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ADVICE ON THE RUN


 

Everyone has been there. You’re making rounds in the hospital and another physician taps you on the shoulder and says, “Can I ask you something?” He then gives the details and diagnosis of a patient’s condition and asks, “What would you suggest?”

Or maybe you stop the cardiologist in the hall to run your planned treatment of a particularly perplexing case by him.

These encounters—called curbside consultations—happen everywhere: hallways, cocktail parties, weddings, parking lots, and, increasingly, on the Internet.

As hospitalists increase their presence, they expose themselves to more curbside consultations—and the risks they entail. The practice is fraught with minefields that can turn the best of intentions into a potential medical and legal nightmare.

The term curbside consults implies opportunity—and hospitalists are most available to other hospitalists as they work in the hospital. In return, hospitalists have a greater opportunity to ask questions of other specialists without even picking up a telephone. A combination of geography and opportunity puts hospitalists at increasingly greater risk.

“We’re so accessible to other doctors in the hospital,” says Janet Nagamine, MD, chair of SHM’s Hospital Quality and Patient Safety committee and a hospitalist at Kaiser Permanente Santa Clara Medical Center in California. “I think we get more requests for informal consultations because we are there. It’s so easy for another physician to tap you on the shoulder and ask what you think about a patient’s condition or treatment. I am more frequently the giver of information than the receiver because it is so easy for a physician to tap me on the shoulder and ask my opinion.”

Proximity also presents an increased opportunity for hospitalists to seek a curbside consult from another physician in the hall. “I think hospitalists are more likely to ask for help from specialists they see in the hospital because hospitalists are generalists and can see a wide variety of conditions in the hospital,” says Clifford Zwillich, MD, professor of medicine at the University of Colorado and a hospitalist at the Denver Veterans Affairs Medical Center.

Think carefully about whether the situation is appropriate for a curbside consultation. Ask probing questions that assure you that the correct and complete information was gathered. … If you don’t have complete faith in the ability of the physician asking you for a consult, it’s best to see the patient.

—Janet Nagamine, MD, chair of SHM’s Hospital Quality and Patient Safety committee and hospitalist, Kaiser Permanente Santa Clara Medical Center (Calif.)

Widespread Practice

In an April 2006 study in the Journal of the Medical Library Association, hospitalists reported that they seek a curbside consultation for a variety of reasons. These include:

  • Confirm what they already know;
  • Get quick answers to a question;
  • Continue their medical education;
  • Determine if a formal consultation is called for;
  • Negotiate an appropriate course of treatment for a particular patient;
  • Spread the emotional risk during a difficult case;
  • Create or sustain camaraderie with physician colleges;
  • Find like thinkers among their physician colleagues;
  • Monitor their own knowledge; and
  • Obtain help to get out of a difficult situation.

Hospitalists who provide curbside consultations reported doing so to provide good patient care, fulfill professional obligations, serve doctors, and encourage formal referrals.

Another study reported that 70% of primary care hospitalists and 68% of subspecialists surveyed participated in at least one informal consult in the previous week.

Critics say an enormous number of hospitalists put themselves at risk and potentially jeopardize patient care by taking part in these consultations. These dangers seem to increase when the consultation veers from the general educational question to advice on treating a specific patient.

“Medical errors are potentially a lot higher in curbside consultations because much is lost in translation,” Dr. Zwillich explains. “When a curbside is used as a substitute for the physician seeing the patient, it can result in an incorrect diagnosis and medical errors.”

Dr. Zwillich is concerned because a physician can give the best treatment advice, but if the underlying diagnosis is wrong patients can be harmed. Because curbsides are quick, one physician doesn’t know if the other physician is leaving out something critical or even if the underlying diagnosis is correct. “By taking a curbside consult, you are giving up your opportunity to make an alternative diagnosis,” Dr. Zwillich says.

When giving advice on a specific patient nothing beats a formal consultation in which the patient is seen and a complete history is taken, he says: “The best care is given at the bedside.”

