eTable 1. Results of Second Cycle Coding: Organizing 44 Process-Oriented Codes Into 11 Discrete Information Exchanges
eTable 2. Consolidated Criteria for Reporting Qualitative Studies (COREQ) Checklist
eAppendix 1. Interview Guides
eAppendix 2. Detailed Description of the 11 Key Information Exchanges of an Ideal Consult, Organized by Consult Stage
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Roche SD, Johansson AC, Giannakoulis J, et al. Patient and Clinician Perceptions of Factors Relevant to Ideal Specialty Consultations. JAMA Netw Open. 2022;5(4):e228867. doi:10.1001/jamanetworkopen.2022.8867
How do stakeholders envision the ideal inpatient consultation and in what ways do consultations commonly fall short of this ideal?
In this qualitative study of 17 specialists, 13 hospitalists, 4 patients, and 4 family members, participants identified 11 key information exchanges that occur during an ideal consultation, as well as 6 common defects and 5 contextual factors that influence how these information exchanges transpire.
These findings suggest that successful inpatient consultation requires a complicated, sequenced series of time-sensitive information exchanges guided primarily by unwritten norms and highly vulnerable to failure.
Inpatient subspecialty consultations, a common and expensive practice within inpatient medicine, do not always go well; however, little is known about the failure modes of consultation, thus making it difficult to identify interventions to improve consultation quality.
To understand how stakeholders envision the ideal inpatient consultation and identify how and why consultations commonly fall short of this ideal.
Design, Setting, and Participants
This qualitative study used in-depth, semistructured interviews collected from April to October 2017 and analyzed from January 2018 to February 2020 using conventional content analysis. The setting was a single academic medical center in Boston, Massachusetts. Participants were hospitalists and specialists who had requested or performed a consultation for a non–intensive care unit patient in the previous 4 months, patients who had received a consultation while hospitalized at the medical center in the previous 15 months, and family members of such patients.
Main Outcomes and Measures
Consultation experiences reported by participants. Clinicians were asked about characteristics of the ideal consultation, positive and negative consultation experiences, costs and benefits, and suggested improvements. Patients and family members were asked about their consultation experience, changes in care, communication preferences, and suggested improvements.
The study included 38 participants: 17 specialists, 13 hospitalists, 4 patients, and 4 family members. More than half (21 of 38) of the participants were female. There were 11 key information exchanges identified that occur among the specialist team, primary team, and patient/family during an ideal consultation. These exchanges are time sensitive and primarily carried out through unwritten protocols. We also identified 6 defects (process failures) that commonly derail information exchanges (complete omission, exclusion of a key stakeholder, poor timing, incomplete or inaccurate information, and misinterpretation) and 5 contextual factors (roles and boundaries, professionalism, team hierarchy, availability, and operational know-how) that influence how information exchange unfolds, making some consultations more prone to defects.
Conclusions and Relevance
Successful inpatient consultation requires a complicated, sequenced series of time-sensitive information exchanges that are highly vulnerable to failure. Maximizing the benefit of consultations will likely entail not only minimizing low-value consultations but also actively preventing defects, such as information inaccuracies and misinterpretation, that commonly derail the consultation process.
Inpatient subspecialty consultation—engagement of a specialist for additional clinical expertise or specialty procedures—is a common and expensive practice within inpatient medicine. In one analysis of 3.1 million admissions of Medicare patients from 2009 to 2010, patients received 2.6 consultations per admission on average.1 A separate study of 736 000 admissions of Medicare patients found subspecialty consultative care accounted for $1.3 billion of Medicare spending in 2014.2 Given the ubiquity and expense of inpatient consultations, research has focused heavily on assessing variation in consultation use1,3-5 and association with patient-level outcomes.6-10
A third research area centers on assessing communication among consultation stakeholders11-17 and identifying factors that influence consultation “effectiveness.”11,13 Although useful for understanding consultation context, such studies do not provide complete insight into how consultations fail, making it difficult to identify interventions. We interviewed hospitalists, specialists, patients, and family members to understand how these stakeholders envisioned the ideal inpatient consultation and ways consultations commonly fall short of this ideal. We hypothesized that different stakeholder groups would vary in their characterization of the ideal consultation and identify multiple points of potential failure.
