The Internist's Guide to the Galaxy of Specialists: A Humorous Yet Practical Guide to Consulting Other Services

Dr Neeraj Manikath , claude.ai

Abstract

Effective inter-specialty consultation represents a critical yet often underappreciated skill in internal medicine. While medical education emphasizes diagnostic reasoning and therapeutic management, the art of engaging specialist colleagues—with its unwritten rules, linguistic nuances, and strategic considerations—remains largely learned through trial, error, and occasional humiliation. This review provides an evidence-informed yet pragmatic approach to consulting subspecialties, acknowledging both the clinical imperatives and the human dynamics that influence optimal patient care. We explore consultation strategies for five major specialties, offering practical "pearls" for successful collaboration while identifying common pitfalls ("oysters") that impede effective communication.

Keywords: Interprofessional collaboration, consultation etiquette, specialist referral, communication strategies, internal medicine

Introduction

The modern internist functions as a clinical conductor, orchestrating care across multiple specialties while maintaining primary responsibility for the patient's overall trajectory. <1> Studies demonstrate that effective consultant-consultee relationships directly impact patient outcomes, length of stay, and healthcare costs. <2,3> Yet paradoxically, formal training in consultation communication remains sparse in most residency curricula.

The subspecialist consultation serves multiple functions: diagnostic clarification, procedural expertise, co-management, and sometimes simply reassurance that "we tried everything." <4> Understanding each specialty's priorities, constraints, and preferred communication styles transforms consultation from a potential source of friction into a collaborative patient-centered process.

This guide draws upon published consultation guidelines, <5,6> communication literature, <7> and two-and-a-half decades of navigating the sometimes treacherous waters between medical services. The goal: to help you obtain excellent specialist input without compromising relationships or patient care.

Cardiology: How to Get Their Attention Without Crying "STEMI"

The Landscape

Cardiologists operate in a high-stakes, procedure-oriented environment where genuine emergencies are frequent and dramatic. <8> The specialty attracts physicians comfortable with immediate, protocol-driven interventions. This creates a cultural divide with internists who often favor watchful waiting and diagnostic deliberation.

Pearl #1: Master the Pre-Test Probability

Before consulting, establish whether you're dealing with:

Acute coronary syndrome (ACS): Requires immediate cardiology involvement
Structural heart disease: May warrant echo and elective follow-up
Arrhythmia management: Often depends on hemodynamic stability
Risk stratification: Usually within internist purview

The Framingham Risk Score, HEART score for chest pain, and CHA₂DS₂-VASc for atrial fibrillation should be second nature. <9,10> Demonstrating you've considered these frameworks signals clinical sophistication.

Pearl #2: Lead with What You Know, Not What You Fear

Less effective: "I have a patient with chest pain. Can you see them?"

More effective: "I have a 62-year-old with atypical chest pain, HEART score of 4, troponin trending from 0.02 to 0.04 (baseline 0.01), non-ischemic ECG changes. I've started aspirin and statin. Would appreciate your assessment for possible Type 2 MI versus demand ischemia in the setting of sepsis."

This approach demonstrates you've initiated appropriate care and have a working differential. <11>

Oyster #1: The Boy Who Cried "STEMI"

Overusing emergent consultation language creates alarm fatigue. Reserve terms like "STEMI," "cardiogenic shock," and "stat consult" for true emergencies. One study found that inappropriate "urgent" consultations decreased specialist responsiveness to genuinely emergent cases. <12>

Pearl #3: Understand Their Procedural Threshold

Cardiologists think interventionally. Know the current ACC/AHA guidelines for catheterization, valve intervention, and device placement. <13> If your patient doesn't meet criteria for intervention, acknowledge this: "I recognize she may not be a PCI candidate given her frailty, but I'd value your input on optimal medical management."

Hack: Keep a Cardiology "Cheat Sheet"

Maintain updated guidelines for:

ACS management (STEMI vs. NSTEMI pathways)
Heart failure classification (HFrEF vs. HFpEF management)
Anticoagulation for atrial fibrillation
Indications for ICD/pacemaker

Having these at your fingertips during the consult call demonstrates preparedness and earns respect.

