Watson Professor of Medicine and former Chief of Gastroenterology and Hepatology at the University of Rochester Medical Center. He has over two decades of experience in academic GI with a particular expertise in interventional endoscopy. He has extensive experience in building APP programs and collaborating with and mentoring subspecialty APPs in gastroenterology and hepatology. Dr. Call is a member of ASGE's Reimbursement Committee and the chair of the ASGE EUS Special Interest Group. He has served as faculty on several ASGE and other national and international courses. Dr. Call, thank you for starting us off with your first lecture, Fundamentals of a GI Consult. Thank you very much, Sarah, for that very kind introduction. I want to also thank ASGE and Dr. Beccari, as well as the course directors, Aaron and Sarah for inviting me back to this amazing course. This is a very special group that I'm more with and a very novel course, such as which doesn't exist at this point other than this course. So very excited to be here. I think the stage is set for us to discuss the very basic element of patient interaction, which is required in the vast majority of patients who come in for procedures, which is doing the initial consult. So Fundamentals of the GI Consult. These are my disclosures. So the first couple of slides, I just wanted to put the idea of a consult is not new, obviously. This is a paper from Gastroenterology from about 40 years ago or more from Duke, actually, looking at analysis of patients referred to a GI practice in a community hospital. It's an interesting paper. And you look at the next slide. It's a little hard to read because it's an old kind of a fax or a scan. But many of the same items are prevalent in the questionnaire for the consult, including referring physician, the reason for the consult, what procedures have had been done in the past, what the initial diagnosis is, seen by a fellow or not, and so forth, but including the follow-up plan and outpatient consult workup suggested. So, you know, almost 40, 50 years ago, the same paradigm was in place. These principles haven't changed. And that was the purpose of my showing this archival kind of a paper. So the objectives of my talk is to define what a GI consult is, what is really the role of a consultant, and then, of course, talk a little bit of a subtle difference between inpatient and outpatient consults and how we approach that, what are the principal elements of a GI consult, and what is the significance and importance of each of these components. I like talking about who is an ideal consultant because we teach a lot at the university and we were trained and taught multiple generations of trainees. I think this is one aspect that is the art of the consult more than even the science. And then we'll finish up with some key take-home messages. So what is a GI consult? A subspecialty-level assessment and recommendation that is generated in response to a question or a set of questions which are posed by the referring provider in the context of a clinical care of a patient. So several principles already in that one statement, it is a subspecialty-level assessment, which means when you are in GI and hepatology or you're in cardiology or pulmonary medicine, you are a subspecialist and or you're representing a subspecialty team, which has a very key and focused area of delivery of care. There should ideally be a question, which unfortunately sometimes in consults, it's not clear what the question is. So I think it's important to clarify what the actual question is being asked. It makes your life easier. And I do believe it makes actually patient care much better. There is typically a referring provider, it could be a primary care physician or provider. It could be a GI physician, it could be a surgeon, an oncologist. So it's key to identify not only for best practice and communication, but also for medical legal reasons, who the referring entity is. And then of course, the whole point here is to deliver the best care for the patient. So all these elements are important. The consult does and should outline recommendations for further testing procedures and or medical therapy. And this is a big favorite of mine. You need to have a follow-up plan for this patient that you've seen in consult, regardless of which setting you've seen them. These are not only important from a patient awareness standpoint as to what's happening to them next. It's an important tenet for us to communicate back to primary care physicians or to providers, whoever is referring the patient. But it also has significant medical legal implications. So you can't leave that box unchecked. The role of a GI consultant is to provide timely and complete subspecialty level assessment and recommendations regarding a specific clinical question or a set of questions to the referring provider. This is a very specific role. And I think unfortunately, as we come out of the pandemic and we realize how delays have impacted our life, the timeliness of a consult is really key, especially when you're looking at cancer diagnoses or other acute illnesses. So a timely consult, answering the question and getting back to the provider is really key. And they sound simple principles, but they're obviously the details and the details. And that's where the best practices differentiate themselves from the average ones. The role of a GI consultant, again, some of the points are re-emphasized for good reason, is to receive the consultation. Now, I don't know about all of you there in the audience, I think we have a fair number of folks here and as well as the panelists, but I get these consults from all mechanisms in the universe. And most of us do, who've been practicing for a long time. And that is a direct attribute to our availability, accessibility, and of course, our reputations in the region. So we get them through the electronic record, we get them through text, email. And the only thing we don't get it from is a pigeon service, but we can get these coming from all angles. By the time you collate all these referrals and consults, it can be quite a pile. There should be a process for triaging these consultations, especially if they're coming at you from various sources. And