As a medical student sitting in an enormous lecture hall with 100 of my closest friends at St. Elsewhere University, it is quite easy to be a team player. In school, they constantly drilled us about the crucial aspects of teamwork in medicine, and we all agreed that teamwork was essential for safe patient care. Future physicians must communicate clearly, respect others, and work together as a unit…right?

Once you are out of the classroom and into a string of 13 straight overnight shifts, working with consultants whose egos are the size of “The Rock’s” biceps, I must admit, it is quite difficult to apply these teachings to your daily practice. There is no other place where this becomes more apparent than in the hustle and bustle of the emergency department.

The ED is the front line of any hospital. At times, it can seem like an actual war zone, with bursts of sudden chaos and nonstop movement of people and objects. As an emergency physician, you take people and situations as they come, often in the most unexpected of ways. However, sometimes a patient’s condition needs more care than we can provide, and years of medical training and multiple brilliant minds are just not enough. That’s when we, sometimes hesitantly, sometimes skeptically, call upon our colleagues for a second, or third or fourth opinion – the consultation.

In the ED, where time is everything, an effective consultation can save a life. Our single greatest asset as emergency physicians is the ability to talk. It is our skill in getting others to do what we want them to do, for the betterment of the patient, that is our saving grace in emergency medicine.

We have all bore witness to a bad consult. It seems to always start with, “Yeah, this is surgery.” Take a second to introduce yourself, and expect the same from the consultant. What happens when consultations go bad (a new TV show coming to an ED near you)? Does the patient benefit? Surely not. Think back to “hard on the issues, soft on the people,” as made famous by Fisher and Ury.

We all know just how important consultations and communication are in emergency medicine. So why is it that we do not have formal guidelines and training for them? The skill of an effective consultation seems to be a missing piece in medical training. Our research has taken on the challenge of analyzing this somewhat forgotten component, especially as it applies to EM consultations. In 2010, our three-phase study, “Consultation in the Emergency Department: A Qualitative Analysis and Review,” asked physicians what was most important for consultations

(J. Emerg. Med. 2011 May 26 [doi:10.1016/j.jemermed.2011.01.025]). We found that effective organizational skills, interpersonal and communication skills, and medical knowledge were the three most common themes mentioned by respondents.

A novel way of looking at the consultation process is through the 5 Cs model. Adapted from the business literature, this model focuses on five main points: Contact, Communication, Core question, Collaboration, and Closing the loop. If consultations are focused around these five points, I believe we can really improve patient care through improved communication.

This quarterly “Consultation Nightmares” column is aimed at starting, and continuing, the conversation around improving consultations in the ED and across the board in medicine. As we share our stories about and experiences with consultations, we can explore better methods of communication in various situations and discuss the ways to improve day-to-day patient care. I invite you to share your consultation horror stories, submit questions, and make comments. Consider this to be your “Dear Consultant” column!

Dr. Kessler is the Section Chief of Emergency Medicine at Jesse Brown VA Hospital, Chicago, and Clinical Associate Professor in the departments of Emergency Medicine, Medical Education, and Internal Medicine at the University of Illinois–Chicago, where he is also Associate Program Director of the Combined IM/EM Residency. Please send any consultant challenges, questions, or comments to acepnews@acep.org.