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Are non-clinical factors driving subspecialty consultations in the hospital?
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By Julia E. Szymczak, PhD, Christopher P. Bonafide, MD, MSCE and Jeffrey S. Gerber, MD, PhD

Drivers of Inpatient Subspecialty Consultation Among Pediatric Hospitalists: A Qualitative Study

Intro
Pediatrics itself is a medical specialty, and pediatric professionals can further subspecialize in a focused area of expertise. Children’s hospitals offer families the expertise of pediatric subspecialities who work together provide a comprehensive, multidisciplinary approach to care. Such coordinated care is quarterbacked by pediatric hospitalists, who are attending physicians subspecialized in the field of Pediatric Hospital Medicine.

Hospitalists frequently rely on consultations from other subspecialists such as gastroenterologists, cardiologists, and infectious diseases clinicians to inform patient care, but when used inappropriately, the risks—including increased unnecessary testing, cost, and length of stay, as well as delays in care—can outweigh the benefits. So, a team of researchers explored how pediatric hospitalists make decisions about subspeciality consultation, in hopes of generating insights to inform process improvement.

Study Design and Findings
This single-center qualitative study (which was a component of a larger explanatory sequential mixed-methods study of consultation patterns) included 12 participants, evenly distributed between high-consulting and low-consulting pediatric hospitalists. Interviews identified factors influencing their consultation requests, and responses were systematically analyzed.

Drivers of consultation included individual physicians’ perceived confidence and desire for concordance among the care team; provider and patient/family characteristics such as uncommon conditions, unexpected test results or outcomes and family expectations of subspecialist escalation; organizational characteristics such as institutional reputation for provision of subspecialty care and availability of secure text messaging for informal “curbside” consultations; and professional culture norms that promote consultation. 

Research in Practice Implications 
The results of this study suggest that many factors influence decisions to engage subspecialists, including factors unrelated to patient need. The authors conclude that strategies for reducing pediatric subspecialist consultations must address non-clinical social and organizational dynamics that promote consultation.  

Actionable Insights: 

  • Clinical: When considering engaging a subspecialist, pause to consider how non-clinical factors may be impacting the decision.
  • Research: Identify how subspecialists, families, and administrative leadership think about consultation; Develop interventions that incorporate social and organizational dynamics; Establish best practices for aligning consultation use with medical necessity; Examine the potential of e-consultations (“curbside” discussions) to mitigate need for formal consultation supports.

Information & Resources
•    CHOP Pediatric Hospital Medicine

Clinical Futures author(s): 
Julia E Szymczak, PhD; Jeffrey S Gerber, MD, PhD; Christopher P Bonafide, MD, MSCE

Citation: 
Kern-Goldberger AS, Bracy D, Szymczak JE, Gonzalez D, Rothberg MB, Gerber JS, Bonafide CP. Drivers of Inpatient Subspecialty Consultation Among Pediatric Hospitalists: A Qualitative Study. Hosp Pediatr. 2024 Sep 1;14(9):782-789. doi: 10.1542/hpeds.2023-007589. PMID: 39188250.