consults

[Law2Doc]

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this conversation reminds me of an infamous consult I heard the other day:


Pediatrics resident in the ER: "Hi, this is Dr X with peds, we have a 2 y/o child here in the ER, he was riding w/ his dad on an ATV that flipped over. His CT scan shows a small intracranial hemorrhage, no skull fracture, but he's got significant hydrocephalus"

Neurosurgery resident: "Whats the clinical question?"

Pediatrics resident: "Uhh, with his CT showing hydrocephalus and his deteriorating mental status...."

Neurosurgery resident: "I'll ask you again, WHATS the clinical question?"

Pediatrics resident: "We need your assistance with possible surgical intervention for his hydrocephalus"

Neurosurgery resident: "So what do you want us to do, whats the question?"

Peds resident: "THE ****ING QUESTION IS ARE YOU GOING TO COME DOWN HERE AND PUT A EVD (external ventricular drain) IN THIS KID OR DO YOU WANT ME TO DO IT?"

I guess I'm missing the point here -- who are you saying is wrong? The peds guy really should have lead off with " we have a pediatric patient status post MVC with hydrocephalus and changing mental status, can you evaluate for ventriculostomy?" and the conversation would have been over. It's the dancing around the reason for the consult that's the time waster here.

 

[Socrates25]

I guess I'm missing the point here -- who are you saying is wrong? The peds guy really should have lead off with " we have a pediatric patient status post MVC with hydrocephalus and changing mental status, can you evaluate for ventriculostomy?" and the conversation would have been over. It's the dancing around the reason for the consult that's the time waster here.

Well yes the peds guy could have been more direct. My point is that the neurosurgery resident was so focused on a red herring argument of "whats the question" and trying to get out of the consult that it turned into absurdity.

A reasonable neurosurgery resident would have known what the clinical question is from the 2nd reply of the peds resident.

 

[45408]

I guess I'm missing the point here -- who are you saying is wrong? The peds guy really should have lead off with " we have a pediatric patient status post MVC with hydrocephalus and changing mental status, can you evaluate for ventriculostomy?" and the conversation would have been over. It's the dancing around the reason for the consult that's the time waster here.

I see no dancing. The opening line sounds pretty clear, and the following lines are even more clear:

"We need your assistance with possible surgical intervention for his hydrocephalus"

 

[maxheadroom]

I guess I'm missing the point here -- who are you saying is wrong? The peds guy really should have lead off with " we have a pediatric patient status post MVC with hydrocephalus and changing mental status, can you evaluate for ventriculostomy?" and the conversation would have been over. It's the dancing around the reason for the consult that's the time waster here.

As a surgeon, I don't even expect that much out of a Pediatrician in the ED. While I'm not a Neurosurgeon, I would expect the opening statement of a patient in MVC with ICH and hydrocephalus as more than adequate "bullet" to tell the consultant that this is a patient who requires his/her services.

I don't expect every service that consults me to understand the pathology the way that I do -- I expect them to correctly identify that the patient has a problem that requires my expertise and communicate that with me.

 

[Law2Doc]

I see no dancing. The opening line sounds pretty clear, and the following lines are even more clear:

"We need your assistance with possible surgical intervention for his hydrocephalus"

He could have gotten to the point in the initial statement. That's the dancing. Possible surgical intervention for hydrocephalus was the third sentence in the dialogue after two prompts from the neurosurgeon. Up until then it was unclear whether they wanted the neurosurgeon to help with the hydrocephalus or the bleed or maybe just to suggest another study. The last prompt by the neurosurgeon was probably superfluous. I agree this wasn't a particularly egregious example. There are plenty of similar real life cases where the intern never actually gets to the point, even after prompting. All too often he doesn't know why he's calling a consult, just that the attending or team he's cross covering for asked him to call. I think there's also a difference here where an ED person is possibly looking for a surgeon to assume care of a patient versus the consult situation not coming from the ED, where the consultant is simply being brought in to consult. Either way the person calling the consult ought to be calling the consultant for a specific reason, not just a "you figure out why I'm calling" kind of call. I don't really have a problem with the neurosurgeon here making the person calling the consult actually state an actual reason that he's calling a neurosurgeon rather than just a neurologist.

 

[Groove]

this conversation reminds me of an infamous consult I heard the other day:


Pediatrics resident in the ER: "Hi, this is Dr X with peds, we have a 2 y/o child here in the ER, he was riding w/ his dad on an ATV that flipped over. His CT scan shows a small intracranial hemorrhage, no skull fracture, but he's got significant hydrocephalus"

Neurosurgery resident: "Whats the clinical question?"

Pediatrics resident: "Uhh, with his CT showing hydrocephalus and his deteriorating mental status...."

Neurosurgery resident: "I'll ask you again, WHATS the clinical question?"

Pediatrics resident: "We need your assistance with possible surgical intervention for his hydrocephalus"

Neurosurgery resident: "So what do you want us to do, whats the question?"

Peds resident: "THE ****ING QUESTION IS ARE YOU GOING TO COME DOWN HERE AND PUT A EVD (external ventricular drain) IN THIS KID OR DO YOU WANT ME TO DO IT?"

LOL, classic.

 

[Groove]

I see no problem at all with the Peds ED consult. It's beyond obvious that it's a NSGY issue. C'mon guys... Blood in brain after trauma, hydrocephalus --> NSGY. It's not rocket science. Also, with a 2y/o do you really want to be sitting there asking a million questions for 10 minutes? Think the mom or dad or the NSGY attending for that matter would approve? It means there's blood in the brain and hydro with associated trauma. That's a consult that is quick and has every excuse in the book to be brief.

