Formal vs. Informal Consultations
dwshapiro at HOTMAIL.COM
Sat Jul 9 15:50:29 UTC 2016
I divide consultations into two types: a formal or full consultation (which includes a review of the chart, an in-person history and physical, a note in the medical record, and clear establishment of a legal doctor-patient relationship and the attendant attachment of a duty of care and follow-up), and an informal consultation (also called a curbside consult, in which the informal consultant usually does not review the chart, does not see the patient, is not informed of all aspects of the patient's condition, does not write a note, and does not want a doctor-patient relationship to be established). The issues include when an informal consultation is appropriate, and whether and how an informal consultation should be documented.
from a patient safety standpoint, informal consultations can aid providing quality care, but they also pose a risk of producing unsound advice because of the limited (and possibly different) information conveyed to the informal consultant, who might obtain a different history or physical exam. In general, I think this risk is acceptable if a more general question is posed (e.g., in patients who present with X, should I routinely order Y test only or should I also add Z test? Or, have you ever seen X symptom with Y disease?). The more that the questions are tailored to the specific presentation of a particular patient, the greater the risk of being led astray by incomplete information, and a formal consultation may be desirable.
I recommend that an informal consultation should not be documented in the medical record and the informal consultant's name should not be mentioned. The consulting doctor should "own" the information and opinion and the care he or she is providing. If the consulting doctor feels the need to include the fact of the informal consultation and the informal consultant's name, that is probably a sign that the consulting doctor is relying on the expertise of the consultant, and wants the "support" of the informal consultant for the care he or she is providing (including to transfer or share the blame for incorrect care). In that case, a formal consultation should probably be obtained (which could be the next day. I advise physicians who are providing an informal consultation to request that their name and the consultation not be mentioned in the chart; if the consulting physician still wants to do that, the consultant should insist on doing a full consultation.
This does not apply to physicians who already have, or have agreed to have (e.g., by virtue of agreeing to perform a consultation), a doctor-patient relationship established with the patient. For those physicians, documenting discussions with other physicians caring for the patient is part of communication and documentation in the process of care. So it is entirely appropriate and advisable for a resident to document having had a discussion with the attending physician, because the attending physician already has a doctor-patient relationship with that patient and has a duty of care (even if he or she has not seen the patient yet). Same for a consultant who has agreed to do a formal consultation, as Dr. Peter indicates he does.
It is impossible to draw clear lines in this area, but I think the "test" of whether the consulting physician feels the need to document an informal consultation is a useful rule of thumb.
-David Shapiro, MD, JD
Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine
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