14b: Electives - Internal Medicine Consults

Dividing and Assigning IM Consults

Mark Krause: Alright, let’s get things rolling. Today we’re talking about Internal Medicine consults. It's kind of a weird service to be on if you have not done it before. There are lots of weird nuances to basic rounding and people often do not know how much they are supposed to do in terms of recommendations or orders. But before we get into all of that, let's start from the top. Let's review how we actually split up Internal Medicine consults, something that—let’s be honest—can get messy fast if you don’t have a system. So, to set the stage, our group uses two teams: Med Consults 1 and 2. Consults 1 has an attending and if there is resident or student assigned, they are usually on this team. Consults 2 is usually just an attending on their own. It varies, but that’s the gist.

Beth Blimmer: Yeah, and one thing I wish someone had hammered into me as a resident is: don’t assume you can just jump in and pick patients from the list in Epic, right? Like, every Monday, you log in, there’s this huge pile of consults—but before you touch anything, you have to check in with the Consult 1 attending. They decide how to split that list, especially after a weekend when the consult numbers explode.

Mark Krause: I’ve seen plenty of people—including myself—get overzealous and start working up a patient only to realize the attending shifted them to Consult 2 or, awkwardly, it turns out it’s actually a Family Med patient and they see their own. You just have to take a breath and let the attending do the draft pick, so-to-speak, before you assign yourself. Otherwise, yeah, you can waste an hour prepping for a patient you're not even seeing.

Beth Blimmer: Oh, 100 percent. I remember as an intern—this is embarrassing—I once did the whole pre-round, wrote my note, even called the primary team for an update, and then found out that the patient had been moved to Family Medicine's list. Such a facepalm moment… Ever since, I check in first thing every morning. It’s way less stressful and makes things smoother for everyone.

Vicky Muller: Exactly. That’s why the 8 a.m. group check-in is non-negotiable for me, just to clarify the game plan for the day. Once consults are divided, they generally stick with your team, so you get the continuity for follow-up, which just makes things neater, safer, and honestly more efficient.

Mark Krause: Speaking of Epic, you find your lists under “System Lists”—it’s like… buried, but you’ll see Internal Medicine Consults, and under that Consult 1, Consult 2, and “Pending I.P.” consults. But just to hammer it home—don’t go rogue. Always clear it with your attending first.

Navigating Consult Types and Common Requests

Mark Krause: So… consults come in all flavors, and the way the primary team asks—well, that really changes how you approach things. There’s “opinion only,” where you’re just giving your thoughts but not actually putting in orders. Then, “co-management”—that’s when you’ve got the green light to put in orders, but still you gotta run the big stuff by the main team, like no surprise CT chests when Ortho’s trying to get to the OR. And sometimes, it’s a full-on “transfer of service,” which—let’s be honest—is when things tend to get, um, spicy.

Beth Blimmer: Yeah, and the bread-and-butter consults—perioperative risk assessments, managing hyponatremia, acute kidney injury, those just keep coming. I feel like every other day it’s a UTI consult, or someone needs help with anticoagulation. Sometimes it’s chest pain that isn’t cardiac, but, you know, no one wants to miss anything.

Vicky Muller: Beth what is your approach when they have specific question like UTI but you notice other issues like anemia or acute kidney injury, things we commonly deal with?

Beth Blimmer: I put a full assessment in, each problem even if not what I am asked to see. I think that is common and helpful even to guide my plan as it is hard to make a good recommendation if you don't have the full picture.

Vicky Muller: Totally. The big picture really is what is important. We are generalist so look for the things that are important across any system just to make sure all problems are addressed.

Mark Krause: I had a consult for hypertension but the patient was actually a bit hypotensive after surgery. The resident asked if we should just sign off, rolling his eyes and suggesting the consult was not a good one. I told him to focus on blood pressure management as whole. Think about what we can do to help the patient because at home, they are on several antihypertensive agents. We can help the primary team with a plan to thoughtfully reintroduce them.

