Throughout residency training, we have all encountered physicians who are more inclined to consult subspecialists. As a trainee, we may have even altered our own practice habits to align with a leader’s predilection for consultation. More often than not, we probably didn’t probe further into the reasoning behind the desired consultation.
In this issue of Hospital Pediatrics, Kern-Goldberger et al. sought to investigate physician decision-making considerations in obtaining subspecialty consultation among pediatric hospitalists (10.1542/hpeds.2023-007589). In previously published work1, Kern-Goldberger et al. identified substantial variability in consultation practices for 15 common pediatric conditions, describing physicians with frequent versus infrequent consulting behaviors, with those in the upper quartile having a 2.3 times higher rate of consultation than those in the lowest quartile. They enrolled 6 participants from each of these previously identified groups with whom to conduct qualitative interviews about drivers for consultation.
Analysis of interview transcripts revealed many factors associated with consultation that were grouped broadly into four categories: individual physician; patient, provider team, and family characteristics; hospital and organizational characteristics; and professional culture. Individual factors included comfort with managing a particular medical condition, and previous knowledge and experience. Importantly, involving consultants to arrange for long-term follow-up was noted as part of the multifactorial decision process. Unsurprisingly, family concerns and desire to maintain a good relationship were cited as reasons to seek consultation. Lower functioning teams and higher familiarity with the consultant were also reported as reasons for seeking consults more frequently. The reputation of the hospital was perceived to influence families to expect involvement of subspecialists, while increasing use of information systems such as direct text messaging allowed hospitalists to utilize “curbside consults” to potentially decrease unnecessary consultations. The impact of professional culture, namely expectations of colleagues who would assume care of the patients, clinical practice guideline recommendations, and availability of subspecialty consultants were also deemed to play a role in the decision.
This article demonstrates that the process of deciding when to involve subspecialty consultants is varied and complex. After reading, I hope each of us will reflect upon our own practices and seek to identify opportunities to reduce overconsultation, in an effort to strive for high-value care, and importantly to promote equity amongst the different patients that we care for. We should challenge our learners to first think about their own diagnostic workup and differential for a patient, before moving on to identify the gaps that a consultant can fill. We should also encourage discussions about the social and situational factors that drive the consultation, exposing trainees to the “gray areas” of medicine by vocalizing our thought process in requesting a consultation. Both of these actions are important for showing trainees the uncertainties within pediatric hospital medicine and setting them up to develop and reflect on their own practice styles.
References
- Kern-Goldberger AS, Dalton EM, Rasooly IR, et al. Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists. JAMA Netw Open. Mar 1 2023;6(3):e232648
