June 15th, 2008

Curbside Consults: What are They Worth?

Below is a friendly email exchange I had last week with with one of our hospital’s primary care providers:

Dear Paul, do you know anything about whether pts should be given prophylactic antibiotics prior to dental procedures etc. if they have an indwelling IV catheter?  I have a pt. who has a BardPort porta cath in her subclavian that was placed surgically for her chemo treatment about 2 years ago and she is doing well but asked me this question and I could not find an answer.

Hi Cathy,
It is not formally recommended; and in this virulent C diff era, I wouldn’t do it.  But some oncologists still recommend prophylaxis (and/or some patients really want it), so if they insist, I suggest you use the endocarditis prevention guidelines.Regards, Paul

Thanks much, very helpful.  Cathy

According to the Allied Physicians Salary Survey, the average salary of an Infectious Diseases Specialist with at least 3 years experience is $178,000/year. If we assume a fifty-hour work-week (ha), with 4 weeks for vacation, that comes to an hourly rate of $74/hour, or $1.24/minute.

The time it took me to read the email, type a response, then open her gracious note of thanks (note to curbsiders  — we like being thanked) was all of around 5 minutes. Applying the above hourly rate, we find the email curbside consultation was worth approximately … 6 dollars.

In other words, for what a curbside consult “costs”, you could get a gallon of gas and a cup of coffee at your nearby Quik Mart. But not much more.

But is that really all a curbside consult is worth? Didn’t my response also save the primary care provider some time? The patient a potentially severe (and costly) adverse effect (C difficile colitis — very scary these days)? What about the training and experience required to to answer the question authoritatively?  Or the time it took away from other critically important activities? 

Sure, I’ve been asked this question before (so it was kind of a slam dunk, to invoke the currently appropriate Boston sports metaphor), but isn’t that why we pay the experienced neurosurgeon his/her $500K+ a year?  Because they’ve done brain surgery before?

The sad fact (for us ID doctors, at least) is that curbside consultations don’t fit into any reimbursement model for health care.  And by the way, the “price” for a curbside consult isn’t even $6 — it’s $0.

9 Responses to “Curbside Consults: What are They Worth?”

  1. HH says:

    I don’t think there are going to be many neurosurgeons and ophthalmologists looking at your blog but since my time is also only worth about a buck and a quarter a minute I have the time to.

    Sticking in a VP shunt: $15,000
    Plucking out a cataract: $5,000
    Knowing how to spell gentamicin: Priceless. 🙂


  2. IVF-MD says:

    It was certainly a kind gesture of you to help share your wisdom with the PCP. Bear in mind that you did it voluntarily out of the kindness of your heart, and of your own free will.

    I get approached for free advice all the time, not only by doctors, but by people at parties. I make a choice each time just how much to sacrifice my time and energy. If I give freely, that’s my choice. If I deflect the question, that too is my choice.

    Freedom allows you to give a generous gift of a curbside consult or not to give. I personally would rather have the recognition of having given a gift than to get paid $6. 🙂 That’s just my opinion, I could be wrong.

  3. Paul Sax says:

    Yes, I agree the collegiality engendered by doing a curbside counts for a lot — so much, in fact, that’s it’s really why I do it! We are all working together to try and take care of patients, and doing a curbside is part of the process.

    On the other hand, if I’d taken that $6 and invested in Microsoft back in the 1980s …

  4. Kelly says:

    We recently wrote an article on curbiside consulting at Brain Blogger. As you know, a “curbside consult” is when a doctor asks another for an unofficial consult, or when a a friend or stranger asks a doctor for his opinion. But where do you draw the line; is it right to give a complete stranger a diagnosis on a few symptoms?

    We would like to read your comments on our article. Thank you.


  5. Joe Nussbaum, MD says:

    This post brings up a hazy recollection of an ICAAC poster on the 60% accuracy of curbside consultation (as compared with “gold standard” formal consult). The errors were largely attributable to missing but crucial bits of information that the physician seeking the curbside didn’t mention (usually because they didn’t recognize the omissions as being relevant).

  6. Paul Sax says:

    At an IDSA meeting a few years ago, the ID group from the U of VT calculated that curbsides accounted for 22% of their clinical work — all uncompensated, of course! It was a very interesting poster, I don’t think it was ever published, however.

  7. Marsha Kadlecik says:

    Dear Dr Sax,

    I sure would appreciate a copy of the poster you referred to as “ICAAC poster” in regards to curbside consultation, or a link that you may be familiar with to refer me to for one.

    Many Thanks,
    Marsha K, PA-C

  8. Paul Sax says:

    The poster was presented at IDSA, here is the reference: Grace CJ et al, IDSA 2005; Abstract #127.

  9. j. says:

    When you take into account that a Solo PCP is paid much lower on discounted reimbursement than the 6 figure salary stated for infectious disease, plus overhead out of pocket costs to do first line, preventative and non reimbursed education/coordination of patients makes the sharing of knowledge from a sub-specialist to the PCP I am sure much appreciated.

    About curbsides, if they are not your patient refer them back to their PCP, so that tests and treatments do not overlap. Period. If they are your patient tell them that with certain diagnosis there are certain questions that must by answered first and that this genre is not condusive for that type of examination, but to call and make an appointment asap so it can be taken care of. Say it with a smile and most will understand and if they were trying to avoid a co-payment they will probably get a little purturbed, but should you care, if you are doing what is truly best for the patient?

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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