Mandatory Consults - A Problem for Primary Care Physicians?

December 13, 2010
Melissa Young, MD

The hospital I am affiliated with has just instituted a new policy - all patients with septic shock must have a critical care consult ordered. The rationale was improved patient care; early implementation of aggressive intervention; early and appropriate use of central lines; activated Protein C, etc. The objective: decreased morbidity and mortality, and improved patient outcomes. So what’s the problem?

This topic actually has very little to do with me or my practice, but I was at a meeting today in which there was a very animated discussion, and I wanted to share with you.

The hospital I am affiliated with has just instituted a new policy - all patients with septic shock must have a critical care consult ordered. The rationale was improved patient care; early implementation of aggressive intervention; early and appropriate use of central lines; activated Protein C, etc. The objective: decreased morbidity and mortality, and improved patient outcomes.

So what’s the problem? Well, some internists and family medicine physicians take offense at this. Is it implying that they are incompetent? Is this policy, in effect, saying that they are incapable of caring for these patients? Well, maybe it is. But is that necessarily a bad thing? Isn’t that why specialists exist? Medicine is such a broad and quickly growing science that even the best of the best can’t keep up with all the advances. There should be no shame in saying the sickest of the sick need specialists who deal with this all the time.

The other issue was the loss of autonomy of the primary care physician. Does having a critical care consult mean the PCP can’t order what he thinks is best? Not in our institution, it was pointed out. As opposed to other hospitals where the ICU is a closed unit (i.e. the patients are admitted to the intensivist and the PCP has to stay hands-off), in our situation, the consultant is just that - a consultant - and the PCP is still the attending of record. Is this better? In reality, will it make a difference? Will the PCP actually undo what the intensivist has done?

I’m not a general internist, I’m a specialist. I only see people in the hospital if I am asked to do so in consultation. So how do I feel about mandated consults? I think the focus should be what is best for the patient. And if the data shows he’ll do better with a critical care consult, then a critical care consult he should have. Personally, I think if I were a PCP, I’d gladly hand the case over to someone else. I’d be able to see more patients in the office, finish rounds more quickly, and let the intensivist get called at 3 a.m. with the BP of 60. But, maybe that’s just me.