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Trent's Laws of Consultancy

4 min read October 17, 2017 at 9:52am on Infection

The first piece of advice one of my bosses gave me when I became an advanced trainee in infectious diseases was "don't give any infection control advice without checking with the infection control nurses".  It's still good advice, and I pass it on to all my registrars now, more than 10 years later.

But I'm going to talk about some of the other important things I pass along to my trainees;  it's relevant because they also apply well outside of infectious diseases.

By way of minimal background, infection is sometimes referred to as a "quaternary specialty".  Our positions tend to be clustered in tertiary hospitals (although thankfully, this is changing), and most of our work is consultative.  Our team has had only a single inpatient this week - this sometimes leads to "so what do you do all day?" discussions;  we see patients belonging to other teams and give advice on the management of complex infections.

You might have some familiarity with the "healthcare pyramid".  Most people aren't sick.  Most sick people tough it out at home.  Most people who seek healthcare are sorted out by their GP etc.

Well, here's my five-minute job for infectious diseases physicians.

The very pointy end of the pyramid is "patients with infection, on whom we consult, where we change management", because we give quite a lot of advice, much of which is "yes, that sounds fine".

Quite a number of hospital infections are unexpected complications.  Many of these are no-fault - because "Staph happens" as I said to my team on Friday.  Many of the ones where there are "opportunities for quality improvement" relate to systems issues, and very occasionally there are instances where "in a no-blame environment, things could have been managed better" (thanks to Karsten Gnann, the first SHO I worked with as an intern, for this quote). 

So as someone who occupies the rarefied air at the pointy bit of the pyramid, there's a couple of important things to watch out for.

1.  "I can't believe the orthopedic surgeon did [X]"

We see complex patients with difficult-to-manage infections.  That's our job - as specialists in infection.

Because our bread-and-butter is other teams asking us for help in dealing with complex problems, there can be a tendency to cynically reduce the requests to see these complex patients to "no cardiologist [so as not to unfairly target my ortho colleagues] can treat any infection properly".

If it was a simple infection, they'd probably be in the "inpatients with infection [who we don't get consulted on]" tier of the pyramid.  For every patient we see, the referring clinician has probably managed 20, 50, 100 patients with a similar condition where everything went just fine.

The fact they can't manage this infection doesn't mean they can't manage other ones.

Sure, there might be an opportunity to help manage the simple ones better - that's why I'm forever educating people about antibiotic use.

2. "This is simple. Why are they calling me?"

Specialist.

Infection.

I'm not going to deliver your baby, or stent your coronary artery, or plate your bones back together when you come off your motorbike.  If you're an obstetrician / interventional cardiologist / orthopedic surgeon, then you might think these things are simple.  They're not.  We need to remember that we are actually specialists in a defined body of knowledge, and to assume that everyone should be able to do it as well as we do is to diminish our own value.

(this is an oversimplification, and there's an argument to be made another day that "all doctors can prescribe antibiotics" also diminishes our specialist skills, but that's not what I'm talking about today.

3. You can't help the patient they don't ask you to see

This is another quote from David Looke, the first boss from the first paragraph.

If you're a dick to your colleagues, they won't call you, and they'll have a crack at managing the complex infections themselves.  Which probably won't be good for your patients.

4.  They don't actually have to follow your advice

For patients we see as consults, it's not my name on the end of the bed.  If something goes wrong, I'm not the one who ends up carrying the can - it's the treating consultant.  Following on from the "they have their own specialist knowledge" point above, there are two ways you can deal with this:

"Why did they bother wasting my time if they weren't going to do what I suggested?!!?!?!1"

 - I can assure you, this leads to rapidly accumulated frustration

"I have given my advice, and they can do with it as they will; if there is a critical issue that I think must be managed differently, I'll advocate more strongly".

 

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Now my homework for all the non-medical readers of my blog is to go back and re-read the post, mentally replacing "infection" with whatever your specialist area of knowledge is.  In the last couple of months, I've seen this sort of thinking in:

 - Healthcare IT
- Information security
- Financial corporations management
- Carpentry

Remember:  just because you only see when the shit hits the fan, it doesn't mean it doesn't usually end up in the toilet the rest of the time.