How to Deal with Difficult Consultants

Jonathan S. Jones, MD FAAEM

“Are you an idiot?”

“I didn’t know you completed a fellowship in jerkiness.”

These are two questions we’ve all felt like asking some of our favorite consultants, and I’m sure a few of us have uttered statements similar to these. Difficult consultants are quite possibly the worst part of being an emergency physician, and while there will always be difficult people in this world, we needn’t let them ruin our day (or night).

There are ways we can win our battles with these people. Several tactics can help us when dealing with difficult people (and I’d be happy to write about them if this column is useful), but unless we know what we want from our consultant and why we want it, no tactic will help us. If we don’t know this prior to calling the consultant, then we’ve already lost our main advantage—we know more about the patient then the consultant does.

What do we want from our consultants? To unconditionally agree with us, to realize that we are smarter than they are, or to admit that they are idiots? That may feel like a victory, but it is not. We need to shift the focus from ourselves to the patient. What we seek is an admission, an expedited consult, or a guaranteed clinic appointment in the morning.

We also need to determine, prior to speaking with the consultant, if there is an acceptable alternative. I may want to admit my high-risk chest pain patient with normal cardiac markers to the cardiologist, but is it also acceptable to admit him to an ED chest pain unit if the cardiologist promises to check on the patient in the morning and help determine appropriate risk stratification? Maybe it is, maybe it isn’t, but this is something I need to consider prior to calling the cardiologist.

So often I hear my residents asking a consultant to “come evaluate the patient.” Is this what we really want? We’ve already evaluated the patient and determined an appropriate course of action; we don’t need someone else to evaluate the patient. We want a recommendation from the consultant, not an evaluation. Many times, we don’t really want a recommendation either; we want the consultant to execute our recommendation. It sounds simple, but knowing what you want is the first step in getting what you want.

The second step is to know why you want it. I’m not talking about basic medical knowledge (it’s a little harder to fix that), but about the real reasons we want the consultant to act. We’ve all had that elderly patient with slightly elevated BUN/creatinine that we would like to admit for “dehydration and renal insufficiency,” but is the real problem that his only caregiver is his equally frail and elderly wife who has dementia? Don’t hide this from the consultant; tell him what you honestly want and why you feel it’s necessary. It’s easy for a consultant to argue that mild dehydration isn’t the same as acute renal failure and that it can easily be treated with simple oral hydration as an outpatient. It’s harder to argue that a patient with early pre-renal failure is going to improve by going back to the same situation that started the condition.

All too often we try to hide the real reason for the consult. We know what our consultants dislike, but by failing to be open with our consultants or trying to skirt the issue, we hurt our credibility and earn the distrust of our colleagues.

A common reason I hear for wanting an admission is, “I don’t feel comfortable sending this patient home.” Again, we are selling ourselves short by not using all our advantages (information) to get the consultant to do what we want. There are innumerable responses that the difficult or rude consultant can make to the above statement, and some may not even be inappropriate, given the uselessness of the statement. What we should do instead is tell the consultant why we don’t feel comfortable sending the patient home.

Some difficult consultants are difficult because we don’t help them be cooperative. What we end up doing is asking a consultant to reach the same logical conclusion we reached, but we hold back some of the (often vital) information that we used in reaching that conclusion. Decide what you want, why you want it, and then share this with your consultant. This information will improve your future interactions with that “favorite” consultant.