Medical "Curbside" Consultations:Are There Problems with It?
If you didn't already know, what is called in the medical profession "curbside consultations" are going on
every day and really no standards of practice have been set for this behavior. "Curbside Consultation" is simply a brief meeting between two doctors, perhaps in a hallway of a hospital or at the same dining table and one doctor is taking care of a puzzling case of a sick patient and asks the other doctor who isn't involved with the care of that patient to give some advice about what to do next in terms of workup, diagnosis or treatment. Often the requesting doctor is one in general medicine and the other is a specialist but may be just another general physician who has had a similar case. In this brief conversation, the requesting doctor will attempt to present some of the facts (history, physical findings and labs) that the doctor can recall and present in a few minutes or less and then will wait for advice and suggestions made by the "curbside consultant" doctor.The patient is usually unidentified and the case is usually unknown by the "consultant". This activity is considered and performed as a "professional courtesy", a friendly and perhaps expected professional communication between two doctors, in which the "consultant" is not providing the advice for any fee and has no intent to provide direct management to the patient under discussion and a consultation about which the patient is unaware and may not be told later. This is in contrast to a formal consultation where a referring physician informs the patient of the need for consultation and arranges an appointment with the consultant who may provide further diagnosis and advice and perhaps further management of the patient.
One motivation for the curbside consultant to participate may be to be considered by the referring physician for later formal care. One motivation for the requesting physician to ask for a "curbside" would be get advice for no monetary charge to the patient. Occasionally, the requesting physician may repeat communication with the doctor who had made the "curbside" advice as a courteous followup report. However,the requesting doctor may be looking for addition advice. Repeated followup informal consults may not be appreciated by the consult doctor both out of concern for the proper care of the patient and for the consulting doctor's own financial interest.
As I have already mentioned, though this consultative action has great popularity in the medical profession and is considered a common and professionally accepted activity, the law and the ethics of "curbside consultations" is missing.This is unfortunate since this lack of rules can lead to malpractice actions taken upon the consulting doctor as well as the requesting doctor if serious problems in the patient's management occurs. In this regard, it is not clear whether the consulting physician's name should be noted in the patient's medical records. Laws defining malpractice issues in this form of consultation may vary from state to state in the United States. The threat of malpractice, may, particularly if large financial penalties of malpractice suits are decided, discourage such consultations and might impair a route of possible valuable transfer of medical advice. It also is unclear whether Federal HIPAA laws regarding privacy of the patient's history,identified by name or not, permit informing another individual who is not directly attending the patient for care or responsible for insurance payment. In addition, there is no consensus with regard to what the consulting physician's ethical responsibilities such as attention to doing a "good" and avoiding harm, are with regard to the unnamed patient. Or would all ethical responsibilities remain with the patient's own physician? Another issue is whether it is ethical for the patient's physician to carry out a consultation with another physician without necessarily providing the full medical history and without the patient's knowledge or permission, both of which might be considered ethically unprofessional. I suggest that in view of these uncertainties within a long establish and common professional activity, it is important that these questions should be answered from both the legal and ethical aspects so the requesting doctor and the "curbside consultant" and the patient will be aware of what are the limits of this practice.
My question to my visitors is with the information I have written about "curbside consultations", would you want your doctor, if he or she felt it was necessary, to request from another doctor such a consult? Or would you rather have a formally arranged appointment with the consultant? If you were aware that the "curbside" activity had already occurred in your case and without your prior knowledge, would you approve? Would you consider that the doctor who advised your physician in this manner had any personal or professional responsibility of what would actually happen in your care if so should be held responsible? ..Maurice.
Graphic: "At Curbside" photograph taken by me 2-10-2013.
posted by Maurice Bernstein, M.D. @ 12:47:00 PM
6 comments
6 Comments:
No new concept here,happens all the time. In fact, I
believe it is more acceptable and leaves the responsibility
with that physician for the care of his patient. It is a well
known fact that when you have two or more physicians
caring for you, one will assume the other assumes
responsibility. The old saying, too many fingers in the
pie so to speak.
My point being that two physicians assigned to your care
rarely communicate with eath other. They often resent
the "competition and shun responsibility, rarely does
the care complement one another.
PT
PT, do you feel satisfied that the "curbside consultant" bears no ethical or legal responsibility to the perhaps anonymous patient? Yet, it may well be that the patient's physician will be using the very advice which was provided by the consultant to either the betterment or harm to the patient. And if responsible, shouldn't the patient be made aware of the source of the advice or even provide consent prior to the consultation? I know this doesn't happen in this common professional behavior but should it? ..Maurice.
I don't have a problem with it. If my doctor is chatting with another doctor about the case, I think he's getting other thoughts, and maybe a little education. He's still the one responsible for patient care. If that doesn't suffice, then a formal consult might be required.
TAM
Every time I visit a specialist I ask for a copy of the report. It's alarming that 99% of the time there is at least one fact that is incorrect and sometimes big mistakes are made.
This said, there is so much miscommunication in healthcare, the person who doesn't know you and all the details of your history might say something that is appropriate for the case that would not ensure the best outcome.
All of my doctors tell me when they've consulted with someone and even provide who it is and sometimes recommend a follow up appointment.
Too many mistakes in healthcare and you have to take care of you.
belinda
First, I want to say that I have requested and participated in "curbside consultations" in my internal medicine practice because it was the commonplace and potentially useful way to become educated about issues about which I was uncertain. But thinking about this activity these days has led me to write this thread.
TAM's use of the word "chatting" as a description of the communication between the doctors is both appropriate and realistic. Because, that is actually what is going on.
"Oh..Frank..do you have a moment? I have a case that is bothering me. I don't know what this lady's rash has to do with her chronic back pain..." "Sure, Bill..I haven't seen you around for a month, have you been ill?" "No.. I was on a trip to Europe with my family. I recently got back and one of the first patients I saw was this lady." "So..briefly Bill, what does the rash look like?" "Well, it's macular and pruritic and located on her cheeks and upper chest." "So..So Bill, what did you think it was?" "Frank, I wondered about lupus.." "Was her serology abnormal?" "I haven't seen the results, so.." "Bill, I've got to run, but let me know about the results."
Though the above narrative may be a bit of an exaggeration of what really goes on in a "curbside consultation", it also could be realistic and this is my concern. Often, the session is brief, and represents an unprepared and undocumented summary based on the primary physician's recollection at the moment. What should be simply a brief education toward the general medical knowledge of the requesting physician (which I think is of value) becomes instead, at least to that doctor, as a direction to the diagnosis or treatment of a specific patient. And that is where the issues including fragmentary history, fragmentary responses and patient responsibilities enter this discussion. And, unfortunately there have been no professional guidelines or rules or consistent laws for this common activity. ..Maurice.
I should also bring up here the occasional occurrence of a "curbside consult" precipitated not by another doctor but by a lay person acquaintance or friend, not the doctor's established patient, who meets the doctor outside of the doctor's office such as at a social gathering or in a grocery checkout line and wants to talk to the doctor to understand more about their illness or symptoms or tests or treatments. They often want help in medical decision-making. In this case, what do you think should be the response of the doctor to such a request? Have you ever tried this "curbside consultation" and what was the outcome? ..Maurice.
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