First of all, everyone needs to realize that ED consults are a bit different than floor consults. I hear a lot of "appropriateness" of the consult which I think tends to get hyper focused on during <insert specialty> residency. The problem with this from a resident perspective is that you will always have a tendency as a resident to downplay the appropriateness and always have an incentive to decline or try to "get out of" the consult. It's human nature. It's extra work for you, and you are not getting paid. You're thinking about things such as "how long is this pt going to sit on my census list...can I get him out in 3-4 days or will he be here for 3-4 weeks?", etc.. I'm an ED resident, but I did my ward months on the floor during my intern year and can remember how it felt from the other side. You can't and don't think as an attending. If you were an attending, you're thinking of $$$ and establishing a good relationship with the consulting doc and potential referrals depending on your specialty. Sure, an inappropriate 11p.m. consult on a Sat night where you're being asked to come into the ED might cause some distress, but by and large you are in a completely different frame of mind. Hopefully, you aren't being asked without a good reason.

I also have no problem playing the "who's your attending on tonight/today?" card. No, I don't call their attending myself without letting my attending know of what transpired and my intention. More than likely, they will want to make the call themselves. Some of these situations just can't be avoided and sadly these interactions can drastically be influenced by the culture of the residency program and the individual personality of who is being consulted, not how the consult was phrased or how it was presented. It's important to try your best to establish a good working relationship with your consultants but some of these interactions can't be avoided.

SouthernIM, you've got it backwards. If you got "curbsided" and I document in my note that you recommended X... but there's no note from you in the chart and a bad outcome, you can easily say... hey.. I had no idea the pt had X, X and X going on, the managing doc never asked me to personally evaluate the pt, etc.. If I had only known X, I would recommended something completely different. You are not liable. I am. A curbside is a completely appropriate and courteous thing to do when you don't need a formal evaluation or note written, ESPECIALLY in the ED. If I have a guy with hx of seizures come in, becoming more frequent, work up negative for anything else going on, Neuro appt scheduled for 4 months from now, question about his medication dosing and any more outpatient studies done prior to his appt along with moving the appt up, better believe I'm going to give the neuro resident a courteous phone consult and get his opinion on some of these things after I briefly discuss the case. Do I need them to personally evaluate the pt? No. Do I need a formal note? No. Am I confident enough in my evaluation and dx of the pt to take the liability, knowing that it's a "non-official" consult? Of course. It gets the pt out faster, is an easy and quick interaction with the other service, and they not only appreciate it but remember things like that when I DO need a formal consult in the future.

 

[SouthernSurgeon]

SouthernIM, you've got it backwards. If you got "curbsided" and I document in my note that you recommended X... but there's no note from you in the chart and a bad outcome, you can easily say... hey.. I had no idea the pt had X, X and X going on, the managing doc never asked me to personally evaluate the pt, etc.. If I had only known X, I would recommended something completely different. You are not liable. I am.

That's not what my staff would say...we had a resident in our program get in deep trouble for a curbside where the person calling then went on to document in their note that "Surgery recommended X"...then a couple of days later the patient gots truly sick and an actual consult got called. The surgery consult attending saw that the notes document "surgery's" recommendations when they had never heard anything about the patient. The spotlight then turned to the resident who got called several days back but never evaluated the patient.

"Curbsides" may be seen as a courtesy to the resident you are calling, but the "courtesy" you're providing them is a shortcut. Most of the time, sure, it's innocent...but sometimes it has the potential to cause an important medical error. Same as "appropriate" vs "inappropriate" consults, there are appropriate and inappropriate curbsides...and most of the time at least in my experience they are inappropriate. And again part of that may just be institutional bias...but in my program, you'll waste a little time up front, but save yourself a world of potential trouble if you see the patient yourself and staff them appropriately with your attending.

 

[Law2Doc]

That's not what my staff would say....

agreed. Where I'm at they frown on curbsides because several services have been dinged where another service puts into the medical record that they "spoke to XYZ service, who indicated ..." If someone else is going to paraphrase your informal advice incorrectly into the record, you can bet you are assuming the same kind of liability as you would if you did the formal consult, plus you don't get to hedge or otherwise CYA, and more importantly you assume all the risk but none of the benefits because you can't send a bill. So lots of hospital risk analysts will get pretty upset when they get wind of curbsides or informal opinions.

 

[docB]

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.

 

[SouthernSurgeon]

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.

That is actually the ultimate trump card, even beyond pulling the "attending" card. I've only had to use it once, with a cards fellow who refused to see a patient on a Sunday. Telling someone that you are going to document their refusal to see the patient in the medical record certainly changes their tone in a hurry...

 

[Groove]

Maybe it's an institutional thing but I work at a busy Level 1 Trauma center and we simply don't need a formal consult every time we talk to a specialist, nor do they have the time or manpower, nor would they appreciate it. I'm often "running something by them" about some minor issue in pt management. It's also never with an acutely sick pt or if there is any concern for an emergent issue. In my above example, I think it's unwise not to document that I spoke with the neurologist about changing medication dosages, moving up appt's, EEG study as outpatient per their request, etc.. Otherwise, if someone else sees the pt a few weeks from now and are looking through the records, how difficult would it be figuring out where the medication change occurred and why? It's common sense to me. Now, you document clearly... "No acute issues identified with pt. Briefly discussed pt unofficially by phone with Dr. X from neurology about opinion on potential medication dosage adjustments and outside studies that could be beneficial prior to next appt. Dr. X recommended changing etc.., etc.., and scheduling outpatient EEG and was fine with moving up appt."

http://cid.oxfordjournals.org/content/23/3/616.full.pdf

Is a useful, albeit a bit old, document on medico legal aspects of "curbside" consults. I'm sure there are some newer ones but there have been enough cases to establish a clear standard.

