05 May Curbside Consult: A Recipe For Disaster?

Diagnostic Imaging | When I tell people I’m a physician, I feel like I’m at risk. Everybody has a medical question or a family member who needs help. I’ve gone from being enthralled by these conversations as an eager medical student to becoming concerned about how helpful I am actually being and about how much risk I am exposing myself to.

A curbside consult is the solicitation of medical advice regarding a specific patient’s medical condition, care, or treatment without the consultant actually seeing the patient and can be obtained by either physician or non-physician individuals. This definition also outlines the inherent disadvantages to this type of consult. For example, the information provided by the individual may be incomplete or inaccurate, the consult may be obtained in an environment that is clinically suboptimal (i.e. dinner table), being named as a consultant without giving the patient permission to do so, and being unable to follow-up on the actual care and treatment plan of the patient.

When it comes to curbside consultation for non-physician individuals (i.e. family members, friends, and associates) risk management professionals say not to do it. A physician is likely to be held liable by the courts even if the individual who received the information is not an established patient.  Legal issues include whether or not there was a prior patient-physician relationship, length of the conversation, whether there was a physical exam involved, or how emergent the clinical situation was.  As a radiologist, when consulted about emergent situations or urgent situations, a referral to an emergency department or a primary care specialist are usually safe bets.  A referral to a primary care specialist will both allow the individual to be followed on a regular basis and it may also be a teaching opportunity as many individuals feel the need to see a specialist first for every ailment.

As for physicians who request curbside consults, the ultimate legal responsibility is on the doctor seeking the advice, but radiologists who provide such consultations should document these interactions according to the American College of Radiology (ACR) Appropriateness Criteria 2010.  According to this guideline, curbside consults may be performed in times that don’t allow proper documentation and often the referring clinician’s notes are the only record of the communication.  It suggests that these instances are documented by the radiologist as well in order to improve patient care.

A Journal of the American Medical Association (JAMA) article also published a good set of guidelines for engaging in this type of consult:

1. Keep the curbside consultation brief and simple. If the case requires consideration of two or more confounding variables or a detailed discussion of the patient’s history and physical examination, formal consultation should be considered.

2. The attending physician should offer the option of a formal consultation as a courtesy if the complexity of a specific patient problem or the consultant’s desire to formally see the patient is not clear.  As a radiologist, you should feel free to ask to see any associated imaging and if necessary have the patient formally evaluated if the situation is too complex.

3. Consider a formal consultation if contacted by a treating physician a second time concerning a particular patient.

4. When a curbside consultation is obtained, the name of the consulting physician should not be recorded in the patient’s medical record without the consultant’s permission.  This should be made clear.

5. Physicians who are given a financial incentive to keep referrals to the minimum should avoid the temptation of managing difficult patient care problems by seeking informal rather than formal consultations.

Also, as a radiologist it is good to follow-up on the consult to determine how your input assisted the management of the patient.

Finally, I regard myself a radiologist, but also as a physician. That means I need to be as helpful as possible to my fellow beings while balancing the realities of a tort-torn society. As sworn by Apollo during the Hippocratic oath, “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan…I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.”

Those are the basics tenets of our oath; let us do more good than harm. And that includes offering impromptu advice when we don’t have all the facts.

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