consults

[oldbearprofessor]

Yep. Informal consults open you up to liability. I wouldnt even call it a gray area -- it's pretty established law. You can't give advice on a patient and try and fall back on some notion that you didnt owe that patient a duty. Most of the time it's irrelevant because you work for an organization that is in some way affiliated with the patient's caregiver. Eg if your hospitals ED informally consults a cardiologist who works for or at the hospital, the duty exists through that nexis anyhow. But even outside of such framework, if you give advice knowing someone is going to rely on it, and they do in fact rely on it to their patients detriment, you can certainly be liable. You may never have seen the patient, and the patient may never have heard of you until he obtains a copy of his medical records, but you will still have a big liability risk. Don't try to kid yourself that you get a pass because you didn't meet the patient or send a bill. If you don't believe it, talk to your hospital's risk management folks. They will advise you to stop doing these curbsides in no uncertain terms.

I mostly agree with you until the last sentence. I assure you, our hospital risk management does not wish us to stop taking calls from outside hospitals and outside physicians that might lead to the transfer of patients to our hospital or that otherwise support the development of collaborating relationships with physicians in other hospitals who might refer patients to us. It is part of the accepted risk management policy of the hospital that we take these calls. That is why they have a recording policy for them.

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[Doctor Bagel]

Yep. Informal consults open you up to liability. I wouldnt even call it a gray area -- it's pretty established law. You can't give advice on a patient and try and fall back on some notion that you didnt owe that patient a duty. Most of the time it's irrelevant because you work for an organization that is in some way affiliated with the patient's caregiver. Eg if your hospitals ED informally consults a cardiologist who works for or at the hospital, the duty exists through that nexis anyhow. But even outside of such framework, if you give advice knowing someone is going to rely on it, and they do in fact rely on it to their patients detriment, you can certainly be liable. You may never have seen the patient, and the patient may never have heard of you until he obtains a copy of his medical records, but you will still have a big liability risk. Don't try to kid yourself that you get a pass because you didn't meet the patient or send a bill. If you don't believe it, talk to your hospital's risk management folks. They will advise you to stop doing these curbsides in no uncertain terms.

I can totally see your argument, but it's weird that it happens so often with our hospitals not providing any formal education or warnings about it. If it's really a problem, wouldn't our hospital risk management people be a little more proactive about educating us on this? I work in a large university hospital setting with lots of management folks around. It's just odd that no one has formally addressed this with us. We get lectures on documentation all the time. Why not curbsides which happen every day in our hospital? Apparently we don't have a consensus here on whether or not they're a good idea in general or even on how to document them.

 

[wine thief]

Change "unofficial" to "informal", how's that?

Irrelevant.

There is definitely a medico-legal distinction between formal and informal consults and liability.

Wrong.

 

[wine thief]

There's no such thing as an "unofficial" consult, but me calling you for advice and/or follow-up on a patient does not, by itself, create a doctor-patient relationship.

If your name is in mentioned in the documentation, "spoke with Dr. X who will see the patient in his office in 2 day", yeah you're going to get named. And you'll get dropped.

This lack of relationship is one of the reasons EM docs are twitchy about making sure our consultants come in to see sick patients. If you give us wrong advice and we follow it, then we go down alone.

The lawyers are trying to say that there IS a relationship because the ER doc and the specialist both work for the same health care system.

Do you think it's ok to get dropped? Do you understand that you have to list that on every application for credentialing, privileges, license renewals, malpractice?

Then either handle the problem yourself or get a formal consult. It's not "about the patient" for you, it's about loading the boat and moving the meat. Waiting for a consultant to write a note takes time. Maybe he'll want more studies or imaging. More time. A quick "curbside" phone call and a note in the chart is a lot faster, right?

 

[Groove]

Irrelevant.



Wrong.

How many links do I have to post for you dude... Can you google?

"The difference in liability arising from formal versus informal consultations turns on the existence of the first element: a legal duty. While a legal duty can be created by contract or other arrangement, it most typically arises from the establishment of a physician-patient relationship."

