The Dying Hospital Consult Save

Consult service and hospital on-call is an obligation for many, a lowly assignment for some and an adventure for few.

Consults service is essential and time-allotted for many in academic or teaching centers and large group practices – which, according to my surveys of rheumatologists, accounts for about one-third of US rheumatologists. But for the remaining majority of rheums who do office-based practice, hospital consults are a painful necessity that has become a hard pill to swallow. Necessary -  as there are many inpatients that must be managed by a rheumatologist. The painful reasons are many:

1. Lost income: In the time it takes to go to the hospital, find and see the patient and communicate with the referring physician or team, most rheumatologists could have seen 6-8 follow-up patients, while infusing 3-4 patients with Prolia or Orencia and getting caught up on charting. Consults could also occur before work (that means two hours less sleep or workout time) or after work (which means someone is going to be mad at you for missing an appointment or a little league game or an anniversary).
2. Lost income #2: hospitalized consults just don’t pay. Many of these needful patients do not have insurance and are unlikely to become future patients for those same reasons. Most rheumatologists estimate that only a minority of such consults end up with some compensation.
3. Being called inappropriately late: It seems the algorithm for consultants has the rheumatologists last in line. Either the patient with newly diagnosed giant cell arteritis is going home tomorrow and needs to be seen today or the patient (in the 3rd week of hospitalization) is now in renal failure on steroids and team thinks it’s about time the rheumatologist came by.
4. Goofy consults: like #3 above, there are times when it would have been smarter to call for a post-discharge office appointment rather than an inpatient consultation. Inappropriate consults are only confirmed after the effort has been made and in many, cannot be accurately ascertained over the phone. Common goofy consults include: A) “your patient is in the hospital and wants to see you”; B) the perplexing positive ANA; C) no one knows the diagnosis; D) the neuroradiologist says the MRI shows vasculitis; or E) calling the rheumatologist when they should be calling the dermatologist (good luck getting them to the hospital), gastroenterologist or orthopedist. 
5. Too many cooks in the kitchen: by the time the rheumatologist is called there are a plethora of “experts” calling the shots – including the hospitalists, infectious disease and other medical sub-specialists, orthopedists, the chairman of medicine and the hospital CEO. In these scenarios, the only job worse than the rheumatologist joining or taking over the crosstalk, is the resident who has to negotiate and act on these (sometimes disparate) orders and directives.

The rheumatologist’s difficulty with inpatient consults may also be from maverick residents (who believe they can float a line and manage scleroderma renal crisis) and hospitalists. If you had asked me in 1984 (when I began fellowship) what a “hospitalist” was I would have guessed “that guy sitting in the information booth in the hospital lobby?” Today the hospitalist is instead an integral player in the big business of in-patient medicine – largely because primary care doctors have stopped going to the hospital (see noted reasons above).

Today’s hospitalist is a modern MASH physician. No, they are not “meatball surgeons” or internists. Most hospitalists are damn good at what they do, and they care greatly about delivering comprehensive patient care. Yet I liken them to MASH doctors because they have similar goals – diagnose, treat and ship ‘em out the door. The problem is that many don’t know when to call for a rheumatology consultation; hence, they call us last too often. Some believe they know enough to diagnose and treat gout, lupus, perioperative rheumatoids and Wegener’s (“what’s this granulomatous with polyangiitis or GPA you keep writing in the chart”).

There may be times we are never called and may not know of the success achieved by the hospitalist and team. But when we are called, all too often it seems our role is to help those who cannot see the forest for the trees, arbitrate between wrong impressions and misleading labs or provide the diagnosis, treatment or pathway to discharge. All of these are major disincentives for anyone considering inpatient consultations.

For me, the unanswered question is whether inpatients are in peril for not having access to timely and accurate rheumatology consultation. Of course this may depend on the reason for hospitalization. I can’t imagine many patients being admitted for joint pain or myalgia, serologic abnormalities or initiation of therapy alone. Most consults are for: 1) acute gout vs septic arthritis; 2) undiagnosed fevers and FUO; 3) new musculoskeletal complications or sequelae in someone primarily admitted for medical or surgical reasons and 4) exacerbation or deterioration of an existing autoimmune disorder (e.g., SLE); or 5) new medical comorbidities (e.g., thrombotic event, lymphoma, infection) arising in patients with an established rheumatic disorder. Since I don’t know how rheum-worthy each consult is, am I obliged to see all of them? I could see none of them and make this burden for other rheumatologists, department heads and hospital administrators. Or I could have a list of must-see consults and leave all other up to peer-to-peer communication.

Lastly, despite the disincentives, poor compensation and potentially wasted time, all rheumatologists acknowledge that inpatient rheumatology is one of the most exciting and challenging aspects of our training or current responsibilities. This is the setting where we, as a group, can shine at how well we diagnose and manage gout, GCA, reactive arthritis, septic arthritis, Still’s disease and other FUOs, complex lupus, vasculitis and progressive myopathies or scleroderma. It’s hard to imagine anyone but the rheumatologists being in charge of such patients. Hence, the problem is large, the need for our services is great, but what are needed are adequate incentives, compensation and effective input.

Solutions

• Let your referral base, peers, administration and patients know your policy on hospital consultations. If you deem them necessary, but wish to keep these to a minimum, develop a call schedule with like-minded rheumatologists.
• If you are part of a rheumatology call schedule there should be rules for call coverage. My groups rules included: no refills on narcotics, no consultations for medical problems (afib, pneumonia, etc.), and call physicians are not to be used in lieu of emergency rooms or earlier office appointments, etc.
• Have a list of consults requests that you must see or prefer to see. For example:
  • Any MSK or undiagnosed patient requiring or on > 40 mg of prednisone    
  • Acute monarthritis
  • MSK patients with any of the following: fever >102^oF, cytopenias, hemoptysis, seizures, altered mental status, acute polyarthritis, weakness or inability to ambulate     
  • FUOs and Still’s disease (that would be my area of personal interest and research).
• Negotiate with department chairmen and hospital administrators for a half-time or full-time hospitalists devoted fully to rheumatologic care and consultations. I have good evidence that the more accessible the rheumatologist is, the more consultations he/she will receive. The converse is also true. Moreover, the availability of rheumatologic consultations improves the accuracy of diagnosis, while shortening hospital stays and lowering overall cost of care. In many hospitals, especially systems that are struggling financially, one of the key issues is the declining number of consultants going to or providing services to the hospital. Partnerships in the form of hospitalist positions or other innovation are sorely needed.