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OBTAINING A CONSULTATION

Virtually every physician sometimes must rely on specialty consultants because of the nature of modern medical practice. No physician can be all things to all patients. Consultations can offer patients the comfort and continuity of receiving care from a single physician, while benefiting from the expertise of specialists. The attending physician benefits from the help and advice of other physicians but retains the primary relationship with the patient.

Consultations have two functions. More commonly, they allow physicians to manage problems that require additional expertise but are within the physician's general area of skill. They are also useful in helping physicians determine if a patient's problem is beyond their skills or available facilities, thus necessitating a referral. The consultation itself does not transfer the responsibility for the patient's care, but the consultant does assume certain duties to the patient. Since the primary physician retains the responsibility for the patient's care, it is this physician, not the consultant, who makes the final treatment decisions. Responsibility becomes an issue only when the consultant and the attending physician disagree about the proper course of action.

The attending physician's better knowledge of the patient and the history of the condition may lead him or her to decide against the recommendations of a consultant, or the attending physician may find that the consultant is not as knowledgeable or skilled as was thought at the time the consultation was requested. When the attending physician disagrees with the consultant, both parties should discuss the disagreement with the patient and their reasons for recommending differing courses of action. It is best for the attending physician and the consultant to talk with the patient at the same time. In discussing the differing recommendations, it is important to differentiate between facts such as laboratory tests and opinions such as interpretation of a panel of tests. This avoids misunderstandings and can sometimes result in a negotiated care plan that meets the needs of all parties. The attending physician should consider a second consultation, but this should not be seen as a poll of the best two out of three. No matter how many consultations are obtained, the medical responsibility remains with the attending physician. It is critical to obtain the patient's informed consent when choosing to ignore the recommendations of a consultant. If the patient decides to follow the advice of the consultant rather than that of the attending physician, the latter should discuss whether the patient needs a different attending physician.

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