"Informal consultations for which the physician does not see the patient (curbside consultation). Case law clearly establishes that a physician-patient relationship does not arise when a physician provides advice to a colleague on the basis of an informal request for assistance. Although the physician's name may appear in the medical record or may be identified through a deposition, most courts have held that in the absence of a referral, a formal consultation, or some other contractual relationship no physician-patient relationship exists."

I'm sure we can find exceptions but the few case law searches I did seem to overwhelming indicate this standard as still holding. Also, as the article indicates, curbsides are quite common.

I even start out sometimes "Hey Bill....I've got a formal consult and an unofficial curbside question for you, etc..." They all know I will document each as such. Medico-legally it's extremely difficult for you to be held liable when you were never formally consulted, never asked to see the pt, did not see the pt and therefore did not establish a pt physician relationship.

 

[Groove]

That is actually the ultimate trump card, even beyond pulling the "attending" card. I've only had to use it once, with a cards fellow who refused to see a patient on a Sunday. Telling someone that you are going to document their refusal to see the patient in the medical record certainly changes their tone in a hurry...

This is because if it's done in the ED, it's a federal EMTALA violation to refuse an ED formal consult and carries a very hefty fine. You can also get fired for it. You can "refuse", but "technically"...you can't ever refuse. I didn't make the rules. The same people that made the rule that I have to see anyone and everyone (drug seeker, homeless guy looking for a stretcher to sleep on, etc..) that shows up in the ED, regardless of if it's emergent or not, and I can't kick them out without offering a medical screening exam...are the same ones who made that one.

I did have a colleague moonlighting who was trying to transfer a pt (service of care not available at hospital and pt request) and outside hospitalist refused the transfer because they did not want to come in at 2a.m. and eval/write orders. He was told this was EMTALA violation and would he please repeat what he just said to the nurse standing nearby...he did. He was told the hospital administration would be contacted tomorrow morning and an EMTALA violation would be reported. He said that he didn't care. Colleague got a phone call the next day from that hospital's administration apologizing for incident and stating that it would never happen again because Dr. X was no longer an employee of the hospital.

 

[dynx]

He could have gotten to the point in the initial statement. That's the dancing. Possible surgical intervention for hydrocephalus was the third sentence in the dialogue after two prompts from the neurosurgeon. Up until then it was unclear whether they wanted the neurosurgeon to help with the hydrocephalus or the bleed or maybe just to suggest another study. The last prompt by the neurosurgeon was probably superfluous. I agree this wasn't a particularly egregious example. There are plenty of similar real life cases where the intern never actually gets to the point, even after prompting. All too often he doesn't know why he's calling a consult, just that the attending or team he's cross covering for asked him to call. I think there's also a difference here where an ED person is possibly looking for a surgeon to assume care of a patient versus the consult situation not coming from the ED, where the consultant is simply being brought in to consult. Either way the person calling the consult ought to be calling the consultant for a specific reason, not just a "you figure out why I'm calling" kind of call. I don't really have a problem with the neurosurgeon here making the person calling the consult actually state an actual reason that he's calling a neurosurgeon rather than just a neurologist.

I disagree. The initial description was adequate to infer the question. If you're annoyed that you need to actually perform an analysis beyond answering a yes/no question then you're a douche.

I'd much prefer this type of consult to the classic "we've got a guy here with X. He needs to go to the OR"...Oh really? well then I'll call and have them open the room for you. What time do you want to take them? Actually, why don't you just sit-tight there speed and let me decide if he's going to surgery.

 

[Gastrapathy]

He could have gotten to the point in the initial statement. That's the dancing. Possible surgical intervention for hydrocephalus was the third sentence in the dialogue after two prompts from the neurosurgeon. Up until then it was unclear whether they wanted the neurosurgeon to help with the hydrocephalus or the bleed or maybe just to suggest another study. The last prompt by the neurosurgeon was probably superfluous. I agree this wasn't a particularly egregious example. There are plenty of similar real life cases where the intern never actually gets to the point, even after prompting. All too often he doesn't know why he's calling a consult, just that the attending or team he's cross covering for asked him to call. I think there's also a difference here where an ED person is possibly looking for a surgeon to assume care of a patient versus the consult situation not coming from the ED, where the consultant is simply being brought in to consult. Either way the person calling the consult ought to be calling the consultant for a specific reason, not just a "you figure out why I'm calling" kind of call. I don't really have a problem with the neurosurgeon here making the person calling the consult actually state an actual reason that he's calling a neurosurgeon rather than just a neurologist.

You definitely are a lawyer. Rhetorical tricks, passive-aggressive responses and crushings interns who don't totally get why they are consulting you are tactics to stall work. When I tell my team to consult someone, the consult better get done. Trainees may struggle to explain the consult, but don't ever take that to mean that I don't know why I want it. I can't call every consult, this is part of their education. You aren't so special. I bet I could find fault in any presentation you gave me if that was my goal.

I just had an Ortho resident block an inpt consult. His justification later was that the intern got a minor detail wrong. He told my intern that he needed the attending to call him since she "just didn't know the patient." I was sitting next to her and heard the whole conversation. It was a solid presentation (not perfect but really not bad and clearly good enough, much like the peds example above).

I called the staff. Patient went to the OR. I made the attending promise not to let that resident scrub.

Oh, and in the real world...block me one time and I'll just never call you again. As a GI doc, I'm a source of good surgical consults (ie the kind that lead to surgery) and, I can tell you, that the GS attendings bend over backwards to keep me happy.

