Why specialists don’t do more curbside consults

One of the simultaneously most enjoyable and exasperating aspects of being an infectious disease specialist is the large volume of “curbside” consultations we get from colleagues.

For example, here’s this week’s tally — and it’s only Tuesday — done from memory and without systematically keeping track of emails, pages, phone calls, etc.:

  1. Duration of antibiotics after urosepsis, organism resistant to TMP/SMX and quinolones
  2. Need for repeat immunizations in splenectomized adults (got that one last week too, coincidentally)
  3. Work-up for diarrhea and mild eosinophilia in someone just returning from Nigeria
  4. Best outpatient antibiotic for prevention of MRSA recurrence
  5. Interpretation of Lyme immunoblot
  6. When to suspect false-positive HIV viral load test
  7. Can someone catch hepatitis C from sharing a toothbrush?  (Very, very unlikely — but why do it, ugh.)

The pluses of doing curbsides are numerous, and extend beyond just helping our colleagues and their patients.  It’s also a way of fostering a friendlier clinical environment, one which generates interesting referrals and open communication among different specialties.

After all, lacking a billable procedure (the lucrative gram stain has been outlawed by OSHA years ago), we are hardly going to rake in the dough under the current fee-for-service health care structure regardless.  So why not do it?

One potential answer is in this paper recently published in Clinical Infectious Diseases, from the ID group at the University of Vermont.  They kept track of all curbside consults done in 1 year period, and “converted” them into the work component of the relative value unit, or RVUs.

Not surprisingly, lots of their work is done via curbside:

A total of 1001 curbside consultations were fielded: 66% involved outpatients, and 97% were coded as initial consultations. A total of 78% of curbside consultations were considered complex in nature, being assigned a CPT code of level 4–5, including 84% of the inpatient and 75% of the outpatient curbside consultations … Curbside consultations represented 17% (2480/14,601) of the clinical work value of the infectious diseases unit. If the infectious diseases unit had performed these curbside consultations as formal consultations, an additional $93,979 in revenue would have been generated.

In other words, time is money — only in this case, time isn’t money at all.  The paper concludes by stating:

Hospital administrators, managed care groups, insurance companies, and academic societies need to recognize that curbside consultations represent a large volume of work, are complex in nature, and represent potentially large sources of lost revenue for infectious diseases specialists.  The curbside consultation should be incorporated into measures of provider workloads, productivity, contribution to health care delivery, and financial compensation.

Amen to that.

Paul Sax is the Clinical Director of Infectious Diseases at Brigham and Women’s Hospital. His blog HIV and ID Observations, is part of Journal Watch, where he is Editor of Journal Watch AIDS Clinical Care.

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  • family practitioner

    With very few exceptions, curbside consulting is quite rude.
    It is akin to a patient asking medical advice of me when I am spotted in the supermarket, or at a soccer game.
    To my fellow primary care doctors: either get an official consult or look the answer up yourself.

  • ridiculous

    I like FP’s, but the response from “family practitioner” is ridiculous. Since when did we decide to let stupid Medicare payment policies determine what is rude?

    The obvious solution here is to change the payment policies to make them more consistent with high-value work (and as Dr. Sax points out, the IC curbside is an extremely high-value service) or to exit the system via retainer-based practice. As a general internist I would love a system in which I had a modest retainer to cover my own “curbsides” from patients calling me at all hours, and I could pass some of this retainer on to my cadre of specialists whose curbsides I find especially timely, helpful, and competent.

    But rudeness? When we start to accept payment policies as guides to our manners, we’ve lost.

  • anonymous

    i don’t read the first comment as commenting that payment policies are the reason the curbside is rude. rather, the curbside itself is rude, even if you think you are doing the other person a favor by ‘saving’ them a ‘consult’.

    • family practitioner

      Thanks for defending me anonymous.
      There are times that curbsides are ok; but we should not take advantage of our specialist colleagues anymore than we want them to take advantage of us. It is about etiquette, not money.

  • Resident

    I hate to be “debbie downer” but I don’t see the current administration doing much to pay us MORE for any kind of work we do, from seeing patients, to surgery, to imaging. The admin views physicians as “overpaid” and is treating us as the cause of the high cost of health care. They realize that it is easier to put the squeeze on physicians than it is to tackle the real problems in healthcare (insurance infrastructure, malpractice, and all of the other middlemen/bottom-feeders, etc). Wish it were different, but it’s not.

    • gzuckier

      Again, to play Devil’s Advocate, if you’re going to cut costs you have to pinch dollars, not pennies. As has been done to death on this blog and elsewhere, even a complete ban on malpractice torts is unlikely to net even 5% savings. Insurance companies layer on 25% overhead, but in exchange for that 25% they negotiate like a 75% lower payment schedule. If medical providers are anxious to eliminate that 25% overhead to the public, a good place to start might be to offer the general public that same fee structure they accept from Medicare and all the other big volume players. As I’m sure somebody will point out, the number of patients who actually pay those billed amounts rather than the contracted allowed amounts is vanishingly low, so it’s not like the loss would be crippling; and it would speak to a willingness to unilaterally bow out of the greedy business of extorting the best bargain you can get by twisting the arm of smaller guys to make up for the bigger guys twisting your arm, which characterizes medical provider payment structure.

      Of course, the yearly income of physicians covers a very wide spread, perhaps the widest of all professions. It would not make any sense to hound the overworked underpaid GP when the bulk of the expenses come from glamour specialties; so you can bet that hounding the GPs is probably the route we’ll take, as a nation.

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