Informal consultations among practitioners represent an important part of clinical practice. They can increase knowledge among physicians and may also improve care and treatment of patients who present with complex comorbidities. Also known as curbside consultation, the informal consultation is for general advice. With an informal consult, a patient exam is not performed nor is there a review of the record. In fact, even patient identity should not be revealed.
Benefits
An informal consult is beneficial for physicians who are seeking general information outside of their area of expertise. When done properly, this consult promotes the sharing of knowledge, which can improve patient outcomes. Moreover, the informal consultation can help determine if a formal consult is required.
While informal consults are commonplace and provide clear benefits, physicians must use caution when agreeing to provide one in order to avoid implying a relationship with the patient that in turn can create liability for the consulting physician.
Risks and Potential Pitfalls
A patient-physician relationship can be implied if the recommendation given during the consult is patient-specific. An example is advice regarding discharge/admission/diagnosis.
Offering recommendations in these areas may be perceived as directing care and will potentially be seen as creating a duty-to-care.
Reviewing the patient record and/or documenting patient-specific advice would be perceived as creating a duty-to-care.
Should the treating physician document the consultation in the record, this will imply that the consultant is a member of the patient’s care team.
If the patient is aware of the informal consultation, then the consultant can be viewed as a member of the treating team.
In the event of a poor outcome and subsequent litigation, if the plaintiff’s attorney is aware of the consultation and is able to correlate that the information provided may have contributed to the outcome, then the consulting physician can expect to be named in the lawsuit.
Mitigating and Avoiding Liability
In order to engage in the practice of providing informal consultations and avoid the aforementioned pitfalls, we recommend the following strategies.
The consultant should clearly communicate that their intention is to provide non-specific advice, not a treatment decision.
Ask the treating physician not to document the consult in the record. If the physician indicates that he or she would like to, then ask that it be indicated that the case was presented anonymously or consider that a formal consult is more appropriate.
If the case requires the consultant to know a detailed history or conduct an exam, then a formal consult should be requested.
There is no need to document in the record if the information provided is not patient-specific. Conversely, patient-specific advice should be documented and, as such, a formal consult would be required.
If the treating physician indicates that he or she will be making a treatment decision based on the information being provided, then a formal consultation is called for.
If it is identified that a formal consultation is required, then ask that one be requested; this will be better for both the patient and the consulting physician. The formal consult will allow for the record to be reviewed to provide a better understanding of the patient condition.
While the use of the informal consultation is beneficial for both the requesting physician and the patient, it may be difficult to identify what is garnered by the practitioner providing it, other than the risks we have identified. However, by taking part in this unique type of peer-to-peer exchange while utilizing the recommendations outlined in this article, the consultant can also benefit by supporting the collegial environment that the profession of medicine is dependent on supporting safe clinical practices.
Cynthia Mayhan is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to cmayhan@CAPphysicians.com.
Resources
1. Chesanow, N. (2017, October 04). When a Curbside Consult Is a Liability Risk. Retrieved August 12, 2019, from https://www.medscape.com/viewarticle/883538
2. Klumpp, E. (2010, May). Curbside consultations. Retrieved August 12, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2882285/ (Psychiatry (Edgmont). 2010 May; 7(5): 51–53. Published online 2010 May.)
3. Miller, J. (2019, April 13). How to engage in 'curbside consultations.' Retrieved August 12, 2019, from https://malpractice-law.net/how-to-engage-in-curbside-consultations-2/
4. Ownby, G. (2018, December 17). "Curbside Consults and EHR." Retrieved August 12, 2019, from http://www.CAPphysicians.com/articles/curbside-consults-and-ehr