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Consulting with Colleagues about Quandaries


Mark A. Hurt MD

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I have never met anyone who knows everything, including me (perhaps [i]especially[/i] me). Thus, there is a real need for consultations.

In my practice, the most common kind of consultation is the [u][i]internal[/i][/u] consultation. It usually takes the following form:[list]
[*]I have a quandary that I cannot solve easily from experience or by reading books or the literature.
[*]I write on my worksheet what I believe is the differential diagnosis.
[*]I circulate the case with my questions to all of my colleagues, hoping that a better diagnosis than mine will emerge.
[*]When I get the opinions back, I write the report to include the opinions from my colleagues as well as my own. Sometimes these discussions will elaborate on the differential proposed by my colleagues.
[*]Everything is documented thoroughly, after all, this is a legal document as well as a professional opinion.
[*]Documentation is also made so that inspectors can identify that internal consultation is occurring (for QI purposes).
[/list]
The second type of consultation is the [u][i]external[/i][/u] consultation. These are different from internal consultations; they are more formal, they require that one has a real sense of how the consultant will help solve the problem at hand, and, in general, they require that the one who consults provides a real context so that the consultant can be truly useful.

Here is how I frame an external consult:[list]
[*]The consultant needs all the information that you have been able to review. Make sure he receives the glass and the paraffin blocks. Make sure that they are sent via a secure tracking mechanism, and make sure that they are packaged so that slides don't break and paraffin doesn't melt.
[*]Make sure your questions are clear, and don't be afraid to provide a list of [u][i]all[/i][/u] your questions; I have found it very useful to do so.
[*]In a cover letter, explain your dilemma and why the consultation is being sought.
[*]Make sure to "cc" all physicians who are in the "loop", even if there are opinions at odds with each other. As a rule, this serves a positive function, as it makes clear what you think the issues are (if there are disagreements), and it will help the consultant understand what is a stake.
[*]Make sure to include telephone numbers and fax numbers.
[*]Follow-up with the consultant.
[*]When the consultant's report is received, make it part of the record and make sure that every one in the "loop" gets a copy of the report.
[/list]
In my experience, consultations occur chiefly to resolve the diagnosis of a melanocytic proliferation, whether benign or malignant. As you might imagine, a lot is at stake for everyone involved.

Please let me know what you do and whether you agree or disagree with my approach.
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Dr. Richard Carr

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A council of excellence! I will add a couple of points. If there is lots of pathology and you don't know what it is cutting levels till there is no tissue left rarely helps. Better to stop at the first 2 or 3 levels and then ask someone else. Then you leave plenty of material in the block in case referral is required or the consulted pathologist wants to do additional stains or techniques. In my experience impossible melanocytic cases are just as hard in the 1st and (sometimes!) 10th level.

If I want to use a rare, interesting or difficult case (on initial review) for teaching / education (e.g. for the international melanocytic slide club), consent permitting, I get an experienced lab tech to cut serial sections (e.g. x30) and then I select slide 10, 20 and 30 to be the Levels 1, 2 and 3 (for example) as a permanent record in the patient files. A good tech will still leave plenty of tissue for referral and additional studies (IHC, FISH, molecular etc) even on a relatively small lesion if required. All too often when recieving consultant cases the block is already too thin to risk cutting so many sections for an educational club or meeting etc.
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