A “curbside” consultation can be described as an event in which one physician informally asks another for information or advice to aid in the management of a particular patient. A curbside consultation can also include an informal encounter with a “patient” who asks for and receives medical advice in an informal setting. In general, the “curbside consultant” does not review the patient’s medical record, but instead bases advice on information provided by the requesting physician or patient – information that may be incomplete and/or inaccurate
For example, radiologists may also be asked to view an image and provide interpretation and/or advice based on that image outside the radiology suite, in a setting in which viewing conditions of available images may be suboptimal and comparison studies and accompanying reports or an adequate patient history are lacking.
Many curbside consults are likely beneficial or, at worst, benign. But when they are wrong or incomplete, and the requesting physician relies on the information, and there is an adverse outcome, and the patient sues... the consult is difficult to defend, for both the requesting and consulting physician.
When a requesting physician bases treatment decisions on faulty recommendations from other physicians, medical liability exposure and patient safety risk increases. Normally, the requesting physician is not legally responsible for errors of the consulting physician, but those legal niceties often disappear when a complaint is filed. NORCAL Group claims data and nationwide appellate court opinions clearly indicate that curbside consultants are often drawn into medical liability lawsuits when their advice arguably plays a role in patient injury.
Without a radiologist realizing it, a casual curbside consultation, if relied upon by the requesting physician, will likely be treated in a malpractice case no different than a formal consultation. While a “consultant” radiologist may assume he or she is engaging in an academic conversation over a cup of coffee, the conversation may get specific enough to create a duty of care between the consultant radiologist and the requesting physician’s patient. This is especially true when a radiologist is asked to view and interpret an image. Because a curbside consultant rarely documents the event in the patient’s chart the defense of the claim becomes further complicated by the inability to recall the details that medical records would normally contain. The lack of medical records is also a further departure from professional standards and will inevitably prove harmful in a lawsuit.
It should also be noted that while billing for an interpretation or consultation may be used to show that a physician-patient relationship was established, the reverse is not necessarily true. A radiologist should not assume that by not billing for the interpretation no physician-patient relationship exists. Although the point at which the physician-patient relationship is established is not always clear and absolute, a relationship can be created if the recipient of an informal consultation might reasonably depend upon the medical advice given
The defense becomes further complicated when the requesting physician documents the curbside consulting radiologist’s recommendations and his or her documentation differs from the curbside consultant’s memories of the event (assuming the consultant has a memory of the event). Different versions can lead to confusing or conflicting testimony among defendants and even finger-pointing during litigation, which rarely plays out well for any of the defendants involved.
American College of Radiology Practice Parameters for Informal Communications
The American College of Radiology (ACR) has developed practice parameters to assist physicians in providing appropriate care for patients. These tools can be found on the ACR Practice Parameters and Technical Standards web site. The ACR Practice Parameter for Communication of Diagnostic Imaging Findings includes the following statement on informal communication of radiological findings:
Occasionally, an interpreting physician may be asked to provide an interpretation that does not result in a “formal” report but is used to make treatment decisions. Such communications may take the form of a “curbside consult,” a “wet reading,” or an “informal opinion” that may occur during clinical conferences, interpretations while involved in other activities, or review of an outside study. These circumstances may preclude immediate documentation and may occur in suboptimal viewing conditions without comparison studies and their accompanying reports or adequate patient history. Informal communications carry inherent risk, and frequently the ordering physician’s/health care provider’s documentation of the informal consultation may be the only written record of the communication. Interpreting physicians who provide consultations of this nature in the spirit of improving patient care are encouraged to document those interpretations. A system for reporting outside studies is encouraged.*
To minimize liability risks and provide quality care, consider the following risk management recommendations:
- Entertain informal consultations with caution and as rarely as possible. Follow up a wet read with a formal written opinion.
- When radiologists are asked to view and interpret images in an informal consultation, the image should be reviewed in a formal medium and the interpretation should be documented unless extenuating circumstances exist. If the discussion or interpretation impacts treatment decisions, diagnosis, or admission or discharge recommendations, consider requesting that you be allowed to follow up with a consultation following normal procedures.
- When you do accept an informal consultation, clarify the nature of the consult.
- Make it clear that you are not providing formal treatment recommendations based on the review and examination normally undertaken.
- Advise the requesting physician of the assumptions underlying your advice to mitigate the concern that you may not have all of the facts.
- Recommend that a formal consultation be conducted should the same physician ask you to do more than one informal consultation on the same patient.
- Document when appropriate, even if that means dictating brief notes into a “generic consult file.” A true curbside consultation – providing general academic advice for the benefit of the physician seeking the consult – should not need to be documented. Realize when you have crossed the line, such as when you have interpreted an image, and have established a physician-patient relationship. When this is the case, documentation can protect you against possible inaccuracies in other physicians’ memories of what advice or diagnosis was provided during the consultation.
- Develop a system for documenting outside consultations when necessary. It is very likely that later you will not remember what you said during an informal consultation. Detail the advice you gave to the extent necessary to accurately reflect your involvement with the patient’s situation.
Curbside consultations are a recognized component of medical practice; however, they raise substantial liability concerns for both the consulting and requesting physicians and safety risks for patients. The process of extricating a curbside consultant from a lawsuit can be complicated and lengthy due to faded memories and a lack of documentation in the medical records. Even if a consulting radiologist is ultimately found to have no liability for the patient’s injuries, he or she will still have endured the inconvenience, potential expense, potential loss of income, and heartache of being a defendant in a medical malpractice case. Implementing the risk management recommendations in this document should decrease the liability exposure associated with these common conversations among colleagues.
Reference
* American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. Resolution 11 – 2014. (accessed 7/14/2017)
