Consult or curbside?

As a consultant my expertise is sought out in largely two ways – a formal consultation (a request to see a patient, obtain a history and perform a physical examination, review laboratory tests and recommend further evaluation or treatment), or a curbside question (a quick hypothetical or general question with the expectation of a simple answer).

An example of a curbside question might be “How many pneumococcal serotype responses would you expect to be normal in an immune evaluation..?”. The answer is 5-10 depending on the age and immunization status of the child, but in reality the correct response is “why the heck are you ordering an immune evaluation on a kid that I know nothing about…?”. The indications for performing an immune evaluation (frequent or unusual infections) are generally the sort of thing an Infectious Disease specialist should have been consulted on!

People often start a curbside question with “This isn’t a consult, but…” as if a consult is a bad thing. It isn’t. A consultation isn’t an inconvenience, it’s what I get paid to do (salaried or not, divisional revenues ARE based on the consults I get called to see). It’s what I ENJOY doing – if it wasn’t I wouldn’t be in the job in the first place. And even if I AM busy, tied up in clinic, or off-site taking call from home, it’s in the patient’s best interest.

No matter how well you quiz someone over the phone, there is no way they can adequately convey the entire medical history and physical exam, the concerns of the patient and family, trends in lab values, recent antibiotics and other meds, and the simple gut vibe of a case… A complete consult, done properly, can take up to an hour and may involve field trips to radiology and the micro lab to check things out for yourself. That is a considerable chunk of time (certainly more than a curbside question) but the value of having a subspecialist see the whole picture cannot be overstated.

The dangers of answering a curbside about a specific patient are legion – you may miss drug allergies or interactions, co-existing diseases or subtle clues in the history or exam that would point towards a specific diagnosis, you will tend to overtreat “just in case”, lacking the reassurance of seeing the patient for yourself, but may just as easily undertreat an infection that had been missed or misdiagnosed. Worse, for the consultant, chances are good that their name will end up in the chart “case discussed with ID”, which medico-legally puts us in a bit of a spot. Then the onus is on you to show that you had no medical obligation or responsibility to the patient should something bad happen…a hassle and horrific waste of time at best.

The other issue is “added value”. Even when I’m called to answer a specific question, I almost always end up offering something else. If I’m asked about best treatment options, I will offer alternative diagnoses. If the question is what this disease could be, I will recommend empiric therapy as well. Every consult is a teaching opportunity, whether about a specific disease or a general bit of advice on ID. For THAT patient I want the docs who consult me to know as much about the disease as I do.

That’s all in theory – what about the evidence? One study of mandatory ID consultation for outpatient IV antibiotic therapy found that 39 of 44 patients had a change of therapy (!), meaning that 88% of the time the current plan was not ideal. 39% of the patients were sent home on oral instead of IV antibiotics, 13 patients (30%) changed medications, 5 patients changed dose, 3 changed planned duration, and 1 patient was stopped entirely. Cost savings were $500 per patient EVEN TAKING INTO ACCOUNT THE CONSULT FEE.  In Germany and the US, ID consults have been linked to significantly reduced mortality from staph infections.  In Italy, formal ID consultation on ICU patients reduced cost, mortality, ICU stay, length of mechanical ventilation – all due to improvements in antibiotic usage. A financial analysis of curbside consultations suggested that close to $94,000 in revenues were lost in a year by giving advice over the phone without performing (and billing for) an appropriate level of consult. With antibiotic cost savings and increased revenues to the hospital, consults really are a win/win situation.

So what’s really happening when you say “This isn’t a consult, but…”? You’re putting your patient at risk of being treated for the wrong diagnosis, or being wrongly treated for the right diagnosis, you’re increasing hospital costs and increasing patient mortality, and you’re passing up the opportunity to learn something yourself. It’s not good medicine – it’s not good for anyone.

Say it after me: “I’ve got a consult for you…”

 

 

This post may or may not have been inspired by the fact that I have had an inordinate number of consults this week which started out as curbsides that would have led to inappropriate care….

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  1. #1 by Alice Ackerman, MD (@CloseToHomeMD) on July 29, 2012 - 10:26

    NIck. I agree with you totally. As a department chair, I would love to outlaw “curbside” consults. They are dangerous. Period. What is even worse is when the requester leaves a note in the chart: “Per peds I.D. no need to ____” REALLY? When you were asked the question you may or may not have known it represented a real kid, with a real problem.

    I am trying to teach my faculty to ask for real consults and to provide REAL consults. As you said, its in the patient’s best interest.

    Thanks for posting this.

  2. #2 by Robert S. Miller, MD on August 6, 2012 - 11:41

    Nick,
    Great blog post, and I am in agreement with most of what you say. I am a medical oncologist who spent 17 years in private practice and now practice in an academic medical center. I believe some courts have indeed held that a doctor-patient relationship did exist even when it was only a curbside, even more reasons to minimize or eliminate these interactions.

    There are some situations, often more related to heme issues, where I think there can be some value to a curbside however. When I was in practice, I would usually review the outside records, when available, of patients scheduled for an outpatient consult. Not infrequently a PCP would refer a patient with a minor lab abnormality – Hgb 11.9, polyclonal increase in gamma globulins, etc. In some cases, after reviewing the records, it was obvious that all was needed was follow up, repeating the initial abnormal lab, or clarifying the diagnosis with some additional testing first, before having the patient see me as a subspecialist. I believe I ultimately saved the system some money (even if taking it out of my own pocket), and I know I often spared the patient a frightening trip to my office with the sign Cancer Center emblazoned on the door, when there was little chance there was a diagnosis or malignancy or something that required subspecialty follow-up. Another example was the patient with a suspected diagnosis of cancer but no biopsy yet. While some situations are obvious – a patient who almost certainly has AML for example – it may not be in the patient’s best interest to have me as an oncologist see a patient with a new lung mass, when what they really need is a biopsy and a surgical referral, even if I may end up seeing the patient later. And rarely, it turned out not to be cancer at all. I remember one case where I agree to admit a patient with multiple liver lesions because the ER doc just knew it was cancer. And while it was quite suspicious at first, it turned out to be multiple liver abscesses without any malignancy. So there are some times when I would prefer to do a curbside to get more information and then more appropriately triage the patient.

    I realize that is a chance for any of these examples that I might have otherwise missed a more serious issue if I didn’t physically see the patient, and that could have exposed the patient to greater harm and me to liability risk. But I think the odds are probably small if I use good judgment. From a business standpoint, it is never good to routinely turn down work, and if there was any question that the referring doc and/or patient would feel better if I did the consult, I always would. However, I know ultimately that my referring PCP’s were grateful that I used my discretion on occasion when it seemed like the right thing to do.

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