Gastroenterology: The GI Bleed That Isn't, and The Constipation That Is

The Landscape

Gastroenterologists balance outpatient diagnostic procedures (where the money is) with inpatient consultations (where the liability is). They're masters of the "scope," but also manage complex medical conditions like inflammatory bowel disease and chronic liver disease. <14>

Pearl #4: Distinguish Upper from Lower, and Bleed from No-Bleed

The Glasgow-Blatchford Score and Rockall Score exist for a reason. <15> Calculate them. A patient with melanotic stools who is hemodynamically stable, hemoglobin 11.5 g/dL (baseline 11.8), and Glasgow-Blatchford score of 1 probably doesn't need emergent endoscopy at 2 AM.

Effective consultation: "I have a patient with melena, hemoglobin stable at 10.2, Glasgow-Blatchford score 4, on aspirin for recent stroke. Started PPI infusion. Requesting scope within 24 hours per guidelines."

Oyster #2: The Constipation Consult

Gastroenterologists receive frequent consultations for constipation that could be managed with nursing protocols and stool softeners. <16> Before consulting:

Rule out obstruction (clinical exam, imaging if indicated)
Optimize bowel regimen (docusate + senna + polyethylene glycol)
Review medication list (opioids, anticholinergics)
Consider simple interventions (mobility, hydration)

When to consult: Suspected obstruction, severe constipation in inflammatory bowel disease, failed medical management requiring endoscopic disimpaction.

Pearl #5: Speak Liver

For patients with cirrhosis, know:

Child-Pugh score and MELD-Na (they'll ask)
Recent paracentesis results (SAAG, cell count, culture)
Hepatic encephalopathy grade
Varices history and beta-blocker status

Power phrase: "This is a MELD-Na 24 patient with decompensated cirrhosis, new-onset ascites with SAAG >1.1, no SBP. I've started albumin and diuretics per guidelines. Would value your input on lactulose dosing and screening endoscopy timing."

Pearl #6: The Diarrhea Differential Matters

Not all diarrhea requires GI consultation. Your job:

Send stool studies (C. difficile, culture, ova/parasites, fecal leukocytes)
Check medications (antibiotics, PPIs, metformin)
Consider ischemic colitis (elderly, cardiovascular disease)
Think about microscopic colitis (chronic watery diarrhea)

Consult when: Bloody diarrhea, suspected IBD flare, negative workup with persistent symptoms, need for colonoscopy.

Hack: The PPI Question

Many GI consults can be preempted by appropriate PPI use. For suspected upper GI bleeding, start high-dose PPI (pantoprazole 80 mg IV bolus, then 8 mg/hour infusion). <17> For dyspepsia, consider Helicobacter pylori testing before consulting.

Nephrology: Speaking Their Language (Electrolytes, GFR, and the Magic of Urine)

The Landscape

Nephrologists are medical intellectuals who love acid-base disorders, electrolyte mysteries, and complex fluid management. They're simultaneously grateful for interesting cases and frustrated by consults for "rising creatinine" without basic workup. <18>

Pearl #7: Always Send the Urinalysis and Urine Electrolytes

Before any nephrology consult for acute kidney injury (AKI), obtain:

Urinalysis with microscopy (casts, cells, crystals)
Urine sodium, creatinine (calculate FeNa or FeUrea)
Urine protein-to-creatinine ratio (if proteinuria suspected)

The FeNa distinguishes prerenal (<1%) from intrinsic renal injury (>2%), though diuretics confound this. <19> FeUrea (<35%) works better in diuretic-treated patients.

Pearl #8: Categorize the AKI

Use the KDIGO classification (Stage 1-3 based on creatinine rise and urine output). <20> Then determine:

Prerenal: Hypotension, volume depletion (FeNa <1%, responds to fluids)
Intrinsic: Acute tubular necrosis (muddy brown casts), acute interstitial nephritis (eosinophils, drug exposure), glomerulonephritis (RBC casts)
Postrenal: Obstruction (bladder scan, renal ultrasound)

Effective consultation: "I have a 68-year-old with AKI, creatinine 3.2 from baseline 1.1, KDIGO Stage 3. Urinalysis shows muddy brown casts, FeNa 2.8%. Likely ATN in setting of septic shock. Requesting input on renal replacement therapy timing given persistent metabolic acidosis and volume overload."

