Comparison of Diagnostic Recommendations from Individual Physicians versus the Collective Intelligence of Multiple Physicians in Ambulatory Cases Referred for Specialist Consultation

Background Studies report higher diagnostic accuracy using the collective intelligence (CI) of multiple clinicians compared with individual clinicians. However, the diagnostic process is iterative, and unexplored is the value of CI in improving clinical recommendations leading to a final diagnosis. Methods To compare the appropriateness of diagnostic recommendations advised by individual physicians versus the CI of physicians, we entered actual consultation requests sent by primary care physicians to specialists onto a web-based CI platform capable of collecting diagnostic recommendations (next steps for care) from multiple physicians. We solicited responses to 35 cases (12 endocrinology, 13 gynecology, 10 neurology) from ≥3 physicians of any specialty through the CI platform, which aggregated responses into a CI output. The primary outcome was the appropriateness of individual physician recommendations versus the CI output recommendations, using recommendations agreed upon by 2 specialists in the same specialty as a gold standard. The secondary outcome was the recommendations’ potential for harm. Results A total of 177 physicians responded. Cases had a median of 7 respondents (interquartile range: 5–10). Diagnostic recommendations in the CI output achieved higher levels of appropriateness (69%) than recommendations from individual physicians (45%; χ2 = 5.95, P = 0.015). Of the CI recommendations, 54% were potentially harmful, as compared with 41% of individuals’ recommendations (χ2 = 2.49, P = 0.11). Limitations Cases were from a single institution. CI was solicited using a single algorithm/platform. Conclusions When seeking specialist guidance, diagnostic recommendations from the CI of multiple physicians are more appropriate than recommendations from most individual physicians, measured against specialist recommendations. Although CI provides useful recommendations, some have potential for harm. Future research should explore how to use CI to improve diagnosis while limiting harm from inappropriate tests/therapies.

MP17: Education innovation: A tool to teach consultation skills using rapid cycle deliberate practice

Innovation Concept: Consultation skills (the collaborator role) are key for safe and effective Emergency Medicine practice. The tool described uses educational techniques familiar to Emergency Physicians and residents (rapid cycle deliberate practice and focused debriefing) to incorporate teaching of this skill into on-shift clinical teaching of Emergency Medicine residents. Methods: We searched the literature for consultation teaching methods. We developed a tool to teach consultation as part of on-shift clinical teaching using pedagogical concepts familiar to Emergency Medicine residents, rapid cycle deliberate practice and focused debriefing. The developed tool has three phases; 1) Introduction to a framework for good consultation skills, 2) Managing push-back and understanding competing frames of reference and 3) Direct observation and feedback on the actual consultation. The tool is designed to be used during a clinical shift. Over a series of consecutive cycles the resident refines a consultation and is eventually directly observed during the actual interaction with a consultant. Curriculum, Tool or Material: For each of the three phases the tool provides a framework for the preceptor to use to guide the presentation and discussion. During phases 1 and 2 the resident will present the consultation a number of times and the preceptor will provide focused debriefing allowing the presentation to be refined and optimized. During phase 3 the preceptor provides direct observation of the actual consultation followed by focused debriefing. Phase 1: Focuses on understanding the learners current skill level and presents a framework for a high quality consultation. Phase 2: Introduces the concept of competing frames of reference and push-back and patient centred strategies for managing this situation. Phase 3: The actual consultation interaction between resident and consultant is observed and debriefed. Conclusion: Consultation skills are important in the day to day practice of Emergency Medicine but rarely the subject of specific teaching. The tool presented can be used during clinical shifts to teach consultation skills using pedagogy familiar to both Emergency Physicians adEM residents.

Evaluation of cultural responsiveness using a transcultural secondary consultation model

This article describes the expansion of a transcultural secondary consultation model run by a state-wide transcultural unit. The model aims to enhance cultural responsiveness in partnership with mental health services. We discuss a series of 12 consultations that occurred between 2011 and 2012. We outline the processes of setting up the structure of secondary consultation, the actual consultation-facilitation format, and methods of evaluation. Evaluations were done in two phases: the first immediately after the consult and the second after a period of 3–6 months. The discussion highlights the usefulness of a transcultural model of consultation and, based on the evaluations, identifies the benefits the model brings to understanding and intervening with clients, culture, and systems. The results emphasise the need for multidisciplinary collaboration and a facilitated space for clinical teams to explore culturally responsive therapeutic practices.

Strategically eliciting concessions from patients in treatment decision-making discussions

In this paper it is examined how doctors may strategically elicit concessions from their patients in order to create a favorable point of departure for the treatment decision-making discussion. Using the dialectical profile for establishing starting points in an argumentative discussion (van Eemeren, Houtlosser, and Snoeck Henkemans 2007) as an analytic tool, an overview is provided of the different — analytically relevant — dialectical moves that doctors may make at the opening stage of the discussion and the possible subsequent dialectical pathways. Based on examples taken from actual consultation practice, each of these pathways is illustrated. Moreover, some of the strategic maneuvers doctors may deploy to start the critical resolution process in the most favorable way are identified, linking these maneuvers to the aims that are inherently embedded in the broader institutional context in which the discussion takes place.

Implementation of a broadband video consultation service for children with posture and movement disorders

We evaluated the implementation of a video consultation service in a regional community of paediatric physiotherapists. Twenty-two paediatric therapists in primary care settings and a rehabilitation centre participated in this study. The implementation comprised three phases: introduction, learning and consultation. Evaluation of the implementation focused on the participants' satisfaction with regard to the implementation procedure, the education received, the technical helpdesk support and the usage of the application once put into practice. The introduction phase was very short (only two sessions) but the learning phase took much longer; it took 12 months for 21 therapists to complete the learning phase. Only 14 of the 21 therapists entered the actual consultation phase. Participants were generally satisfied with the education received and judged the helpdesk to be sufficient. The helpdesk was contacted 36 times by 14 participants. Within the 12-month study period, the therapists performed 24 video consultations. The average time to compose a question was 115 min and the average time to answer it was 43 min. Implementation of a video consultation service is possible but takes more time than initially foreseen and only about two-thirds of the professionals actually adopted it into routine practice.

Consultation in Afghanistan: A Case Study

This case describes the experiences of one consultant working in Afghanistan, for ten weeks. The case is organized around the consultation cycle, and the problems for which consultation was requested. It raises important questions in terms of how consultants from one culture work in another; how multilateral agencies contract for consultant services — a process which usually prevents the consultant and consultee from interacting around the problems prior to the actual consultation; and how one consultation builds upon the previous consultations, albeit by different consultants. Implicit is the recognition of the need for special preparation in consultation for health educators and for working in cross-cultural contexts.

Evaluation of Medical-Psychiatric Consultation

This report describes four approaches to the evaluation of hospital psychiatric consultation. These are: 1) a survey of actual consultation use; 2) a house staff attitudinal survey; 3) a patient chart review; and 4) a patient questionnaire. The findings of this project and those previously reported are: 1) The psychiatric consultation is under-utilized and a large number of house staff find it not useful. 2) The psychiatric and non-psychiatric house staff view the functions of consultation in markedly different ways. 3) A high percentage of written consultation reports are too vague to determine if the needs of the referring physician were met. 4) Patients usually respond positively to psychiatric consultation. The implications of these findings are discussed in this report.