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Every time you’re hospitalized, your primary physician will probably call in a consultant to help him manage your case. If you have heart failure, he’ll call in a cardiologist; if uncontrolled diabetes, an endocrinologist; if kidney failure, a nephrologist, and so on. Complex cases often need the special expertise of the subspecialist. It’s not unusual to have three or four life-threatening conditions all going on at the same time, which means three or four consults (hospital jargon for consultations). Unless the consultants communicate and coordinate effectively, the result will be fragmentation of care.
Multiple consultations are often necessary, but sometimes they’re not. For example, a primary care internist may be perfectly able to treat an acute myocardial infarction in a patient who isn’t a candidate for more aggressive measures, but hospital regulations may require a cardiology consult. If you have an infection, they may mandate an infectious disease consult.
Then there’s defensive medicine, when a doctor orders consultations and tests that he wouldn’t otherwise order, to validate his actions in case he’s sued. That’s another story in itself.
Some doctors with busy practices may work in their offices 8-10 hours a day. They may have contracts with multiple insurance companies, and/or they may see walk-in patients in a poor urban area. They can have 20-30 patients hospitalized in one or more hospitals at any given time. There is not enough time for them to adequately care for such a large number of hospital patients. The solution: “practice by consult.” For each hospital patient, they will call one or more consultants. They themselves will make hospital rounds in the morning, before office hours, see each patient very briefly, and enter a quick note in the chart. These will be cursory notes, often illegible, more for documentation of the visit for billing, than for any useful medical purpose. The consultants will be the ones actually managing their hospital cases.
Sometimes, multiple consultations are the result of a practice called “ping-ponging,” also called “churning.” This is when a doctor calls on his colleagues, in a variety of subspecialties, to do consults, even when they’re not really necessary. His colleagues then return the favor by calling him to consult on their cases. More studies on this website. This happens mostly in hospitals, but it can also occur in long term care. It tends to happen within multi-specialty groups, or with informal cliques that are often social, ethnic, or religious. Ping-ponging occurs mainly among internists who are also subspecialists in some area of medicine. Internists without a subspecialty, who are pure primary care and therefore do not get called in consultation themselves, cannot participate in this kind of scheme on a consult-for-consult basis, but they can participate in “arrangements” to receive compensation for their referrals. This is illegal, not to mention unethical and immoral, but it happens. In other professions, referral fees are legal and ethical, but in medicine they are illegal kickbacks.
While some consults may not be of real necessity, there will always be an abnormal physical or x-ray finding, or laboratory abnormality which will create an arguable perception of necessity in an individual case. Furthermore, there will always be some study in the medical literature to validate even the most aggressive and invasive diagnostic procedure. If the doctor is questioned, it comes down to a matter of judgment. “In my professional judgment, based on an unexplained abnormal <insert name of test(s)>, this <consultation, test, procedure, drug> was absolutely necessary.”
What’s particularly bad about “ping-ponging” and “arrangements” is that they limit the doctor’s choice of a consultant to someone who is part of an in-group, rather than the most skilled surgeon or most competent specialist available. Multiple consultations may also result in more medications and invasive studies, with additional cost and the risk of adverse side effects, since each consultant has his own favorite tests that he will order or suggest. Cardiologists will order an echocardiogram; gastroenterologists will suggest endoscopy. Some such tests may be perfectly valid in a younger patient, but may be excessive in an older patient with, say, advanced dementia.
Mandated consults, practicing by consult, defensive medicine consults, and ping-ponging undoubtedly contribute to the high cost of care during the last years of life. They happen in hospitals, but their effects linger on, in long term care, as polypharmacy.