The Infectious Disease Borg

"We are the Borg. You will be assimilated. Resistance is futile."

As a fourth-year medical student, I planned to write a series of blog posts about what I had learned from different medical specialties. For a variety of reasons, those never materialized, and the drafts I started are languishing on Blogger. But this week I was inspired to start yet another mini-essay, and having the evening off provided the time to compose it.

This week I had five days of elective; I chose to join the Infectious Disease team. (I was there for the drugs--to learn more about antibiotics, that is.) The way we were treated, one would be forgiven for thinking that I had assimilated to the Borg. Instead, I learned a little something about the best way to utilize consulting services.

Over the course of the week, our attending pointed out repeatedly that the ID fellow or attending on service frequently gets a call from a primary service that goes something like this: "Hi, you know about So-and-So, right? We consulted ID a couple weeks ago. Well, ...." But the fellow or attending does not actually know much if anything about So-and-So, because when the ID team was consulted a couple weeks ago, s/he was not on service. (Primary teams have turnover too, so it's a little unclear why they think consulting teams are any different.) If the person who was on service for ID did not explicitly say to the primary team, "We are signing off," and write that in their consult note, then the primary team often assumes that someone from ID is chart-stalking the patient. There is a department-wide sign out every Monday morning, but every week a new attending and fellow do the consults for the hospital, joined by a rotating gaggle of residents and medical students. The ID department is not the Borg, and they do not share a consciousness.

Lesson #1: When calling a consult, always provide a relevant identification and history.

Lesson #2: When performing consults, don't just fade away. Be clear about when your team is or isn't following a patient.

The experience clarified for me what it means to serve on a consult team. It does not mean that I have any more or special knowledge than most of the people--other physicians, mind you--calling consults. I have not joined the hivemind. What I do have is time, and access to an ID fellow and attending who know more than I do off the top of their heads. Otherwise, the work I do is a careful patient history and a literature review, which a primary team could do, if they weren't caring for so many other patients. This was reinforced for me when I was assigned a very interesting consult with a clear question, interviewed the patient, searched through the medical record, and spent an hour on PubMed. After running the case by the attending, I called the senior resident with my (our) recommendations. "Oh good," he replied, "that's what our research told us too."

So why, exactly, did they consult ID? This was not a question my attending knew off the top of her head. We are all physicians with the ability to read and synthesize medical literature. There is nothing more special about the ID intern's ability to read and understand than about the primary team intern's ability. As much fun as I had researching and answering the question, I felt disappointed and redundant. I worked long hours during this "easy" week of elective and perhaps could have used that time doing something else. I guess I'm glad the primary team attempted to answer the question on their own without reflexively calling a consult, but I wanted to feel more...special.

Lesson #3: When you call a consult, have a clear question in mind that you can't answer yourself.

Our ID attending also told us about the time a surgeon paged her while she was driving home from the hospital to ask the dose for an antibiotic. When she refused to stop driving to look it up, they accused her of not doing her job. She shot back they weren't doing their job. As, you know, physicians with the ability to read and synthesize.

Lesson #4: When you call a consult, don't do it because you're lazy.

I once "consulted" another intern about a renal question her first day on the service. Of course she couldn't answer it. She hadn't assimilated to the renal-pulm borg any more than I had assimilated to the ID borg and could answer a senior resident's impromptu question about what drug(s) to start for a recently transplanted patient with a fever. Because I had already signed off for the day and would otherwise have had to look up an answer myself, I referred her to the ID fellow, who at least would have had a little more experience with the issue. Because I am still just an intern, the ID team isn't the borg, and they don't share a consciousness. They just have a little more time to focus on one piece of the patient puzzle.

So I was less than thrilled to discover that another intern had copied and pasted the recommendations I had made as the primary plan for a patient, with minor updates. Forget intellectual pride and ownership over that text (ownership doesn't exist in an EMR), I wasn't charged with seeing the patient as a whole, just the ID part. In using my recs as the plan, this intern missed out on the rest of the patient's problems and systems. Recommendations are always just that, as it is the primary team's responsibility to decide whether and how to enact them.

Lesson #5: Don't blindly follow recommendations; rather, incorporate them into your plan of care for the patient.

Lesson #6: Always thank your consultant(s) for their time and effort!