Why are you even complaining? Aren't you anesthesia? We never consult you guys from the ED at my institution. I mean...theoretically if we consulted you, it would be for an intervention, which would be formal. What on earth would we consult you for that would constitute an informal consult from the ED that would be frequent enough to put you up in arms in the first place? I'm perplexed.

 

[Groove]

And regardless... there's an easy solution to this... If you're paranoid about an "informal consult", then just document it yourself. Write down the conversation that you recall and file it away. Problem solved.

 

[oldbearprofessor]

How many links do I have to post for you dude... Can you google?

Thanks for the link. Reading the section towards the end about informal consults confirmed my belief and experience in this regard that risk is inherent in the types of informal consults my colleagues and I routinely perform. You may interpret this article differently.

Here is a relevant quote "More recent cases have carved out some exceptions to this general rule where the consulting physician goes beyond "an informal interest and involvement in plaintiff's condition" or where the physician consulted is "on call" or similarly obligated to provide consultative services.28 Thus, a medical malpractice action was allowed to proceed against a cardiologist where an emergency room physician contacted him by telephone, reviewed the patient's symptoms and test results, then obtained the cardiologist's opinion that the patient's symptoms were not cardiac in nature.29 The emergency room physician testified that he informed the patient of the cardiologist's opinion and that he discharged the patient in reliance upon the cardiologist's opinion.30 Thus, the testimony of the doctor requesting the informal consultation likely kept the consultant in the lawsuit.31"

It is possible to disagree without insulting the intelligence of those with whom you disagree. I and some others are simply warning of what we believe to be a risk in informal consults, especially within a health care team even if it involves multiple hospitals. As opposed to others, I do not find this a reason to not do them or even to be afraid of them, as they are crucial to the functioning of many systems. However, they do, like any other patient interaction, pose a legal risk that should be recognized. Keeping informal records of informal consults, especially for hospital systems with EMRs would be a good idea, but probably hard to do in a practical sense.

 

[gutonc]

Keeping informal records of informal consults, especially for hospital systems with EMRs would be a good idea, but probably hard to do in a practical sense.

This is what I generally do. I place a brief note documenting what I was told, what I was able to review myself (labs, vitals, imaging), that I did NOT examine the patient myself as no formal request for evaluation was made of me and then document my recs. My recs always include, that they should call back and/or request a formal consult if further issues arise. Is it perfect? No. Does it generally work? Yes.

 

[jdh71]

So here's the question: What should we do about this?

I'm not so entirely cynical as to simply accuse the ED of informally "loading the boat" (which I think is a douchey thing to do), as much as I tend to assume they are trying to save me a trip to the ED to do a full consult. An attitude I tend to appreciate. So should the ED just formally consult then, and when they start doing this are you all going to stop bitching? Or will that be wrong too?

 

[Doctor Bagel]

So here's the question: What should we do about this?

I'm not so entirely cynical as to simply accuse the ED of informally "loading the boat" (which I think is a douchey thing to do), as much as I tend to assume they are trying to save me a trip to the ED to do a full consult. An attitude I tend to appreciate. So should the ED just formally consult then, and when they start doing this are you all going to stop bitching? Or will that be wrong too?

I view curbsides that same way and think this is a good question. Maybe leaving a note is a good solution like gutonc mentioned is a good idea?

 

[Arcan57]

The lawyers are trying to say that there IS a relationship because the ER doc and the specialist both work for the same health care system.

Do you think it's ok to get dropped? Do you understand that you have to list that on every application for credentialing, privileges, license renewals, malpractice?

Then either handle the problem yourself or get a formal consult. It's not "about the patient" for you, it's about loading the boat and moving the meat. Waiting for a consultant to write a note takes time. Maybe he'll want more studies or imaging. More time. A quick "curbside" phone call and a note in the chart is a lot faster, right?

Doing a current quick lit review, it does appear that the notion of the consultant not having a duty to the patient is being reconsidered. Exceptions for which duty have been established have been noted for HMO type set-ups or for "curbside" consults that involve lengthy or detailed communication.