This study was approved by the institutional review board of Beth Israel Deaconess Medical Center. All participants provided written informed consent. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.
This study took place at a single academic medical center in Boston, Massachusetts. Study participants included English-speaking adults who were (1) hospitalists, (2) specialists, (3) patients, or (4) family members of patients. Our sampling frame for physicians included residents, fellows, and attendings who had requested or performed a consultation for a non–intensive care unit patient in the previous 4 months. Our sampling frames for patients and family members were, respectively, patients who had received a consultation while hospitalized at the medical center in the previous 15 months and family members of such patients.
This study used purposive sampling. A research assistant (RA) emailed the medical center’s hospitalist and medical residency program listservs describing the study and followed up with interested individuals. After each interview, we asked participants for suggestions as to whom else to interview. We invited members of the medical center’s Patient and Family Advisory Council to participate.18-20
Our semistructured interview guides (eAppendix 1 in the Supplement) asked clinicians about the ideal consultation, costs and benefits, positive and negative consultation experiences, and suggested improvements; and patients/family members were asked about their consultation experience, changes in care, communication preferences, and suggested improvements. We pilot-tested the guides with 2 to 4 individuals from each sampling frame and revised them for clarity.
From April to October 2017, author S.D.R.—a female RA with master’s-level training in qualitative research—interviewed each participant once in a private conference room or via phone. S.D.R. had no prior relationship with any participants. Each interview was recorded, transcribed verbatim, and spot-checked for accuracy.
We analyzed data in NVivo 12 (QSR International) using conventional content analysis from January 2018 to February 2020.21 S.D.R. and A.C.J.—a coinvestigator with doctoral training in qualitative research—independently reviewed a sample of transcripts and developed a preliminary codebook, which they further refined with authors J.P.S. and J.G. The final codebook included 44 codes capturing information exchange processes and 5 codes capturing relevant contextual factors. All transcripts were coded by author S.D.R. and checked by author A.C.J., with disagreements resolved through group discussion. We performed second-cycle pattern coding22,23 to arrange the 44 process codes into discrete information exchanges (eTable 1 in the Supplement) and defects (process failures). eTable 2 in the Supplement includes additional details about our methods.
We interviewed 38 individuals: 17 specialists (7 [41%] were female), 13 hospitalists (6 [46%] were female), 4 patients (all were female), and 4 family members (all were female). Approximately one-third of interviews (12 of 38) were conducted in-person, with the remainder conducted by phone. Median (IQR) interview duration was 29 (24-34) minutes.
Aside from one third-year primary team resident, all clinicians were attendings. Specialists included 5 physicians who specialized in surgery; 3 in cardiology; 1 in neurology; and 2 each in gastroenterology, infectious disease, hematology/oncology, and pulmonology.
The first theme identified was that the ideal consultation features a series of information exchanges that were dictated by mostly unwritten protocols performed during distinct stages of the consultation process. Collectively, participants identified 11 primary information exchanges (IEs) that occur in an ideal consultation (Table 1; eAppendix 2 in the Supplement). These IEs featured clinical information (eg, patient’s medical history) and process information (eg, “consult request received”) that signal “whose court the ball is in” as the work passes between the primary and specialist teams (Figure). Many clinicians noted that the consultation process was largely guided by informal protocols. According to one hospitalist, “Most consultations are typically seen and staffed by an attending within 24 hours. At least that’s sort of an unwritten expectation” (Participant 12).
Across teams and specialties, clinicians’ descriptions of the ideal consultation were similar in their key processes, division of labor, and flow, with nearly all dividing it into 5 main stages (Figure). Patients and families participated in the consultation process but in a more limited way, focusing on whether they were notified of the consultation in advance, their interaction with the specialist, and what ultimately resulted from the consultation.
