The Consultant's Playbook: How to Be Indispensable to Your Surgical and Specialty Colleagues

A Review Article for Postgraduate Training in Internal Medicine

Dr Neeraj Manikath , claude.ai

Abstract

The transition from primary care provider to consultant represents a fundamental shift in professional identity for internists. This review explores evidence-based strategies and practical frameworks for delivering high-quality consultation services to surgical and specialty colleagues. We examine the critical components of effective consultation including structured communication, perioperative risk assessment, appropriate management of informal requests, and establishing clear co-management agreements. By mastering these competencies, internists can enhance patient safety, improve interdisciplinary collaboration, and establish themselves as indispensable members of the healthcare team.

Keywords: Medical consultation, perioperative medicine, interdisciplinary communication, co-management, professional development

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Introduction

The role of the medical consultant has evolved dramatically over the past two decades. Modern healthcare delivery requires internists to function not merely as disease specialists but as integrators of complex medical information, risk stratifiers, and collaborative partners in multidisciplinary care teams. Despite this critical role, formal training in consultation medicine remains inconsistent across residency and fellowship programs. Goldman et al. first articulated the "Ten Commandments" of effective consultation in 1983, yet contemporary practice demands an expanded skill set that addresses systems-based care, medicolegal considerations, and the complexities of modern surgical and procedural medicine.

This review provides a practical framework for internists seeking to excel in the consultant role, with particular emphasis on perioperative medicine where the stakes are highest and the potential for impact is greatest. We synthesize current evidence with expert consensus to provide actionable strategies for the practicing clinician.

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The "Five-Minute Phone Call" Rule: How to Frame Your Initial Recommendation for Maximum Clarity and Impact

The Foundation of Effective Consultation

The initial verbal communication between consultant and requesting clinician represents the most critical moment in the consultation process. Studies demonstrate that poor communication accounts for up to 70% of sentinel events in hospitals, with consultant-to-primary team handoffs being particularly vulnerable. The "Five-Minute Phone Call" rule provides a structured framework that ensures clarity, actionability, and mutual understanding.

The SBAR-C Framework for Consultation Communication

Adapting the Situation-Background-Assessment-Recommendation (SBAR) model with an added "Caveats" component creates a comprehensive consultation summary:

Situation: Begin with a one-sentence summary of why you were consulted and what the primary team wants to know. Example: "You consulted me regarding perioperative cardiac risk assessment for Mr. Johnson, who is scheduled for elective colon resection."

Background: Provide the salient medical history in 30 seconds or less. Focus only on information directly relevant to the consultation question. Avoid the temptation to recite a complete history; the requesting team already knows the patient.

Assessment: State your risk stratification or diagnostic impression clearly. Use quantitative data when available: "Based on his revised cardiac risk index score of 3, his risk of major adverse cardiac events is approximately 9%."

Recommendation: Provide specific, actionable recommendations numbered in order of priority. Avoid vague language such as "optimize" or "consider." Instead: "First, start carvedilol 6.25 mg twice daily today and titrate to 25 mg twice daily over one week. Second, delay surgery for two weeks to allow beta-blockade to take effect. Third, ensure hemoglobin is above 10 g/dL before proceeding."

Caveats: Explicitly state what you cannot assess without further information and what red flags should prompt immediate re-consultation. Example: "If he develops chest pain or his troponin rises above baseline, call me immediately before proceeding with surgery."

Pearl: The "Headline" Technique

Lead with your bottom-line recommendation in the first 10 seconds: "I recommend we delay surgery for two weeks for cardiac optimization." This prevents the cognitive burden of uncertainty while you elaborate on your reasoning. Surgical colleagues particularly appreciate this direct approach, as it aligns with their decision-making culture.

Oyster: The Hidden Complexity of Timing

Many consultations fail because timing expectations are unclear. Always specify when recommendations should be implemented: "Start this medication today" vs. "Start this on post-operative day 1" vs. "This is for long-term management after discharge." Similarly, clarify your availability: "I'll see the patient daily throughout the perioperative period" vs. "Call me if complications arise."

