Zebra hunter

Working on a consult service is very different than taking care of my own patients. The primary care team calls up neurology when they think that a patient of theirs has neurological problems. The neurology team evaluates the patient, gives the primary team a set of recommendations, and follows the patient until the neurological issues are resolved.

Over the past two weeks, I have seen what a "good" consult looks like and what a "bad" consult looks like. A "good" consult has a true neurological problem with a clear question for the neurology team.

We had a "bad" consult the other day that was essentially, "I think my patient has corticobasilar degeneration," a neurodegenerative disorder similar to Parkinson's disease but much more rare. The resident who ordered the neurology consult anchored onto a very rare neurologic diagnosis and basically wanted the neurology team to confirm his diagnosis.

On exam the patient did indeed have some parkinsonian signs and symptoms, but he was also taking some medications that could potentially cause those symptoms.

My neurology resident got frustrated when he was pressed on corticobasilar degeneration. He finally told the primary care resident (in a very professional manner) that the neurology recommendations would be the same regardless of whether the true diagnosis ends up being corticobasilar degeneration, Parkinson's disease, or drug-induced parkinsonism: Discontinue all medications that could cause parkinsonian symptoms and re-evaluate the patient in two days.

This could have been a "good" consult if it was worded differently: "I have a patient with intention tremor, small handwriting, and cogwheel rigidity who is also taking psychotropic medications. Our team wants you to evaluate the patient to rule out Parkinson's disease or parkinsonian variants."

Aside from learning what good and bad consults sound like, I also learned that one quickly develops a reputation based on behavior like this. When my resident staffed this patient with the neurology attending, the attending interrupted to ask, "Is this the zebra hunter resident who ordered this consult?" His reputation had preceded him.