Primary Care Doctors, Subspecialists Disagree On Value Of 'Curbside Consults'

September 09, 1998

Most primary care physicians rely on informal consultations with subspecialists to meet patient-care needs. Most subspecialists are concerned that they are not getting enough information to offer sound clinical advice, but they continue to accept informal consultations because they don't want to jeopardize possible referrals.

These findings come from a new study of curbsiding that appears in the Sept. 9, 1998, Journal of the American Medical Association.

"The impact that this curbside consultation process has on patient care and outcomes is unknown," said David Gifford, M.D., assistant professor in the Brown University School of Medicine. "Curbside consultations may add efficiency to medical care, particularly for patients who find it difficult to get to a subspecialist. However, a patient doesn't get the benefit of hearing and questioning the subspecialist's recommendations."

The study of 413 Rhode Island primary care physicians and medical subspecialists, such as allergists and cardiologists, was led by David Kuo, M.D., former teaching fellow at Brown, now at Morristown Memorial Hospital in New Jersey. Co-authors are Gifford and Michael Stein, M.D., associate professor of medicine. Gifford and Stein are based at Rhode Island Hospital.

During a curbside consultation, one physician asks another for advice. Frequently, primary care physicians ask subspecialists for advice, particularly because managed care may limit patient visits to subspecialists. Yet during a curbside consultation, the subspecialist is generally unfamiliar with the patient and does not have the opportunity to examine the patient or review the medical record. Thus, recommendations are based almost exclusively on information provided to the subspecialist by the primary care physician.

The study showed that 70 percent of primary care doctors and 68 percent of subspecialists had participated in at least one informal consult in the previous week, usually via a brief corridor or office chat, or over the telephone. During that previous week, primary care physicians obtained slightly more than three casual consults, while subspecialists received almost four consult requests.

Consults were most often used to select diagnostic tests or initiate treatment for a patient, to determine the need for a formal consultation, or to help interpret laboratory or radiology results. Subspecialties most frequently involved in curbside consultations were cardiology, gastroenterology and infectious diseases.

Under managed care, many primary care physicians have assumed greater responsibility for managing treatment of conditions once considered the realm of the subspecialists. The authors of the study suggest that primary care physicians will obtain more casual consults from subspecialists to maintain quality care while limiting the number of formal referrals.

Indeed, the study showed that physicians practicing in HMOs were almost twice as likely to obtain casual consults as non-HMO doctors - 5.6 versus 2.9 consults per week, respectively. However, the HMO physician consults were more likely to result in formal consultations compared to consults by fee-for-service physicians.

Although curbsiding is widespread, primary care physicians and subspecialists disagree as to the quality of information exchanged during a consultation. Subspecialists are more likely than primary care physicians to believe that information communicated is insufficient - 80.2 percent versus 49.8 percent, respectively - and that important clinical information is missing - 77.6 percent versus 43.5 percent, respectively.

The results may suggest that subspecialists do not trust the ability of primary care physicians to take histories,to examine patients or to communicate information, said the authors. "When primary care physicians consult a subspecialist, they filter information; what the primary care physician doesn't think is important may be left out of the presentation to the subspecialist," Gifford said.

Despite the shortcomings of information exchanges, subspecialists are more likely than primary care physicians to report that informal consultations are essential for maintaining good relations with other physicians - 77.2 percent versus 38.6 percent.

For subspecialists, these casual contacts can lead to formal consultations and help maintain a referral base, Gifford said. "Subspecialists are not reimbursed for the time spent in informal consults. They do them because they want to help their colleagues and the patient. Curbside consultations also make good business sense."

The authors also suggest that curbside consultations may benefit patients by developing more capable and effective primary care physicians.

"Casual consultations may help educate primary care doctors by keeping them current with medical information," Gifford said. "So the physician becomes a better doctor in the next situation. It also helps in patient care when a primary care physician develops a working relationship with a subspecialist, because it will be easier to refer a patient when the need for a formal consultation arises."
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Brown University

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