Documentation That Mirrors Your Verbal Communication

Your written consultation note should serve as a permanent record of your verbal conversation, not replace it. Studies show that only 40% of recommendations in written consultation notes are fully implemented when not accompanied by direct verbal communication. Structure your note using the same SBAR-C framework, ensuring perfect concordance between verbal and written recommendations.

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Pre-Optimization and Perioperative Medicine Beyond CHA₂DS₂-VASc: Thinking Systems-Based to Reduce Surgical Risk

Moving Beyond Algorithmic Risk Stratification

While risk calculators such as CHA₂DS₂-VASc, RCRI (Revised Cardiac Risk Index), and ARISCAT (Assess Respiratory Risk in Surgical Patients in Catalonia) provide valuable frameworks, expert consultants recognize their limitations. These tools were derived from population-level data and may not capture the nuanced reality of an individual patient's physiologic reserve, frailty status, or social determinants of health.

The Comprehensive Perioperative Assessment: A Systems-Based Approach

Cardiovascular Optimization:

Beyond traditional cardiac risk stratification, consider functional capacity assessment using validated tools such as the Duke Activity Status Index (DASI). Patients unable to achieve 4 metabolic equivalents (METs) face substantially elevated risk. For patients with known coronary disease, the timing of surgery relative to prior coronary interventions is critical. Current guidelines recommend delaying elective surgery for at least 14 days after balloon angioplasty, 30 days after bare-metal stent placement, and ideally 6-12 months after drug-eluting stent placement.

The decision to continue or withhold cardiac medications perioperatively requires nuanced judgment. Beta-blockers should generally be continued in patients already taking them but initiating beta-blockade immediately before surgery increases stroke risk and mortality. ACE inhibitors and ARBs present a dilemma: continuing them may cause intraoperative hypotension, yet abrupt withdrawal can trigger rebound hypertension and increased cardiac stress.

Pearl: For high-risk patients, consider N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement. Levels above 300 pg/mL predict perioperative cardiac complications with greater sensitivity than clinical risk scores alone and can guide enhanced monitoring strategies.

Respiratory Risk Mitigation:

Postoperative pulmonary complications (PPCs) occur in 5-10% of surgical patients and carry mortality rates up to 30%. The ARISCAT score identifies high-risk patients, but risk reduction requires active intervention. Preoperative inspiratory muscle training, even for just two weeks, reduces PPCs by up to 50% in high-risk patients undergoing abdominal surgery.

Smoking cessation timing is nuanced. While long-term cessation (>8 weeks) clearly reduces risk, cessation less than 4 weeks before surgery may paradoxically increase pulmonary complications due to increased sputum production and impaired ciliary function. The pragmatic approach: encourage cessation regardless of timing for long-term benefits, but implement aggressive pulmonary hygiene protocols for recent quitters.

Hack: Create a "Respiratory Bundle" checklist for high-risk patients: preoperative incentive spirometry training, DVT prophylaxis to enable early mobilization, multimodal analgesia to reduce opioid-related respiratory depression, and scheduled postoperative chest physiotherapy. Bundle implementation reduces PPCs by 40-60%.

Metabolic and Endocrine Considerations:

Perioperative glucose management extends beyond insulin sliding scales. Preoperative HbA1c above 8% correlates with increased surgical site infections and delayed wound healing. However, delaying surgery for glycemic optimization must be balanced against the urgency of the procedure and risks of postponement.

The stress of surgery induces a catabolic state with insulin resistance. Target glucose ranges of 140-180 mg/dL balance the risks of hyperglycemia against the dangers of hypoglycemia in the perioperative period. Metformin should be held on the day of surgery due to lactic acidosis risk, while SGLT-2 inhibitors require discontinuation 3-4 days preoperatively given their association with euglycemic ketoacidosis during physiologic stress.

