Article

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


 

References

From a consultant’s point of view, curbside consultations have the potential to be educational, especially when they force the specialist to search for the answer. It can also save the specialist time from completing or documenting a formal consultation. Furthermore, these consultations can help maintain professional relationships for future referrals. When the consultant is able to guide and educate fellow providers, it also provides a sense of personal and professional satisfaction.

Our recommendation

There are positive and negative aspects to curbside consultations. When used appropriately, these consultations can result in effective and improved patient care. Simple questions are most suitable for curbside consultations.5 For example, “What does quadruple therapy consist of?” or “How many days should a patient be on a clear liquid diet prior to colonoscopy?” are excellent examples of questions that can be answered through a curbside consultation with a gastroenterologist. These questions can be answered without having the specialist elicit a detailed history, review laboratory results, or consider multiple confounding issues. More complex cases and questions, however, should be addressed through a formal consultation. “What medication should I start for this patient with ulcerative colitis?” or “Would you scope an 80-year-old woman?” are questions that require far more details to provide a response and should not be addressed through a curbside consultation. To improve on this common practice, a few factors should be kept in mind.5

First, curbside consultations should involve only simple, straightforward questions. Complex questions that require a great deal of clarification and additional history should be addressed through formal consultation. Second, if the preference of the consultant or appropriateness of the curbside consult is unclear, the option of completing a formal consultation should be presented. If the requesting physician does not provide this option, the consultant should request a formal consultation, especially if this is more appropriate for patient care. Finally, when curbside consultations involving the same patient are repeated, formal consultation should be considered because the case is likely to be more complex.

Regardless of the medium through which a curbside consultation is requested or completed, it is important to maintain patient confidentiality and abide by the Health Insurance Portability and Accountability Act guidelines. Email is an increasingly popular vehicle for curbside consultation, therefore health providers need to be deliberate and careful with the content. Protected health information should be excluded, particularly in unsecure email systems. Patient identifiers can be included in secure and encrypted email systems such as those provided by certain hospitals and health care systems.

Medical-legal aspect

The most feared consequence of participating in curbside consultations is litigation;16 fortunately, this does not appear to be common. As courts have repeatedly affirmed, actual liability, for which a physician could be held responsible for medical malpractice, requires the existence of a doctor-patient relationship. The latter is not established during a curbside consult as previously defined because a doctor-patient relationship does not arise until a doctor assumes some responsibility for the diagnosis, care, or treatment of a patient.7 The courts are likely to apply the same standard even when the subject of the consultation is the requesting physician or one of their family members. In the absence of a doctor-patient relationship, the curbside consult generally is regarded as a service provided to a medical colleague and not to the patient. Similarly, while being paid for a curbside consult, for example, during an online interaction, would raise the scrutiny regarding the existence of a doctor-patient relationship, payment in and of itself does not establish a doctor-patient relationship. Recognizing that one can be sued even when there is no factual and legal basis for a lawsuit, a plaintiff could allege liability based on any curbside consult, requiring the curbside consultant to become involved in a complicated, emotionally draining process defending the alleged liability. Thankfully, medical malpractice tort reform and the well-established precedents regarding curbside consults appear to have made this type of litigation uncommon.1

Conclusions

Curbside consultation is often practiced but incompletely understood by the medical community. The consultant is not liable from a medical-legal standpoint in a true curbside consultation; however, we need to recognize when curbside consultations are inappropriate and when formal consultations are required. If practiced without discretion and attention to whether a doctor–patient relationship is being established, curbside consultations can be dangerous. If used sensibly, they can result in efficient medical care.

References

1. Cotton, V.R. Legal risks of “curbside” consults. Am J Cardiol. 2010;106:135-8.

2. Kuo, D., Gifford, D.R., Stein, M.D. Curbside consultation practices and attitudes among primary care physicians and medical subspecialties. JAMA. 1998;280:905-9.

Next Article: