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Received: 08 September 2020 / / Accepted: 19 October 2020 / Published online: 30 October 2020 DOI 10.34689/SH.2020.22.5.006 UDC 614.88+611.08
DIFFICULTIES ARISING FROM CONSULTATION PROCESS FACED BY EMERGENCY PHYSICIANS: A CROSS-SECTIONAL STUDY
Ishaaq Sakwa Eshikumo, Afsin Emre Kayipmaz, Cemil Kavalci*, Meliha Findik, Murat Muratoglu
Baskent University Faculty of Medicine, Department of Emergency, Ankara, Turkey
Abstract
Objective: To discuss the difficulties that emergency physicians face during the consultation. Materials and Methods: The included physicians were reached by e-mail groups, social media, and one-to-one contact, and electronic questionnaires including 22 questions were filled by the physicians. The questionnaire was designed to be filled anonymously.
Results: Altogether 307 emergency physicians participated in our study. The mean age of the participants was (36.7±7.64) years, among whom 53.1% were males and 46.9% were females. Pulmonary disease (46.6%) were the branches with the highest frequency where the emergency physicians have difficulties in consultations. The majority of the physicians' problems were concentrated on weekends (76.2%) and between 24:00-08:00 (67.1%). In addition, 73% of emergency physicians had verbal conflict with consulting physicians, and 16.3% had physical conflict.
Conclusions: For the consultation process to be more professional, both requesting and consulting physicians should be educated. In addition, it is possible to minimize problems by increasing mutual communication skills. Keywords: Emergencies; Healthcare; Referral and consultation.
Резюме
ТРУДНОСТИ, ВОЗНИКАЮЩИЕ В КОНСУЛЬТАЦИОННОМ ПРОЦЕССЕ У ВРАЧЕЙ СКОРОЙ НЕОТЛОЖНОЙ ПОМОЩИ: КРОСС-СЕКЦИОННОЕ ИССЛЕДОВАНИЕ
Исхак Саква Эшикумо1, Афсин Эмре Кайипмаз1, Джемиль Кавальчи 1*, Мелиха Финдик1, Мурат Муратоглу1
1 Медицинский факультет Университета Башкент, отделение неотложной помощи, Анкара, Турция Цель: обсудить трудности, с которыми врачи скорой помощи сталкиваются во время консультации. Материалы и методы: врачи, включенные в исследование, были набраны в выборку через электронную почту, социальные сети и индивидуальные контакты, врачи заполнили электронные анкеты, включающие 22 вопроса. Анкета предназначена для анонимного заполнения.
Результаты. В нашем исследовании приняли участие 307 врачей неотложной медицины. Средний возраст участников составлял 36,7 ± 7,64 лет, среди которых 53,1% были мужчинами и 46,9% женщинами. Заболевания легких (46,6%) были наиболее частым разделом медицины, в котором врачи неотложной медицины испытывают трудности с консультациями. Большинство проблем врачей приходилось на выходные (76,2%) и с 24:00 до 08:00 (67,1%). Кроме того, 73% врачей неотложной помощи имели словесный конфликт с врачами-консультантами, а 16,3% имели физический конфликт.
Выводы: Для того чтобы процесс консультации был более профессиональным, как запрашивающие, так и консультирующие врачи должны пройти обучение. Кроме того, можно свести к минимуму проблемы, повысив навыки взаимных коммуникаций.
Ключевые слова: Чрезвычайные ситуации; Здравоохранение; Направление и консультация.
Туйшдеме
ЖЕДЕЛ Ш¥ГЫЛ К0МЕК ДЭР1ГЕРЛЕР1НДЕП КОНСУЛЬТАЦИЯЛЫК ПРОЦЕСТЕН ТУЫНДАЙТЫН КИЫНДЫКТАР: КРОСС - СЕКЦИЯЛЫК ЗЕРТТЕУ
Исхак Саква Эшикумо1, Афсин Эмре Кайыпмаз1, Джемил Кавалчи 1*, Мелиха Финдик1, Мурат Муратоглы1
1 Башкент университетшщ медицина факультет^ жедел жэрдем бeлiмi, Анкара, Туркия Максаты: жедел жэрдем д8рiгерлерi консультация кезЫде кездесетЫ киынды^тарды тал^ылау.
