A consultation is any “service type provided by a physician whose opinion or advice regarding evaluation or management of a specific problem is requested by another physician or other appropriate source” [6]. According to the National Center for Health Statistics, USA, the number of ED visits increased from 23% to 32% in the past decade [7, 8]. Lee and associates [9] reported that 20–40% of patients who are evaluated in the ED and then admitted to the hospital received at least one consultation in the department [9]. In the international setting, where many EM educational and practice systems are still in the early stages of development, effective consultations can help promote communication and proper patient care. Succinctly, consultations are part of the backbone of the emergency medicine (EM) culture.

Medical mistakes have been linked statistically to communication failures [10]. Miscommunication results in costly clinical errors and delays treatment [4, 5, 9, 11]. Patient handoffs between physicians, for example, have been recognized as a process marred by inadequate communication leading to increased patient mortality and health care costs [12]. In addition, a lack of standardization and guidance in ED handoffs has led to inefficiency and increased patient morbidity and mortality [12].

Consultation and communication are also vital pieces of EM education. Consultations fall within the core competency of interpersonal skills and communication, required by the Accreditation Council for Graduate Medical Education (ACGME); that is, residents must be able to demonstrate effective information exchange and communication with other health care providers [13]. Accreditation agencies for many health professional training programs require documentation of trainees’ level of competence in interpersonal communication. Illustrating the importance of developing communication skills, Eisenberg wrote, “Two of the first things medical students learn are history taking and differential diagnosis, but they may not be aware of how these interactions constitute a process of translation during which significant information may be lost. By developing a better understanding of the translation process from story to list and back again, all parties could potentially become more aware of those points of translation which put the patient most at risk” [10]. Clearly, consultations and communication, in general, represent a crucial part of medical education.

With time constraints and overcrowding cited as major problems in providing efficient ED care, an improvement in consultations becomes a plausible node to effect change [14]. The art of practicing consultation and good communication is a critical skill necessary for patient care and physician training.

It’s not the same to talk of bulls as to be in the bullring (No es lo mismo hablar de toros, que estar en el redondel).

—Spanish proverb

Transitions in care, when health care workers exchange specific information and responsibility, are often referred to as sign-outs, handoffs, or handovers in clinical practice [5, 15]. Patient handoffs and consultations in EM have become key topics of interest in light of patient safety regulations and the 2011 ACGME work hours policy [16]. A challenge to successful handoffs and consultations is how to provide the proper set of essential information to the recipient. The clarity of clinical information of interest shared with another party is absolutely dependent on the situation and cannot be generalized. There is currently neither a standardized method of consultation from the ED for any type of consult nor a widely accepted taxonomy of consultation types, reasons for consultations, or components of information necessary for a successful consultation. Without these classifications, research on the subject is difficult and varied and lacks standardization. In addition, improving specific and measurable objective patient outcomes becomes difficult. Consensus is needed regarding the structure, content, and reasons for consultations in order to assess the strengths and weaknesses of various taxonomic groups and for simplification of the design of patient outcome studies.

Several players are involved in the ED consultation process. The patient provides a medical history and is a source of diagnostic information. The ED staff, including physicians, physician extenders, nurses, residents, students, and technicians, gather information, triage the patient, and begin the process of identifying treatment options. A consulting physician is sought when the primary team or provider needs expert advice or an opinion regarding a procedure or question.

Briefly, the types of communication can be stratified as handoff versus consultation. A handoff inherently implies a transition in care, an admission from an emergency physician (EP) to another service, such as internal medicine, whereas a sign-out implies transfer of a patient from one EP to another without transferring the patient out of the department. This type of communication occurs in the ED initially among emergency medical services (EMS) personnel, prehospital personnel, and the EP and also between physicians during shift changes and outside the ED, it can occur multiple times during a patient’s hospital stay. Implicitly, handoffs are “vulnerable moments in emergency care for many reasons, including physical and psychological noise, lack of a backstage, bias for certainty, unwillingness to question prior judgments and decisions, and a lack of resolution to empirical questions due to face concerns” [10].

