Why banning curbside consults may not be the answer

Everybody hates curbside consults – the informal, “Hey, Joe, how would you treat asymptomatic pyuria in my 80-year-old nursing home patient?”-type questions that dominate those Doctor’s Lounge conversations that aren’t about sports, Wall Street, or ObamaCare.

Consultants hate being asked clinical questions out of context; they know that they may give incorrect advice if the underlying facts and assumptions aren’t right (the old garbage in, garbage out phenomenon). They also don’t enjoy giving away their time and intellectual capital for free. Risk managers hate curbside consults because they sometimes figure into the pathogenesis of a lawsuit, such as when a hospitalist or ER doctor acts after receiving (non-documented) curbside guidance and things go sideways.

There is some evidence to support this antipathy. A recent study published in the Journal of Hospital Medicine examined 47 curbside consultations by hospitalists, in which formal consults by different hospitalists (unaware of the details of the curbside encounter) were performed soon thereafter. Conducted by a team of researchers from the University of Colorado, the study found that the information given to the curbside consultant was incomplete or inaccurate roughly half the time, and that management advice offered via the two forms of consultation differed 60 percent of the time. (In those cases in which the consultant was given inaccurate or incomplete information, the advice differed more than 90 percent of the time!) This is not the first warning about the dangers of such consults (see also here and here), and it won’t be the last.

I recall several cases at my own institution in which curbside consults contributed to mistakes with tragic consequences. In a memorable one from nearly a decade ago, a cardiology fellow was curbsided to look at an ECG in a young patient with non-cardiac symptoms. The primary team attributed her symptoms to a pulmonary illness and asked the specialist whether the patient’s potentially alarming ECG findings could be seen in that syndrome. His “yes” answer – which may have been correct in theory – led the team to stick with its original diagnosis, an error that contributed to the patient’s death. There seems little question that had the cardiologist actually seen the patient, reviewed the history in detail, and looked at the electrocardiogram in that context, his recommendation would have been different, and the outcome might have been as well.

Cases like this, and studies like the JHM paper, inevitably cause some to lobby to ban curbside consults, and I’ve heard of a few organizations and subspecialty services that have done just that. While such a move seems logical on the surface, my own belief is that it would be an extremely dangerous thing to do.

Imagine a law firm or a business in which none of the partners were comfortable asking for the advice of a colleague without a formal, written request. Let’s also imagine that the advice could only be given after the colleague had reviewed the case file for half an hour and spoken to the client himself. This would be a disaster – collegial, informal exchange of information and ideas is what lubricates the gears of every effective organization; it’s what a “learning organization” looks like. Stripped of this lubrication, the machinery freezes up; before you know it you have a hidebound, bureaucratic monstrosity. One of the key lessons of the past decade is that healthcare organizations are so-called “complex adaptive systems,” in which formulaic approaches tend to fail. In such organizations, it’s crucial to nurture the informal connections that allow for the diffusion of wisdom: from senior leaders to front-line managers, from teachers to students, and yes, from specialists to generalists.

What would actually happen if we did ban curbside consultations? Picture a resident caring for a patient with a tough case of C. difficile colitis. The resident spies an overworked, underfed GI or ID fellow looking harried. The resident would realize that if he asked the fellow the question, “Cynthia, I got this guy with recurrent C. diff. What’s the best treatment?” the response would be: “Are you asking me for a formal consult?”(Accompanied by a Please-God-No facial expression and toe tapping that would put Savion Glover to shame). Faced with that scenario, it’s likely that the resident wouldn’t ask the question of the specialist, instead choosing to wing it with the help of UpToDate or perhaps another resident’s advice. In other words, while we know that curbside consults can be dangerous, what we don’t know is how much useful information is transmitted via such consultations, and whether the advantage of better formal consults would trump the loss of shared wisdom through this fractal information market. I suspect it would not.

As with so many complex issues in medicine, the right answer will require a nuanced approach. For complex clinical questions whose answers truly hinge on the consultant having a deep understanding of the patient’s history, physical examination and clinical situation, a full-bore consultation is appropriate and should be required. I’m guessing that that description covers the minority of day-to-day clinical situations. To deal with the others, we need to get creative. Rather than banning curbside consults, we should develop new “consult-lite” models: ones in which the consultant feels comfortable opining without being obligated to see the patient and the complete dataset. For example, a pulmonologist might be comfortable rendering a recommendation after hearing a thumbnail history and seeing a chest CT; a dermatologist might need little more than a photo of a rash; a neurologist might be able to observe a hospitalist examining a patient through a video link and make a recommendation with confidence. (These recommendations and the information on which they were based should be briefly documented in the medical record.) Of course, there is a chance that their judgments might have changed had they spent 30 minutes talking to and examining the patient (and some will undoubtedly complain about the further dehumanization of medicine), so we need to weigh these concerns against the efficiency of this consult-lite approach.