Материалдар мен эдютер: зерттеуге енпзтген д8р^ерлер электрондык пошта, 8леуметтiк желiлер ж8не жеке байланыстар аркылы сухбат алдь. Д8рiгерлер 22 сурактан туратын электрондь сауалнамань толтырды. Сауалнама анонимдi толтыруга арналган.
Нэтижелерi. Бiздiи зерттеуге 307 жедел ж8рдем д8рiгерi катысты. ^атысушылардыщ орташа жасы (36,7 ± 7,64) болды, олардыщ 53,1% - ы ерлер ж8не 46,9% - ы 8йелдер. ©кпе аурулары (46,6%) жиi кездеседi, онда жедел ж8рдем д8рiгерлерi ке^ес беруде киындыктарга тап болады. Проблемалык ке^естердщ квпшiлiгi демалыс кYндерi (76,2%) ж8не 24:00-ден 08:00-ге дейiн (67,1%) болды. Сонымен катар, жедел ж8рдем д8р^ерлерЫщ 73%-ында кечесшi Д8рiгерлермен ауызша жанжал болган, ал 16,3% - ында физикалык жанжал болган.
Корытынды: ке^ес беру процесi незлым к8сiби болуы Yшiн Сурау салушы да, ке^ес берушi д8рiгерлер де окытылуы керек. Сонымен катар, взара карым-катынас давдыларын арттыру аркылы проблемаларды азайтуга болады.
TYurndi свздер: твтенше жагдайлар; Денсаулык сактау; жолдама жэне кецес беру.
Bibliographic citation:
Eshikumo I.-S., Kayipmaz A.-E., Kavalci C., Findik M., Muratoglu M. Difficulties arising from consultation process faced by emergency physicians: A cross-sectional study // Nauka i Zdravookhranenie [Science & Healthcare]. 2020, (Vol.22) 5, pp. 68-73. doi 10.34689/SH.2020.22.5.006
Эшикумо И.-С., Кайипмаз А.-Э., Кавальчи Дж., Финдик М., Муратоглу М. Трудности, возникающие в консультационном процессе у врачей скорой неотложной помощи: кросс-секционное исследование // Наука и Здравоохранение. 2020. 5(Т.22). С. 68-73. doi 10.34689/SH.2020.22.5.006
Эшикумо И.-С., Кайипмаз А.-Э., Кавальчи Дж., Финдик М., Муратоглу М. Жедел шугыл квмек д8р^ерлерЫдеп консультациялык процестен туындайтын киындыктар: кросс - секциялык зерттеу // Гылым ж8не Денсаулык сактау. 2020. 5 (Т.22). Б. 68-73. doi 10.34689/SH.2020.22.5.006
Introduction
Consultation is considered among the main patient care procedures in emergency medicine. In an emergency department, the emergency physicians would invite physicians (consulting physician) from other specialties in order to make proper management of the patient. Consulting physicians should be specialists of the branch relevant to the preliminary diagnoses, and who will decide which ward the patient needs to be transferred to [1]. After evaluating the patient, consulting physician may decide to hospitalize or discharge the patient or recommend calling physicians from other branches for consultation [2,3].
The annual number of emergency appeals in the Turkish Republic is detected to be much higher than our population number, which causes excessive crowding in emergency departments. An increasing number of patients and admission of many complicated patients results in the increased consultation demands by emergency departments that are already inundated by consultations. Therefore in order to implement an effective consultation process, emergency physicians should know the guidelines which include recommendations for consultations, have good communication skills, understand how the problems emerge and provide solutions. It is obvious that an effective consultation process will contribute to diagnosis and treatment of the patients [4].
Goldman, et al. summarized golden rules for effective consultation as follows: a consulting physician should focus on the question assigned to him/her; define urgency of consultation as very urgent/urgent/elective; don't reach a conclusion from patient charts; be concise; give specific recommendations; give recommendations directly to the physician who requested the consultation and follows the patients appropriately [5].
All physicians that request and perform consultation are members of a team that aims patient's benefit. Although physicians work for a single common purpose and obey the pre-mentioned rules, stressful, crowded, and tense
environment of emergency may cause some problems among physicians. At this point, studies in our country that revealed difficulties of emergency physicians in the consultation process and help to provide recommendations for a solution. The aim of this study was to discuss difficulties that emergency physicians face during consultation.