 

[Gastrapathy]

I even start out sometimes "Hey Bill....I've got a formal consult and an unofficial curbside question for you, etc..." They all know I will document each as such. Medico-legally it's extremely difficult for you to be held liable when you were never formally consulted, never asked to see the pt, did not see the pt and therefore did not establish a pt physician relationship.

For me, the problem with this is that people often aren't as diligent in how they document curbsides. Often, if I take a look at that chart later, the notes make it sound like I was consulted. I try to avoid curbsides for this reason.

 

[Groove]

For me, the problem with this is that people often aren't as diligent in how they document curbsides. Often, if I take a look at that chart later, the notes make it sound like I was consulted. I try to avoid curbsides for this reason.

I understand the reticence... but formal consults require you to evaluate the patient personally and leave a note. Informal ones do not. If you evaluate the pt personally, you naturally leave a note documenting that, along with your recommendations, etc... In fact, if I request a "formal" consult, I often times will check to make sure they left a note because it's the only proof that I have that a formal consult took place when I document that in my chart. If I have no proof that it took place, and you didn't leave a note, it's as if you weren't there from a legal point of view and no pt-physician relationship/care was established. I mean, it's very difficult to prosecute someone for a pt care encounter that you can't prove ever took place, regardless of what I document. In our particular ED, all our phone consult discussions are recorded for this very purpose. If there's ever any confusion about what was said, you can always find the conversation and play it back. Don't know how many other places do that sort of thing.

I understand the hesitation though....we all work in a medically defensive climate.

 

[michaelrack]

C'mon guys... Blood in brain after trauma, hydrocephalus --> NSGY. It's not rocket science. .

just brain surgery

 

[Law2Doc]

I understand the reticence... but formal consults require you to evaluate the patient personally and leave a note. Informal ones do not. If you evaluate the pt personally, you naturally leave a note documenting that, along with your recommendations, etc... In fact, if I request a "formal" consult, I often times will check to make sure they left a note because it's the only proof that I have that a formal consult took place when I document that in my chart. If I have no proof that it took place, and you didn't leave a note, it's as if you weren't there from a legal point of view and no pt-physician relationship/care was established. I mean, it's very difficult to prosecute someone for a pt care encounter that you can't prove ever took place, regardless of what I document. In our particular ED, all our phone consult discussions are recorded for this very purpose. If there's ever any confusion about what was said, you can always find the conversation and play it back. Don't know how many other places do that sort of thing.

I understand the hesitation though....we all work in a medically defensive climate.

The point is that if you do an informal curbside but then you jot in the medical record "spoke with Dr Smith in neurosurgery, who suggested..." the lawyer reviewing the case later is going to add Dr Smith to the case. And he's going to be stuck defending your paraphrase of his advice rather than his actual advice. The "I never said anything like that" defense doesn't fly because it's presumed you dutifully recorded what transpired in the medical record. And Dr Smith is hauled into court on a patient he never even billed for anything, so he got all the negatives and none of the positives of a consult. Which is why at many institutions the curbside or informal consult is frowned upon. Now sure if you have telephone records recorded that helps, but it still won't help the flagging a person down in the hall type encounter. Curbsides are bad news legalistically. Consultants should avoid them.

 

[gutonc]

For me, the problem with this is that people often aren't as diligent in how they document curbsides. Often, if I take a look at that chart later, the notes make it sound like I was consulted. I try to avoid curbsides for this reason.

If by "not diligent in how they document" you mean "they make things up" I'm completely with you.

We've recently been instructed that all curbsides are to go directly to the attending on service and they can decide how to deal with it. It generates a little extra work for the resident/fellow on service but so far it hasn't been too bad. And it takes the pressure off the trainee when things inevitably get screwed up in the chart after a curbside.

 

[Gastrapathy]

In our particular ED, all our phone consult discussions are recorded for this very purpose. If there's ever any confusion about what was said, you can always find the conversation and play it back. Don't know how many other places do that sort of thing.

I understand the hesitation though....we all work in a medically defensive climate.

😱😱😱😱😱

You record my phone call?!? Wow. So, now any little mildly inappropriate comment from my just-woken up, addled state can be replayed for all to hear? Do your consultants know that? I'm not sure how I would respond to that but, depending on the situation, I might stop taking calls from your ED. I've never heard of that before anywhere. Crazy.

 

[Gastrapathy]

If by "not diligent in how they document" you mean "they make things up" I'm completely with you.

We've recently been instructed that all curbsides are to go directly to the attending on service and they can decide how to deal with it. It generates a little extra work for the resident/fellow on service but so far it hasn't been too bad. And it takes the pressure off the trainee when things inevitably get screwed up in the chart after a curbside.

Yup. I had one a couple months ago where the resident curbsided my fellow and wrote a note that made it sound like we'd seen the patient. Then the IM attending, in his addendum, thanked ME for seeing the patient. I had a good fellow who noticed this and wrote a consult. The scary part is that most of the time, I'm probably totally unaware when stuff like this happens.

 

[Doctor Bagel]

The point is that if you do an informal curbside but then you jot in the medical record "spoke with Dr Smith in neurosurgery, who suggested..." the lawyer reviewing the case later is going to add Dr Smith to the case. And he's going to be stuck defending your paraphrase of his advice rather than his actual advice. The "I never said anything like that" defense doesn't fly because it's presumed you dutifully recorded what transpired in the medical record. And Dr Smith is hauled into court on a patient he never even billed for anything, so he got all the negatives and none of the positives of a consult. Which is why at many institutions the curbside or informal consult is frowned upon. Now sure if you have telephone records recorded that helps, but it still won't help the flagging a person down in the hall type encounter. Curbsides are bad news legalistically. Consultants should avoid them.

