Consulting curbside? Listener, beware!
Half of what you hear curbside may be wrong or incomplete
Keywords: Hospital physicians find big problems with curbside consults
by Paula S. Katz
Published in the March 2013 issue of Today's Hospitalist
YOUR WORST FEARS ABOUT CURBSIDE CONSULTS were just confirmed: The information you get is often inaccurate or incomplete, compromising management decisions and, potentially, patient care.
That's according to a study conducted at Denver Health Medical Center and published in January in the Journal of Hospital Medicine. While past studies have looked at perceptions of how accurate curbside consults may be, hospitalist Marisha Burden, MD, was prompted to look at hard data because of her personal experiences with informal consults.
The study compared the recommendations made by a hospitalist
during a curbside consult to
those from an official, face-to-face consult. (Of the service's 30-plus hospitalists, 18 participated by taking curbside consults for the study; the hospitalist who received the curbside then notified a different hospitalist to do a formal consult.) The second hospitalist received only the patient's name and clinical questions to ensure an unbiased result.
|"Physicians asking for a curbside may not know the pertinent information the consultant needs."|
–Marisha Burden, MD
Denver Health Medical Center
While Dr. Burden expected to uncover some problems, the magnitude of her findings was a shock. In 51% of 47 cases, the information given during the informal consult was inaccurate or incomplete.
"Over half is an impressive number given that we do curbside consults almost every day," says Dr. Burden, who was lead author. The study found that attendings as well as residents gave information that was inaccurate or incomplete, and that there was no way to predict when you were not going to receive the information you needed.
The study also found that 60% of patients had different management recommendations after the formal consult, 36% of which were major changes. Dr. Burden, chief of hospital medicine at Denver Health and assistant professor of medicine at the University of Colorado School of Medicine, talked with Today's Hospitalist about problems with—and alternatives to—curbside consults.
Physicians have complained for years about the accuracy of curbside consults. What prompted you to dig deeper now?
I have received curbside consults for years, and at times I would go to the patient's chart to review the case in more detail. Not infrequently, I would find that the information was either inaccurate or incomplete. About a year before the study, I received a curbside consult for a patient on the psychiatry service who'd been discharged from the medicine service but was still having abdominal pain.
Psychiatry asked me whether to do any additional imaging. They also mentioned that they had curbsided a colleague of mine a few days before regarding elevated platelets, which was thought to be due to an iron deficiency. Ultimately, I asked to officially evaluate the patient.
After talking with the patient and reviewing the record, I found that two curbsides had gone awry. The patient did indeed have elevated platelets, but it wasn't due to iron deficiency. What psychiatry didn't mention was that the patient had had a positive blood culture. The primary team had called the microbiology lab a few days before and because they couldn't fully identify the organism, they felt it was likely a contaminant. The patient had also had a low-grade fever. Based on this information, we got a CT scan and found appendicitis with perforation. The case confirmed my suspicions about curbsides, and we decided to formally study them.
What's an example where the formal consult made a major difference in treatment?
We had one gentleman with a platelet count of over 1 million. He was asymptomatic and the question was, "What do we do?" Our providers started thinking it was a primary blood problem based on the fact that there were no symptoms and no clinical history that the platelets were reactive in nature. But when we formally evaluated the patient, we found that he had a recent stab wound and lung infection, and he had been on IV antibiotics that had been switched to oral agents.
Based on that additional information—which we weren't told curbside—we knew the platelets were high because of a reactive thrombocytosis and there wasn't a primary blood disorder. That changed the whole differential.
What about a case where the change was minor?
A minor case might be one in which the informal and formal consult hospitalists recommended different management for hypertension or diabetes.
Is the problem who's doing the asking, or how they're approaching the consult?
Physicians asking for a curbside may not know the pertinent information the consultant needs. Or conversely, they may know the case quite well and may have talked to other providers. But during the curbside interaction, they may accidentally forget to tell you a pertinent piece of information.
How have the results affected your practice and your hospital?
Several years ago, I stopped providing curbside consults, as I prefer to just see the patient. And in light of the study and as part of a recent improvement project, our general process for consults is changing. Because housestaff can over- or under-consult, attendings will first vet the consults that residents want to request to assess the urgency and need. We hope to cut out some unnecessary consults and give higher priority to others. We have also asked that providers not convert formal consults to curbsides and that all curbsides receive a formal evaluation.
If hospitalists aren't in a position to say no to curbside consults, how should they handle them?
Be cautious and aware that there's a decent chance you're not getting enough information. One technique that I use when providers insist that a formal consult isn't necessary is telling them that I can offer advice based only upon what they are telling me.
What are the challenges in terms of time and liability in moving from informal to formal consults?
Although it may increase workload to move informal consults to formal ones, it's hard to get a true picture of what is going on with patients without seeing and examining them. As medical records are improving, we can more accurately and quickly look at the record, labs and notes. But the problem is that the more we do that, the more closely we're tied to that patient's care without doing a formal face-to-face evaluation. You need to be careful if you start looking at charts or labs because you teeter on the edge of forming a physician-patient relationship without completely evaluating the patient.
Given these discrepancies, what's the case for curbside consults at all?
I think there will always be some role for curbside consults. It just depends on your situation. In an academic setting where we have all subspecialties available, I have a hard time supporting the idea. But if not all subspecialties are available, say in rural areas, curbside consults are better than nothing.
There are some benefits to curbsides: They can validate your medical knowledge on a topic and answer questions quickly. You can also use curbsides to gauge whether you need a formal consult. I don't think physicians should stop talking to each other, but when you're talking about a specific patient and have specific questions, consider asking for a formal evaluation of the patient.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.