the most important thing that myself and my team really focuses on is the level of urgency of the question and the clinical issue, especially on bookends, when you're looking at Mondays and Fridays, what needs to happen today? What needs to be addressed right now? So emergent, urgent, semi-elective, and elective. This is extremely important, especially in the post-pandemic era, where we already are backlogged, several delays coming in from 2020. And of course, business is ripe again, and we are back to almost normal scheduling, but we still have to deal with that backlog. And there are a lot of important clinical issues that have not been addressed, unfortunately, due to the pandemic. Now, the scheduling guidance, of course, is key on the receiving end, and then on the forwarding end, there should be a competent team managing the scheduling aspect of it. And of course, as we will talk a little bit more about the electronic consultation and the video visits and tele-home paradigm, that could be a big help going forward, but something has to be decided and clearly stated for the consult scheduling team. And then of course, finally, when you get to see the patient, you'd have to provide the appropriate consultation. So receiving and processing a consult request will be obviously different, where this is where the pathway is going to separate a little bit. The inpatient processing and pathways are a little different than the outpatient ones. Obviously, for the outpatient setting, whatever mechanism you're getting the consult through, eventually, the discussion will end up in the electronic health record, and should end up in the electronic health record with clear documentation of where you received the consult from and what you did with it and what the plan is. Here's where I think APPs and even some of our nursing teams will play a significant role in delivering the communications and documenting and making sure that the guidance that was generated from the clinical team initially is actually carried through. At least in my practice, in our practice, division-wide, and many others that I'm aware of, this is a key area for APPs and physicians to collaborate around the care of the patient, especially in a subspecialty practice, and especially for those providers who've been working together for a long time, and they've pretty much nailed down the algorithm for specific diagnoses, and it's almost an easy flow for them on a daily basis. So that's an area that I wanted to highlight. For the inpatient setting, we're very lucky, we've established a paradigm for an inpatient APP support with our two fellows who are on in a very busy 1,200-bed hospital setup. So that activity has been integrated, and there is a period of orientation and learning, but an inpatient APP certainly is a tremendous help. And also, for the appropriate person with the appropriate career ideas in that line, it could be a very fulfilling and gratifying time spent on doing inpatient coordination care and consultation. So that's more to come on that in a separate talk. So the example of a referral processing pathway is on this slide. So the referral received, the internal and external referrals are all kind of collated. They come to the MD or to the MD APP team. I talked about triaging it and organizing it into the scheduling process here. Now, obviously, elective items can go to next available dates, and that has to be ratified and made sure that that's happening appropriately and that we don't miss any urgent diagnoses that are in that pathway. And of course, for complex referrals, the team needs to spend a little bit more time and find the appropriate intervals for scheduling. This is really key because, not to get off topic, but a lot of the medical legal issues in GI come from delayed diagnoses and delayed referral processing, and some of them include missed cancer and delayed diagnosis of cancer. So that's a key area there, and especially going into a weekend, especially going into a long weekend, or especially around times when provider services are at an ebb, it's particularly important to take the basket and look at what is really urgent and what needs to be dealt with very quickly. And then, of course, the secretarial or what you call the physician support team will take it from there. And that has to be monitored, especially in the pandemic, we learned that we all need to keep our lists and Excel sheets and sometimes even handwritten lists where we actively monitor what happened to our guidance and where that patient is right now. So a little emphasis on the inpatient versus outpatient consult paradigm. The outpatient consults can be elective and semi-elective, typically. Now occasionally there are some more urgent consults that come through, but most of these patients are relatively healthier, and there's typically a more focused question, you know, this is a patient with a pancreatic mass or diarrhea, and obviously in the second, third opinion world, the questions can be more complex. This is a more one-on-one event, typically, whether it's private practice or academics, you know, the attending physician will typically see the patient either themselves or in collaboration with a shared visit with an APP. And sometimes, of course, the APP is an independent practice and we have all those models in place. Testing and further workup and follow-up typically obviously takes more time and it has been the case particularly so in the post-pandemic era. On the inpatient side, the consults obviously at least in tertiary and quaternary care facilities are more urgent and emergent. The patients are much sicker. Decision-making is complex. Many other teams are involved with the patient's evaluation at the same time. And the key mantra there really is a multidisciplinary approach where, you know, you are part of a care team and you need to talk to each other and come up with kind of a singular plan without redundancy. And that's really the holy grail for medical care on the inpatient side right now. The ability to provide timely, efficient, and a meaningful care and consultation on the inpatient side directly impacts length of stay. And length of stay is amazingly important quality metric right now that feeds into