Material and methods
Ethics approval. This study was performed after approval by Baskent University Medical and Health Sciences Research Council (11.04.2017, Project No: KA17/49).
Data collection. The emergency physicians in our country constituted the study samples. Physicians were reached by e-mail groups, social media, and one-to-one contact.
Questionnaire
Electronic questionnaires including 22 questions were filled by the physicians. The questions included in the questionnaire are as follows; which speciality presented more problems during the consultation process, which day of week experienced many difficulties, which sex of consulting physicians presented many difficulties, which working hours experienced many difficulties (08:00- 6:00, 16:00-24:00, 24:00-08:00), which negative situations are experienced with consulting physicians such as not coming for consultation on time, giving unnecessary suggestions or not admitting patients who need admission, whether or not the consulting physician follows the laws of consultation set up by the institution, which kind of technology is used during consultation such as whatsapp, messenger or facebook, whether physical or verbal fights are experienced with consultants during consultation, what are the reasons why too many consultations are done in the emergency department, whether or not all the suggestions given by the consulting physicians are implemented. Sixth, 12th, 14th, and 22nd questions could be answered according to personal observations of emergency physicians
(subjectively) (Attachment 1). The questionnaire was designed to be filled anonymously. At the end of the work, the collected data were analyzed with Microsoft Office Excel 365 software.
Questionnaire Attachment 1. Evaluation of difficulties emergency physicians encounter during consultation process
1. Age_
2. Gender: • Female • Male
3. Working institution
• State hospital
• State university
• Private hospital
• Training and research hospital
• Foundation university
4. Academic degree of emergency physician.
• Genel practitioner
• Resident
• Chief resident
• Specialist
• Training assistant
• Lecturer
• Assistant professor
• Associate professor
• Professor
5. Years of working experience in the emergency department.
• 0-5 • 6-10 • 10 and over
6. Subjectively which speciality presented more difficulties during consultation.
• Cardiology
• Pulmonary diseases
• Ortopedics and traumatology
• General surgery
• Neurosurgery
• Neurology
• Plastic surgery
• Ear Nose Throat
• infectious diseases
• internal medicine
• Chest surgery
• Pediatry
• Gynecology
• Urology
• Pediatric surgery
• Cardiovascular surgery
• Pychiatry
• Others
7. Which day of the week presented many difficulties.
• Week days • Weekend
8. Which sex of consulting physicians presented many difficulties.
• Male consultants • Female consultants
9. which working hours experienced many difficulties.
• 08:00 - 16:00 • 16:00 - 24:00
• 24:00 - 08:00
10. During the process of consultation what difficulties are you likely to encounter.
• Consulting physician not coming for consultation
• Consulting physician wanting test that are not neccessary
• Consulting physician suggesting another department to be consulted
• Consulting physician misdirecting the patient or relatives
• Onsulting physician not admitting a patient who needs admission due to several reasons
• Having to convince a consulting physician to com efor a consultation
11. Before requesting a written consultation do you consult patients verbally.
• Not at all • Rarely
• Usually • Always
12. Does the consulting physician follows the laws of consultation set up by the institution
• Yes • No
13. During the process of consultation do you use technology such as whatsapp, messenger or facebook.
• Not at all • Rarely
• Usually • Always
14. During consultation does the consulting physician give adequate feedback to the patient or relatives.
• Not at all • Rarely
• Usually • Always
15. Until today have you ever been assaulted by consulting physician either verbally or physically.
• Yes, I was assaulted physically
• Yes, I was assaulted verbally
• No
16. When a patient is supposed to be transfered to another hospital who is supoosed to help with the preparation of transfer documents and procedure.
• Consulting physician
• Emergency physician
• Others
17. What do you think is the reason for too many consultations being done in the emergency department.
• Lack of knowledge and skills
• Emergency physician protection in case of legal problems
• Excessive care given to some patients
• Need to share patient responsibilities with consulting physicians
18. Do you follow all the proposals that the consulting physician give.
• Not at all • Rarely
• Sometimes • Always
19. Have you ever requested a consultation other than for medical reasons.
• Yes • No
20. Have you ever had training on how to do proper consultation.
• Yes • No
21. Do people you request consultation from your seniors or minors.
• Senior • Minor
22. Who solves the problems related to consultation in your hospital.
• Residents • Specialists
• Mentors • Hospital management
• others
Results
Between 14th April 2017 and 12th June 2017, 307 emergency physicians participated in our study. The mean age of the participants was (36.7±7.64) years, among whom 53.1% (n=163) were males and 46.9% (n=144) were females.
