July 9th, 2017

Should You Answer Medical Questions from Clinicians You Don’t Know About Patients You’ve Never Seen?

This email popped into my inbox the other day from a person I’ve never met:

Hi Dr. Sax,
I do mostly hospital-based ID in Pennsylvania, and was consulted on a newly diagnosed HIV patient with CD4 10, viral load 210,000, and lymphoma. I started him on Truvada and dolutegravir, which is going well so far. Because he complained of blurred vision, he had an ophtho evaluation yesterday which showed CMV retinitis. My drug-interaction checker says I can’t use valganciclovir with either tenofovir or abacavir, and if I replace the Truvada with a boosted PI, it will interact with his chemotherapy. What should I do for his ART?
Thanks so much.
Marie

There are two issues with this email worth discussing.

The easy part first — the medical question. Here’s my response:

Hi Marie,
There is no significant interaction between ganciclovir and tenofovir alafenamide, and even the interaction with tenofovir DF is theoretical, not an absolute contraindication. No interaction with abacavir either, so not sure where you are getting your information! (Use this site, it’s awesome:  www.hiv-druginteractions.org.) So switch the Truvada to Descovy (tenofovir alafenamide/emtricitabine), that’s all you need to do. Safer for kidneys and bones, too.
Regards,
Paul

The second item to cover is whether we should be answering questions like this at all. Remember, this is from a person I don’t know, asking about a patient I’ve never seen.

Though I obviously responded to the query, there are a few reasons not to answer questions from clinicians you’ve never met about patients you haven’t seen.

The medical information might not be correct, or complete enough, to make a good recommendation. If you make the wrong suggestion, or your recommendation is misquoted, there’s the potential for patient harm. Even worse: if your name is in the chart, there’s a medicolegal risk — especially if you review patient data sent to you. The risk may be small, but who wants to take that chance?

And if you ask an economist, they would say it definitely makes no sense to answer these questions — not only are you being paid nothing, but there’s little chance of downstream revenues, and it takes time away from other remunerative tasks and opportunities.

But economists can be short-sighted, and this is one of those times. Obviously I thought it was better to answer the question than to ignore it for a bunch of reasons.

  1. Answering helps the patient. Sometimes cliches are true: helping people remains the primary reason most of us went to medical school to begin with.
  2. Answering helps the clinician. When I see a difficult case of coccidioidomycosis, I of course call an expert in this tricky fungal infection; cases of cocci are rare in Boston. And I’m so grateful when John Galgiani responds, given his voluminous experience. Ditto various cases over the years involving rapidly growing mycobacteria (Richard Wallace), bartonella (Jane Koehler), toxoplasmosis (Jose Montoya), Mycobacterium avium complex (Chuck Daley, Gwen Huitt), cytomegalovirus (Richard Whitley), and many others. Thank you!
  3. It was a straightforward, focused question, presented clearly. I didn’t quote the whole email, which included numerous other details about the chemotherapy regimen, but those were thoughtfully placed at the bottom of the communication.
  4. The person asking was polite. No dreaded Red Exclamation Point indicating that this was of the utmost urgency. (Here’s a thought — let’s ban that particular means of communication.) No “Thanks in advance for your rapid reply.” (Ugh.)
  5. It’s flattering when someone asks you questions in your area of expertise. Gosh, Marie chose to ask me about her patient’s HIV therapy? When there are so many other people she could have asked? Hey, maybe I should be thanking her! (Of course she might have sent the same email to 20 others, but … who’s to know?)

The bottom line is that I think we should be helping out other clinicians when we can — it’s just the right thing to do.

 

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8 Responses to “Should You Answer Medical Questions from Clinicians You Don’t Know About Patients You’ve Never Seen?”

  1. Loretta S says:

    You are very kind and polite, Paul. My first thought was why didn’t this person consult her hospital-based ID specialist PharmD? You recently wrote about the importance of PharmD specialists, and I wholeheartedly agreed with you. I realize it’s possible the email writer had already discussed this clinical question with her PharmD colleague(s) — since you did not quote the entire email — but it just struck me as a question perfectly-suited for a specialist PharmD whose job it is to answer just those types of questions.

    That said, since you answered quickly, it was probably more expedient to put the question in an email and get an answer from an expert HIV clinician. Especially one who is so kind and polite!

  2. Janine Jagger says:

    Part B of this question is: Should you be giving medical advice to a patient you have never seen when you are not even a physician? All of the risks of bad or harmful advice detailed here are compounded exponentially by a lack of knowledge. The final correlary: “The less aware of one’s lack of medical knowledge, the greater the confidence in giving dumb medical advice.”

  3. Dave Mittman, PA, DFAAPA says:

    Interesting question.
    I have been a PA for decades and found my education and expertise was enough to carry me through most clinical experiences I have had. Like most others, sometimes I needed an opinion, a curbside consult and more. While I never consulted people I had never heard of, I did call and consult clinicians I had never actually met, usually over the phone and ask their opinions.
    As we transfer to more complex care systems and the mix of clinicians will be varied we will all have to collaborate more and more. Especially those of us that provide primary care. While I understand there are legal implications, it’s truly what’s best for the patient.
    Dave Mittman, PA, DFAAPA

    • Paul Sax says:

      Thanks for your comment, David. I agree we should try to go with what’s best for the patient.

      Note that curbsiding a colleague within your practice, hospital, or healthcare system is different from one of these “out of the blue” queries, like the example I gave. For the former, the person responding could ask to see the patient for a formal consultation, or review the primary data, or may even rarely get paid to respond to these queries.

      Paul

  4. Hello,
    Please, consider we ‘ve the same situations in Europe, and in my case in Belgium.
    We try to do the best for the patients.
    But often the case is complicate, data are lacking and it’s difficut (and risky) to give a respons within a few minutes (by phone sometimes) in situations that could be lifethreatening. Moreover, it’s often different to have a situation resumed by a physician (it’s a pneumonia caused by a Klebs pneumonia Resitant to carbapenems) and a clinical situation (pneumonia, which pneumonia for this patient extubated yesterday?). So, in my mind, we have to take the time for dificult situations and it’s not so obvious to do so.
    Sincerly yours
    Dr Frédéric Frippiat,
    Internal Medicine and Infectious Diseases
    University Hopsital
    CHU Liège, Belgium

  5. Paul
    I could not agree with you more – I have answered many e-mail questions from patients through the years – especially after publishing a review article on a certain topic (Mono, Strep pharyngitis, HSV, Psittacosis are some through the years that come to mind) ——– and I remember emailing Mike Saag in 1994 who I had never met regarding a patient with cryptococcal meningitis / CD4 count of 32 – his advice to stop amphotericin and change to oral fluconazole (against another consultants advise) in the face of declining renal function – and then starting Indinavir (which we obtained through the Merck ” lottery”) I believe is why this patient is still alive today and volunteers at our clinic.

  6. N Elias says:

    One could also respond with the caveat that you are answering based only on the information provided and any co-morbidities or other undisclosed clinical issues could change this response.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

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