Like the handoff, a consultation can be viewed in different ways and decoupled: (i) an intervention or procedural consult, (ii) a consult with a specialist, (iii) a courtesy call between services, or (iv) curbsiding between disparate teams and/or services [9]. An intervention or procedural consult is a call placed by an EP to another service when a necessary intervention or procedure is outside the scope of practice of the EP. A consult with a specialist is a call placed by an EP to another service when a patient’s management is outside the scope of knowledge of the EP. A courtesy call between services is a call regarding a patient’s current condition made to a physician who was responsible for the patient’s medical care in the past. A curbside is not an official consultation but a common situation in which an EP or other physician requests advice from another service for a specific circumstance or for confirmation of a finding. Irrespective of the taxonomy of the consultation type, the ability to communicate effectively is marred by barriers that the trained EP can learn to overcome with the use of a crucial conceptual framework in communication.

The single biggest problem in communication is the illusion that it has taken place.

—George Bernard Shaw

A myriad of factors make the process of consultation difficult. There is no standardized model or paradigm for physician–physician consultations. In a survey of EPs, 29% reported a lack of a clear consultation protocol [3]. Another survey found that the majority of EPs believe residents are inadequately trained in consultations [14]. Although each physician subscribes to his or her own style of consultation, the lack of a standardized approach can and has led to omitted information, miscommunications, and, ultimately, unsafe patient care.

Very early in their medical careers, medical students are taught to interview patients and then convey this information to senior physicians. This process has been honed and focuses on simple checklists that frame pertinent information that must be presented. A similar checklist process does not exist for communication from one physician to another. EPs, or any physician, for that matter, generally do not receive formal training in consultations and therefore must struggle to learn the core competency of communication in the job [11, 17]. Many training curricula are limited by the lack of theory or an organizing framework underlying communication skills, a mismatch between assessment and communication skills, an ambiguous definition of communication skills, or the failure to document changes in behavior that persist in actual clinical situations [18, 19]. Unfortunately, evaluation of communication skills is generally limited to subjective participant-reported satisfaction from the encounter. There is a lack of an objective evaluation based on a core clinical competency, similar to the judicious testing of diagnostic skills.

Furthermore, the ED environment can create barriers to consultations and communication. On average, ED staff deal with 42 distinct communication events each hour [20]. Each point of communication is saturated with interruptions: attending physicians are interrupted every 9 min; residents, every 14 min [21]. Routinely, physicians face multiple and overlapping patient encounters. Many patients require unscheduled care delivered by ED personnel who have incomplete knowledge of the individual’s medical history. Most EDs are saturated with large patient volumes that create obvious time constraints and can force rushed decisions. In one study, 15% of surveyed EM physicians reported that they are adversely affected by time constraints, leading to difficulty in obtaining consultations [11]. The timeliness of consultations is often at the mercy of the consultant physicians, their schedules, and their patient responsibilities. In addition, feedback regarding care is lacking because ED physicians typically do not develop long-term relationships with patients. The ED, by its nature, creates a fragmented nature of health care. The combination of physicians from multiple departments, multiple shifts, and numerous nurses and support staff leads to challenging cross-functional communication [10].

Less tangible issues such as stress and personal, social, and gender biases can also contribute to loss of association during a consultation. In the international setting, the uncertainty about the emerging role of the EM physician and the ED can add to the level of miscommunication. This can lead to the so-called inappropriate consults (whether real or perceived). These factors can affect the quality of the consultation, and physicians may become reluctant to consult each other based on their experiences. The consultation process includes both the ED staff and the consultant; barriers to communication can arise from either party [22].