Oyster #3: The "Rising Creatinine" Without Context

Nephrologists bristle at vague consultations. "Creatinine is rising" without baseline kidney function, medication list, urine studies, or volume status assessment wastes everyone's time.

Pearl #9: Know When Dialysis Is (and Isn't) Indicated

Classic indications for urgent dialysis: AEIOU

Acidosis (severe, pH <7.1)
Electrolytes (hyperkalemia >6.5 with ECG changes, refractory to medical management)
Ingestion (toxic alcohols, lithium, salicylates)
Overload (pulmonary edema unresponsive to diuretics)
Uremia (encephalopathy, pericarditis, bleeding)

Consulting "for rising creatinine" without these features suggests unfamiliarity with dialysis indications. <21>

Pearl #10: Chronic Kidney Disease Requires Different Framing

For CKD consultations:

State the estimated GFR and stage
Document proteinuria quantification
List potentially nephrotoxic medications
Note comorbidities (diabetes, hypertension control)

Example: "I have a patient with Stage 3b CKD (eGFR 38), nephrotic-range proteinuria (4.2 g/day), diabetic for 20 years with suboptimal A1c control. Requesting evaluation for diabetic nephropathy and SGLT2 inhibitor candidacy."

Hack: The Electrolyte Quick-Fix

Many "renal consults" for electrolyte abnormalities can be managed by internists:

Hyponatremia: Calculate serum osmolality, assess volume status, check urine sodium and osmolality <22>
Hyperkalemia: ECG, insulin/glucose, calcium gluconate, patiromer/sodium zirconium cyclosilicate
Metabolic acidosis: Calculate anion gap, consider causes (MUDPILES for high AG, normal AG if GI or renal losses)

Master these, and you'll reduce unnecessary consults while impressing nephrology when you do call.

Pulmonology/ICU: When to Escalate and What They Need to Hear

The Landscape

Pulmonologists and intensivists manage respiratory failure, complex ventilator issues, and critically ill patients. They value efficiency, data, and decisiveness. <23> Unlike some consultants, they're accustomed to rapid decision-making under uncertainty.

Pearl #11: Use Objective Respiratory Failure Criteria

Don't consult for "shortness of breath." Provide data:

Hypoxemia: PaO₂ <60 mmHg or SpO₂ <90% on supplemental oxygen
Hypercapnia: PaCO₂ >50 mmHg with acidosis (pH <7.35)
Work of breathing: Respiratory rate >30, accessory muscle use, inability to speak in full sentences

PEARL within a PEARL: Know your P/F ratio (PaO₂/FiO₂). A P/F ratio <300 indicates acute respiratory distress syndrome (ARDS) if bilateral infiltrates are present. <24>

Pearl #12: Have a Ventilation Plan (or Ask for One)

If considering ICU transfer for possible intubation:

Document failed non-invasive interventions (high-flow nasal cannula, BiPAP)
State hemodynamic stability (some unstable patients need ICU even without respiratory failure)
Mention goals of care conversations: "Patient is full code, wants aggressive treatment"

Effective consultation: "I have a 55-year-old with bilateral pneumonia, P/F ratio 180, worsening despite high-flow nasal cannula at 50 L/min, FiO₂ 0.7. Respiratory rate 35, using accessory muscles. Meets ARDS criteria. Requesting ICU evaluation for possible intubation."

Oyster #4: The 11 PM "Pre-emptive" ICU Consult

Calling ICU at night because a patient "might" decompensate tomorrow creates boy-who-cried-wolf dynamics. Unless there's objective deterioration or imminent instability, manage overnight and reassess in the morning with the primary team.

Pearl #13: For Chronic Respiratory Issues, Provide Pulmonary Function Tests

Consulting pulmonology for "dyspnea workup" without basic testing is premature. Obtain:

Chest imaging (radiograph, CT if indicated)
Spirometry (obstructive vs. restrictive pattern)
BNP/NT-proBNP (to assess cardiac contribution)
Echocardiogram (pulmonary hypertension, left heart dysfunction)

Pearl #14: Master the Language of Oxygen Delivery Systems

Know the approximate FiO₂ delivered by each device:

Nasal cannula: ~24-44% (at 1-6 L/min)
Simple face mask: ~40-60% (at 5-10 L/min)
Non-rebreather: ~60-90% (at 10-15 L/min)
High-flow nasal cannula: Up to 100% (adjustable flow)
BiPAP: Variable FiO₂ with positive pressure support

This vocabulary demonstrates sophistication and helps frame severity.