a lot of issues that we all are aware of. So key considerations for a consultant, what is the question being asked? I mean, I can't tell you how many times in clinic when we have a fellow, we have APPs, and students of all nature. Sometimes the team in the clinic can get up to seven or eight people on a half clinic day, all here to learn and see patients. The most number one important question is who sent the patient and what is the question? If we can't get over that hurdle quickly, it's gonna be very difficult to focus our energies on doing a MANGUP consult. Who is sending the patient? It is very important. Is this somebody that we know, somebody who we can trust their information, and somebody who typically will send a certain amount of data? Or is somebody that we don't know and we need to dig deeper and figure out what's going on? And different entities will pose the question in different ways and provide varying levels of information up front. So it's important to know your provider, especially for young providers who are setting up their practices. Most of these referring providers will be new to them. And if I can share one secret from a quarter century ago when I started almost, it's very, very important to engage and network with those referring providers. You do that a couple of times, and there's a relationship built for life. And I think they will send you patients and they will be happy sending you the patients. And that relationship is very difficult to break. And then of course, why is the patient being sent to me or us? For me personally, that's a very important question as I have sub-specialized over the years. Is there a reason that I am seeing this patient? Is there a particular procedure that only I can do or my team can do? Is it because of a longstanding referral relationship? Is it word of mouth? I got a patient from South Africa the other day, through Wyoming and other states, and it was a purely internet referral. So it's important to know your patient, know your provider, know the reason the patient is there. And then when you walk into the room, you sound much more intelligent and you certainly should be able to provide a more appropriate service. Now, the other considerations are, is this an elective or a semi-elective consult? Especially the outpatient setting. As I mentioned, many patients are healthier and the questions are more of a routine basis in the vast majority of practices. But in sub-specialty practices, especially in the IBD, liver, and pancreas biliary world, many of these consults really need more urgent attention. And we've had several times a year patients who are directly shipped off to the emergency room, sometimes with a chaperone, sometimes with 911, because they just do not belong in the outpatient realm. And one of my favorites, again, is the ability of the patient, used to be patient and family, but that went away for a while. And now that's coming back, we're allowing attendance back into the room. Is the patient competent? Is the family on board, especially for very high-risk procedures that we now engage in? And is the patient unit able to make decisions meaningfully? And can you have a short version of it is what's the patient literacy? And can you trust that discussion? That's very important in the consult. So my initial approach is basically, the critical questions is how is the patient doing and what is the patient's understanding of why they're there? It may be one thing that the referring provider sent the patient for, the patient may have a complete different understanding. I had a patient this Wednesday where the patient had a lymphoma that was in remission, but now has a mass in the spleen and at the splenic hilum, which nobody will want to biopsy. So I end up seeing the patient because I will biopsy it. But the patient had no idea why they were seeing me. And the first 20 minutes was spent in basically unraveling the cobwebs from the last several months. And that's important because if I had not done that, no matter what else I did for that patient, it would have been a dissatisfying experience. And for sure, if they get a post-FNA bleed, that is not gonna be a happy scenario from a medical legal perspective. So education, discussion, and the patient's literacy and understanding of what's happening to them is really a huge part of the consult and cannot be overemphasized. What are the evaluations that have been done so far? That's a big point, and our fellows in APPs are very good at digging that out if they're the primary folks seeing the patient. The other thing that's important for a consultant to know is what has worked and what has not worked. And these are intangibles that really need to get into. And I think sometimes in our busy schedules, these are the questions that we find hard to find time for. But I can almost guarantee that if we are able to get these paradigms into our discussion every time or most times, we will end up being respected more and we'll have a better outcome for the patient and longer and healthier relationships. And then finally, of course, at the end of the visit, I do ask the patient, are you satisfied with the plan? Are there any concerns that we haven't addressed? Is there something else that they're looking for? And each of my notes will have that the patient is agreeable with and satisfied with the plan. And that usually reflects, honestly, our discussion. Principal elements of a consult. Of course, these are more tangible elements. Record review, obtaining records can be a challenge. Imaging review, medication reconciliation can be painful. And we have a team that tries to help us with that, but it's something that the onus is on the consultant to make sure that that's accurate. And obviously, the review of symptoms and systems and specific symptoms. Detailed physical examination. There's a new guidance in this for the E&M course that will come up in our course as well. It's more focused now. I already referred to the patient education aspect of it. And then, of course, everything that you do has to be documented and billed at the appropriate level. There cannot be a significant variance or discordance between what you have done as a service and what you're billing for, because