Climate change and consultation training

Climate change revisited

The article “Clearing the air about climate change” (ACP Internist, September 2016) starts with a non sequitur about a patient's fear of the Zika virus. The implicit implication is that climate change is responsible for Zika's spread. Evenhandedly, though belatedly, in paragraph 20, the author admits that there is not a clear link between climate change and the spread of vector-borne diseases. Obviously! If climate change were the determinative factor in spreading mosquito-borne diseases such as malaria, we should have seen an increase rather than the eradication of malaria in the United States over the past 150 years.

The ACP position paper on climate change, published online by Annals of Internal Medicine on May 3, 2016, adds to panic by repeating exaggerated warnings of catastrophe. In this act of self-importance, a group of physicians reviewed the evidence and concurred with the findings of the Intergovernmental Panel on Climate Change. I don't understand why ACP feels the need to spend time and money determining the validity of climate scientists' findings. Perhaps it is a response to Michael Crichton, MD's, 2003 lecture, “Aliens cause global warming.”

Moreover, if doctors are to be taken seriously, we should be exact in our language. Please use “global warming” instead of the nebulous “climate change” when you are warning about the rise in the Earth's temperature. Would Annals of Internal Medicine accept articles that were so lax in the use of medical language? “Lipid change causes heart attacks.” “Blood pressure change caused by increased sodium ingestion.” “Obesity causes sugar change.”

We strive to follow evidence-based guidelines. We want medicines proven safe and effective by controlled, double-blind experiments. We should demand the same scientific scrutiny before pontificating on political issues concerning climate science, an area where most doctors have little training or knowledge.

Face it, it is hard enough to come up with coherent policies on issues like hypertension, where we actually have expertise. The earth's climate, like the practice of medicine, is constantly changing. Embrace the change.

Russell Kamer, MD, FACP
White Plains, N.Y.

In response: As ACP's President, I would like to clarify some important points. The evidence is clear that global climate change has occurred since the beginning of the industrial age. Ninety-seven percent of the world's climate scientists agree, and there have been more than 2,000 original research papers and reviews confirming this phenomenon. The increase in temperature has led to recession of the glaciers, rise in sea level, and more extreme weather events.

The ACP position paper Dr. Kamer mentions was published by Annals of Internal Medicine after peer review and was held to the same standards as any other article published in the journal. The College does not claim to be an expert on climate change, but as internists we are experts in the area of human health. The health effects of climate change include increased air pollution, increased incidence of infectious disease (insect- and tick-borne and waterborne), prolonged allergy seasons, heat waves, food insecurity and malnutrition, and mass migration. The Zika virus is one of several infections whose incidence can be correlated to climate change.

The term “global warming” that Dr. Kamer cites as more appropriate is imprecise and does not include various parameters of climate change, including temperature rise, sea-level rise, extreme weather events, droughts, and flooding. A better term is “global climate change.”

The Paris Agreement from the United Nations Framework Convention on Climate Change recognizes the importance of the health effects of climate change and calls on the medical community to be leaders in mitigating them. China, India, and the United States have subsequently signed an agreement to decrease carbon dioxide emissions by 35% by 2030. The Second Global Conference on Health and Climate has endorsed the Paris Agreement and has reiterated the importance of health consequences and the responsibility of the medical community to educate others on the health effects of climate change and advocate for movement to renewable energy sources to improve human health.

As guardians of the health of our patients, we have a moral and ethical imperative to mitigate against the health effects of climate change and improve lives into the 21st century.

Nitin S. Damle, MD, MS, MACP
Providence, R.I.

Consultation training in med ed

Physicians just out of residency, depending on their subspecialty, may be asked to provide expert consultation. However, residency programs may sometimes lack formal training in this area.

Educators work to ensure that all residents at completion of training achieve competency in medical knowledge, patient care, systems-based practice, practice-based learning/improvement, professionalism, and communication and interpersonal skills. The last two competencies require added emphasis in preparing graduates to perform high-quality consultations.

For example, many consultation requests today occur at a remove. Physicians write orders and staff members arrange them; there is no direct verbal communication between the requesting physician and the consultant. In some situations, especially nonurgent ones, this approach is reasonable, although not ideal. In urgent situations, direct physician-to-physician communication is imperative.

I also feel today's typical graduate is not well prepared to address key questions before seeing the patient, including the reason for the consultation, whether the clinical situation is urgent, whether he or she can write orders for the patient, and whether the referring physician wants him or her to follow the patient. Direct communication with the referring physician beforehand could help here.

As for the consultation itself, consultants should first introduce themselves to the patient (and family, if present) and clearly state their subspecialty and the reason for the consultation, noting that the patient's physician has requested it. It is usually appropriate for consultants to explain to the patient what they have found and what recommendations they will make to the referring physician.

Consultants should speak in terms patients easily understand and should leave time for questions, while avoiding criticism of the referring physician or of the overall care the patient has received. At the end of the consultation, consultants should thank patients for the opportunity to participate in their care.

In most cases, consultants should call the referring physician after the consultation is complete to report their findings and recommendations directly. This helps resolve whether consultants may write orders and/or proceed with a recommended procedure and determines the agreed-upon follow-up. If consultants have not yet discussed their findings with the patient, it's appropriate to do so after talking to the referring physician.

Accurate documentation of the consultation in the medical record is critical. Consultants' findings and recommendations should be clearly outlined at the beginning of the documentation. An example is as follows:

Cardiology consultation at the request of Dr. A to assess the cause of Mr. Smith's chest pain and to help determine if cardiac catheterization is indicated. The patient was seen and examined. I have also reviewed the medical record in detail.

Findings and recommendations:

1. 1. I believe Mr. Smith's chest pain is cardiac in origin. and I agree with the current management.
2. 2. I agree with Dr. A's physical exam findings, specifically absence of a murmur or any findings of congestive heart failure.
3. 3. I have discussed with Mr. Smith and his wife my recommendation to proceed with cardiac catheterization. Benefits and potential risks were discussed in detail and their questions were answered. Mr. Smith would like to discuss further with Dr. A this afternoon before deciding if he wishes to proceed.
4. 4. I told Mr. Smith I would see him again tomorrow morning to answer any additional questions and to follow up on his decision.

Thank you for the opportunity to see your patient. If there are any questions about my recommendations, please contact me.

These concepts are not difficult, but I believe they have been neglected in medical training. Enhanced emphasis during residency on these aspects of high-quality consultation will better prepare our graduates and contribute to the excellent medical care our patients deserve.

Daniel M. Lichtstein, MD, MACP
Boca Raton, Fla.