Curbside Consults: Risks and Solutions

‘Curbside consults’ are informal conversations in which one clinician solicits medical advice about a patient from another clinician. These informal ‘consultations’ are a well-established practice in medicine and, one can easily argue, increase the quality of patient care and the sense of camaraderie and mutual support among clinicians. Medicine includes a large aspect of learning through apprenticeship, and conferring informally with colleagues is a crucial part in forming seasoned clinicians and maintaining them in a state of up-to-date knowledge and skill.

But there are risks to these ‘curbside consults.’ First, the clinician requesting advice may come to overly rely on these informal exchanges instead of ordering formal consultation on challenging patient cases. A ‘curbside consult’ cannot and should not replace formal consultation. Second, the clinician providing advice is placed into a position of advising on a patient that they have never seen, let alone systematically evaluated. This often – and appropriately – stirs up feelings of unease. And third, there is a degree of medical-legal risk involved, although the degree of such risk remains contested.

A recent case decided by the Minnesota Supreme Court has raised new concerns for those providing ‘curbside consultation.’ The decision is quite narrow and only applies to the state of Minnesota. I add the reference to the case below. The author of the law case review titled her article “Just Walk Away: How an Overbroad Foreseeability of Harm Standard Could Kill “Curbside Consultations” — Warren v. Dinter.” This sounds dire, of course. I won’t delve into this case. Suffice to say that the author does not discuss the fact that the options are not limited to giving vs refusing ‘curbside consultations.’ I have a third way.

Solution to Curbside Consultation

Here I share with you my approach to ‘curbside consultation.’ I keep this term in quotes because I often provide advice to colleagues that are not in the form of a ‘consultation.’ My goal is both to share my expertise with colleagues and help them navigate challenging patient situations, and to avoid having my advice misinterpreted and placing myself at unnecessary medical-legal risk in case of a bad outcome.

In short, I frame my advice as ‘general medical advice’ and absolutely, positively not as ‘a patient consultation.’ I simply do not do ‘curbside consultations’ and instead do something similar but with lower risk of misinterpretation, misuse, and exposure to malpractice risk. General medical advice is what you can learn from a medical textbook or a lecture. The information learned can be highly relevant and offer clear guidance to the soliciting clinician but in no way refers to a specific patient.

Let me illustrate with a scenario the likes of which I’ve experienced many times over my career. Imagine I’m still practicing at the University of Illinois, department of psychiatry, and a colleague from primary care solicits my advice on a case of ‘treatment-resistant depression.’ Let’s say I learn from my colleague that the patient is a 34-year-old man with chronic waxing and waning depression since his teenage years and that he has been on “a ton of different antidepressants and none of them worked well, if at all.”

At this point I can go one of two ways: I can ask for more information about this case, or I can just start giving advice. Now, it may seem self-evident that the clinician giving advice would want to learn more in order to be more helpful and accurate.

But let me provide the counterargument: the more I learn about the patient that has flummoxed my colleague the more I appear to be ‘consulting’ on that patient. Indeed, I may ask for just a tiny bit more information to help direct my advice, but I will keep my advice in the realm of theoretical ‘general medical advice.’ My contention here is that keeping the discussion focused on ‘cases such as the one you’re presenting’ is just as useful – more useful, in fact, as I’ll touch on later – than focusing the discussion on this particular patient.

This is the kind of ‘advice’ I would provide to guide my colleague.

So, this is what I would advise. And, by the way, this is general medical advice and not a consultation on this patient you’re concerned about, a person I haven’t met nor examined. Notice first that you said the patient has ‘treatment-resistant depression.’ You may be right, but you might be wrong. Treatment resistance means that a patient with a depression such as major depressive disorder has failed to recover from their depression with two adequate trials of an antidepressant. This presumes a lot: that the patient has a depression like MDD and that he has received adequate treatment for it.

Let me tell you about the concept of pseudo-treatment-resistant depression. This condition presents like treatment-resistant depression, but the patient may be misdiagnosed and/or never received adequate treatment. So, the advice I’m about to give you starts at square one and presumes nothing.

