The Ten Commandments of Consulting

Program Director’s Corner – June 2019

The Ten Commandments of Consulting

David Lieb, MD
Program Director, Endocrine Fellowship Program
Eastern Virginia Medical School

Before I get into this month’s PD Corner topic – I wanted to follow up on a previous post. I know everyone is getting ready for the new fellows starting in July. I also know that this is a particularly stressful time – not just for new fellows, but for current fellows (that are taking on new, progressive responsibilities) – and also program coordinators, associate program directors, and program directors. Please remember to look out for each other – and be sure to sure to take care of yourselves, too.

Each year at Eastern Virginia Medical School our GME Office puts together a great Fellows’ Orientation for all medical and surgical fellows starting their programs in Norfolk. For the last few years I’ve had the pleasure of giving a talk about how to be an effective consultant. When I was first approached to give this talk, I reviewed Pubmed to see if there were any good articles covering the topic. I found a few – and the one that stood out was called “The Ten Commandments for Effective Consultations”, published by Goldman, Lee and Rudd in 1983 in Archives of Internal Medicine. It’s a great article, and what was true in the early 80s is even more true in 2019. The Prime Directive, if you will, of providing effective specialty consultations is good communication. And communication has changed significantly from the time of Return of the Jedi, ALF and the Care Bears.

Our fellows communicate via phone, email, texting, Twitter, Facebook, Instagram, and Snapchat (whatever that is). And each of these forms of communication have their advantages and disadvantages. Is a direct message on Twitter HIPAA compliant? (No -and it’s probably no mistake that the talk immediately following mine at the orientation is from EVMS Risk Management). Is texting a complicated insulin regimen the most effective way to communicate a patient plan? Probably not.  Is an email or a note buried in the EMR the best way to sign off from a consult you’ve been part of for a month? Not in most cases. Commandment number IX is “Talk is Cheap…and Effective”, and it’s true.  Fellows need to know that a phone call early on may take up more time than a text or a comment in the EMR – but it may save so much time in the future (sometimes for them, sometimes for their attending).

During my talk I stress the importance of picking up the phone – or pulling it out of your pocket – or connecting to it through Bluetooth – or whatever – and CALLING people.  Do you clearly understand the question you’ve been asked to answer? If not, call the team that called you back, and ask for more details. Lee (1983) and Rudd (1978) reported that up to 15% of consults start with different impressions of the reason for consultation. And that the consultant (that’s us) may completely ignore the question up to 12% of the time. “Determining the Question” is the First Commandment.

I also spend a fair amount of time talking about communication in the medical chart. Commandment Number IV is “Be as Brief as Appropriate”. I remind the new fellows that the EMR is not a novel – they need to be brief, but helpful. No one has time to read a treatise on the differences between total and free cortisol (as interesting as that is). If it’s an interesting topic that they’d like to share and discuss with residents and medical students – maybe the fellow can offer to participate in a morning report. It’s ok to mention a reference (or two) in a progress note, but not more than that. We talk about cutting and pasting (I say avoid it – but since everyone does it anyway – at least read what you’ve cut and pasted to ensure it is current). And by all means – do NOT get into an argument with other teams in the medical record. If you disagree about something important – call the other party. I remind the fellows that the medical record is may be reviewed by patients, lawyers and others, and that they need to be cautious in all that they write. Facts – not feelings – belong in the EMR.

Other commandments include establishing the urgency of the consult (can you see the patient tomorrow? Or as an outpatient?), looking through the original patient data yourself (you bring a special angle to data review), to provide contingency plans, and to honor thy turf (don’t covet they neighbor’s patient). It’s a really great article and I highly recommend that all new fellows read it.

Does anyone out there in APDEM-Land have a similar talk provided at their institution? It’s pretty well-received, and hopefully some of what I share sticks. Send me a note by email ( or DM me on Twitter (@dclieb) if I can help you.

Also – if you figure out how to use Snapchat – please let me know.


This entry was posted in Program Director Corner. Bookmark the permalink.

Leave a Reply

Your email address will not be published. Required fields are marked *