Formal vs. Informal Consultations

Karen Cosby kcosby40 at GMAIL.COM
Sun Jul 10 19:17:13 UTC 2016


I discourage the concept of an informal consultation.  When doctors are
unsure enough to ask for a consult, they often also lack expertise enough
to include all information that may in fact ultimately be necessary to get
the answer they seek. The ability to get the information you need rests on
the expertise to ask the right question and provide the necessary
information. When the question is simple enough to ask for an informal
consultation, it's probably something you can look up on your own.  If you
have to ask for a consultant, you probably need their full expertise and
attention to the matter at hand, i.e. a formal consultation.
Many times I've seen a consultation's recommendations change when they
actually see the patient.  First, they attend to the full case (not a
limited question), and they are more cautious when they have to document
their recommendations.  As a matter of principle, I think "informal"
consultations are dangerous and to be avoided.

On Sat, Jul 9, 2016 at 10:50 AM, David Shapiro <dwshapiro at hotmail.com>
wrote:

> 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
>
>
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