that is obviously fraud. And my personal favorite, as I mentioned, is a clear assessment and plan. I teach a lot about, after all of this data collection and interviewing and discussions, you need to have a differential diagnosis for the patient, for yourself, and for the referring provider. Because if you don't have a differential diagnosis, first of all, the consult doesn't come across as intelligent and secondly, you cannot have a plan if you don't have a bullet-pointed differential diagnosis. What's the most likely diagnosis? And then what are the other alternate diagnoses? One could be wrong, and I'm wrong often enough, but at least you have to put your money where your mouth is, and that makes for a much better consultant role. The significance of each element of a GI consult, I've already reviewed that to some extent. I think a lot of the record review is critical because sometimes you get referrals where the data is either incomplete or you need a second opinion or a third opinion. And I think when you dig deep into that and you provide clear recommendations based on what your assessment is, it builds trust with the patient and I think the guidance becomes a little bit more easier. So I cannot overemphasize the importance of accuracy and looking back at what has been done to the patient and incorporating that into your decision-making is really key and avoids future trouble. So an ideal consultant, especially from an APP perspective, is someone who works hard to build a good reputation and is compassionate and empathetic, is responsive, accessible, and affable, answers the questions, so long as you know what the question is, has cognitive, and from a provider MD standpoint, procedural competence, obviously, and for all of us, good communication and timely communication and ensuring that there is appropriate follow-up is key. And even if you are done with the actual question and you've basically finished your role, you always say that you're available for future help and that's always best practice. Strategies for APPs as GI consultants are listed here. If the concept question is unclear, please use your team as a resource and contact the referring provider, consult with senior APPs, MDs, fellows, and our institutions serve as a great resource, and verbally communicate the urgent findings, and then, of course, send over the electronic versions down the road and build a relationship with the referring providers and peers, not just in GI, but in other specialties as well. And something that we've had to do in the post-pandemic landscape is review referrals in advance and arrange to have any additional records sent to you in advance. This is a challenging task in our world, but it's something that is a constant work in progress. E-consults is the last section, real quick. This is a very specific area of consultation which is designed to reduce the cost, increase the efficiency, and get a very relatively basic question answered quickly. So the electronic question comes in and the electronic answer goes back. And typically, it's a primary care provider who will be using this information in the EMR or the HR to make decisions about whether that is enough for them to go on right now or whether they need to engage in a more detailed consultation. It doesn't pay a lot, but by the same token, in the era that we have just lived and emerged from, we have found it relatively useful to do and focus more of our significant energies on the more complex patients where the questions require in-person and or more formal visits. So here are the codes for hospitalized patients. This data will be available to you in the Enduring Materials as part of this course. As I said again, these don't pay a lot, but by the same token, they are efficient and they allow you to answer some of the more mundane and routine questions and keep the patient care going without holding things up. So the final slide, PIRLS, GI consultation, as I tried to explain here, is an art and a science. The initial timely assessment and triage of the consult is really key. You don't wanna have urgent consults and questions sitting around. Clarify the question if it's not clear. It's gonna be very good for your own mental health and personal health if you don't, if you have clarity on what you're trying to achieve here. And try to get all the relevant information for an outpatient consult. It's very embarrassing to be ill-prepared when a patient comes in, especially at a higher level consultation for second, third opinions. Incorporate the key elements that we talked about in the note. Address the consult questions directly. Generate a differential diagnosis. Document all plans clearly and bill accurately and remain available even after. So that is the end of my talk there. Thank you for your attention. And then I think we have a couple of polling questions real quick here. The GI consultation note should include all of the following except, this is an except question, so endoscopic procedure risk stratification, recommendations regarding periprocedural metadjustments, discussion regarding patient's insurance coverage, and discussion around informed consent. So which one is not needed or expected in the consult note? All right, so despite our significant issues with payment, I think we absolutely cannot provide care based on coverage. So we have to, almost everybody got that right. So that's great. Thank you. Let's go to the next question. Which of the following is not the responsibility of the GI consultant? Complete review of all medications patient has ever taken, record review, patient education, and documentation consistent with the level of billing. So which of these four choices is not my responsibility as a consultant? That is correct. Actually, I'm quite impressed. 85% got the answer right. A complete review of all medications patient has ever taken is neither possible nor expected. But all the other elements are really, really key. And documentation still needs to be consistent with the level of billing, although the burden of documentation has been significantly reduced in the new E&M codes. Thank you very much. This was excellent.

Dr. Vishal Call

GI consult

fundamentals

patient education

assessment

GI consultant