Distribution of physicians according to institutes they work was as follows; 25.4% (n=78) were from training and research hospitals, 24.8% (n=76) from state hospitals, 21.2% (n=68) from state university hospitals, 14.7% (n=45) from foundation university and 14% (n=43) from private hospitals.
The titles of the participants were as follows; 35.2% (n=108) attending physicians, 16.9% (n=52) were general practitioners, 17.3% (n=53) were residents, 7.8% (n=24) were assistant professors, 7.8% (n=24) were associate professors, 5.2% (n=16) were instructor doctors, 4.9% (n=15) were professors, 2.6% (n=8) were lecturer doctors and 2.3% (n=7) were chief residents.
Assessment of work durations in emergency department showed that 40.4% (n=124) had over 10 years of emergency department experience and 31.6% (n=97) had 0-5 years, and 28.0% (n=86) had 6-10 years of experience.
The branches that emergency physicians most frequently had problems during consultation process are shown in Table 1.
Table 1. Consulting branches with problems (Participants could mark more than one option).
Participants could mark more than one option for this question in the questionnaire. Therefore, the total number was more than the number of participants. In addition, with the "Other" option, the participants could add the branches that were not included in the list. We detected that the branch emergency physicians had most problems was pulmonary diseases (46.6%). The branch emergency physicians had fewer problems was ophthalmology (0.6%).
Physicians' problems with consultations were more common on the weekends (76.2%). Besides, the problems occurred more commonly between 24:00-08:00 (67.1%).
When we examined types of difficulties according to participants' personal observations, the most common
problem was a recommendation of consultations from other branches by consulting physicians (71.7%) (Table 2). For this question participants also allowed marking more than one option. Therefore the total number seems to be more than the number of participants.
Table 2. Problems related to consultation.
The types of problems Percentage Number
(%) (n)
Recommendation of consultations from 71.7 220
other branches
Inability to hospitalize a patient with an indication for hospitalization due to several 68.1 209
reasons and therefore follow up the patient in the emergency department.
The request of work-up lacking emergency indication 51.8 159
Not coming for consultation 39.1 120
The problem of convincing the consultant for consultation 34.5 106
Wrong guidance for patient/relative 19.5 60
As we learned from the answers about the verbal consulting of physicians, most of the physicians (45.6%) rarely consulted verbally.
To the question of whether consultants obey the consultation instructions of the hospital, 69.7% of the emergency physicians did not obey hospital instructions for consultation.
Our questionnaire also examined whether emergency physicians used communication tools such as "WhatsApp, Facebook, messenger, etc." during the consultation.The results show that 42.7% (n=131) of the emergency physicians use the tools occasionally, 6.8% (n=21) always use, and 37.1% (n=114) rarely use these tools during consultation process. Besides, 13.4% (n=41) reported that they had never used these tools.
In terms of whether consultant physicians adequately inform patients and their relatives according to their observations, results show that nearly half (48.5%) of the emergency physicians thought that consultant physicians give adequate information.
To the question of whether they had a verbal or physical conflict with consulting physicians, 73% of emergency physicians reported verbal conflict and 16.3% had physical conflict with consulting physicians.
In our questionnaire, we also tried to find an answer to the question "Should referral procedures (preparation of referral documents, communication with 112 command center, etc.) be perform?" for patients required to be referred from emergency department. And we found 64.2% of emergency physicians thought consulting physician should obey the referral procedures. However, when the answers were examined, view that there should be a special unit and personnel in emergency department performing referral procedures was also prominent.
