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02/10/2013

Medical "Curbside" Consultations:Are There Problems with It?

If you didn’t already know, what is called in the medical profession “curbside consultations” are going on
every day and really no standards of practice have been set for this behavior. “Curbside Consultation” is simply a brief meeting between two doctors, perhaps in a hallway of a hospital or at the same dining table and one doctor is taking care of a puzzling case of a sick patient and asks the other doctor who isn’t involved with the care of that patient to give some advice about what to do next in terms of workup, diagnosis or treatment. Often the requesting doctor is one in general medicine and the other is a specialist but may be just another general physician who has had a similar case. In this brief conversation, the requesting doctor will attempt to present some of the facts (history, physical findings and labs) that the doctor can recall and present in a few minutes or less and then will wait for advice and suggestions made by the “curbside consultant” doctor.The patient is usually unidentified and the case is usually unknown by the “consultant”. This activity is considered and performed as a “professional courtesy”, a friendly and perhaps expected professional communication between two doctors, in which the “consultant” is not providing the advice for any fee and has no intent to provide direct management to the patient under discussion and a consultation about which the patient is unaware and may not be told later. This is in contrast to a formal consultation where a referring physician informs the patient of the need for consultation and arranges an appointment with the consultant who may provide further diagnosis and advice and perhaps further management   of the patient.

One motivation for the curbside consultant to participate may be to be considered by the referring physician for later formal care. One motivation for the requesting physician to ask for a “curbside” would be get advice for no monetary charge to the patient. Occasionally, the requesting physician may repeat communication with the doctor who had made the “curbside” advice as a courteous followup report. However,the requesting doctor may be looking for addition advice. Repeated followup informal consults may not be appreciated by the consult doctor both out of concern for the proper care of the patient and for the consulting doctor’s own financial interest.

As I have already mentioned, though this consultative action has great popularity in the medical profession and is considered a common and professionally accepted activity, the law and the ethics of “curbside consultations” is missing.This is unfortunate since this lack of rules can lead to malpractice actions taken upon the consulting doctor as well as the requesting doctor if serious problems in the patient’s management occurs. In this regard, it is not clear whether the consulting physician’s name should be noted in the patient’s medical records. Laws defining malpractice issues in this form of consultation may vary from state to state in the United States. The threat of malpractice, may, particularly if large financial penalties of malpractice suits are decided, discourage such consultations and might impair a route of possible valuable transfer of medical advice. It also is unclear whether Federal HIPAA laws regarding privacy of the patient’s history,identified by name or not, permit informing another individual who is not directly attending the patient for care or responsible for insurance payment. In addition, there is no consensus with regard to what the consulting physician’s ethical responsibilities such as attention to doing a “good” and avoiding harm, are with regard to the unnamed patient. Or would all ethical responsibilities remain with the patient’s own physician? Another issue is whether it is ethical for the patient’s physician to carry out a consultation with another physician without necessarily providing the full medical history and without the patient’s knowledge or permission, both of which might be considered ethically unprofessional. I suggest that in view of these uncertainties within a long establish and common professional activity, it is important that these questions should be answered from both the legal and ethical aspects so the requesting doctor and the “curbside consultant” and the patient will be aware of what are the limits of this practice.

My question to my visitors is with the information I have written about “curbside consultations”, would you want your doctor, if he or she felt it was necessary, to request from another doctor such a consult? Or would you rather have a formally arranged appointment with the consultant? If you were aware that the “curbside” activity had already occurred in your case and without your prior knowledge, would you approve? Would you consider that the doctor who advised your physician in this manner had any personal or professional responsibility of what would actually happen in your care if so should be held responsible? ..Maurice.

Graphic: “At Curbside” photograph taken by me 2-10-2013.

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