So far, The Doctors Company of Napa, Calif., hasn't seen a significant number of lawsuits against hospitalists. But courts are allowing suits to proceed against consulting hospitalists.

Legal Liability

Dr. Nagamine also fears the risk hospitalists take for a medical malpractice lawsuit. “My biggest concern is when hospitalists don’t recognize the risk they take on,” she says. “We shouldn’t take a curbside consult without knowing the risks.”

Traditionally, medical malpractice liability for curbside consultations has hinged on an established physician-patient relationship, generally limited to hospitalists seeing a patient. “Courts have been reluctant to extend liability to specialists consulted informally by the patient’s primary physician,” writes Kim Baker, JD, a healthcare attorney with Williams Kastner, in Seattle, Wash., in an analysis of court rulings.

However, courts are allowing suits to proceed against the consulting hospitalist, trying to decide whether a physician-patient relationship existed—and if so whether the [consulting] physician’s advice led to the alleged malpractice. Particularly relevant to hospitalists is the legal question of whether a pre-existing contract between the consulting physician and the hospital creates a physician-patient relationship with patients in that hospital. On this question courts have been mixed. In other cases, liability turned on whether the consultant physician went beyond giving general advice to participating in the patient’s care.

Courts are continually revising their rulings and may change the way they interpret a physician-patient relationship. Baker cautions that this may be a trend with curbside consults. She says trial attorneys are continually trying to find ways to bring more hospitalists into a suit. Baker sees a “discernible shift away from the longstanding policy that favors physician’s expectations over those of patients when determining whether a particular physician owed a duty of care to a particular patient.” She warns that hospitalists who engage in informal consults “may be at greater risk for medical malpractice liability.”

Can’t Stop Lawsuits

The reality of a litigious society is that even if you aren’t liable for malpractice you can still be sued. Attorneys routinely “paper the hospital,” naming in a suit everyone who came in contact with a patient or gave advice on his treatment, says Robin Diamond, MSN, JD, vice president of patient safety at The Doctors Company, Napa, Calif., a professional liability insurer of hospitalists and other hospitalists.

“Even if you have no responsibility, you still have to go through all the pain, expense, and heartache of getting yourself dismissed from the suit,” she explains. “What makes the curbside consultation easy and convenient for the consulting physician is what turns it into a legal nightmare for both of them.” Because the consult is on the run, the consulting physician may not give all the information that reveals the whole clinical picture.

So far The Doctors Company hasn’t seen a significant number of lawsuits against hospitalists—but this could increase as the subspecialty grows, Diamond says. The closest example she knows of is a pending case in which a hospitalist is being sued for advice he gave in a consult in an emergency department.

Two things concern Diamond most about curbside consults. The first is that because there is no documentation in a curbside consult, the physician giving advice cannot prove later what was said. Insurers worry that because there is no documentation of curbside consults it can be one physician’s word against the other’s if the case goes to court. There can be disagreements about what was said, when, and the advice given—and no way to prove who is right, she says.

Her second area of concern is when the conversation goes from general to specific. A physician is easier to defend if it can be proved that the question asked was general and didn’t have a specific application or sharing of clinical expertise. If a specific patient and a specific history is discussed, courts could establish that this constituted a formal consultation and established a patient-physician relationship. They could also establish that the consulting physician relied on the recommendation, which harmed the patient, Diamond says.

Despite the dangers, are hospitalists likely to stop doing curbside consultations? Even the critics answer with a resounding “no.” They say such consults are a fact of life.

“Curbsides are a part of our professional community of care,” Dr. Zwillich says. “It’s good to ask advice of other hospitalists. The danger comes when a curbside is used as a substitute for a needed full consultation.”

Dr. Nagamine thinks curbside consultations are a good way for hospitalists to continue their medical education. “In the hospital setting, many knowledgeable hospitalists are nearby, and you can learn a lot from them. I don’t think that’s bad or wrong,” she says. “The biggest problem we have is not asking for help when you’re not sure. I’m all for making it easy for hospitalists to ask for advice when they are not sure. But I’m in favor of full consultations when appropriate.”