We've actually been encouraged to do more curbsides for the ED for efficiency reasons, but, yeah, I can see where legally it's problematic. That's unfortunate, though, because actually seeing these minor consults creates a ton of busywork for a consult service. I wonder if there's a way to handle curbsides, such as directing the team calling you to resources for research, rather than specifically commenting on the case in question. Of course, it still depends on how they document it.

On that note, I've heard some people complain about people documenting curbsides at all, but that seems problematic, too, because you're cutting out part of your medical decision making in your documentation. Do most institutions have an official policy about this or is it more a cultural issue?

 

[Arcan57]

We've actually been encouraged to do more curbsides for the ED for efficiency reasons, but, yeah, I can see where legally it's problematic. That's unfortunate, though, because actually seeing these minor consults creates a ton of busywork for a consult service. I wonder if there's a way to handle curbsides, such as directing the team calling you to resources for research, rather than specifically commenting on the case in question. Of course, it still depends on how they document it.

On that note, I've heard some people complain about people documenting curbsides at all, but that seems problematic, too, because you're cutting out part of your medical decision making in your documentation. Do most institutions have an official policy about this or is it more a cultural issue?

Most community places are not going to have curbside consults because lack of request for consult = not getting paid for doing work. There may be discussions over lunch regarding approaches to a particular problem, but no patients' names are used and no consultants' names would show up in the medical record.

The closet thing I come to with curbsiding is calling an attending for outpatient follow-up. I will chart who I spoke with and when the expected follow-up will be. During this conversation I'll usually run the plan of care until follow-up by the consultant to make sure that's what they want. For example what type of splint or if what their medical expulsive regimen for uretral stones consists of.

If I request that a consultant comes in and they refuse, that conversation would be documented along with the calls to the chief of staff and hospital COO.

In regards to recording calls, it's very useful from an ED standpoint. Reminding the consultant that they are being recorded can help incentivize them to do the right thing for the patient. The only times I've ever seen the tapes pulled was in cases of blatant misconduct by the consultant or serious disagreement between the consultant and ED doc regarding the substance of their conversation. As long as you do the right thing, it never becomes an issue.

 

[45408]

He could have gotten to the point in the initial statement. That's the dancing. Possible surgical intervention for hydrocephalus was the third sentence in the dialogue after two prompts from the neurosurgeon. Up until then it was unclear whether they wanted the neurosurgeon to help with the hydrocephalus or the bleed or maybe just to suggest another study.

Both of which seem pretty appropriate. If the ER calls us with "free air and peritonitis," we don't drill them with WELL WHAT DO YOU WANT US TO DO? If you're a surgeon, and you can't figure it out with that intro, then God help you.

I don't really have a problem with the neurosurgeon here making the person calling the consult actually state an actual reason that he's calling a neurosurgeon rather than just a neurologist.

I do. I can think of one time ever that we called neurology on a trauma patient, and it was because the patient seized before the MVC. The other 7000 times, we've called neurosurgery for all cerebrospinal trauma.

 

[maxheadroom]

In our particular ED, all our phone consult discussions are recorded for this very purpose. If there's ever any confusion about what was said, you can always find the conversation and play it back. Don't know how many other places do that sort of thing.

I understand the hesitation though....we all work in a medically defensive climate.

I'm pretty sure that I would resign from a medical staff that did something like this. Stuff like this is the reason why Plastic Surgeons continue to abandon larger hospitals. We don't need the larger hospitals for 90% of the surgery that we do and an abusive ED is the #1 reason cited by most private practice guys.

 

[oldbearprofessor]

I'm pretty sure that I would resign from a medical staff that did something like this. Stuff like this is the reason why Plastic Surgeons continue to abandon larger hospitals. We don't need the larger hospitals for 90% of the surgery that we do and an abusive ED is the #1 reason cited by most private practice guys.

Undoubtedly, this is something specialty-specific, but I am genuinely puzzled why an attending would be upset about having their calls from an ER recorded. In my business, we get consult-type calls all the time from outside hospital ERs and other hospital's in-patient units. I would much rather they were recorded, which they are if they go through the proper channels in calling me. For example, let the record show that I said "watch the baby closely and if they become more tachypneic or their oxygen requirement exceeds 30% please call me back immediately and we can transfer the baby." Without that recording, it will be documented most commonly as "spoke with Dr. OBP at big children's hospital and he said we didn't need to transfer baby now." They are right, but they missed documenting a key statement that I'd made. I want that tape to be made.

As always, YMMV, but I'm not offended or upset by having my calls with consulting hospitals recorded.

 

[jdh71]

I'm pretty sure that I would resign from a medical staff that did something like this. Stuff like this is the reason why Plastic Surgeons continue to abandon larger hospitals. We don't need the larger hospitals for 90% of the surgery that we do and an abusive ED is the #1 reason cited by most private practice guys.

How does recording the conversation make it abusive?

 

[Doctor Bagel]

Undoubtedly, this is something specialty-specific, but I am genuinely puzzled why an attending would be upset about having their calls from an ER recorded. In my business, we get consult-type calls all the time from outside hospital ERs and other hospital's in-patient units. I would much rather they were recorded, which they are if they go through the proper channels in calling me. For example, let the record show that I said "watch the baby closely and if they become more tachypneic or their oxygen requirement exceeds 30% please call me back immediately and we can transfer the baby." Without that recording, it will be documented most commonly as "spoke with Dr. OBP at big children's hospital and he said we didn't need to transfer baby now." They are right, but they missed documenting a key statement that I'd made. I want that tape to be made.