The EP must be able to filter and frame relevant patient information with a concern or question in mind, rather than presenting an unfocused string of information and uncertainties to the consultant. The consultant must then be able to filter the information, determine the reason for which the advice is sought, and advise accordingly. Every stage of this process presents the potential for a breakdown in communication. Cumulatively, these factors lead to difficulties and delays in effective consultation [11, 15] and “ensure that divergent and potentially conflicting accounts will develop across multiple physicians” [10]. It is therefore essential to improve and standardize this process.

Communication works for those who work at it.

—John Powell

Medical personnel communicate constantly. Analyzing effective communication is essential because it is a key factor in providing safe and efficient care for patients and results in better health outcomes [23–28]. Therefore, it is imperative to discuss how communication can be improved in the ED. Communication can be enhanced on a number of levels, including the training of physicians, improving individual interactions, and revamping the steps of the consultation process itself.

A recent study found that a hospital’s ED significantly improved in ratings of teamwork while decreasing clinical error rates following training in emergency team coordination and the implementation of formal teamwork structures [29]. The framework called Situation-Background-Assessment-Recommendation (SBAR) was developed by the military and has been adopted by health care, typically in nurse-to-nurse communication, and non-health-care fields, such as the aviation industry. The process consists of four steps [30]. The first step is to define the situation. One should determine what the problem or situation is and the reason for the communication. The second step is to help all parties involved understand the background information of the situation. Third, those involved assess the situation, and, finally, recommendations are made to correct it. One key aspect of SBAR is that it can be implemented at the institutional scale down to the personnel level. In addition, it allows individuals to maintain their own communication style. The use of SBAR promises improvements both in patient care and for health care providers. After its implementation, medical centers have reported less missed information during patient handoffs and improved satisfaction among nurses and physicians [31]. A study of nursing–physician communication demonstrated that 68% of nurses believed handovers had improved and 80% felt more confident when communicating with physicians following implementation of SBAR [32].

A large qualitative study of communication in EDs suggests a number of areas for improvement; primarily, the need for more contextual information on patients when they arrive at the ED. More salient facts about circumstances, medical history, and family history must be obtained to improve the accuracy of the translation of a patient’s story into clinically relevant data. Briefly, physicians and nurses must become more cognizant of the cognitive process of translating stories from the patient to lists of information (during which information may be lost). The study suggests that, first, hospital staff should work more with police officers, EMS personnel, nursing home representatives, staff members at assisted living facilities, and primary care providers to obtain the appropriate information. Second, as the authors also advocate, a standardized method of consultation or framework should be developed to facilitate transfer of information from one physician to another. The study also suggests redesigning rounds to facilitate group thought and dialog. For example, having nurses “round” with physicians may be beneficial if attention is paid to helping them reduce anxiety and pressure when questioning physician decisions. EDs could introduce conversation techniques that allow feedback between team members and create a mental reflection on previous decisions. The department should foster communication with personnel in other parts of the hospital, which is critical, given the nature of the ED and the need to consult other departments [10].

Consideration should also be given to improving consultations at the physician level, both giving and receiving [33]. Ackery et al suggest that the EP should first learn the consultant’s name and give his or her own. This is a simple yet powerful step. It builds a basis for rapport and creates a foundation for positive mutual relationships, which can enhance future consultations. Next, the EP should clearly state what advice or information is being sought from the consultant. This is an active process of reflecting on the problem and identifying exactly what is needed. The relationship between the EP and the consultant must be bilateral. The consultant should actively investigate why the referring physician is seeking advice.

These methods of improving communication and consultations are by no means exhaustive but serve as an example for different levels of the process. The authors believe that consultations can be made beneficial by adopting a standardized process and providing training in its use. In support of this goal, a didactic approach to consultation is presented in the following section.

Technique is communication: the two words are synonymous in conductors.

—Leonard Bernstein

As mentioned earlier, no standardized model of consultations exists. Although every location has different practicing conditions, and each physician may have his or her individual style of consultation, conceptual frameworks can help ensure effective communication. Building on a business model as a framework [34] and detailed qualitative analysis of ED consultations, a modified Delphi method process led to the development of a consultative method called the five C’s of Consultation [35].