Number one, ensure the patient actually has MDD and not a depression secondary to medical illness or a substance, including a prescribed med. Do a good physical exam, order labs, and make sure to include TSH levels and a urine tox screen. If you’re shy about ordering tox screens on patients, later I can tell you what I say to patients to get their agreement.

Number two, do a good psychiatric review of systems. Make sure to rule out a history of manic or hypomanic episodes. In particular, bipolar II disorder can be difficult to distinguish from MDD. In bipolar II the patient spends most of their time depressed but has brief periods of elevated mood and related hypomanic symptoms. These symptoms can be subtle. It often helps to get a collateral source to provide more objective info about the patient. Next ask about substance use and delve into details. Also, evaluate for any hallucinations or delusions because the presence of psychotic symptoms will ensure that antidepressants alone won’t work. Additionally, focus on anxiety and PTSD symptoms because these can lead to ‘treatment-resistance.’

Number three, evaluate the patient for any ongoing strong stressors he may be experiencing. Is he working? If not, why not? Is he financially stressed? Does he have a stable living situation? Is he a victim of domestic violence – yes, men can be too.

If any of the above complicating problems are present, make sure to treat them. If none of these complicating issues are present, then you have narrowed in on chronic MDD or what they now call persistent depressive disorder.

But that still leaves you with choosing the right treatment for this depression.

Number four, review this guy’s past treatments for depression. You say he’s been on a ton of antidepressants. This can mislead you into thinking that they were adequate trials. Don’t assume and ask instead about how long he took the meds, did he take them everyday as prescribed, etc. Ask also which med worked best and how well did it work – 50% or more or less? Then ask if he took more than one med at a time for his depression. Look up his past prescriptions if you can access them.

So, in terms of choosing the right meds for him now, pick the med from his past that worked the best for him. It’s a good start. Keep titrating it up until he responds or can’t tolerate it. You don’t need to rush. If he doesn’t respond fully add an augmenting med. Most of the second-generation antipsychotics work well for this and are FDA approved for it. You can easily find review articles on this topic, so I won’t go into it now.
Also, I always have to add; make sure you evaluate him for risk of suicide and violence.

Of course, if this is ‘above your pay grade,’ no worries at all. Just refer him to psychiatry or, if you wish to continue to treat him, then you can ask for a formal consult to give you specific treatment advice.

Last thing. I just gave you a bunch of general medical advice. I did not offer specifics about this patient. Please do not write in the chart that Jack Krasuski, MD consulted on this patient. I didn’t and instead walked you through the thinking process of assessing and treating patients who don’t respond to depression treatment.

I wrote above that keeping the discussion general is more helpful than delving into details of the specific patient case. How can keeping things general be more helpful than getting specific? Reasons include that I am providing a useful framework to follow to get to the right diagnosis and to choose a reasonable treatment. In these cases, it’s inevitable that the colleague soliciting advice hasn’t thought the case through well enough, doesn’t have a framework for doing so, and doesn’t have all the necessary details to render a verdict on the actual disorder or disorders the patient suffers from nor to choose a good treatment. So, if I start offering specific advice on choosing this or that med, I am making an error of choosing treatment without an adequate basis upon which to do so. By being general, I am guiding my colleague to do what needs to be done and, at this point, it is premature to be talking about specific meds to prescribe.

Thanks, and let me know what you think and which topic you would want me to cover.

Dr. Jack

Language Brief

“People can have the best of intentions when they tell their loved ones how they should be living their lives. But often times, when we are in struggle, we are seeking to be supported, not solved.”  ― Jaeda DeWalt

“People who give the best are those who give of themselves – your time, talents, words, knowledge.”  ― Omoakhuana Anthonia

“Sometimes an outside perspective is the clearer perspective.” ― Shannon A. Thompson

“The people sensible enough to give good advice are usually sensible enough to give none.” ― Eden Phillpotts