As always, YMMV, but I'm not offended or upset by having my calls with consulting hospitals recorded.

That makes sense, but I can see why people would want to be notified that they're being recorded in advance. Anyway, aren't there laws about recording conversations without everyone's permissions (or at least without notifying all the parties). I know it varies by situation and state, but recording a conversation without notifying someone is probably an iffy proposition.

 

[oldbearprofessor]

That makes sense, but I can see why people would want to be notified that they're being recorded in advance. Anyway, aren't there laws about recording conversations without everyone's permissions (or at least without notifying all the parties). I know it varies by situation and state, but recording a conversation without notifying someone is probably an iffy proposition.

When going through the hospital operator to speak with us, they are told "this conversation is being recorded".

 

[Doctor Bagel]

When going through the hospital operator to speak with us, they are told "this conversation is being recorded".

Makes sense. I'm much more OK with this practice now.

 

[Arcan57]

That makes sense, but I can see why people would want to be notified that they're being recorded in advance. Anyway, aren't there laws about recording conversations without everyone's permissions (or at least without notifying all the parties). I know it varies by situation and state, but recording a conversation without notifying someone is probably an iffy proposition.

It depends on the state. In TN (and in TX I believe), only one party has to be aware that the call is being recorded. If you're talking to a physician through a transfer center or calling into a random ED, assume that the call is being recorded.

In regards to ED's being "abusive" to plastics, I guess it depends on the institution. The typical scenario I've seen generate complaints is plastics being pissed they have to come in for someone without insurance. I consult plastics about 1-2 times a year, and about half the time it's at the patient's insistence (which I am up front about on the phone).

 

[gutonc]

When going through the hospital operator to speak with us, they are told "this conversation is being recorded".

All of our outside calls are handled this way.

"Transfer Center, you're on a recorded line, thank you for calling back Dr. Gutonc, I have Dr. Dumas on the line from Boonies General Hospital calling with a consult question and possible transfer, go ahead please."

The first time I dealt with this it freaked me out. Every time since I've been thankful for it. Keeps me on my toes (which at 3am is often helpful) and keeps the calling doc honest.

 

[SoCuteMD]

.

 

[J-Rad]

Why? You are a professional. Are you not capable of behaving like one?

I've worked at two separate hospitals - one with plastics residents and one without. The plastics residents are always resistant to coming in on the rare occasion that we call them (usually when they are on for hand or when patients demand plastics). At the other hospital we rarely call them (I think I've called them for two lacs ever, one at the request of the patient and the other at my discretion). Both times the surgeon was there promptly, took care of everything quickly, and on the way out THANKED me for calling them and gave me their card in case I ever needed to get in touch with them again. Neither of them seemed to feel particularly "abused."

I think s/he's referring to being recorded. If this is being done without the consent of all parties, then this could constitute illegal wiretapping in some areas. As such, s/he has every right to feel that this is abusive. If the recording is made clear to all parties involved then that is a different story.

 

[Groove]

To the plastics guy... if you don't want to come into the ED for a legit consult, regardless of insurance status then don't negotiate a contract with the hospital where you take call. Don't need the hospital for 90% of your stuff? Fine then, don't work there. Good luck with those referral's. Abusive ED...please. You guys are notorious for not wanting to come in for anything....plastics residents that is. Anytime that I've seen a plastics attending called in from a community hospital, they are always without complaint and much easier to work with. It's not like we sit around in the ED thinking which service we can screw with tonight.

 

[Groove]

As far as the recorded lines... it's common knowledge and known with every service in the hospital. As oldbear said... it's very useful, not only for us but for everyone. What do you have to be afraid of saying on a line that you don't want to be known? If I'm talking to paramedics in the field that want permission to stop coding a pt, or taking a telemedicine consult from a rural ED in the region, or doing a toxicology consult to an ED 100 miles away, you'd better believe I want all my stuff recorded. Likewise, recording everything that comes through the ED lines protects everyone from mis-documentation and/or mis-representation. We do a lot more on those phones than just talk to consultants.

 

[jdh71]

To the plastics guy... if you don't want to come into the ED for a legit consult, regardless of insurance status then don't negotiate a contract with the hospital where you take call. Don't need the hospital for 90% of your stuff? Fine then, don't work there. Good luck with those referral's. Abusive ED...please. You guys are notorious for not wanting to come in for anything....plastics residents that is. Anytime that I've seen a plastics attending called in from a community hospital, they are always without complaint and much easier to work with. It's not like we sit around in the ED thinking which service we can screw with tonight.

Bull****!

I don't believe you!!

 

[Groove]

Bull****!

I don't believe you!!

Damn...busted by our own recorded lines when we call each other! 😀

 

[wine thief]

Now, you document clearly... "No acute issues identified with pt. Briefly discussed pt unofficially by phone with Dr. X from neurology about opinion on potential..."

Are you crazy? Nothing is unofficial when you put it in the chart. Do your consultants know you're documenting their discussion? I highly doubt it.

And you are flat out wrong about curbsides relieving consultants of liability. There are definitely cases of curbsided consultants who didn't even know the name of the patient, who get sued and have to pay. You are throwing your consultants under the bus.

 

[Groove]

Are you crazy? Nothing is unofficial when you put it in the chart. Do your consultants know you're documenting their discussion? I highly doubt it.

And you are flat out wrong about curbsides relieving consultants of liability. There are definitely cases of curbsided consultants who didn't even know the name of the patient, who get sued and have to pay. You are throwing your consultants under the bus.