Vicky Muller: So glad you mentioned medications. Medication reconciliation is the MOST important thing for new consults. Often the primary team does not do this for any number of reasons so it is important that do this. I print the list and go line-by-line to make sure each medication including why they are taking it specifically.

Mark Krause: Yeah, I wish med recs were done consistently but they just aren't so it's important to make sure that is being addressed. We have a lot of pharmacy support but they can't get to everyone. I will even call pharmacies directly myself.

Beth Blimmer: So see each patient, understand the reason for consult, do a med rec and make sure histories are updated and you are off to a good start.

Best Practices for Documentation and Handoffs

Vicky Muller: Alright, documentation. I know it’s nobody’s favorite, but it’s pretty much the backbone of consult services. The biggest shift coming to consults from general inpatient is switching to a structure with a totally separate recommendations section. You want your assessment and impression right at the top: why the patient’s here, what the acute and chronic problems are, but keep it free of anything you actually want done. Save that for your recommendations so the team doesn’t have to squint for what you want.

Mark Krause: That's so true. Even for perioperative risk assessment consults, it's okay to think about medical management in that context—this patient had both diabetes and stage three CKD. The note had to be hyper-targeted: which diabetic meds to hold, how to dose insulin around surgery, watching kidney function with fluids. The trick was putting all the recommendations right at the end, really obvious for the team—otherwise it just gets lost in the weeds.

Vicky Muller: Yeah, if you bury the plan in a wall of text, the surgical resident trying to get things done will miss it. This kind of communication isn’t just paperwork—it really shapes care. And, like you said, it’s not always about the major stuff. Sometimes it’s tiny things—like restarting somebody’s antihypertensive meds—that make the biggest difference.

Beth Blimmer: I think adapting to that consult note structure was hard for me at first. I’d forget and just use cut-and-paste general medicine notes, and recommendations would end up buried in the HPI or assessment. But separating them out—wow, it makes Monday mornings so much easier for the next person. And, honestly, makes you look more put together.

Vicky Muller: Yeah, and thorough notes literally save lives sometimes. There was a case where I’d listed every med and double-checked what had been restarted after admission, and caught a home med that wasn’t on the inpatient list—turned out we were missing some chronic steroid use, important before a surgery. A quick recommendation to restart and a comment that I reordered it was all I need to do. Simple one-liner visible to the primary team between cases. Good notes are safety tools, not just busywork.

Beth Blimmer: And it is so important that you put the reason they are in the hospital in your notes. Sometimes we get consulted for something like diabetes and all we do is type up information about that. Even if most of our HPI may focus on their diabetes history, it is important that we don't forget to document the reason they are here for surgery, or that they arrived by transfer for a stroke.

Mark Krause: People often ask me why make a consult note so thorough, especially if just asking a targeted question? The MOST important thing I emphasize to resident is that every consult has the potential to become a transfer of service request, meaning Internal Medicine takes over as primary. If something happens post operatively: a new problem like AKI, blood clot, sepsis, specialized services may ask internal medicine to take over. For this reason, I make my consult notes have enough information that I can easily do this without having to go back and add things on the fly.

Beth Blimmer: Good point. That is always a potential. Even more reason to make sure your handoffs are ready for that sort of thing. And if you’re handing off weekend coverage, be clear—like, don’t say “diabetes”; say “chart check glucose for titrating insulin, currently on 36 of Lantus, home dose 40, probably needs to go up if numbers are still high.” Or, if you want someone to eyeball a patient on a Sunday, make that obvious so they don’t miss them.

Effective Communication with the Consult Team

Beth Blimmer: So, let’s talk about how we actually talk to each other, because nothing tanks a consult like silence or missed texts. Secure messaging is your friend—but only if you use it. Having a set check-in time, or just being clear who’s covering what, that’s half the battle. We do so much better when everyone knows how to reach each other and when.

Mark Krause: Templates are underrated. You throw your follow-up questions or updates in a standard format, and suddenly nobody is stuck playing detective. Something as simple as saying “question for primary: please clarify plan for OR timing” helps avoid a whole lot of back-and-forth and, you know, angry calls at 2am.