Yes, I think in general it's "ok" to get dropped. I don't know of anyone who has had their ability to get a license or credentials withheld because of being named in a lawsuit from which they were dismissed. Yes, it's extra record keeping but for credentialing you usually have to keep track of every hospital you've ever worked at (+/- requiring a form from said hospital), every state license, DEA number, malpractice insurance carrier, etc. I'd recommend to trainees to start keeping track of these things now, including contact information for administration, since it can be difficult to dredge up again 3-4 years out.

And in terms of the snarky and just plain misinformed opinion about why we consult, you couldn't be more wrong. I wish our consultants would appreciate the fact that showing up 4-5 hours after we call places a large burden on the patient, the ED doc, and the patients in the lobby waiting for that bed However, if they need to get seen by the consultant in the ED they get seen by the consultant in the ED.

Most patients don't need to be emergently seen in the ED, so they either get admitted to be seen in the morning (older healthy patient with melanotic stool in need of colonoscopy comes to mind) if too sick to go home or we call up the consultant to inform them we're sending a patient to the office to follow-up. During this courtesy call, we often will go over the basics of what has been done and give the consultant a chance for feedback. The other option is just to give the patient the telephone number and not say anything to the doc, which seems less collegial since if they were on call for the ED when the patient came in they are obligated to provide initial follow-up care.

 

[45408]

This. I'm a big fan of curbsides but you certainly don't document that you've done it.

That's how I feel. I would get a curbside opinion in a situation in which I thought I was already doing the right thing, and I just want informal agreement from an expert that they don't think it needs further evaluation at that time either. Then in my note, I would say something like "Because of these symptoms, I don't feel that this represents a condition that requires evaluation by a cardiologist."

Now, if I spoke with someone and arranged follow-up as an outpatient, I probably would name them: "Dr. Heart said he would see the patient in follow-up in 2 weeks." If Dr. Heart is smart (IMO), he'd make a note (in our system, you can just dictate a note of a telephone conversation) that said "Dr. Prowler called me about a patient with X and Y symptoms. With those findings, it's reasonable to see me in 2 weeks in clinic."

 

[45408]

And regardless... there's an easy solution to this... If you're paranoid about an "informal consult", then just document it yourself. Write down the conversation that you recall and file it away. Problem solved.

We have some people who do this, sometimes to a ridiculous extent...

This is what I generally do. I place a brief note documenting what I was told, what I was able to review myself (labs, vitals, imaging), that I did NOT examine the patient myself as no formal request for evaluation was made of me and then document my recs. My recs always include, that they should call back and/or request a formal consult if further issues arise. Is it perfect? No. Does it generally work? Yes.

I think this is the happy medium, for anything more than a brief question/answer about broad principles.

 

[Buzz Me]

At the attending level everywhere I've ever worked a curbside by definition does not go into the record. In fact it often gets explicitly stated during the conversation at some point. "I'm not going to write down you name but how do you guys usually handle this?" Whenever anyone puts a curbside in the record they are hurting everyone involved

I do frequently run into the situation where consultants refuse the consult. They will say "I don't need to see that. Tell them to consult me later if it changes." Those I do document.

Having been burned by providing curbsides in the past, every time I get asked a clinical question I let the primary team know that a full consult will have to be done. I've seen my name explicitly mentioned in charts (ER/Medicine H&Ps) when I was curbsided and it just kills me.

The other thing that frequently happens here:

ER resident (calling Gen Surg resident): "We have a reducible inguinal hernia patient down here and he needs a clinic follow-up appointment. When do you guys have clinic?"
Gen Surg resident: "Wednesdays."
ER resident: "OK, thanks."

And what ends up in the ER resident's assessment and plan?

"Spoke with General Surgery resident <name>, patient cleared to be discharged home with clinic follow-up appointment."

 

[Groove]

Couldn't agree more with Arcan... Ultimately, we're usually trying to save the consultant a trip down to the ED or a drive in from home. Formal consults are great when they are needed, but if every consultant only felt comfortable with a formal vs an informal consult, then ED throughput times are going to grind to a screeching halt and the ED's are already overloaded as it is. That's taking up precious time in a room that could be spent treating someone else out in the waiting room with a potential emergent problem.

