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February • 13 • 2025
Curbside Consults: Collegiality, Courtesy, and Caution
Article
Summary
Consider a number of issues when providing informal consultations.
In January 2018, a 40-year-old female was brought to the emergency department (ED) after she developed stroke-like symptoms. Noting her history of migraines, the ED physician concluded that she was likely suffering from a complex migraine and recommended against a computed tomography (CT) scan.
That evening, the ED physician called a local neurologist to informally consult about the patient’s diagnosis and to ask him to see her in the neurology clinic the following day. The hospital had an unwritten agreement with the neurologist and his partner to provide ten days of neurology consults to the ED physicians per month as a condition for being allowed to admit patients to the hospital. At the time of the consult, the neurologist had no previous relationship with the patient and neither examined her at the hospital, reviewed her medical records, nor spoke to the patient or her husband that evening. After speaking with the neurologist, the ED physician discharged the patient without ordering further testing. Upon returning home, she suffered a stroke that left her permanently disabled.
The patient and her husband sued the hospital that employed the ED physician and the neurologist for medical malpractice, alleging that they deviated from the standard of care by not performing a CT scan. They contended that a CT scan would have alerted the clinicians to the signs of an impending stroke, which would have allowed them to provide preventive treatment. Prior to trial, the court found that no doctor-patient relationship existed between the neurologist and the patient and granted the neurologist’s Motion for Summary Judgement. The patient and her husband appealed the trial court’s ruling.
The appellate court noted that the key issue in determining whether a duty is owed to a patient arising out of informal consultation is the existence of a physician-patient relationship. The court noted that in the case at issue:
Clinical consultations are essential to the delivery of safe, high-quality patient care. Treating clinicians often seek consultations when they recognize situations that are beyond their level of expertise or when there is uncertainty in arriving at a final diagnosis. Formal consultations are well defined. In a formal consultation, the consulting clinician examines the patient, reviews medical records, delivers a diagnosis, recommends treatment, and bills for the consultation. If the consultation results in patient injury, the imposition of liability is also well defined—the law imposes a duty of care on the consultant arising out of the practitioner-patient relationship created by the encounter.
In contrast, while informal or “curbside” consults are commonplace, there are no defined rules for participation in these collaborative discussions. During an informal consultation, the treating clinician asks for input about a patient in an informal setting—by telephone, by email, in the hallway, etc. As a professional courtesy, the consulted clinician offers a clinical opinion based on the information provided by the clinician requesting the consultation. The consulted clinician neither reviews the patient records, examines the patient, nor receives payment for the service. If an informal consult results in patient injury, the question of liability is more complex and highly dependent on state case law.
Informal consultations can be a valuable tool to assist treating practitioners in formulating a differential diagnosis, expanding their diagnostic focus, or considering treatment options. However, providing consultations without having accurate or complete clinical information can create patient safety issues, result in erroneous diagnoses, and expose the consultant to liability. Consider the following when providing informal consultations:
Informal consultations and professional dialogue among healthcare providers can improve the care team’s ability to provide safe, quality patient care. Understanding the potential for liability associated with these conversations and implementing proactive risk management strategies can help minimize the associated risks.
That evening, the ED physician called a local neurologist to informally consult about the patient’s diagnosis and to ask him to see her in the neurology clinic the following day. The hospital had an unwritten agreement with the neurologist and his partner to provide ten days of neurology consults to the ED physicians per month as a condition for being allowed to admit patients to the hospital. At the time of the consult, the neurologist had no previous relationship with the patient and neither examined her at the hospital, reviewed her medical records, nor spoke to the patient or her husband that evening. After speaking with the neurologist, the ED physician discharged the patient without ordering further testing. Upon returning home, she suffered a stroke that left her permanently disabled.
The patient and her husband sued the hospital that employed the ED physician and the neurologist for medical malpractice, alleging that they deviated from the standard of care by not performing a CT scan. They contended that a CT scan would have alerted the clinicians to the signs of an impending stroke, which would have allowed them to provide preventive treatment. Prior to trial, the court found that no doctor-patient relationship existed between the neurologist and the patient and granted the neurologist’s Motion for Summary Judgement. The patient and her husband appealed the trial court’s ruling.
The appellate court noted that the key issue in determining whether a duty is owed to a patient arising out of informal consultation is the existence of a physician-patient relationship. The court noted that in the case at issue:
- The neurologist was on-call and therefore expected the type of call he received from the ED physician.
- During the informal consultation, the neurologist was informed of the patient’s history, symptoms, possible diagnosis, and proposed course of treatment.
- He offered an opinion based on that information.
Clinical consultations are essential to the delivery of safe, high-quality patient care. Treating clinicians often seek consultations when they recognize situations that are beyond their level of expertise or when there is uncertainty in arriving at a final diagnosis. Formal consultations are well defined. In a formal consultation, the consulting clinician examines the patient, reviews medical records, delivers a diagnosis, recommends treatment, and bills for the consultation. If the consultation results in patient injury, the imposition of liability is also well defined—the law imposes a duty of care on the consultant arising out of the practitioner-patient relationship created by the encounter.
In contrast, while informal or “curbside” consults are commonplace, there are no defined rules for participation in these collaborative discussions. During an informal consultation, the treating clinician asks for input about a patient in an informal setting—by telephone, by email, in the hallway, etc. As a professional courtesy, the consulted clinician offers a clinical opinion based on the information provided by the clinician requesting the consultation. The consulted clinician neither reviews the patient records, examines the patient, nor receives payment for the service. If an informal consult results in patient injury, the question of liability is more complex and highly dependent on state case law.
Risk Recommendations:
Informal consultations can be a valuable tool to assist treating practitioners in formulating a differential diagnosis, expanding their diagnostic focus, or considering treatment options. However, providing consultations without having accurate or complete clinical information can create patient safety issues, result in erroneous diagnoses, and expose the consultant to liability. Consider the following when providing informal consultations:
- Understand the law. To state a case against a healthcare practitioner for medical negligence, the patient must show that there was a duty owed to them by the practitioner. Typically, that duty arises out of the practitioner-patient relationship. The specific factors that give rise to that relationship vary from state to state based on statutory and case law. Work with an attorney to understand how and when that relationship is created in the states in which you practice.
- Keep it simple. Information provided in an informal consultation should not be patient specific, rather, it should focus on the provision of general education or simple information such as general diagnostic criteria or pathophysiology. Decline informal consult requests that involve complex medical situations, controversial care or require examination of the patient.
- Know when a formal consult is required. If you are asked to review records, see the patient, or place orders, offer to provide a formal consultation. If the information provided by the requesting practitioner is too limited, if the questions become more complex or require further exploration of the patient history or clinical presentation, recommend that the consultation become a formal one. Do not bill for informal consultations.
- Use caution when providing written responses. Given the prevalence of email and text messaging, informal consults are no longer confined to the hallway or a quick phone call. Consider using alternative methods of communication (i.e., telephone) when responding to a written consultation request. If you choose to respond in writing, indicate that the consult is informal and keep your response simple and general.
- Clarify intentions. Ensure the requesting practitioner understands that the feedback you are providing is not a treatment decision. Confirm that the requesting colleague will not document your name in the medical record without your permission until you have provided a formal consultation.
Informal consultations and professional dialogue among healthcare providers can improve the care team’s ability to provide safe, quality patient care. Understanding the potential for liability associated with these conversations and implementing proactive risk management strategies can help minimize the associated risks.
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.