Vicky Muller: And, honestly, fast responses make us look good, too. Even a quick “got it, will review and update” shows you’re part of a team. The goal isn’t to ping-pong messages all day, but to make sure nobody’s wondering if, say, a potassium of 2.8 slipped through the cracks. Foster teamwork, ask when you’re not sure, and don’t wait until end of day to clarify things.

Beth Blimmer: Yeah, and I’ll add—encourage everyone around you to ask those “dumb” follow-ups. Sometimes a quick clarifier kept someone from missing a critical step. Just helps the whole culture; nobody feels stuck guessing or worrying about looking inexperienced.

Vicky Muller: Agreed. It's important to keep in mind how helpful consultant roles can be, even if you feel the topic at hand is super easy--that's the whole point. For Internal Medicine, think about when we consult Infectious Disease or Neurology...sometimes the question we ask them is complex or nuanced to us but to them is the "easiest consult" they see. That is okay. It's nice when a consult question is very much in our realm of expertise. It allows us to quickly be helpful and be efficient. Surgical groups or hyper subspecialized groups do not have the same training and think about if the roles were reversed, we would want their input.

Beth Blimmer: Should we talk about transfer of service requests because these come with some additional communication needs as well.

Mark Krause: Yes, this process takes a bit more time but if you've done a good med rec and already have a thorough note with all their histories, things go so much easier. After that, I just usually confirm essentials like their code status and emergency contact and medical decision maker because those are things we need to know if taking over as the primary. Then, you can move them over to a cross coverage team and geography will determine final placement.

Beth Blimmer: But not all transfers need to be accepted. Patients coming to our services should have active medical needs that need ongoing management. If a patient is merely waiting for rehab or skilled placement, they should stay with their main team. Or sometimes even if discharge is not soon, keeping them on their main team may prevent lapses in orders and discharge. For example, the complex burn patient needing specialized wound care, or the ortho patient here for a second wound dehiscence.

Managing Consult Outcomes and Follow-Up

Vicky Muller: Alright, last but not least: once the consult’s done, your job isn’t really over. You have to track outcomes—follow up on whether your recommendations actually made a difference. That means reviewing test results, watching for unresolved issues, and circling back if something’s still hanging or didn’t get addressed. Treat each consult like a mini quality-improvement cycle.

Mark Krause: And if a consult lingers, make a point to have a process for timely follow-up. I’ve seen plenty of “pending actions” still on the list two days later because nobody circled back—super frustrating. Whether you’re calling, using the chart, or reviewing with the team, just don’t assume someone else will catch it later.

Beth Blimmer: Those regular multidisciplinary meetings help a ton, too. We can toss around complex cases, compare how different consults panned out, and spot where our communication or systems need tweaking. Plus, it just builds a stronger team, which patients absolutely feel.

Beth Blimmer: As far as when to "sign off" a patient, it's always nice to check in with the primary team before you do so. Sometimes there is a lingering question and it saves a lot of work to know this on the front end. If signing off, make sure all follow up needs are taken care off. This may include medications under your jurisdiction such as insulin -- make discharge dosing recommendations and ensure they have a glucometer, follow up plans in place, and things of that nature. And also, don't feel rushed to sign off. Sometimes even following along as a "chart check" to ensure things are going well without seeing or billing the patient is okay. Most often, the primary team just wants one more review of medications prior to signing off to keep things efficient when that day happens.

Vicky Muller: Exactly. Following up, closing the loop, and learning from each case—that’s how we actually get better at this over time, not just for the individual patient, but for how the whole team works. Alright, I think we've covered the essentials for today. Beth, Mark, good stuff as always.

Beth Blimmer: Yeah, this was awesome—super practical. I always walk away a little sharper. Thanks, you two!

Mark Krause: Yeah, had a blast. Hope everyone listening picked up a pearl or two. We'll catch you next time on Starting Strong!