1. Medical Consult Service Orientation
Welcome!!!
Updated: APRIL 2018
Mirek Otremba, MD

2. Outline Structure of the service Schedule & Call Teaching & Feedback
Clinics
Misc.

3. Structure of the service
Hospitals covered
TWH – 2 residents max
UNIV AVENUE = TGH (+PMH, TRI), MSH – 2-4 residents
🗣 – Discuss where elective students/residents will spend time
Inpatient consultations
Services requesting consults
Surgery, Psychiatry, Gyne, OB (after 5/weekends)
🗣 - Discuss Common reasons for consultations
Clinics
Pre-op clinics – 3 sites
OB clinic – OPG site – 700 University

4. Room 431 at MSH (Dr. Otremba’s office)
Your space
There is a room designated for med consult residents/students
Room 431 at MSH (Dr. Otremba’s office)
Sign out entry key from Patricia in room 431 and return at end of rotation
Computer & phone available there
Water/Fridge/Microwave/etc. available there
Insert Title here

5. Requests for transfer of care & PESU at TWH
At times, we will be asked to see patients on surgical services with the request for transfer to medicine
TWH: For medical issues in psychiatry patients in ED, psychiatry will call med consults first 8-5, M-F and CTU team after hours and weekends/holidays
Med consults will see and decide:
A) Patient can remain under original service with our service following
B) Patient benefits from GIM admission/transfer: discuss with MC staff and then GIM on call resident/staff and pass on information

6. Schedule 🗣 Review the on-call schedule – HOME call
8am-5pm – designated resident at UNIV and TWH
RESIDENT RECEIVING CALLS ROTATES WEEKLY
5pm – 8am
ONE ON-CALL RESIDENT COVERS ALL SITES
Weekends: 8am – 8am
Round only on sick patients (update signout list on FRIDAY with ‘TO SEE’)
🗣 Review the clinic schedule
AM CLINICS – all UNIV AVE residents attend
Huddle in AM & decide if all stay in clinic or cover ward/consults
PM CLINICS/OB – one TWH resident attends

7. Obstetrics - MSH Dr. Shital Gandhi
Pager Office
OB medicine covers consults Mon-Fri 8AM-5PM
Weekend/Evening coverage
By med consults
OB hands over any acute issues
UNIV ave med consult staff reviews new consults/issues
Hand over to OB medicine next AM
Wednesday OB clinic (1-5pm)
OPG – 3rd floor University Ave
R3 level clinic – attendance required!

8. Teaching rounds schedule CanMeds 2005 Roles – Medical expert; Scholar
Monday 8 AM – Harvey Rounds
TWH 8th floor New East Wing – Cecilia Miller Conference Room
Tuesday 8 AM – Evidence based rounds (🗣 REVIEW RESIDENT ASSIGNMENTS)
MSH PAU classroom
Wednesday 8 AM – Staff teaches rounds
Wednesday 12 noon – Grand Rounds
Thursday 8AM – OB Medicine Rounds
60 Murray St. 3rd floor Seminar room 4
Friday 8:30 AM – Bedside Physical examination
Location rotates based on patient availability
Friday noon once/month - OB medicine rounds
OPG 3rd floor classroom A – see monthly consult schedule for details

9. Feedback Please seek out Feedback from staff on an on-going basis
UNIV AVE Staff with the UNIV AVE residents
TWH Staff with the TWH residents
Competency by design - Seek assessments during your rotation
1 per week
End of rotation evaluation at the end of the month with input from all staff

10. Sign out CanMEDS 2005 Roles: Communicator
Sign out website
Accessible through the med consult website (under Useful Links)
consult.otremba.org
Sign out login
Use your Cerner/Powerchart credentials
Secondary password: ‘consult’
Med consult website
UN: consult PW: consult

11. Sign-out ETIQUETTE
For ON-CALL - please indicate only MUST-DOs for known patients with issue overnight/weekend needing follow-up
For new patients seen but NOT reviewed with staff add: NEW PATIENT - STAFF TO SEE
For patient seen in clinic and needs follow-up add patient and location as PRE-ADMIT and date of planned surgery
New consults to be seen following morning add patient to list as “NEW CONSULT – PLEASE SEE”
Patients signed off but possible re-consult in future change location to SIGNED-OFF

12. Computer access & dictation
Computer access & training required
UHN – EPR ( )
MSH – PowerChart ( x 2100)
Dictation
UHN ( x 6000) OR via
MSH ( x 2649)

13. Suggest Orders At MSH suggestions should be placed electronically:
Decide with the consulting service if you can order direct or as suggestions
Suggest Orders – Medical Consult order allows you to enter suggestions to be activated later by the primary team
Urgent/emergent orders should be placed directly so they are active without primary team needing to be contacted

14. Suggest orders/communication

15. MSH Suggest orders
Insert Title here

16. Computer CPOE – TGH/PMH/TWH
Leave your suggestions on paper orders
Most patient care orders still on paper only
Urgent orders to be placed directly into EPR

17. Half days, Lieu days, away time CanMeds 2005 Roles – Physician as a Manager
Half-day Coverage
Covered by another resident at the site or staff
Academic sessions
Staff/resident colleague covers
Lieu days
Arrange time with your colleagues/staff
Doctor’s appointments & other away time
Arrange coverage with your colleagues

18. 🗣 REVIEW Contact information
Staff contact information
Ensure accuracy of resident contact information
Elective student/resident contact information
Admin - Patricia Davison
Director - Mirek Otremba

19. Optional information
Role of the consultant Problems in consultation medicine

20. Role of the consultant – The 10 commandments (1/4)
Determine your customer
Ask the requesting physician how you can best help them, if a specific question is not obvious
They may want co-management
Establish urgency
Emergent, urgent, elective

21. Role of the consultant (2/4)
Look for yourself
Be as brief as appropriate
Need not repeat in full detail data that were already recorded
Be specific, thorough, and descend from thy ivory tower to help when requested
Do they need help order writing/entry

22. Role of the consultant (3/4)
Provide contingency plans and discuss their execution
Thou may negotiate joint title to thy neighbour’s turf
Frank discussion defining which specialty is responsible for what aspects of patient care is needed
Teach with tact and pragmatism
Judgement on leaving references should be tailored to level of training and service

23. Role of the consultant (4/4)
Talk is essential
There is no substitute for direct personal contact with primary physician
Follow-up daily
Daily written follow-up is desirable
When patient’s problems are not active, consultant should discuss signing-off with the requesting physician beforehand

24. Problems in consultation medicine (1/3)
Based on Detsky’s article in your book
Reasons for requesting Consultation
Knee jerk/reflex reaction to a clinical entity
Threat of litigation after an adverse event occurred
Supervisor requests consultation even though residents do not feel it is indicated
Resident or medical student requests consultation without knowledge of the attending staff

25. Problems in consultation medicine (2/3)
Failure to Request consultation when help is needed
Strategy during the consultation process
Too many consultations – the Double Whammy
Poor communication
Holding the patient hostage

26. Problems in consultation medicine (3/3)
Problems of Ego, Pride, and Embarrassment
Consultee is embarrassed because of criticism contained in consultant’s note
Consultant’s advice is not taken
Consultant is told to mind his/her own business
Request for help is viewed as a sign of weakness