To make all of this feasible, it will be important to take the matter of professional fee billing off the table. One hopes that the movement toward a value-not-volume payment system will give healthcare organizations the freedom to organize themselves in ways that promote appropriate types of consultation and information exchange. In places like Kaiser Permanente, which offer us a head start on envisioning the future, they try to maximize these informal interactions (for example, through co-locating specialists and primary care doctors in ambulatory practices). Their hope is that this structure allows primary care doctors and hospitalists to deliver appropriate care, less expensively than requiring that specialists be involved every step of the way.

A complete prohibition of curbside consultation would create only two options when it came to generalist-specialist interactions: purely educational forums (aka CME) and formal consultation. There’s a lot of good care and information exchange that lives in-between these poles. In a 2005 Annals of Internal Medicine article, Ferrer and colleagues addressed the need for flexibility when it comes to generalist-specialist interactions:

Generalists should work with specialists to address the following questions: What are the volume–outcome relationships for a specific condition in both primary and specialty care and how can they be optimized? When is referral too early, and when is it too late? They should create communication patterns that support the proper selection of steps along the referral continuum of advice, formal consultation, co-management, or referral.

To thrive in the next decade, healthcare delivery systems will need new models of generalist-specialist information exchange that produce the best outcomes at the lowest cost. To be successful, these models must leave all of the involved clinicians feeling professionally satisfied, protected from undue malpractice risk, and fairly compensated. I’m pretty sure that they will not include an outright ban on curbside consults.

In 2003, cutting residency duty hours seemed like a straightforward solution to a tangible problem: resident fatigue. Yet we now know that this change did not result in improved safety (or education, for that matter), because we failed to address the many collateral issues, ranging from resident scut work to the dangers of handoffs, nor fully appreciate how care is actually delivered in the trenches. Banning curbside consults is similarly seductive: it seems like a straightforward solution to a palpable problem. But I’m afraid it would likely have the same unfortunate outcome. Let’s be smarter – and more imaginative – this time around.

Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

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  • Dr. Drake Ramoray

    “In 2003, cutting residency duty hours seemed like a straightforward solution to a tangible problem: resident fatigue. Yet we now know that this change did not result in improved safety (or education, for that matter), because we failed to address the many collateral issues, ranging from resident scut work to the dangers of handoffs, nor fully appreciate how care is actually delivered in the trenches.”

    If by we, you mean you, then you are correct. I was a resident during this transition. Everyone in the trenches knew that your “solution” was not going to fix the problem and was just going to create other problems.

    Curb side consults are evil, especially if you expect me to take on any legal liability of the mangement of the patient based on incomplete information.

    “(In those cases in which the consultant was given inaccurate or incomplete information, the advice differed more than 90 percent of the time!) ”

    I am very reluctant to dispense curb side advice and actually insisted on seeing a patient once when the hospitalist said I didn’t have to do so. (It became evident that something more serious and dangerous was going on than I was led to believe.) As long as I have a medico-legal responsibility for the patient I will not dispense curbside advice unless it is prelude to a formal consultation (“What tests would you like before you see the patient?”).

    PCMH, ACO, or any other organization will not change my opinion on the subject, and your suggestion that it does is completely unfounded. Furthermore the notion that curb-side consultation becomes more appropriate because we won’t get paid as consultants for a formal consult individually in one one of these models is absolutely abhorrent. Ideas like this will probably become all too prevalent when doctors aren’t paid for their work, and then you will wonder why it has occurred and attribute it to the proverbial “we.” I will have no part of it.

    • southerndoc1

      Wow! We’ve hit a trifecta of posts by destructive IM “leaders”: Doherty, Sinsky, and Wachter.

      • Dr. Drake Ramoray

        Depressing. If they weren’t “leaders” and didn’t appear to have some impact on my career I would say it’s akin the The Three Stooges. Afer this week, I have to double check and make sure I haven’t wandered on to the satirical website The Onion.

    • Mengles

      What’s interesting is that in their love of everything European, the prototype being Donald Berwick, it’s interesting to me that while they want to change the healthcare system to the NHS, they don’t wish to do the same with residency education. For example in the UK, residency is 40 hours per week. Hence, keep the workhorses and unbearable conditions, but not the rewards.

      • Dr. Drake Ramoray

        What you forget is Donald Berwick and the like are pushing for the use of NP’s markedly out of proportion to what is used in Canada, the UK, and Australia.

        Conveniently this curb side consultation plan makes it easier for those with lesser training to perfrom the role of primary care provider. They can just curb side all of the specialists. I tried several times to link some info on those healthsystems and NP’s but Disqus keeps eating it.

        • southerndoc1

          They’re also working to destroy private practice, which is the basis of health care in most Western European countries.

