Sunday, November 12, 2017

Why Curbside Consults are Dangerous

One of the skills and stresses about being a doctor, is giving advice to or about patients we have never seen.  If readers think these are rare events, it happens nearly every day.  Often during weekend or evening hours when I am on call, my partners’ patients will call with questions on their condition or about their medications.  Radiology departments contact me during off hours with abnormal CAT scan results of patients I do not know.  Or, a doctor may call me during the day for some informal advice about one of his patients.  These physician-to-physician inquiries are called ‘curbside consults’, which are appropriate for simple questions that do not require a formal face to face consultations.

Physicians must be cautious when providing a curbside opinion on a patient he has not seen as even informal advice could result in legal exposure if the patient later files a medical malpractice claim.  Consider this hypothetical example.

An internist contacts a gastroenterologist for a curbside opinion on an elderly patient who had some mild rectal bleeding.  The internist suspects hemorrhoids and doesn’t want to refer the patient for a colonoscopy as the patient had one 3 years ago at which time hemorrhoids were discovered.  The gastroenterologist reassures the physician that the bleeding is probably from hemorrhoids, which is a very rationale conjecture.  But, it may be wrong.  The bleeding now may be from a colon cancer that was either missed on the last colonoscopy or has developed since.  The cancer won’t be discovered for another year.  Is the 'curbside' gastroenterologist responsible here?

I think so because, even though he hasn’t seen the patient, he has rendered medical advice directed toward a specific patient, rather than simply offer generic comments.  Indeed, the internist may have told the patient and his family that the 'curbside' gastroenterologist agreed that no testing was necessary.  Had the gastroenterologist pushed back against the internist and insisted on arranging for a colonoscopy or seeing the patient in the office, then the outcome may have been different.

Had I been asked for a curbside opinion regarding above inquiry, I would have been much more circumspect with my response, and ideally, I would have entered a chart note in my electronic medical records.  Memories of physicians and patients can fade over time.  I would feel more secure if my chart note recorded that I recommended that the patient be sent to me for an office consultation.

Some questions should never be answered ‘from the curb’.  I would not, for example, give informal advice to an internist about changing his patient’s medications for Crohn’s disease.

If I have any discomfort in responding to an inquiry on the phone, then I recommend an office visit when I can provide a thoughtful and informed opinion. 

Some inquiries are so innocuous that I respond readily even without entering a chart note.  These generic questions do not directly connect me to an actual patient.  To clarify, I will list a few examples.

What’s the proper schedule for the hepatitis B vaccine?
Is the generic for Nexium equally effective?
Are ulcers caused by stress?

There’s a skill set physicians need when we are advising strangers.  Sometimes, the skill is knowing when to remain silent or when to push back.  If you're not careful, it's easy to trip over the curb.

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