Consults without imaging

[Guest]

How do you guys handle consults without appropriate imaging?
Last week I had an ED try to consult me for a lady seen one month ago for a tiny right sided parafalcine meningioma who was coming in with new right sided arm weakness with the only new imaging done being a normal head CT.
Next the several neck and back pain consults with negative CT scans from the hospitalists.
And the one I'm not so happy about.  A 60 male with back pain, constipation, and urinary retention with a negative CT and ED calling saying the can't get an MRI because of a pacer.  I tell them get a CT myelogram if they are really worried about cord compression and if shows anything we will consult and see patient after imaging.  The ED doctor didn't really argue with me or fight me on it, he just wrote me up and sent it to hospital administration saying I was refusing consultation.   Anyways they were able to get an MRI after all the next day, which came back completely negative.

Any similar experiences or advice on how to handle this?  I know some people would say take the easy consultation fees, but we get 10-15 consults per day and I'm trying to cut down on unnecessary ones.

[Guest]

(08-03-2020, 11:14 AM)Guest Wrote: How do you guys handle consults without appropriate imaging?
Last week I had an ED try to consult me for a lady seen one month ago for a tiny right sided parafalcine meningioma who was coming in with new right sided arm weakness with the only new imaging done being a normal head CT.
Next the several neck and back pain consults with negative CT scans from the hospitalists.
And the one I'm not so happy about.  A 60 male with back pain, constipation, and urinary retention with a negative CT and ED calling saying the can't get an MRI because of a pacer.  I tell them get a CT myelogram if they are really worried about cord compression and if shows anything we will consult and see patient after imaging.  The ED doctor didn't really argue with me or fight me on it, he just wrote me up and sent it to hospital administration saying I was refusing consultation.   Anyways they were able to get an MRI after all the next day, which came back completely negative.

Any similar experiences or advice on how to handle this?  I know some people would say take the easy consultation fees, but we get 10-15 consults per day and I'm trying to cut down on unnecessary ones.

Insist on them articulating the exact consult question. If it is an imaging question, or what scan to order, you are not a radiologist. If the patient has a neurological symptom without corresponding imaging finding or neurosurgical history, you are not a neurologist. If the patient still needs workup outside of the ED, it can happen on the medicine service, and they can call you if something is discovered.

[Guest]

I mean it depends on you're setting. If you're in practice you should really chat with them so that they understand why you need the imaging. 'insisting' is really something people do who have poor relationships with other services. They're going to be your colleagues for the long haul, a little extra time at the beginning of the relationship will pay dividends. The reality is you want them to understand the hows and whys of when to consult you, which will make them feel confident in sitting on the patient while the MRI is being conducted. 'Insisting' still gets your name in the chart, and you're medico-legally on the hook as soon as they open their mouth to you, even if you talk them out of the consult, ('Neurosurgery relayed that a consult was not necessary because imaging hadn't been obtained'). The fundamental reality is that although we like to think of ourselves as in control of our own destiny, we're at the mercy of primary services and the ED and the only safe way to protect yourself and improve patient care is education (or getting an institutional level SOP or policy in place) , anything else will likely just increase your liability.

[Guest]

Just see the consult

[Guest]

I do agree that we get a lot of consult calls that are inappropriate: workup/imaging not done, obvious alternative diagnosis, etc. which unfortunately goes with the territory when our typical chief complaints are "headache" or "back pain."

As consulting neurosurgeons, we offer two basic services: imaging review, and the ability to do a real neurological exam. There is a decent-sized group of patients we get called about whose imaging is incomplete (or complete but unimpressive) who can still benefit from a careful H&P. You can rule out most problems, help yourself sleep better at night, and maybe save the patient the trouble of getting an unnecessary MRI or LP or whatever.

[Guest]

Don't be one of those residents who spends more time avoiding a consult than it would take to just see the patient.

It takes me <20 minutes to get a quick story, do a neuro exam, and write a plan saying "get MRI". Saves you the headache of arguing with the ED, and saves you that once in a blue moon event where an attending gets offended and reports you.

[admin]

Sounds like the OP is an attending given the "consultation fees."

Personally, I add them to my rounding list and see them when convenient. Leave a note with reccs/communicate to the hospitalist or ED doc. A consult is, after all, a recommendation. If they do not get the needed studies, that is the decision of the primary service and patient.