Safer Consults

If hospitalists are going to participate in curbside consults they can make them safer by following this advice: Tread carefully, keep it general, think before you speak, and consider documenting what you say. And never hesitate to ask to see the patient.

Keep the curbside consultation general and brief: Curbside consultations may be safer when they are more general and used for the physician’s general education, experts agree. It’s when the discussion gets complex or about a specific patient that it’s time to think before you speak and be cautious.

Diamond says it is probably safe to say to another physician: “This is what I just saw. Have you ever seen it before?” But once the question goes from there to asking the physician what he or she did in such a case, “That’s when you’ve got to say, ‘Wait a minute, this is becoming so complex that it would be better if we did a formal consult.’ ”

Consider the risk of being wrong: “You have to ask yourself what is the downside—or the risk—of the question you’re asking,” Dr. Nagamine says. “If you know you’re going to order some tests and want to know which one to do first, this is far less risky than [deciding] if … we admit someone to the hospital or send him home.” In the first case there’s probably not much risk because you can order other tests if the first ones don’t give you the results you need. But in the second, if you send someone home and you are wrong, you can cause harm, she explains.

Dr. Nagamine also recommends considering the seriousness of the patient’s condition. Patients rarely die from a rash but can if you’re wrong about chest pain, for example.

“You need to ask yourself, ‘What’s the complexity of the case and the downside of being wrong and what, exactly [is my colleague] asking me?’ ” she says.

Ask specific questions: “Think very carefully about whether the situation is appropriate for a curbside consultation,” Dr. Nagamine cautions. “Ask probing questions that assure you that the correct and complete information was gathered. What is the quality of the information you’re being given?” If you don’t have complete faith in the ability of the physician asking you for a consult, it’s best to see the patient, she says.

Consider facts not given: Diamond recommends the hospitalists consider the facts not given before deciding to give advice in a curbside consultation. The physician asking for the consult is going to give the information he feels is important at the time. He may have left out or discounted important facts about the patient’s history. Ask “What am I not getting here?” she recommends.

Don’t hesitate to ask to see the patient: Dr. Nagamine urges hospitalists not to refrain from asking to see the patient involved. “Many times I feel like the other physician really wants me to see the patient but doesn’t want to bother me. I find they are relieved when I suggest that I see the patient,” she says. “Other times hospitalists don’t like to admit they are in over their heads and ask for help. In many cases when I see the patient I’m glad I did.”

Document the conversation: The Doctors Company recommends hospitalists document curbside consultations. “Keep a brief record of it in a memo to yourself, “ Diamond says. However, that can be a Catch-22. “If you end up in court you have to supply all the information you have. So we say that if it gets to the point that you feel like you need to document a curbside consult, you need to bump it up to a formal consultation.”

Know your responsibilities to the hospital: For those hospitalists who work at more than one hospital, Diamond recommends you make sure you are following hospital protocol and not doing more than the hospital expects from you. Some hospitalists think it’s their responsibility to take a curbside consult from a facility’s hospitalists, and it may not be the case. All hospitals don’t have the same expectations of hospitalists, she says.

Dr. Nagamine thinks the stakes are higher for hospitalists taking curbside consultations because hospitalized patients are usually sicker than in an office setting. So the hospitalist may need to be even more cautious. TH

Barbara Dillard is a medical journalist based in Chicago.

Resources

  1. Manian FA. Curbside consultations: a closer look at a common practice. JAMA. 1996;275(22):145-147.
  2. Perley CM. Physician use of the curbside consultation to address information needs. J Med Libr Assoc. 2006 April;94(2);137-144.
  3. Pearson SD, Moreno R, Trnka Y. Informal consultations provided to general internists by the gastroenterology department of an HMO. J Gen Intern Med. 1998 July;13(7):435-438.

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