I think we can all agree that there definitely is a medico-legal distinction between the two types of consults. Also, if you read that last article... it gives examples of consultant interactions that prevented the name from being dropped and allowed it to go to court, but did not specify the specific outcome. I still find it difficult to believe that an informal consultant could be found liable and successfully prosecuted in situations like these unless it were a gross exception to the norm. That being said, nobody likes to be named in a lawsuit so I can understand the degree of anxiety.

As JD was saying... I don't know what the specific answer to this problem is ultimately going to be. I don't see informal consults going away, and I don't see specialists being too excited about coming into the ED every time they are called or updated on a pt that is being treated there non-emergently and does not require a formal evaluation. I see the options being the following....

1) Don't document in the ED chart that you spoke with the consultant. - Multiple problems with this... and it's just plain bad medicine. Good documentation always trumps bad documentation and if I spoke with a specialist about the pt, or spoke with the primary, or spoke with the pt's mother or aunt or whomever... I jot it down in the chart. It not only allows me to remember the encounter and accurately document it, but helps any other physician who might be treating the pt as an outpatient later on and wonders what happened in the ED or which specialist/primary I might have spoken to during that encounter.

2) Specialists start denying all informal consults and requiring formal ones. If you're an academic attending, this is an easy thing to say...and have your residents/fellows adhere to it but is completely impractical outside of academia. Also, it will drastically slow down already overloaded EDs. I can see this as something hospital administration would start getting involved in when they start asking why ED throughput is stagnating and why did pt AAA bleed out and code in the waiting room.

3) Specialists start making their own documentation about the encounter. I see this as the easiest solution for everyone if you're paranoid about the consult. If the case is ever brought to court and they are relying on my documentation of the conversation, then you've got your own documentation of the conversation. Also, I still think recorded ED lines is a great solution that might mitigate the necessity of excessive documentation from the consultant in situations like these. If I document that you said "Y" and the recorded conversation clearly shows that you said "X", then that covers you.

Again though... I think everyone needs to back up for a second and look at the big picture. It shouldn't be this complicated for a professional colleague to get your brief opinion on a pt, courteously inform you of your pt's presence in the ED and give you a chance to recommend anything or an entire host of similar situations which arise frequently. We can thank defensive medicine and malpractice lawyers for this thread.



Buzz... If that happened, then just bring it to the attention of the ED faculty, or your own faculty so that it can be escalated. The resident obviously mis-documented or took it out of context, but again... big picture here. How many reducible inguinal hernias do we see in the ED that don't need surgery to evaluate them? Lots. Also, we even have policy guidelines in scheduling certain pt's for outpatient followup that require that I call the specialty and inform them of the pt in the ED so that our own PI dept can successfully make the appt. I have no clue if there is a similar situation at your institution but regardless... just bring it up with your staff, problem solved. I'm sure it doesn't mean that you want to personally come and evaluate every reducible hernia... Hell, I don't even want you to feel required to do this. I get along great with my surgery colleagues and try to save them from as much extra hassle as possible. In my institution, I make these calls for the above reason specified and then document... "Spoke with Dr. X from Surgery who will see the pt in clinic on Wednesday." which allows our PI to schedule the appt with the surgery clinic. I think stating "Dr. X cleared for discharge." is obviously the wrong thing to document.

I feel bad for our optho residents. They actually do have a policy that some of you are suggesting where every call, regardless of it's nature about a pt, requires a formal consult. You can imagine the headaches this causes them and I cringe to call them sometimes. I might have a bad corneal abrasion or an ulceration that needs to be seen in clinic tomorrow but I have to call them to make sure they can be seen. It doesn't necessitate them coming in, but they are forced to regardless by this policy. It's frustrating for the optho residents but also frustrating for us because it keeps the pt in the ED much longer than they need to be and most of those guys are driving in from home so you can imagine how long the pt has to wait to get discharged and how exasperating it is for the optho resident to drive in to see something that did not require emergent evaluation tonight.

 

[Law2Doc]

This is what I generally do. I place a brief note documenting what I was told, what I was able to review myself (labs, vitals, imaging), that I did NOT examine the patient myself as no formal request for evaluation was made of me and then document my recs. My recs always include, that they should call back and/or request a formal consult if further issues arise. Is it perfect? No. Does it generally work? Yes.