Change "unofficial" to "informal", how's that? There is definitely a medico-legal distinction between formal and informal consults and liability. You can find cases where someone was sued for an informal consult. I can find many more where they were not sued or it was dropped because it was an informal consult vs a formal consult. Do a few searches on medical malpractice and verify this yourself.

Look, it really doesn't matter to me. If I need your assistance with a pt and you are on call, I'll call you... even if it's not necessarily an emergency and even if I don't necessarily need you to even see/evaluate them personally. Isn't that better for the pt? Isn't that what medicine is all about? Can't we all work together on this? I'm not saying situations like this are going to happen a lot, but they are definitely going to happen.

If the thought of NOT coming in and evaluating the pt personally scares the hell out of you so that you can cover yourself with protective documentation charms and blessings that aren't negated by my ED documentation hexes and curses, then by all means come on in....but don't get pissed at me for calling you if I value your opinion on something. I think it's ridiculous that the only way for you to feel comfortable talking to me on the phone about the pt is for me to sneakily say (on my recorded line.. no less) ... "hey...this phone conversation never happened.. Deal? Cross my heart, hope to die, stick a needle in my eye.. Break!.. So..need your opinion on something..."

 

[Law2Doc]

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

the problem is that although many ED docs seem to think this way, it's not accurate. A lawyer reviewing the medical record is going to name consultants he sees named in that record as defendants. Doesn't really matter if this person gave a formal consult, or if the ED doctor simply jotted down that he Spoke with him. Your advice is deemed no less dangerous if you personally sign a paper or send a bill. Worse still, you are stuck trying to defend or disown a paraphrase of your advice, rather than actual advice. So you don't have the ability to qualify your opinion -- you are at the mercy of whomever is jotting down the quick note.

It's no accident that many hospitals frown on curbsides. These are real consults from a legal standpoint. They can get you embroiled in a lawsuit. They can force your medmal insurers hand to settle cases and raise your premiums. The legal distinction is pretty minimal -- it really is only a distinction to the extent it's harder to wriggle out of a statement you personally signed, but in a world where the vast majority of cases settle before court, you generally won't even get this opportunity to wriggle.

 

[VA Hopeful Dr]

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.

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

 

[oldbearprofessor]

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

If we broadly define curbsides as all individual patient advice requesting and giving from a physician who is not otherwise formally involved in a patient's care, I respectfully disagree and suggest it should be situation specific at the attending level.

I am regularly (several times a week) asked, via phone call, email or in-person to provide advice about patients with certain conditions that I am known as an expert in. These requests come from my own institution, collaborating institutions, competing institutions (!) and institutions out of town and out of the country. Generally they are low (medicolegal) risk advice-giving situations, but not always.

Regardless, I can not personally imagine saying "You should consider doing X for this baby, then recheck Y and if Z, call me back for further advice, but don't document this interaction." Rather, I correctly assume that most of the time, they WILL write on the chart, wherever they are, that they have asked Dr. OBP about this situation and he gave the following advice......Lots of times they specifically tell the family that they spoke to me and what I suggested. Not infrequently a family emails me directly for advice.

Does this pose a legal risk to me? Probably it does, but I don't really mind it because that is part of what I do for a living as an academic physician-scientist doing clinical research, etc, and giving advice in these situations is the right thing to do. By assuming always that this advice will be documented, I structure the advice in a way to make it clear what I do and do not know about the situation and the need for follow-up if the situation changes. Ideally, I would document the interaction, and sometimes I do, but not always.

Regardless, I do not think that being asked about a patient without a formal consult, by a doctor in one's own hospital or across the world, requires a formal statement of secrecy and asking for one will be, in my experience, ineffective, not followed, and unhelpful. I realize this is different than cornering the ID fellow for the correct dose of cefomagic, but the principles aren't much different.

I encourage residents and fellows to graciously provide curbside advice and develop their own style at it that they will use as an attending. Good practice for this occurs at every dinner they ever go to in which a non-medical friend asks for medical advice for themselves.

 

[Gastrapathy]

Just writing the word "unofficially" in the official medical record and believing that has some magic effect is hilarious.

OBP, there is a difference between a specialist calling a subject-matter expert in his field for advice and the ED calling me to curbside me about a Crohn's patient that I've never met. In the former, you assume that the person asking the question is sufficiently advanced in your field to use the information.

In the latter, they are asking how much prednisone to give and I have to figure out whether the patient is actually having a flare, not infected, their other meds, etc. Its just a different level of responsibility and a different type of phone call away from the ivory tower. Your name may end up in the medical record but not the way mine does (called Dr. G and we agreed to start steroids becomes the primary plan).

The reasons recording my phone call are offensive are multiple. Off the top of my head: First of all, the idea that these recordings are kept long enough to protect me from anything is extremely unlikely. They would need to be kept for years. By the time I get sued and would want to show the content of the call, I'm sure they've been recorded over. The only person protected is the ED physician, in the short term. Second, medicine is complex. We aren't always right on the first blush over the phone. Why are we trying to make it easier to sue us? Third, it just shows how little some emergency physicians want to be collegial. Its a heavy-handed approach to consultants that reflects the driving motivation to turf responsibility and liability rather than evaluate.

 

[docB]

If we broadly define curbsides as all individual patient advice requesting and giving from a physician who is not otherwise formally involved in a patient's care, I respectfully disagree and suggest it should be situation specific at the attending level.

I am regularly (several times a week) asked, via phone call, email or in-person to provide advice about patients with certain conditions that I am known as an expert in. These requests come from my own institution, collaborating institutions, competing institutions (!) and institutions out of town and out of the country. Generally they are low (medicolegal) risk advice-giving situations, but not always.