Another question in the questionnaire is what can be the reason for frequent consultation requests. We allowed marking multiple options also for this question. In total, 66.8% (n=205) of the emergency physicians thought the reason is "to reduce the risk of malpractice and also protect the physician in the case of legal problems"; 62.5% (n=192) thought "emergency physician want to share legal
Consulting branches Number Percentage
(n) (%)
Pulmonary disease 143 46.6
All subspecialties of internal medicine 109 35.5
Obstetrics and gynecology 97 31.6
Neurology 92 30.0
General surgery 87 28.3
Cardiology 82 26.7
Plastic surgery 69 22.5
General internal medicine 65 21.2
Infectious diseases 60 19.5
Neurosurgery 56 18.2
Psychiatry 50 16.3
Orthopedics 46 15.0
Cardiovascular surgery 38 12.4
Ear, nose, and throat 33 10.7
Pediatrics 31 10.1
Urology 25 8.1
Thoracic surgery 20 6.5
Pediatric surgery 15 4.9
Ophthalmology 2 0.6
responsibilities of the patient with consulting physician; 47.2% (n=145) believed "lack of knowledge/skills"; and 43.3% (n=133) thought "conscientious care to the patient'.
To the question of whether they adhere to every advice of the consultants, 66.1% (n=203) answered "generally', 5.5% (n=17) "always", 17.3% (n=53) "rarely'. 11.1% (n=34) of the physicians did not adhere any of the suggestions of consultant physicians.
Participants were asked whether they require consultation due to non-medical reasons, for example, social indications. 64.8% (n=199) answered "yes" and 35.2% (n=108) answered "no".
In addition, 57.7% (n=177) of the emergency physicians told that they did not have education regarding the consultation process. The proportion that had such education was 42.3% (n=130).
The final question asked for emergency physicians was who solved the problems that occur during the consultation process. More than one option could be selected for this question and by "other" option open-ended responses could be given. Results showed that problems were solved mainly (67.4%; n=207) by hospital management; 47.9% (n=147) of the physicians stated that the problems were solved by senior supervisors; 26.7% (n=82) by specialists and 10.7% (n=33) by residents.
Discussion
In our study, the branches with most difficulties were pulmonary diseases (46.6%), subspecialties of internal medicine (35.5%), obstetrics and gynecology (31.6%), neurology (30%), general surgery (28.3%), and cardiology (26.7%).
The most common presenting complaint for pulmonary diseases was respiratory symptoms. The most identified case for pulmonary disease consultations was chronic obstructive pulmonary disease [7]. During winter months respiratory symptoms become more frequent with more admissions of chronic respiratory diseases to emergency departments due to cold weather. We think the reason for pulmonary diseases being the most difficult branch was its complicated patient profile that requires chronic, long-term treatments and their implications for the emergency department [6,7].
Moulin et al. found a neurology consultation rate in emergency admissions as 14.7%. The authors listed reasons for consultation in order of frequency as stroke, epilepsy, unconsciousness, headache, confusion, peripheral nerve diseases, and vertigo [8]. Neurology is also a department dealing with chronic and complicated patients just like pulmonary diseases does. Naturally, neurological cases also stay for long times in emergency department due to the requirement of imaging and long follow-up periods. We think this is an important factor making neurology one of the most problematic branches.
According to the results of our questionnaire, another problematic branch was general surgery. Previous studies showed that 92% of the consultations for general surgery were from emergency departments [9]. One of the most common reasons for consultation from general surgery is abdominal pain. Acute abdomen is the name of a common picture in general surgery, which is due to many complicated and varying diseases. Therefore, despite current advanced assessment methods, many undiagnosed
cases underwent diagnostic surgery with a preliminary diagnosis of acute abdomen [10]. We think that all the pre-mentioned factors contribute to an increased number of general surgery consultations, making this branch is one of the most problematic branches.
Various studies have shown that rate of internal medicine consultations from emergency department change between 10%-20% [11]. The reasons for this high rate are acceptance of elderly people with multiple serious conditions by emergency departments, inability to discharge them due to co-morbid diseases, thus, needing more consultations from relevant branches [12]. With increasing of human lifespan, emergency and internal medicine physicians are facing older patients in our country and worldwide [12]. In addition, Roger et al. found that patients treated in emergency or internal medicine wards had at least 3 accompanying diseases and were taking at least 4 medications at the same time [13]. Kellett et al. demonstrated that with more co-morbid diseases, longer hospitalization duration, higher mortality rate, and higher readmission rate, internal medicine patients are in great need of consultations [14].