While this is better than nothing, it requires you to put a note in the chart, which means you are already going over to where the patient is located in most cases, so the savings over actually doing a formal consult are likely pretty minimal. And this still doesn't help you much if the EDs paraphrase of your advice and what you put in the chart hours later are not the same -- you still will end up in court defending yourself based on someone else's note. Now sure, you have a more contemporaneous writing to bolster your position, and that helps, but in a system where it's easier to settle than actually go to court on these things, you've probably already lost the case once the ED doc documents things in a way that gets a plaintiffs lawyer excited, regardless of how you clarify it a few hours later.

The only real options, as described above, are 1 to frown on or disallow informal consults, as quite a few hospitals do these days. Formal consults are a lot more work, but eliminate the risk and result in more billing for the hospital. 2. Record all communication with ED docs. There are privacy issues with recording all calls, particularly since many people use their own phones where t hey do have more of an expectation of privacy. It also doesn't help with the true "curbside" consult where one doc flags down another in the hallway. Finally 3 instilling more of a team CYA approach could be an option. Right now all too many consulting physicians want to be able to jot down in the record that they consulted with someone before they discharge a patient. They are covering their own butts. You eg dont want to send that potentially but not obviously sick heart patient back out on the street without having cardiology bless the move. So you call them for an informal consult, and dutifully jot their name into the chart. You have covered your butt and talked to a specialist. You have passed the buck. A lot of this stems from traditional turf wars in medicine, rather than an organizational approach. It's part of the reason for high healthcare costs as well -- it plays right into defensive medicine. A team approach where your responsibility isn't simply to cover your own butt but that of the organization might make you more careful in how you document things.

 

[captaincrunch]

I think writing a brief note is a good idea for consultants; sometimes I'm amazed at how little documentation some consultants provide, even on formal consults.

As an aside, I do a similar thing when cross-covering patients as a hospitalist. If I get a call from the nurse about an abnormal lab (or whatever), I document what I did, even if I didn't see the patient. The note is proof that I reviewed the result and acted accordingly. It also lets the primary doc know what I did if I don't talk to them directly. The notes are simple and I cannot bill for them, but I think its good medicine.

 

[45408]

While this is better than nothing, it requires you to put a note in the chart, which means you are already going over to where the patient is located in most cases, so the savings over actually doing a formal consult are likely pretty minimal.

Maybe if you only have paper charts, but you can call into our dictating system from any phone in the US and put in a telephone note that shows up in our EMR within a day (or less).

 

[Buzz Me]

I tend to only write notes if I see the patient.

 

[The Angriest Bird]

All I can say is that consultation is handled so differently in private and public hospitals. Anything beyond this will cross the line of being politically incorrect.

 

[jdh71]

Can I reiterate again please be as clear as possible what you want your consultant to do or what expectations you may have of your consultants.

It save some of us from dealing with irate attendings. The irate kind that get irate right before you were going to leave for the day, causing unreasonable delay in a nice long weekend, which could have easily be dealt with during the normal working day if you'd have taken the time to actually spell out what it was you wanted.

Just a helpful way to play nice.

 

[gutonc]

While this is better than nothing, it requires you to put a note in the chart, which means you are already going over to where the patient is located in most cases, so the savings over actually doing a formal consult are likely pretty minimal.

EMR accessible from home. Quick dictation if you're still in one of those dinosaur institutions that doesn't have an EMR. Problem solved.

I can do all that at 3am in my boxers, and frequently do.

 

[45408]

EMR accessible from home. Quick dictation if you're still in one of those dinosaur institutions that doesn't have an EMR. Problem solved.

I can do all that at 3am in my boxers, and frequently do.

I find that dictating into an EMR is the best of both worlds. You don't have to read somebody's craptastic spelling or an insane number of abbreviations, and even though someone like me can type really fast, it's almost always faster to dictate.

 

[Smurfette]

I can do all that at 3am in my boxers, and frequently do.

hmm...next time I call a consult in the middle of the night I will have to consider the whole "consultant in their underwear" factor. Not sure if that'll be hilarious or an indication for zofran.

