Audit of the consultation process on general internal medicine services

Objective: To determine the proportion of consultations requested by general internal medicine services that communicate key components of the consultation process to medical subspecialists. Design: Retrospective chart review by two researchers, using a standardised chart abstraction instrument (93.1% agreement, kappa 0.85). Setting: Calgary, Alberta, Canada. Sample: A random sample of medical consultations was selected from those generated on two medical teaching units (MTUs) from 2003 to 2004. Measurements: The primary measure of interest was whether a "clear clinical question'' was posed to the subspecialist, a binary variable. Results: Two hundred consultations were sampled from the 2885 subspecialty consultations. Of the selected consultations, 94.0% (188/200) were available for review. A clear clinical question was posed in 69.7% (131/188) of consultations (CI 0.63 to 0.74). In a secondary analysis involving a larger sample permitting comparison across subspecialties, 95.1% (368/387) of the consultations, representative of the subspecialties, were available for review. An MTU member contacted the subspecialist for 74.2% of consultations. If a consultation was urgent, a member of the MTU contacted the subspecialist in 81.0% of consultations. Of these urgent consultations, 63.3% had a clear clinical question. Conclusion: More than one in four consultations does not contain a clear clinical question, illustrating suboptimal communication between physicians. Innovative strategies that provide a sustainable solution for overcoming barriers to communication could have a significant impact on quality of care.