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Curbside consultations – the good, the bad, and the ugly


 

References

Curbside consultations are as old as our medical profession. Professional communication and interaction around best patient care is valuable, educational, and necessary. As consultants, we have special knowledge about how to manage people with digestive disorders and often are willing to share our expertise. We also understand that the days of leisurely lunch discussions in the “Doctor’s Dining Room” are long gone. Nowadays, even my wife tunes me out if my sentences exceed 140 characters. In this age of rapid electronic communication, Dr. Lin and colleagues remind us of some critical legal and professional parameters related to curbside consultations.

John I. Allen, MD, MBA, AGAF

Special Section Editor

During a routine workday, while you are seeing patients in the clinic or waiting for the next colonoscopy to get set up, you receive a text message from a primary care physician who often sends new referrals and frequent texts with questions about patients you have never seen. It reads: “41M with dyspepsia, +H pylori IgG. EGD?” You text back that, if there are no red-flag signs or symptoms, he should treat with quadruple therapy first. This all-too-familiar scenario is an illustration of a curbside consultation. It used to occur at the curb of a doctor’s parking lot, but as we will discuss, curbside consultations can take on several different forms. We will define curbside consultation, discuss the perceptions of this practice, review the practice of curbside consults, and examine the medical-legal aspects of curbside consultation in this article.

The basics

Curbside consultation is a ubiquitous practice within the medical field. Most medical professionals have asked for a curbside consultation or received a request to assist with a curbside consultation at some point in his or her career. For some providers, it happens on a monthly, weekly, or even daily basis. Colloquially, a curbside consultation is the process whereby a provider informally obtains information or advice from another provider to assist in the management of a particular, real patient. However, from a medical-legal standpoint, it is more complex. A curbside consultation must satisfy several criteria to be considered a “curbside consultation.”1

A curbside consultation must be 1) an informal process, 2) occurring between two physicians and involving a consultant, 3) who does not already have a pre-existing patient-physician relationship with the patient in question and is not covering for a physician who does. 4) The consultation cannot involve an on-call consultant or the care of a patient in the emergency room. 5) Furthermore, the consultant should not have any contact with the patient in question. The consultation 6) cannot result in a formal report, and 7) generally does not result in a charge or payment. Curbside consultations also cannot occur between a supervising physician and supervised health care providers, including other physicians, because the latter are acting under the authority of the former. In addition, specialists such as radiologists, cardiologists, and pathologists who are involved in the formal interpretation of films, electrocardiograms, specimens, or other tests or studies are responsible for issuing accurate interpretations, and their involvement cannot be construed as a curbside consultation. It is important to note that a written record of the curbside consultation (for example, whether it is conducted by email or texting), does not annul the curbside-consultation nature of the communication as long as all the criteria noted earlier are met. Based on self-reported occurrences, primary care physicians obtain an average of 3.2 curbside consults per week while subspecialists report receiving approximately 3.6 curbside consult requests per week.2 Formal consultation occurs approximately three times more frequently.

Gastroenterology is a particularly popular target, and gastroenterologists receive the second most formal consultations and the second most curbside consultations. The most common reasons for curbside consultations based on self-reported data from primary care physicians and specialists in Rhode Island are for selecting diagnostic tests, determining the need for formal consultation, formulating an appropriate treatment plan, or interpreting laboratory or radiographic data. In one study, gastroenterologists reported spending 7.2 hours per week providing curbside consultations for an entire health maintenance organization.3 An electronic consultation (e-consultation) is a relatively new process whereby a specialist is asked to answer a specific question by electronically reviewing the patient’s chart and pertinent information. There are several varieties of e-consultations including some involving the exchange of payment of the consultant. Although some e-consultations may fall under the umbrella concept of a curbside consultation, these would need to be examined on a case-by-case basis specifically to see if a physician–patient relationship has been established.

Perceptions

Although more than half of primary care physicians and specialists have reported that they enjoy curbside consultations, sentiments vary regarding other aspects of this practice.2 Relatively similar proportions of primary care physicians and subspecialists believe that curbside consultations are an important way for physicians to stay current with medical knowledge (49% vs. 42.3%) and are a faster way to obtain advice (60.9% vs. 55.4%). However, up to 80% of subspecialists believe that there is insufficient clinical information exchanged during these informal consultations and that important clinical findings are missed because consultants do not get to see the patient. On the other hand, less than 50% of primary care physicians share these sentiments. In one prospective cohort study, Burden et al.4 compared the accuracy and completeness of information received from 47 providers requesting curbside consultations from hospitalists, with formal consultations on the same patient. They showed that when inaccurate or incomplete information is presented during curbside consultations, recommendations in curbside and formal consultations frequently differ. These differences result in both minor and sometimes major changes in management. However, when information is completely and accurately exchanged, recommendations between the formal consultation and curbside consultation often are similar and only occasionally result in minor changes in patient care. Other disadvantages with this practice include lack of financial compensation and fear of being named in litigation.5 With so many issues with curbside consultations, why is it such a common practice? From a primary care physician’s perspective, curbside consultations come at no extra cost for the consulting physician and patient and save time spent searching for an answer. Some answers are not found easily in a journal or textbook; even when they are found, it may not be clear to a generalist whether these answers are still accurate or whether the standard of care has changed. With a telephone call or an email, a reliable and accurate answer can be obtained efficiently. Although there are cases when the services of subspecialists are required, having too many physicians involved in a single case may limit the role of the primary care physician or produce conflicting advice.

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