Hack: The "Tripod Position" Sign

When describing respiratory distress, mention if the patient is sitting upright, leaning forward on outstretched arms (tripod position)—a sign of severe distress that pulmonologists recognize immediately. Similarly, "unable to complete full sentences" is more meaningful than "subjective dyspnea."

General Surgery: How to Make Them Want to See Your Patient

The Landscape

Surgeons are action-oriented decision-makers who value efficiency and dislike ambiguity. <25> They're called for everything from clearly surgical emergencies to vague abdominal pain that "might need surgery someday." This creates consultation fatigue.

Pearl #15: Know the Absolute Surgical Emergencies

Certain conditions require immediate surgical consultation without extensive workup:

Perforated viscus: Free air on imaging, peritonitis
Bowel obstruction with ischemia: Fever, leukocytosis, lactate elevation, peritoneal signs
Ruptured AAA: Hypotension, pulsatile mass, flank ecchymosis
Acute mesenteric ischemia: Severe pain out of proportion to exam, lactate elevation
Necrotizing soft tissue infection: Rapidly progressive, systemic toxicity

For these, call immediately: "I have a surgical emergency—perforated viscus with free air and peritonitis. Patient is being resuscitated now."

Pearl #16: Do the Medical Workup First

For non-emergent consultations, demonstrate you've considered medical causes:

Abdominal pain: CBC, CMP, lipase, LFTs, urinalysis, imaging (CT abdomen/pelvis)
GI bleeding: As discussed in GI section
Suspected cholecystitis: Right upper quadrant ultrasound, assess for Murphy's sign

Effective consultation: "I have a 45-year-old with right upper quadrant pain, positive Murphy's sign, ultrasound showing gallstones with gallbladder wall thickening and pericholecystic fluid, WBC 14,000. Consistent with acute cholecystitis. Requesting evaluation for cholecystectomy."

Oyster #5: The Vague "Abdominal Pain" Consult

Surgeons cannot add value to undifferentiated abdominal pain without imaging or laboratory data. A CT scan is almost always required before surgical consultation for non-acute abdominal issues. <26>

Pearl #17: Frame Risk Appropriately

Surgeons appreciate when you've considered operative risk:

Cardiac risk: Revised Cardiac Risk Index (RCRI) <27>
Pulmonary risk: Assess COPD severity, oxygenation
Bleeding risk: INR, platelet count, anticoagulation status
Functional status: Can they climb stairs? Perform ADLs?

"I recognize the patient is high-risk (RCRI score 3, severe COPD), but given the alternative is likely death from perforation, I think surgery is still indicated" shows sophisticated thinking.

Pearl #18: Mention Code Status and Goals of Care

Before consulting for potentially major surgery in a critically ill or elderly patient, address goals of care. <28> Surgeons are frustrated when asked to evaluate patients who are DNR/DNI or have limited life expectancy, making major surgery inappropriate.

Ideal: "Patient and family understand the high risk but want to proceed with surgery. Patient is full code."

Pearl #19: For Soft Tissue Infections, Provide the LRINEC Score

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score helps risk-stratify patients with soft tissue infections. <29> Score ≥6 suggests higher risk and warrants urgent surgical evaluation.

Components: CRP, WBC, hemoglobin, sodium, creatinine, glucose.

Hack: Use the "Surgery-Friendly" Phrase

When calling surgery, especially for borderline cases, try: "I have a patient I'd appreciate your surgical eye on." This acknowledges their expertise without demanding a specific action, allowing them to assess whether operative intervention is needed.

