When a Neurology Consult Is Unnecessary

Stephen Krieger, MD


June 06, 2019

This transcript has been edited for clarity.

Hi. I'm Dr Stephen Krieger, and I'm the neurology residency program director at Mount Sinai in New York. I'm here at the American Academy of Neurology Annual Meeting 2019 in Philadelphia, and I'd like to discuss two neurology education research projects that we're presenting here at this national meeting.

The first project looks at something that I think we all can identify with, which is the feeling of the inappropriate consult during residency training. Many of us have had the experience, either ourselves or seeing it with our residents and colleagues, where the phone rings for a consult request and the resident feels that it's wildly inappropriate, a total waste of their time, and doesn't understand why they are being asked this question.

We looked at this in our program via a survey a couple of years ago, looking at the bias that neurology residents often felt. This bias was that other people should know the answers to the questions that they're being asked, be it about dizziness, vertigo, or transient symptoms. It's a failure to recognize our own expertise as neurologists or neurologists in training.

We did a different study this past year,[1] where we embedded medical students in the neurology consult service. Every time the neurology resident received a consult or a consult request, the student would give the resident a questionnaire about the appropriateness of the consult, including questions about the necessity of the consult and whether the person on the consulting side should have been able to take care of the patient without the consult.

Then, the student asked the person who called the consult the same questions about consult appropriateness. Compared with the requesting provider, the neurology residents felt that approximately 35% of the consult requests were inappropriate.

We looked at this in a variety of ways, including when the service was busy—did that inform the perception of inappropriateness? It did not. We looked at who was calling the consult. It almost didn't seem to matter whether it was an intern or an attending calling the consult. Overall, there was a discordance of the perception of appropriateness for the consults.

Interestingly, we also found that the neurology residents thought some of the consults were more appropriate than the person calling it, which also reflects the fact that people in different fields don't really know what other fields do. There is a need for better interdisciplinary communication between neurologists/neurology residents and clinicians in other fields to better understand what it is that neurology residents and neurologists, in general, bring to the care of our shared patients.

We also looked at the feeling of medicolegal reasons for these inappropriate consults. We're presenting that here as a separate poster about the medicolegal drivers of consultation requests.[2]

Diagnostic Accuracy Among Residents

The second neurology education research project that we're presenting here at the American Academy of Neurology Annual Meeting examines the clinical acumen of the junior neurology resident.[3] Most residencies have a daily morning report where the junior resident presents cases that she's seen the night before—that initial diagnostic impression.

At Mount Sinai, we do this every day. Since I took over as program director almost a decade ago, we've been capturing each day's morning report presentation in a log. A week after that presentation, we close the loop on those cases to see whether the resident's impression was accurate, partially accurate, or wrong. It's been a really great method of focused education and learning from our mistakes.

At this meeting, we're presenting the data from 1301 cases presented during the morning report to look at junior residents' diagnostic accuracy. Our topline finding was that our junior residents are right about their initial diagnostic impression 64% of the time, they're partially accurate around 5% of the time, and we felt that the junior resident's initial diagnosis was wrong in 31% of cases.

This gives us opportunities to look at those errors to try to figure out when neurology residents are wrong about the initial impression. Why and where in the diagnostic process do they make that error? We broke those errors out into egregious errors, where they failed to recognize neurologic disease altogether; modest errors, where they mistook, let's say, a central from a peripheral nervous system condition; or more subtle errors, where their localization was correct but their etiology was wrong.

We broke this out over different conditions and found that we're 64% accurate for neurologic cases and all-told cases. For the pure neuro cases—the ones that turned out to be neurologic disease—we did a little bit better, with accuracy in the high 60s. For cases that proved to be medical or psychiatric, we didn't do as well, and our accuracy dropped into the 50s.

Most of the wrong diagnoses made by these junior residents were over calls as neurologic disease which, as a program director, I think is a more favorable type of mistake to make. I would much rather a resident mistake something that's not neurologic for something neurologic than to miss neurologic disease altogether.

We're looking at those errors, and in some detail, we can break this down by different disease states to see where in the diagnostic pathway a resident made his or her mistake, which gives us opportunities to intervene with educational initiatives.

To my knowledge, this is the first large-scale study of resident accuracy in neurology. This is a single-center project, even though it's 1300 cases, so it would be interesting to see how this might relate to other programs, and for those of you who work with neurology residents, to see whether their diagnostic accuracy is different from what we found in our study.

Reporting for Medscape, from the American Academy of Neurology Annual Meeting in Philadelphia, I'm Stephen Krieger from Mount Sinai.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.