Oyster: Thyroid function rarely requires optimization for surgery. Only patients with overt, symptomatic hyperthyroidism or severe hypothyroidism (TSH >20 mIU/L with symptoms) benefit from delay. Subclinical thyroid disease does not increase perioperative risk.

Hematologic Optimization:

Preoperative anemia affects 30% of surgical patients and independently predicts mortality and morbidity. The traditional transfusion trigger of 7 g/dL applies to stable, non-bleeding patients, but preoperative optimization aims higher. For elective surgery, target hemoglobin above 10 g/dL, particularly for patients with cardiovascular disease.

Iron deficiency, present in 60% of preoperative anemia cases, should be identified and treated. Intravenous iron preparations (ferric carboxymaltose or iron sucrose) correct deficiency more rapidly than oral supplementation and avoid gastrointestinal side effects. For surgical patients, IV iron given 2-4 weeks preoperatively reduces transfusion requirements by 30-40%.

Frailty: The Unified Risk Phenotype

Frailty synthesizes multiple physiologic vulnerabilities into a unified risk predictor more powerful than age or comorbidity counts alone. Simple screening tools such as the Clinical Frailty Scale or FRAIL questionnaire identify high-risk patients who benefit from enhanced perioperative protocols including geriatric co-management, intensive physiotherapy, and nutritional optimization.

Hack: Implement a "Prehabilitation Program" for frail patients undergoing major surgery: combined exercise training (aerobic and resistance), protein supplementation (1.2-1.5 g/kg/day), and anxiety reduction interventions. Even short-duration programs (2-4 weeks) improve functional capacity and reduce complications.

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Managing the "Curbside": When to Give Informal Advice and When to Insist on a Formal Consult to Maintain Quality and Safety

The Medicolegal and Quality Minefield of Informal Consultation

"Curbside" consultations—informal advice given without establishing a formal physician-patient relationship—represent a ubiquitous yet problematic aspect of medical practice. Studies suggest that up to 50% of specialist input occurs through informal channels. While curbsides facilitate efficient communication and education, they carry significant risks: incomplete information, lack of documentation, absent follow-up mechanisms, and ambiguous responsibility for outcomes.

The Framework for Decision-Making: When Informal Advice is Appropriate

Acceptable Curbside Scenarios:

• General educational questions: "What's your approach to starting empagliflozin in heart failure?"
• Confirmation of standard management: "Would you also give stress-dose steroids in this scenario?"
• Test interpretation in stable patients: "Does this ECG show a new LBBB?"
• Resource guidance: "Which consultant should I call for this problem?"

Pearl: The "Would I feel comfortable defending this in court?" test. If the scenario involves any diagnostic uncertainty, unstable physiology, or potential for significant harm from mismanagement, insist on a formal consultation.

When to Insist on Formal Consultation

Mandatory Formal Consultation Criteria:

1. Diagnostic Uncertainty: Any situation requiring your examination, review of imaging, or synthesis of complex data
2. Therapeutic Intervention: Recommendations involving medications, procedures, or significant care plan changes
3. Unstable Patients: Any acute or potentially deteriorating clinical scenario
4. Medicolegal Exposure: Cases involving complications, litigation risk, or family conflict
5. Longitudinal Management: Any situation requiring your ongoing involvement or follow-up

Oyster: The "Liability Transfer Trap." When colleagues seek informal advice on complex cases, they often attempt—consciously or unconsciously—to transfer liability while maintaining primary ownership. Phrases like "I just want to run this by you" or "What would you do?" for unstable or complex patients should trigger your formal consultation requirement.

The Diplomatic Approach to Converting Curbsides to Formal Consults

Maintaining collegial relationships while protecting patients and yourself requires diplomatic communication:

"I appreciate you thinking of me for this case. Based on what you've described, I think a formal consultation would be most appropriate so I can examine the patient, review all the data, and provide comprehensive recommendations. This ensures the patient gets the best care and gives us both proper documentation. I'm happy to see them this afternoon."

