Re-engineering the Specialty Consult Paradigm: Extending the Generalist and Maximizing the Specialist Through Educational Reform

Summary

This paper describes the fundamental restructuring of an academic medical center’s consultative process. The objectives include broadening generalists’ skills while using specialists in a targeted manner. Specialty care training traditionally focuses on the management of complex inpatient problems; outpatient services are regarded as an adjunct to inpatient management. The tempo and scope of specialty care does not integrate easily with service delivery in primary care settings. When generalists have a question they may: 1) try to find a specialist (often time consuming), 2) write a consult to the specialty clinic (inefficient for patients/loses teachable moment for generalist), or 3) attempt to manage the problem without specialty input (potentially resulting in extensive, unfocused or incomplete evaluations). We have shifted the specialty consult paradigm to value the outpatient consult above all other stable patients. Specialists developed service specific preconsult management strategies for routine specialty questions that frequently generate referrals. For clinical questions not covered by these strategies, consultants will evaluate the case over the phone or provide a brief consult with the patient and generalist during the outpatient clinic session. These real-time specialty consults maximize generalist learning through education around clinical issues relevant to generalist practice.