Universal Consultation Principles: The Ten Commandments

Complete your initial evaluation first (except for true emergencies)
Ask a specific question: "Should this patient have X procedure?" not "What do you think?"
Provide relevant data concisely: Past medical history, pertinent findings, key labs/imaging
State what you've already done: Demonstrates initiative and prevents redundant orders
Propose a differential diagnosis: Shows clinical reasoning
Be available: Don't consult and disappear; facilitate the consultant seeing the patient
Document the consult properly: Note who you spoke with, time, and their recommendations
Don't just accept "medical optimization": If this is the recommendation, clarify what optimization entails and the timeline for reassessment
Follow up: Check consultant's note, implement recommendations, communicate changes to the patient
Say thank you: Collegial relationships improve future consultations <30>

Conclusion

Effective consultation is both science and art—requiring clinical knowledge, strategic communication, and emotional intelligence. By understanding each specialty's perspective, speaking their language, and presenting well-formulated questions, internists can transform consultations from potential conflicts into collaborative successes.

The best consultations occur when both parties feel respected, the patient benefits from multidisciplinary expertise, and the final plan is superior to what either physician could have devised alone. Master these principles, and you'll find specialists increasingly receptive, your patients better served, and your professional reputation enhanced.

As the great internist William Osler reputedly said, "Medicine is learned by the bedside and not in the classroom." To this, we might add: "And consultation is learned through humility, preparation, and an occasional dose of humor."

References

Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143(9):1753-1755.
Horwitz LI, Jenq GY, Brewster UC, et al. Comprehensive quality of discharge summaries at an academic medical center. J Hosp Med. 2013;8(8):436-443.
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.
Lee TH, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74(1):106-112.
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.
Kessler C, Afshar M, Sardar G, Yudkowsky R, Ankel F, Schwartz A. A prospective, randomized, controlled study demonstrating a novel, effective model of transfer of care between physicians: the 5 Cs of consultation. Acad Emerg Med. 2012;19(8):968-974.
Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressure, and physician job satisfaction: results from the physician worklife study. J Gen Intern Med. 2000;15(7):441-450.
Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64(24):e139-e228.
Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-196.
Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest. 2010;137(2):263-272.
Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction. Circulation. 2018;138(20):e618-e651.
Podolsky A, Stern DT. The courtship model of doctor-doctor communication. Acad Med. 2011;86(5):582-585.
Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. J Am Coll Cardiol. 2022;79(2):e21-e129.
Shaheen NJ, Hansen RA, Morgan DR, et al. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol. 2006;101(9):2128-2138.
Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000;356(9238):1318-1321.
Wald A. Constipation: advances in diagnosis and treatment. JAMA. 2016;315(2):185-191.
Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345-360.
Mehta RL, Cerdá J, Burdmann EA, et al. International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology. Lancet. 2015;385(9987):2616-2643.
Steiner RW. Interpreting the fractional excretion of sodium. Am J Med. 1984;77(4):699-702.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2:1-138.
Kellum JA, Lameire N, Aspelin P, et al. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2(1):1-138.
Spasovski G, Vanholder R, Allolio B, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Eur J Endocrinol. 2014;170(3):G1-47.
Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Engl J Med. 2005;353(16):1685-1693.
ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526-2533.
Schwarze ML, Bradley CT, Brasel KJ. Surgical "buy-in": the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy. Crit Care Med. 2010;38(3):843-848.
Stoker J, van Randen A, Laméris W, Boermeester MA. Imaging patients with acute abdominal pain. Radiology. 2009;253(1):31-46.
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.
Cooper Z, Koritsanszky LA, Cauley CE, et al. Recommendations for best communication practices to facilitate goal-concordant care for seriously ill older patients with emergency surgical conditions. Ann Surg. 2016;263(1):1-6.
Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-1541.
Patel MS, Reed DA, Loertscher L, McDonald FS, Arora VM. Teaching residents to provide cost-conscious care: a national survey of residency program directors. JAMA Intern Med. 2014;174(3):470-472.

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Correspondence: [Your contact information]

Conflicts of Interest: None declared

Funding: None

Author's Note for Teaching

This review can be adapted for:

Grand rounds presentations (focus on 2-3 specialties with case examples)
Resident teaching sessions (role-play consultation scenarios)
Video content (create specialty-specific consultation tutorials)
Simulation exercises (practice difficult consultation conversations)

The humor serves a pedagogical purpose: it makes the content memorable while addressing real frustrations that trainees experience. Use these principles to empower your learners to communicate effectively across specialties.