I am a hematologist who rounds in a hybrid community-academic hospital. Consultation, at its best, is one of the most powerful tools in modern medicine: a deliberate request for specialized expertise, framed around a clear clinical uncertainty, with the goal of improving patient care. When it works, it works beautifully. When it does not, it becomes something else entirely.
In daily inpatient practice, many consults are placed not because a decision needs help, but because something is abnormal. A lab value is out of range. An imaging finding looks unfamiliar. A diagnosis feels uncomfortable. The consult becomes reflexive, less a request for expertise than a form of documentation: proof that someone noticed the abnormality and escalated it appropriately. I think of these as “yes consults.” There is no question. There is no decision point. My role is reduced to confirming what everyone already knows.
A typical example begins with a consult request for thrombocytopenia. Nothing about the number itself is unusual. The patient is critically ill in the ICU with septic shock, on multiple antibiotics and vasoactive medications, many of which list thrombocytopenia as a known adverse effect. There is diffuse inflammation, hemodilution, bone marrow suppression from acute illness. The platelet count was normal prior to admission. The patient is not bleeding.
I review the chart and call the primary team.
“Hi, this is hematology calling. How can I help?”
“The platelets are low.”
“Yes, I see that. What specifically would you like help with?”
“The platelets are low.”
I try again. Is the concern identifying a dangerous cause? Deciding when to transfuse? Assessing bleeding risk? Determining whether anticoagulation is safe?
There is a pause, and then the same answer, offered without irony: the platelets are low.
At no point is a clinical question articulated. The abnormality itself appears to be the entire reason for the consult.
Thrombocytopenia in hospitalized patients — particularly in the ICU — is extraordinarily common. Between a third and half of critically ill patients will develop it during their admission, most often as a predictable consequence of sepsis, medications, consumption, or marrow suppression related to acute illness. In the absence of bleeding, a precipitous decline, or suspicion for a specific hematologic disorder, isolated thrombocytopenia in this setting is expected physiology, not a diagnostic puzzle. Consulting hematology does not change that biology.
Many studies examining inpatient consultation patterns show that a substantial proportion of consults do not lead to diagnostic or therapeutic changes. Specialists frequently recommend monitoring alone or continuation of existing management. In ICU populations specifically, thrombocytopenia consults rarely uncover new diagnoses, alter transfusion thresholds, or change outcomes. Yet they consume time, generate downstream testing, and often delay decisions while teams wait for reassurance they already anticipate.
These consults are often defended as being placed “for safety.” The implication is that more eyes, more specialists, and more documentation must equate to better care. But over-consultation does not reliably reduce risk. Instead, it can fragment responsibility, slow decision-making, increase cost, and reinforce a culture where clinicians feel unable to act without external validation.
What makes this frustrating is that I have seen the opposite. I have seen consults that were necessary, precise, and genuinely impactful.
One case stands out clearly. A middle-aged woman was admitted with pneumonia and new atrial fibrillation, started on anticoagulation, and then developed a rapid platelet decline over 48 hours. Her platelet count fell from normal to dangerously low. She had mild mucosal bleeding. Her coagulation parameters were evolving. She had recently received heparin, but the timeline was not classic. The primary team called with a clear question: “We are concerned about heparin-induced thrombocytopenia versus sepsis-related thrombocytopenia. We need help deciding whether to stop anticoagulation, whether to start an alternative agent, and how to manage her bleeding risk.”
That consult mattered. The question was defined. The stakes were clear. We reviewed the timing, the trajectory of platelet decline, the clinical context, and the pretest probability. We sent appropriate confirmatory testing, recommended immediate cessation of heparin, initiated non-heparin anticoagulation, and guided transfusion strategy. The consult changed management, reduced risk, and clarified uncertainty. That is what consultation is supposed to look like.
In that moment, the specialist functions not as a validator of abnormality, but as a translator — someone who helps weigh competing diagnoses, interpret imperfect data, and decide when action is necessary and when restraint is safer. A consult should not exist merely to prove that a problem was noticed. It should exist to help answer a question that the primary team cannot confidently answer alone.
The solution is not fewer consults. It is better ones.
Before placing a consult, clinicians should be able to articulate, in a single sentence, what decision they are asking the consultant to help them make. If no such sentence exists, the consult is unlikely to add value. Consultation should be a resource, not a reflex. When used thoughtfully, it elevates care. When used indiscriminately, it risks becoming noise.
The goal should not be to eliminate consultation, but to restore its purpose.
Share your good and bad consult examples in the comments.
Dr. Landau is the medical director of hematology telehealth for the Medical University of South Carolina. He has served many roles throughout his career at different organizations including Chief and interim Chair.
Illustration by Diana Connolly