 

[Buzz Me]

I find that dictating into an EMR is the best of both worlds. You don't have to read somebody's craptastic spelling or an insane number of abbreviations, and even though someone like me can type really fast, it's almost always faster to dictate.

Exactly. Much faster for me to dictate.

 

[dpmd]

Exactly. Much faster for me to dictate.

It is kinda plus/minus for me. I don't have an accent that I know of, and maybe it is more the service we are using for dictation, but they so frequently get stuff wrong in a nonobvious way that the time I have to spend reading my dictations detracts from the time saved over typing.

 

[45408]

It is kinda plus/minus for me. I don't have an accent that I know of, and maybe it is more the service we are using for dictation, but they so frequently get stuff wrong in a nonobvious way that the time I have to spend reading my dictations detracts from the time saved over typing.

They make occasional mistakes, but I speak pretty clearly so that I don't have to go back. Some of the hospitalists mumble horribly, and one of my chiefs talks super duper fast (and the dictations are error-ridden).

My last one was "creatinine was elevated, so the ED physician elevated [elected] not to get a contrast CT." Really? How do you think that makes any sense?

 

[Buzz Me]

Some transcription services are switching to more voice-recognition software, so it's up to the proofreaders to catch errors like that.

 

[Mattchiavelli]

I feel bad for our optho residents. They actually do have a policy that some of you are suggesting where every call, regardless of it's nature about a pt, requires a formal consult. You can imagine the headaches this causes them and I cringe to call them sometimes. I might have a bad corneal abrasion or an ulceration that needs to be seen in clinic tomorrow but I have to call them to make sure they can be seen. It doesn't necessitate them coming in, but they are forced to regardless by this policy. It's frustrating for the optho residents but also frustrating for us because it keeps the pt in the ED much longer than they need to be and most of those guys are driving in from home so you can imagine how long the pt has to wait to get discharged and how exasperating it is for the optho resident to drive in to see something that did not require emergent evaluation tonight.

It's too bad more EDs don't have a 3rd type of place (triage being first and emergency evaluation being second) where a patient has been stabilized and would be d/c'ed to home save for needing a consult like in you example. That way you could take 4 or 6 people waiting for their consult for clinic out of the evaluation portion and evaluate 4 to 6 new people while you wait for the consultant to come in, since you've said the patient is stable. We had the same problem in med school with the no clinic f/u if not seen by a specialist in the ED, but the patient doesn't have an urgent/emergent ED issue. I think we need things like this in EDs since plenty of people are using the ED as quick access to specialist care in situations that aren't really emergent. There were also a few drug seekers that caught on to this snarl and were using it to scam drugs because it was so tough to get gen surg to see their minor hernia/perianal fistula/small stable abscess for gen surg f/u in clinic. In essence, an urgent clinic to see a specialist that doesn't really discharge the patient but gets them out of the ED doc's hair since they are now and have been rock solid stable.

 

[docB]

It's too bad more EDs don't have a 3rd type of place (triage being first and emergency evaluation being second) where a patient has been stabilized and would be d/c'ed to home save for needing a consult like in you example. That way you could take 4 or 6 people waiting for their consult for clinic out of the evaluation portion and evaluate 4 to 6 new people while you wait for the consultant to come in, since you've said the patient is stable. We had the same problem in med school with the no clinic f/u if not seen by a specialist in the ED, but the patient doesn't have an urgent/emergent ED issue. I think we need things like this in EDs since plenty of people are using the ED as quick access to specialist care in situations that aren't really emergent. There were also a few drug seekers that caught on to this snarl and were using it to scam drugs because it was so tough to get gen surg to see their minor hernia/perianal fistula/small stable abscess for gen surg f/u in clinic. In essence, an urgent clinic to see a specialist that doesn't really discharge the patient but gets them out of the ED doc's hair since they are now and have been rock solid stable.

This isn't an issue outside of academic centers. Only academic attendings would ever create a policy where a patient must be seen by them to get a clinic appointment.

That said many EDs do have policies that allow patient's to go back to the waiting room to wait on various things like test results, consults, etc. In my area we frequently evaluate patients in triage, order the work up and then they go back out. This is more of a capacity issue than an efficiency booster but it is done.