Background: High-quality collaboration between hospitalists and subspecialists is essential to timely, coordinated inpatient care. In academic centers, consultation may be influenced by differences between primary teams’ and subspecialists’ training, communication norms, cognitive load, and expectations. Misalignment of expectations can cause conflict, delays in care, and dissatisfaction. Prior interventions focused on improving question clarity and increasing in-person communication have not consistently improved perceived consult quality or reduced “pushback.” We sought to quantify the frequency, timing, perceived drivers, and patient care impact of conflict between primary medicine teams and medicine subspecialists at Yale New Haven Hospital, a large quaternary academic center.
Methods: We distributed an anonymous Qualtrics survey to hospitalists (n=180), including attendings and advanced practice providers (APPs ) as well as fellows, APPs and attendings from five high-volume medicine subspecialties: cardiology, gastroenterology (GI), hematology-oncology (heme-onc), infectious diseases (ID), nephrology with ≥2 weeks of clinical service within the previous 6 months (n=207). Respondents rated overall communication on a 4-point Likert scale, estimated conflict frequency (percentage of consults), identified the consult stage where conflict most often occurred, and ranked possible drivers from ten predefined categories. Data were analyzed descriptively. The study was deemed IRB-exempt as educational/quality improvement.
Results: Responses were obtained from 76 hospitalists and 78 subspecialists (response rate 42% and 38% respectively). 59% of hospitalist respondents were attendings and 41% were APPs; consultants included 44% attendings, 28% fellows, and 6% APPs. In rating consults across all subspecialty services, 51% of primary teams rated overall communication as awful/fair. Highest conflict rate was reported with cardiology consultants (mean 28%), followed by heme-onc (17%), GI (11%), ID (9%), and nephrology (7%). In contrast, 37% of specialists reported awful/fair overall communication. Specialist overall dissatisfaction was highest among cardiology (60%) and ID (45%). Consultants most frequently reporting conflict with medicine were GI (mean 33%) and cardiology (24%). Conflict occurred most often at initial consult placement (65% of primary teams; 41% of consultants). Primary teams identified inadequate consultant staffing (#1), burnout (#2), and unclear consult question (#3) as top drivers. Consultants ranked unclear consult question (#1), lack of communication between providers (#2), and excessive consult volume (#3). Most respondents reported that conflict negatively affected patient care, including length of stay, patient experience and/or care coordination (79% primary teams; 62% consultants).
Conclusions: At a large academic center, both primary medicine teams and subspecialists reported frequent communication challenges and conflict, most often at consult initiation. Perspectives on underlying drivers diverge substantially, particularly regarding staffing limitations and workload versus question clarity and communication processes. Both groups perceived negative impacts on patient care. Future work, including ongoing focus groups, aims to inform targeted interventions across communication workflows and evaluate effects following implementation of an EMR-based messaging platform (Epic SecureChat).
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