed a patient with chronic obstructive pulmonary disease, left heart failure and chronic kidney disease. The patient told the story of how each subspecialist gave different opinions on medications. When the patient switched to 1 good internist, his management was much more clear and the patient benefitted.

Having too many consultants without a designated lead physician resembles the sound that you would get from jazz musicians who each want to play their instrument without regard for the other instruments. Great jazz ensembles communicate, and generally have a conductor.

Thirty or so years ago, during the heyday of managed care, internists and family physicians (both specialists in their own right) received the label of gatekeeper. We always hated that term and the implications that it carried.

What we need from outpatient specialists and inpatient specialists (hospitalists generally) is conducting. We are and should be the conductors for our patients. We may ask the pulmonologist for an opinion, but we should make the final decision on that opinion. We have the responsibility to balance multiple recommendations and to limit the number of consultations to just those that are absolutely necessary.

Too many consultants sometimes means that no 1 physician is really in charge. That is not good for patients. Our patients need us to take responsibility for integrating multiple medical problems, polypharmacy and complex social situations. Only when we consider all factors can we develop a logical “game plan” with the patient.

Subspecialists provide value input to patient care, but too many subspecialists seeing the same patient too often create confusion and conflict. All hospitals should require one physician to integrate all the information and make the final decisions about treatment and testing. To do otherwise too often creates cacophony.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.