Hack: Establish personal guidelines with your frequent collaborators. During a quiet moment, say: "I'm always happy to discuss general approaches, but for specific patient management decisions, I'd like to do a formal consult so we both have documentation and I can give you my best assessment. Does that work for you?" This preemptive conversation prevents awkward moments during emergencies.

Institutional Solutions to the Curbside Problem

Progressive hospitals implement "Consult Light" or "Expert Opinion" mechanisms: brief, documented encounters that provide specialist input without ongoing co-management. These are documented in the medical record, trigger billing, and establish a clear paper trail while remaining less time-intensive than full consultations.

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The Art of the Co-Management Agreement: Defining Roles and Responsibilities Clearly with Surgical Services to Avoid Gaps in Care

The Evolution Toward Structured Co-Management

Traditional consultation models positioned internists as advisors who provided recommendations but held no direct patient care authority. This model created ambiguity: Who manages anticoagulation? Who orders transfusions? Who adjusts cardiac medications? Modern co-management models explicitly delineate responsibilities, reducing errors and improving outcomes.

Studies demonstrate that structured medical co-management reduces length of stay by 1-2 days, decreases medical complications by 20-40%, and improves surgical team satisfaction. Yet successful co-management requires more than goodwill—it demands explicit agreements, regular communication, and mutual respect for each team's expertise.

Essential Elements of a Co-Management Agreement

1. Define Primary vs. Consultative Responsibilities:

Create a written matrix specifying which team manages each aspect of care:

Surgical Service Retains:

• Surgical decision-making
• Operative planning
• Wound management
• Surgical complications
• Surgical antibiotic prophylaxis
• Drain and tube management

Medical Service Assumes:

• Medical comorbidity management
• DVT prophylaxis (medical patients)
• Glycemic control
• Blood pressure management
• Cardiac medications
• Anticoagulation management (in collaboration)
• Code status discussions (in collaboration)

Shared Responsibilities Requiring Communication:

• Transfusion decisions
• Fluid management
• Pain control regimens
• Discharge planning
• Anticoagulation timing

Pearl: The "Default Owner" Principle. For every clinical parameter (glucose, blood pressure, hemoglobin, electrolytes), designate a default owner who has primary authority unless there's explicit communication otherwise. This prevents "assumed responsibility" errors.

2. Establish Communication Protocols:

Define the cadence and method of interdisciplinary communication:

• Daily attending-to-attending contact (phone call or in-person)
• Structured interdisciplinary rounds for complex patients
• Specific triggers for emergent communication (hemodynamic instability, acute mental status change, unexpected ECG changes)
• Handoff procedures for weekend or holiday coverage

Hack: Implement a "Daily Co-Management Huddle"—a brief 5-10 minute morning meeting between medical and surgical teams to preview the day's plan, identify potential issues, and clarify any ambiguities. This small investment prevents hours of confusion later.

3. Clarify Admission and Discharge Authority:

Ambiguity about which service has admission privileges and discharge authority creates bottlenecks. Most co-management models designate the surgical service as the admitting team with ultimate discharge authority, but require medical clearance before discharge for complex medical patients.

4. Define Documentation Expectations:

Both teams should document daily, with clear delineation:

• Medical team: Focused notes on medical issues, medication management, and risk assessment
• Surgical team: Operative progress, surgical complications, and overall clinical trajectory

Avoid duplicative documentation that wastes time without adding value.

Oyster: The "Ghost Consultant" Problem. In some institutions, surgeons request medical co-management but ignore recommendations. This undermines quality and creates medicolegal risk. If recommendations are consistently disregarded, escalate to departmental leadership. Co-management requires mutual respect—you cannot be held responsible for outcomes of unimplemented advice.

