Skip to main content

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.

Comments

Post a Comment

Popular posts from this blog

Why Most Doctors Choose Employment

Increasingly, physicians today are employed and most of them willingly so.  The advantages of this employment model, which I will highlight below, appeal to the current and emerging generations of physicians and medical professionals.  In addition, the alternatives to direct employment are scarce, although they do exist.  Private practice gastroenterology practices in Cleveland, for example, are increasingly rare sightings.  Another practice model is gaining ground rapidly on the medical landscape.   Private equity (PE) firms have   been purchasing medical practices who are in need of capital and management oversight.   PE can provide services efficiently as they may be serving multiple practices and have economies of scale.   While these physicians technically have authority over all medical decisions, the PE partners can exert behavioral influences on physicians which can be ethically problematic. For example, if the PE folks reduce non-medical overhead, this may very directly affe

Should Doctors Wear White Coats?

Many professions can be easily identified by their uniforms or state of dress. Consider how easy it is for us to identify a policeman, a judge, a baseball player, a housekeeper, a chef, or a soldier.  There must be a reason why so many professions require a uniform.  Presumably, it is to create team spirit among colleagues and to communicate a message to the clientele.  It certainly doesn’t enhance professional performance.  For instance, do we think if a judge ditches the robe and is wearing jeans and a T-shirt, that he or she cannot issue sage rulings?  If members of a baseball team showed up dressed in comfortable street clothes, would they commit more errors or achieve fewer hits?  The medical profession for most of its existence has had its own uniform.   Male doctors donned a shirt and tie and all doctors wore the iconic white coat.   The stated reason was that this created an aura of professionalism that inspired confidence in patients and their families.   Indeed, even today

Electronic Medical Records vs Physicians: Not a Fair Fight!

Each work day, I enter the chamber of horrors also known as the electronic medical record (EMR).  I’ve endured several versions of this torture over the years, monstrosities that were designed more to appeal to the needs of billers and coders than physicians. Make sense? I will admit that my current EMR, called Epic, is more physician-friendly than prior competitors, but it remains a formidable adversary.  And it’s not a fair fight.  You might be a great chess player, but odds are that you will not vanquish a computer adversary armed with artificial intelligence. I have a competitive advantage over many other physician contestants in the battle of Man vs Machine.   I can type well and can do so while maintaining eye contact with the patient.   You must think I am a magician or a savant.   While this may be true, the birth of my advanced digital skills started decades ago.   (As an aside, digital competence is essential for gastroenterologists.) During college, I worked as a secretary