September 15th, 2017
Curbside Consultations: Checks and Balances
A 34-year-old male presents to the emergency department with right arm weakness. He woke up 2 days ago unable to move his arm. The patient reports having hypertension but has no history of diabetes, stroke, cardiac disease or tobacco use. He drinks alcohol daily. The patient complains of numbness and tingling in his arm. He lacks wrist extension and has diminished grip power. His function in his biceps and triceps is normal. He has no other deficits or symptoms. You suspect the patient has a radial nerve palsy but feel a little uneasy because he appears to also have some involvement of the ulna and median nerves.
The neurologist has just finished seeing another patient in the ED. You wander over to him as he settles down at the computer to chart. After some small talk, you mention you have a patient with what appears to be a radial nerve palsy but you are questioning why this patient has decreased grasp and pinch strength. You chat for a while about different nerve palsies and ways to isolate peripheral nerves; then you answer his questions about findings suggestive of more serious lesions. When you re-examine your patient based on your conversation, you feel comfortable that the patient has a radial injury. Later, you sit down to chart, and you wonder whether you should document your discussion with the neurologist.
Informal, or “curbside,” consultations are a common and expected part of our medical practice. It’s checks and balances. We talk with each other when we encounter a presentation or condition that is outside of our usual area of expertise or just doesn’t fit the text. This can improve patient care and show thoughtfulness on the part of clinicians. Additionally, talking with colleagues — unlike reading textbooks and consulting web apps — allows for bidirectional learning.
However, such discussions are not risk free. For example, without knowing the specifics of a case or formally examining the patient, a consultant might offer well-intended advice that is inaccurate, incomplete or inappropriate. This can get us into deep water. Additionally, if the treating clinician shares insufficient information with the consultant, she might adversely affect patient care or have misplaced confidence in subsequent management of the patient. Sometimes there’s a disconnect between the consultant and the treating provider about what exactly is being asked. And humans being humans, recall later is likely to be different.
Generally speaking, risk is related to the degree of control the clinician has over patient care. The treating clinician — the individual who is directing care — carries the weight of responsibility for the patient and the medico-legal risk. Just because you discussed the case with the consultant doesn’t mean you are protected. If the consultant puts in orders or examines the patient, professional liability shifts.
Of course, medico-legal risk fluctuates according to setting, access to specialist services, and decisions made as a result of informal consultation discussions. Sometimes a face-to-face consultation is not possible and waiting for one would result in a delay in care. I work 72 miles from a tertiary center and frequently depend on telephone consultations. Some specialists are just not available at my primary site. In these circumstances, an informal consult may be better than no consult. Sometimes, I transfer the patient. This is usually a shared decision between myself, my attending, and the consultant. Such discussions help us identify the correct specialist, prioritize follow-up, and decide on need for transfer. (Here are a few citations I like on decision-making regarding informal consultation and care coordination.)
Academic questions, discussion of new research, requesting follow-up, and utility of tests are all topics that might be suitable for an informal consult. We learn through discussion and it is important that such learning isn’t lost. It’s good to bounce ideas off each other. In the hypothetical case presented, the treating clinician could ask simple questions like:
What is the best way to evaluate for a radial nerve palsy?
Do you think steroids have efficacy in the treatment of nerve palsies?
As a matter of courtesy and professionalism, I avoid documenting the consultant’s name in the medical chart without their permission. I have met consultants upset to find their names in charts of patients whom they have never formally assessed. Asking if you can document the consultant’s name clues specialists in to the import of any advice given and prevents any surprises. I believe this is a mark of collegial respect, engendering the open and honest discussions much needed in medicine.
When is a formal consultation indicated?
As a treating clinician, I consider seeking a formal consult if questions are complex or the consultant needs to examine the patient or review records to give good advice. Additionally, if the patient knows about the consult or if the treatment pathway is dependent on the consultant’s expertise, then a formal consult is warranted. If the consultant orders tests or treatments, this should precipitate a formal consult.
This leaves me with two questions:
How can we improve the safety and utility of curbside consults?
How do you manage curbside consults?