The second theme identified was that in many consultations, information exchanges were derailed by 1 or more defects (process failures). Participants identified 6 defects (Table 2) that commonly derail the IEs in the Figure and lead to confusion, frustration, and/or care inefficiencies. Defects included an IE (1) being completely omitted or (2) occurring too early or late; (3) excluding 1 or more key stakeholders; (4) featuring incomplete or (5) inaccurate information; or (6) involving misinterpretation of otherwise complete, accurate information by 1 or more interactants. Participants described some IEs as more vulnerable to defects than others, and that problems often compound throughout the consultation, with a defect in one IE contributing to defects in later IEs. Noting the high prevalence of defects, some participants expressed surprise that consultations do not lead to serious patient harm more often.
In participant accounts, IEs involving patients/families were commonly omitted entirely or carried out in the absence of a key stakeholder, such as a caregiver. Not knowing that the primary team requested a consultation, patients and families found themselves confused by the information coming from different teams, which was sometimes contradictory or heard by them as contradictory (eg, owing to teams using different terminology). Although defects in these IEs made for poor patient/family experiences, they did not present a hard-stop to the consultation. Defects in other IEs, however, were described as more disruptive and sometimes harmful to the consultation’s overall value. For example, some specialists described occasionally being frustrated by consultations that were requested “too late,” such that their input did not stand to make a difference to the patient’s trajectory. According to one specialist, “[A bad consult] comes late. … [The primary team] call and say, ’This patient’s going home today, but we want Oncology to see them.’ You don’t feel that the input you’re giving is important enough to guide the decision on whether or not they even have to stay in the hospital, so why do you need us to see them that day?” (Participant 9).
Similarly, some clinicians reported that, on occasion, defects jeopardize the utility of the consultation. According to one hospitalist, “Sometimes the reason for the consult doesn’t get appropriately relayed or doesn’t get appropriately understood by the consulting [specialist] team. Then they’re not really answering the question you called them for. They’ll focus on some trivial thing, [and you think,] ’That’s great, but you missed the point of the consult.’ It’s very frustrating, and it delays patient care” (Participant 5).
The third theme identified was that contextual factors influence information exchanges, making them more or less prone to defects. Across participants’ consultation experiences, 5 major contextual factors shaped IEs and their susceptibility to defects (Table 3).
Although clinicians generally had a shared understanding of which team was responsible for which consultation tasks (eg, all agreed it was the primary team’s decision whether to implement the recommendations), for some duties, participants described variation in teams’ understanding of their respective roles. For example, whereas some participants viewed forming a “good” consultation question as the exclusive responsibility of the primary team, others insisted that the specialist team had an obligation to help with this task, as needed. Tensions rose when specialist teams pushed back against consultation questions they perceived to be overly vague, not pertinent to their specialty, or inappropriate for the inpatient setting. Similarly, variation in each team’s understanding of what, when, and how much information the specialist team should share with the patient/family often led to them receiving mixed messages. Other contested responsibilities included whose job it was to gather needed information (eg, outside hospital records) and implement certain recommendations (eg, scheduling outpatient appointments).
The degree to which interactants behaved “professionally” also shaped how IEs unfolded. Some hospitalists described avoiding consulting particular specialties whenever possible because of their reputation for being “rude” (Specialist 1; Hospitalists 7 and 13) or “dismissive” (Specialist 1; Hospitalists 1 and 13), such as making a primary team “feel stupid” (Specialists 2 and 6; Hospitalists 7 and 10). Professionalism—or lack thereof—also surfaced when teams differed in opinion about next steps for care. When one or both teams were unwilling to consider the other’s point of view, participants characterized the disagreement as a “conflict.” However, when each team listened to and acknowledged the other party’s concerns, participants characterized the disagreement as an important part of the consultation process. According to one specialist, “I got consulted recently by Infectious Disease. … They said, ‘The patient needs surgery.’ My contention was, ‘He has a horrible infection in his pelvis for a whole lot of reasons, and surgery will not change any of this. We need to get at the underlying reasons.’ ... [In these situations] we talk it through and decide, ‘Okay, let's just figure out what's best for the patient.’ I listen to them. They listen to me. We educate each other and try to come up with some reasonable solution” (Participant 2).