Special Scenarios in Co-Management

Anticoagulation Management:

Perioperative anticoagulation represents the most common source of co-management conflict. Establish explicit protocols addressing:

• Preoperative anticoagulation cessation timing
• Bridging anticoagulation indications and protocols
• Postoperative anticoagulation resumption timing
• Which team manages bleeding complications vs. thrombotic complications

The current evidence favors against bridging anticoagulation for most patients with atrial fibrillation undergoing surgery, as bridging increases bleeding without reducing thrombotic events. For mechanical heart valves, thrombophilia, or recent VTE, bridging decisions require individual risk-benefit analysis.

Transfusion Threshold Debates:

Surgical teams often favor liberal transfusion thresholds while medical teams advocate restrictive strategies based on RCT evidence. The FOCUS trial demonstrated that restrictive transfusion strategies (trigger <8 g/dL) are safe for most post-surgical patients, including those with cardiovascular disease. Establish institutional protocols that both teams agree to follow, with explicit criteria for exceptions.

Critical Care Transitions:

When patients require ICU-level care, clarify whether the intensivist team assumes primary responsibility or whether the co-management model continues. Most institutions transition to intensivist-led care with surgical and medical consultation, but this must be explicit to prevent gaps.

Measuring Co-Management Success

Implement metrics to assess co-management effectiveness:

• Medical complication rates
• Length of stay
• Readmission rates
• Interdisciplinary satisfaction scores
• Documentation quality scores

Regular review of these metrics with surgical partners creates accountability and drives continuous improvement.

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Conclusion

The role of the medical consultant in modern surgical and procedural medicine demands far more than clinical knowledge—it requires communication excellence, systems thinking, diplomatic skill, and collaborative leadership. By mastering the frameworks outlined in this review, internists can transform themselves from occasional advisors into indispensable partners in patient care.

The transition from primary provider to consultant represents a professional identity shift that requires conscious cultivation. It demands that we synthesize complex medical information into clear recommendations, that we think systematically about risk reduction rather than algorithmically checking boxes, that we maintain quality and safety boundaries even when pressured for expedient answers, and that we build collaborative relationships grounded in explicit expectations and mutual respect.

As healthcare grows increasingly complex and specialized, the consultant internist who masters these competencies becomes not merely useful but essential—the integrator who ensures that patients receive coordinated, evidence-based care that addresses the whole person, not merely the surgical indication.

Excellence in consultation is not innate—it is learned through deliberate practice, reflection, and commitment to continuous improvement. The frameworks provided here offer a starting point, but each consultant must adapt these principles to their institutional culture, their surgical colleagues' preferences, and their own practice style. The result: better outcomes for patients, more satisfying collaborations with colleagues, and a professional identity that is both challenging and deeply rewarding.

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References

1. Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143(9):1753-1755.

2. The Joint Commission. Sentinel event data: Root causes by event type 2004-2015. https://www.jointcommission.org/

3. Katz RI, Barnhart JM, Ho G, et al. A survey on the intended purposes and perceived utility of preoperative cardiology consultations. Anesth Analg. 1998;87(4):830-836.

4. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-1049.

5. Devereaux PJ, Sessler DI. Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med. 2015;373(23):2258-2269.

6. POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839-1847.

7. Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010;113(6):1338-1350.

8. Hulzebos EH, Helders PJ, Favié NJ, et al. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA. 2006;296(15):1851-1857.

9. Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet. 2011;378(9800):1396-1407.

10. Froessler B, Palm P, Weber I, et al. The important role for intravenous iron in perioperative patient blood management in major abdominal surgery: a randomized controlled trial. Ann Surg. 2016;264(1):41-46.

11. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908.

12. Carli F, Scheede-Bergdahl C. Prehabilitation to enhance perioperative care. Anesthesiol Clin. 2015;33(1):17-33.

13. Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360(11):1102-1112.

14. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823-833.

15. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365(26):2453-2462.

16. Auerbach AD, Wachter RM, Cheng HQ, et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med. 2010;170(22):2004-2010.

17. Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med. 2007;167(3):271-275.

18. Wijeysundera DN, Duncan D, Nkonde-Price C, et al. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol. 2014;64(22):2406-2425.