  • crx6871

    I’m pretty sure the straightforward solution to overworked residents is more residents rather than artificially cutting hours.

    Just like the straightfoward solution to dangerous and inappropriate curbsides is clearly defining appropriate boundaries and teaching doctors when to use each rather than banning all curbsides.

    • Dr. Drake Ramoray

      The problem with curb side consults is that they are “consults”, and as such are almost never appropriate. They are consults about the specific management of a specific problem, on a specific patient. If we assume that the cardiologist in the above piece answered the question correctly he has not done anything wrong. He has not been asked to see the patient. “Here’s an EKG. Can you see these changes with diagnosis X?” But that’s not really the question. The primary team is questioning the initial diagnosis and what they really want to know is are these EKG changes representative of diagnosis X in this patient. They are seeking reassurance from the cardiologist that they are going down the right path without the consultant having all of the information.

      For two of the examples used (treatment of C. Diff collitis and the EKG changes) the primary team is seeking reassurance in what they plan to do in an informal way from the specialist. This isn’t terribly different than looking up the information from an external resource (Uptodate was the example used in the article). Now if the primary team looked up EKG changes for diagnosis X on uptodate, were ultimately wrong about the diagnosis, and litigation was pursued do you think Uptodate would be held liable for the treatment decision of the primary team, of course not. Would that cardiologist get examined by a malpractice attorney in that above case, almost absolutley. A case that cardiologist probably barely remembers, and an attorney will invariably ask if the diagnosis being considered, or the patient ultimately had, was so serious then why didn’t you as the specialist think you didn’t need to see the patient? The seemingly weak answer, although correct one, will be because I was not formally asked to evaluate the case.

      In the specious argument about law firms do you think if lawyer A informally consults lawyer B about a case, has a bad outcome that then lawyer B will be specifically sued for the advice given to lawyer A. I don’t think so. Similiary specialists talk amongst themselves regarding cases, but we don’t get sucked in to litigation if that occurs either. Somehow when litigation is pursued in medical cases the curb side consultant gets dragged into the case. Yes I realize the entire law firm may be in trouble were that the case, but unless the auther of this paper is assuming that doctors will start having communal malpractice insurance for their organization the law firm example is bogus.

      Look, I think curb side consults in general are bad medicine. But more than that, If you want to ask a specialist a curb side question with only partial information provided to the specialist and then if there is a bad outcome regarding that advice then the primary team should take the lumps for that outcome. Seeing as I don’t have control over med/mal law in my state I think if you aren’t comfortable managing a problem you should look it up. If you still aren’t comfortable then ask for a formal consultation.

      The author of the original piece puts the blame on billing fee for services. Trust me, I would much rather continue to see my patients in the office than come see the consult that I received during the middle of my office hours for the patient who has been in the hospital for ten days that I could answer in 2 minutes on the phone. With current reimbursement rates I lose money by going to the hospital. Between driving, parking, finding the patient, logging into the different EMR, talking to and examining the patient, synthesizing my plan, documenting my note in the EMR, clicking on my orders, and if necessary communicating with the primary team and then driving back to the office, I could probably see 4-5 patients in the office easily.

      Why do I still go, because A.) it’s bad medicine to perform curb side consults and B.) the malpractice risk of curb side consults. Fix malpractice law and you have some hope of encouraging doctors to perform curb side consults. Curb sides will still be bad medicine, but payment has little or nothing to do with it.

      As an aside I know I’m giving too much credit to the author. The whole idea is just another way to curb costs without paying doctors for their work, a shortcut if you will, and a sad desperate attempt to draw specialist physicians into this terrible ACO idea (You won’t have to see all those consults in our hospital system honest!). Trust me, I’ve played that we will shield you from inpatient consultations in our hospital system game. The author is out of touch and ill informed at best, and has ill intent at worst.

  • azmd

    There’s a pretty big difference between the law/business model and the medicine model for collegial consultation. In a law firm, a senior partner who provides any substantial consultation then bills the client for it. In a business, the executive is paid with a salary that assumes that a certain amount of his or her work will consist of such collegial activities.

    In medicine, where we operate on a piecework system of compensation, (with the pay per piece getting less and less every time we turn around), a practice setting where we are expected to provide informal consultations to mid-levels (let’s call a spade a spade here) really will only work if the MD’s are on a real salary, meaning that we are not expected to “earn” our salary through bringing in patient fees.

    • Dr. Drake Ramoray

      I believe part of his point he is trying to make is that by moving to an ACO model relieving the fees for service and piecemeal part of medicine that this will encourage more curb side consults. I still feel that given the articles that even he cites in terms of accuracy of recommendations as well as the potential for a specialist to get dragged into litigation on patient’s they couldn’t even pick out of a line up that curb side consults are still usually bad medicine.