Professionalism also figured prominently in the experiences of patients and families, who tended to view consultations positively when specialists took the time to introduce themselves, explain their thinking, and answer questions.
Clinicians noted that in academic medical centers, consultation work is often divided along team hierarchies, with the least experienced members frequently tasked with communicating the consultation request or recommendations. These participants insisted that, when attending oversight is insufficient, the risk of IE defects (especially inaccurate or incomplete information) increases but that establishing norms and systems to ensure proper oversight could reduce this risk.
Participants from all groups reported that misalignment of stakeholder availability often led to IEs being entirely omitted, excluding key individuals, and/or not occurring at the right time. Specialist teams’ availability was described as particularly difficult to predict, as it depended not only on time of day and day of week (with fewer specialists on service at night and on weekends) but also on whether the specialist team simultaneously attended to patients in its outpatient clinic. Not knowing, for example, when the specialist would arrive to examine the patient often led to both primary team and family members missing the evaluation and not sharing potentially relevant information with the specialist, such as changes in the patient’s status since the consultation request.
Some participants attributed IE defects to insufficient working knowledge or know-how for operationalizing certain parts of the consultation. For example, hospitalists reported that they often do not know what information (eg, test results) specialist teams need up front to begin working on particular consultation questions, leading to incomplete consultant requests and delays. Similarly, both hospitalists and specialists reported occasional delays in IEs owing to not knowing whom to contact on the other team. According to one specialist, “Sometimes even just trying to figure out who’s the ultimate person in charge is confusing. It’s like, ‘What pager number do I need to get a hold of the Medicine attending? Which attending? Which team?’” (Participant 2).
In this qualitative study, participants envisioned the ideal inpatient consultation as a series of perfect information exchanges; however, participants’ actual consultation experiences suggest that this ideal is rarely achieved because IEs are frequently derailed by defects, such as poor timing, incomplete information, and misinterpretation. The ultimate outcome of these defects ranged widely, from temporary confusion, frustration, and minor delays to major issues that jeopardized care quality. Contextual factors influenced smooth progression of the consultation, including the degree to which teams had a shared understanding of each party’s role in the consultation and whether interactants had sufficient working knowledge of the consultation process.
Our findings on contextual factors align with prior work on barriers and facilitators to consultation communication. Salerno et al13 found that role assignment was often uncertain and variable, and Miloslavsky et al17 found that whether fellows considered teaching part of their role affected their interactions with residents. Professionalism also features prominently in this literature,11,14-17 with several studies identifying pushback from specialists as a major challenge,11,15,17 although pushback decreased with increasing familiarity and trust between teams.11,15-17 Our study adds nuance to the concept of pushback by showing its association with how teams understand their respective roles in the consultation, whereby some specialists viewed questioning seemingly unnecessary consultation requests as part of their responsibility. Although other studies also support our finding that team hierarchy influences whether information is reliably communicated,14,17 we also found that the tone of the communication matters, as primary teams were more likely to perceive pushback when specialists expressed reservations about the consultation in a condescending or dismissive manner, a finding that appeared to be independent of rank within teams. We found that negative interactions—such as specialists making hospitalists “feel stupid” for asking questions—seemed to unveil an informal but endorsed hierarchy that exists beyond the parameters of the formal hierarchy of academic medicine and values specialists over generalists (and, in some cases, certain specialists over others). This finding aligns with other studies that have identified “prestige hierarchies” among the medical specialties.24,25 Finally, our study identified variation in consultation process both within and across specialties (eg, what information is needed up front). This lack of generalizability in the consultation initiation process may increase the likelihood of false starts and contribute to other defects down the line.