Studies on internal medicine consultations requested from emergency department demonstrated that these patients mostly had chronic diseases related to multiple branches, were above 85 years of age, had poor performance status before admission (debilitated), had poor cognitive functions, needed chronic care, had terminal cancer, or were not thought to benefit from a hospital stay [12]. We think these factors contribute to internal medicine subspecialties being one of the most problematic branches.
Evaluation of the problems arising from the consultation process shows that problems occurred more commonly on weekends. We think that this may be due to lack of outpatient service on weekends in public health institutions and presence of on-call duties for branches that do not provide on-duty personnel on weekends. In addition, the problems were more common at 24:00-08:00 time period. Previous studies showed that emergency department admissions were more common at 16:00-18:00, and after 24:00 the number of patients markedly decreased [11]. The reasons for problems being more common after 24:00 may be many physicians being tired and sleepless at that period, their unwillingness to see a patient, and inability to hear the calls during deep sleep.
Previous studies demonstrated that particularly long duration of stay of patients who need to be hospitalized increased crowding of emergency departments, and consultation requests were mostly for hospitalization of patients [11]. Especially old-age general internal medicine patients and patients with multiple traumas require a multidisciplinary approach. Conflicts about where the patients should be admitted and lack of adequate number of beds in the facility results in many patients staying for longer period of time in the emergency department which delays the appropriate management and treatment they were supposed to receive. Again, requirement of a long time for consultation of these patients which delays emergency department processes, uncertainty about the branch that will accept the patient, inability to hospitalize the patient due to lack of a suitable bed, and unwillingness of consulting patients to take the responsibility are important
causes [15]. To solve this problem most commonly used methods are as follows: there should be written rules regarding which branch should take an unattended patient; all physicians should be notified about the written consultation instructions; physical structure and employee capacity of the hospital should be regulated, and knowledge / skills of emergency physicians should be increased by inservice training and courses [15].
Conclusion
The important role of consultation is unarguable in emergency medicine. The physician who examined the patient may require knowledge or expertise of colleagues from different specialties in order to evaluate his/her patient better. This requirement is inevitable especially in emergency departments where many complicated patients admit to. Thinking that way, the consultation process is among the main daily routines of a physician.
Nowadays, physicians require consultations more frequently than before due to both medico-legal reasons and the advancing technology in the medicine field. In the past, a physician could take all the responsibilities of the patient he examined. Today, patient care is not the responsibility of a single physician but instead, it is considered as teamwork. Consulting physicians are irrevocable parts of this team due to their contributions. Although consultation is so important for proper diagnosis, and treatment consultation process may not always go as wanted. The consultation process may cause unhappiness. Requesting physician, consulting physician, or the patient may become disappointed.
For the consultation process to be more professional both requesting and consulting physicians should be educated. In addition, it is possible to minimize problems by increasing mutual communication skills.
Limitations
The 8th question about "Consultants from which sex are more problematic" was submitted as a compulsory question, but due to a mistake in electronic form, we excluded it from the analysis of results. On the other hand, after we prepared the questionnaire and started to receive responses we thought that this question may be sexually biased and directive; therefore we decided to exclude this question. Similarly question number 21 "Is the consulting person more or less experienced than you?" was also defined as a compulsory question. In fact, the consulting physicians may be more or less experienced than the emergency physician depending on the branch of the consultant and schedule of on-duty/on-call consultants of that branch. Because participants obliged to choose only one of two options we also excluded this question from final evaluation.
Conflicts of interest: The authors have no conflicts of interest to declare
Contribution of the authors to the study:
Eshikumo IS. - literature search, writing a review, correspondence with the editorial office.
Kayipmaz AE. - developing ideas and concepts, methodologically assessing the quality of the articles included, writing a review.
Kavalci C. - writing a review, counseling, correspondence with the editorial office.
Muratoglu M and Findik M. - literature search.
Financing: During this work, there was no funding from outside organizations and medical missions.
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* Coresponding Author: Cemil Kavalci, Prof. Dr., MD
SBU SB Di§kapi Yildirim Beyazit Training and Research Hospital, Emergency department, Ankara/Turkey E-mail: cemkavalci@yahoo.com Телефон: +903122036868