Regardless, I can not personally imagine saying "You should consider doing X for this baby, then recheck Y and if Z, call me back for further advice, but don't document this interaction." Rather, I correctly assume that most of the time, they WILL write on the chart, wherever they are, that they have asked Dr. OBP about this situation and he gave the following advice......Lots of times they specifically tell the family that they spoke to me and what I suggested. Not infrequently a family emails me directly for advice.

Does this pose a legal risk to me? Probably it does, but I don't really mind it because that is part of what I do for a living as an academic physician-scientist doing clinical research, etc, and giving advice in these situations is the right thing to do. By assuming always that this advice will be documented, I structure the advice in a way to make it clear what I do and do not know about the situation and the need for follow-up if the situation changes. Ideally, I would document the interaction, and sometimes I do, but not always.

Regardless, I do not think that being asked about a patient without a formal consult, by a doctor in one's own hospital or across the world, requires a formal statement of secrecy and asking for one will be, in my experience, ineffective, not followed, and unhelpful. I realize this is different than cornering the ID fellow for the correct dose of cefomagic, but the principles aren't much different.

I encourage residents and fellows to graciously provide curbside advice and develop their own style at it that they will use as an attending. Good practice for this occurs at every dinner they ever go to in which a non-medical friend asks for medical advice for themselves.

The reason that I don't name curbsides in the record is that there is significant risk to them. The main source of that risk is that they have no input into the record because they don't write a consult. If things go bad they are left with no documentation other than mine. And while I'm not trying to screw them when you have no documentation you're behind the 8 ball.

I agree that there is a slightly different standard when you are calling an academic expert at a tertiary center to try to make a transfer vs. no transfer decision, etc. I think that would be looked at differently in a liability situation.

There are several instances where I do name them:
-When they suggest that I go ahead and formally consult them and they will see the patient.
-When it's their patient who they know and they will see in the office. Two reasons for that, first that's not really a "curbside" as they have actual first hand knowledge of the patient and second, they'll get to document in their records once they see them in follow up.

 

[Top Gun]

He could have gotten to the point in the initial statement. That's the dancing. Possible surgical intervention for hydrocephalus was the third sentence in the dialogue after two prompts from the neurosurgeon. Up until then it was unclear whether they wanted the neurosurgeon to help with the hydrocephalus or the bleed or maybe just to suggest another study. The last prompt by the neurosurgeon was probably superfluous. I agree this wasn't a particularly egregious example. There are plenty of similar real life cases where the intern never actually gets to the point, even after prompting. All too often he doesn't know why he's calling a consult, just that the attending or team he's cross covering for asked him to call. I think there's also a difference here where an ED person is possibly looking for a surgeon to assume care of a patient versus the consult situation not coming from the ED, where the consultant is simply being brought in to consult. Either way the person calling the consult ought to be calling the consultant for a specific reason, not just a "you figure out why I'm calling" kind of call. I don't really have a problem with the neurosurgeon here making the person calling the consult actually state an actual reason that he's calling a neurosurgeon rather than just a neurologist.

The reason for the consult is pretty obvious. Maybe the presentation wasn't perfect, but it was enough to justify the consult.

 

[Arcan57]

the problem is that although many ED docs seem to think this way, it's not accurate. A lawyer reviewing the medical record is going to name consultants he sees named in that record as defendants. Doesn't really matter if this person gave a formal consult, or if the ED doctor simply jotted down that he Spoke with him. Your advice is deemed no less dangerous if you personally sign a paper or send a bill. Worse still, you are stuck trying to defend or disown a paraphrase of your advice, rather than actual advice. So you don't have the ability to qualify your opinion -- you are at the mercy of whomever is jotting down the quick note.

It's no accident that many hospitals frown on curbsides. These are real consults from a legal standpoint. They can get you embroiled in a lawsuit. They can force your medmal insurers hand to settle cases and raise your premiums. The legal distinction is pretty minimal -- it really is only a distinction to the extent it's harder to wriggle out of a statement you personally signed, but in a world where the vast majority of cases settle before court, you generally won't even get this opportunity to wriggle.

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. You can't successfully be sued if you did not have a duty to the patient. Things run differently if you are on-call for the ED and you're refusing to come in to see a patient, but a phone call by itself means nothing.

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.

 

[oldbearprofessor]

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. You can't successfully be sued if you did not have a duty to the patient. Things run differently if you are on-call for the ED and you're refusing to come in to see a patient, but a phone call by itself means nothing.

This is a gray area and I am not a lawyer but I do not agree that there is no doctor-patient relationship without a formal consult. Again, if a doctor, from an ER or anywhere else, calls up my hospital and asks me a question about a patient in their ER or nursery, I believe that I could be held liable for the advice I give. This would be true for any of our doctors who take such calls, including trainees. I believe the concept here is that my hospital has a relationship with the referring hospital as a referral center and although I am not formally consulted, with a note, etc, in this situation, I am acting on behalf of my hospital and am involved in the patient care by taking the phone call. Now if the call comes from a hospital that is not one of our usual referring hospitals, I'd probably have less liability for what I say, but even here I'm unconvinced that I am not liable for my advice.

Bottom line is to always assume that one can be held liable for the specific advice one gives about an individual patient when in the consultant role.

 

[Law2Doc]

This is a gray area and I am not a lawyer but I do not agree that there is no doctor-patient relationship without a formal consult. Again, if a doctor, from an ER or anywhere else, calls up my hospital and asks me a question about a patient in their ER or nursery, I believe that I could be held liable for the advice I give. This would be true for any of our doctors who take such calls, including trainees...

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.