By mapping out information exchange within the ideal consultation, we found that the inpatient consultation process is inherently complicated and potentially prone to failure not only due to the large volume of information and number of people involved, but also the time-sensitive, asynchronous, and multistep nature of the work. Even if each IE were 98% reliable, the overall reliability of the 11-step IE process would be 0.9811 or 80%—a failure rate of 20% (assuming independence of failure rates between each IE). If each IE were 95% reliable, nearly 1 out of every 2 consultations would fail to achieve perfect information exchange. In short, the likelihood of 1 or more defects remains high even when every IE is quite reliable. Hospitals seeking to improve consultation efficiency may consider conducting a failure mode and effects analysis to identify where and how the process is failing and assess the relative impact of identified defects.26 Improvement interventions should be selected based on the specific defect(s). For example, several studies promote increasing direct communication between teams11,12,17; however, this intervention would be ill-suited to address deficits in operational know-how and would potentially exceed what is necessary for a functional IE. That is, the incremental value added by requiring direct communication may not be worth the time cost, particularly if it delays the consultation process. As in the outpatient setting,27 indirect and/or asynchronous communication may be sufficient for certain IEs in particular inpatient contexts, such as having the primary team submit consultation requests via an electronic ordering system. Other defects may be identified or addressed via a well-designed electronic medical record that could, for example, automatically flag when an attending specialist has not vetted a trainee’s preliminary recommendations within a specified amount of time. Other defects will likely require interventions at the individual and interpersonal levels, such as training to improve clinicians’ consultation communication skills.28
Similar to some quantitative investigations,1,3,4,8,10 specialists, patients, and families in our study suggested some consultations did not add value to patient care, although nearly all hospitalists maintained there remained some way to glean value from every consultation. Given the potential harm of unnecessary procedures and the high cost of consultations, eliminating low-value consultations is in the interest of patients, families, and payers. Our study suggests that at least some portion of specialist pushback against consultations may currently serve this gatekeeping function; however, more research is needed to develop acceptable, objective, and reliable gatekeeping mechanisms that ensure rational use but do not block primary teams from obtaining specialist input when they need it.
This study had some limitations. The findings of this single-center study may have limited generalizability to other medical centers, especially nonacademic settings that are resourced differently and may have a different process for (and culture around) conducting inpatient consultations. Participant accounts are subject to recall bias; to mitigate this risk, we restricted eligibility timeframe to 4 months for clinicians and 15 months for patients/family members. We did not collect information on participants' race or ethnicity. Our small, all-female, all-English-speaking sample of Patient and Family Advisory Council members may not have captured the full range of consultation experiences and limits insights into how language barriers affect information exchanges. Future research that includes a larger, more diverse sample of patients and family members—as well as other stakeholders, such as nurses—is needed.
Successful inpatient consultation requires a complicated, sequenced series of time-sensitive information exchanges that are highly vulnerable to failure. Maximizing the benefit of inpatient consultations will likely entail not only eliminating low-value consultations but also preventing defects that commonly derail the consultation process and lower the value of consultations both to clinicians and to the patients and families they serve.
Accepted for Publication: February 20, 2022.
Published: April 25, 2022. doi:10.1001/jamanetworkopen.2022.8867
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Roche SD et al. JAMA Network Open.
Corresponding Author: Jennifer P. Stevens, MD, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (email@example.com).
Author Contributions: Dr Stevens and Roche had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Roche, Johansson, Giannakoulis, Howell, Landon, Stevens.
Acquisition, analysis, or interpretation of data: Roche, Johansson, Cocchi, Howell, Stevens.
Drafting of the manuscript: Roche, Giannakoulis, Stevens.
Critical revision of the manuscript for important intellectual content: Roche, Johansson, Cocchi, Howell, Landon, Stevens.
Statistical analysis: Roche, Stevens.
Obtained funding: Stevens.
Administrative, technical, or material support: Stevens.
Supervision: Cocchi, Stevens.
Conflict of Interest Disclosures: Dr Howell reported receiving equity in Alphabet; he has also received equity from McGraw-Hill for a textbook focused on health care delivery science. No other disclosures were reported.
Funding/Support: This study was funded by the Agency for Healthcare Research and Quality (grant K08HS024288 awarded to Dr Stevens).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.