How do you approach a situation where you disagree with a consultant's recommendation for your patient, particularly when the consultant has more disease-specific expertise, but you have a fuller picture of the patient's overall clinical trajectory?

Thank you for this question. If a consultant provides a recommendation that I disagree with, I try to understand their perspective and rationale. Most of the time, it ends up in a direct phone call to talk through the clinical scenario, listen with intention to understand their perspective, and share my own. Clinical judgment and expertise are priceless, and not something you can easily get from searching UpToDate, ChatGPT, or OpenEvidence for an answer. I recently had a case that illustrates th...

I agree with Dr. @Dr. First Last that direct and coordinated communication is key. When surgeons are involved, I find that email is helpful, as they seem to check between cases, and the path of communication between surgical trainees and attending is sometimes circuitous otherwise. Email (or, if it's a relatively small group of specialists I know well, a PHI-encrypted text chain) groups involving the specialists involved, and ideally their critical outpatient team members (oncologists and primar...

Generalists absolutely have a duty to integrate consultant recommendations into a globally sensible plan of care for patients, even when the specialist knows more (or should know more) about a specific problem. I'll provide some examples to illustrate how and why we can plot our own course despite specialist input.

1. As an intern, I stopped the brisk IV hydration of a BMT induction patient whose sodium plummeted 20 points in a few hours, with suspected cyclophosphamide SIADH, even though my atten...

An important question. I try not to frame these situations as “whose expertise wins?” The consultant has disease-specific expertise that I sought for a reason, but as the leader of the primary team, I bring a different kind of expertise: a more complete view of the patient’s clinical trajectory, competing problems, goals, and how a particular recommendation fits into the patient's overall care.

When those perspectives lead primary and consulting providers to different conclusions, I think the mo...