1. Curbside Consultations May 2015

2. Faculty  John VanBuskirk, DO – Family Medicine/OB  Residency Program TFM MMA Disclosure/Off Label Information:  In accordance with ACCME Standards and the MHS CME policy, all faculty and planners are required to disclose to the event audience any real or apparent conflict(s) of interest related to the content of their presentation(s). None of the faculty or planning committee members had any conflicts of interest to disclose.  Faculty agreed to disclose any unlabeled use of a commercial product or a product under investigation or not yet approved for any reason.

3. Intended audience: Physicians, Advanced Practice Clinicians and other healthcare professionals. Release date: 05/15 Expiration date: 05/17 Instructions:  Complete pre test  Read Curbside Consultation Power Point  Complete post test

4. MultiCare Health System is accredited by the Washington State Medical Association to provide continuing medical education for physicians. MultiCare Health System designates this live activity for a maximum of.75 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This activity meets the criteria for up to.75 hours of Category I CME credit to satisfy the relicensure requirements of the Washington State Medical Quality Assurance Commission

5. After successfully completing this activity participants should be able to: 1. Differentiate between curbside and formal consultation. 2. Determine when to request a curbside consultation versus formal consultation. 3. If in a consultant role, determine when to decline to answer informal questions and to request formal consultation.

6. Click on link or copy and paste into your browser to complete brief pre test. http://www.surveygizmo.com/s3/2106718/P RCME0515-Pre-Test

7.  A hospital based attending physician is admitting a 79 year old medically complex patient and has a question about the role for thoracic surgery for a traumatic hemothorax. He calls the Thoracic Surgeon on Call, she reads the CT Scan image with the referring attending, and gives specific management recommendations to the attending, and does not enter documentation into the medical record. The patient ends up having complications after the hospital discharge. Should the Thoracic Surgeon have “written a note” if she only curbsided? Even if she never saw the patient? Even though she did review an image? What if there was a bad outcome directly related to the consultation, would the answer be different? What is the “standard of care”?

9.  FORMAL CONSULTATION:  Formal process whereby a physician refers a patient to another physician to obtain specialized advice. Includes the core elements: Kuo, JAMA, Sept. 9, 1998  Attending physician requests consult  Specialized evaluation required  Review of patient history  Hands-on evaluation  Formal report issued regarding care and treatment  There is a bill for the consultation

10. CURBSIDE CONSULTATION: Informal process whereby a clinician obtains information and advice from another clinician to assist in the management of a particular patient. Kuo, JAMA, Sept. 9, 1998 Advantages:  convenience (including inexpensive) to attending, consultant, or patient  speed of completion  lack of need for formal documentation by consultant Disadvantages:  Consultant has incomplete relevant information and makes a poor recommendation  There may be a high liability  Clues that this may be a curbside…  “You don’t need to see this guy but…”  “Have you got a minute…”  Can I run something by you…  “I’ve got a fascinating case…”  “This guy’s family asked me to talk with you…”

11. Clues that this perhaps should be a Formal Consultation:  Need to review an image or multiple lab results  Complex medical situation requiring significant analysis of 2 or more confounding variables—not brief and simple  Detailed discussion of the patient’s history and/or exam findings  Request by the attending for a written reply from the consultant

13.  Attending to be careful not to be tempted just to save time or money to obtain free advice when a referral would be a more appropriate choice  Consultants to resist giving specific complex treatment advice on a patient you have not met  Be careful not to give a firm opinion or diagnosis in a specific case unless you are certain there are no other relevant facts, that, if known, would alter your opinion  The consultant should ask to see the patient if called back for a follow up/second curbside consult on the same patient  Clarify if the consultant’s name will be put in the Attending physician’s note  Keep the curbside consultation brief and simple  The “perfect curbside consult” is when: the patient name is not given, patient is not seen, there is no direct communication with the patient, labs and images are not reviewed, the consultant does not document in the medical record, they do not bill, and the opinion is provided directly to the requesting physician.

14.  Potential Consultant responses if they believe they should see the patient:  “That sounds like a great case and I’d be happy to see the patient.”  “That sounds like a very tough problem and before I could offer advice, I think I should see the patient”  If a written reply is unavoidable consider including a disclaimer “this is an informal reply to a general inquiry and does not represent specific advice or recommendations for medical treatment of any particular patient”

16.  Carefully used, curbside consultation can be a very time efficient, respectful way to improve the quality of an individual patient’s care. However, like any tool, it must be used judiciously keeping in mind some of the issues above. Complex questions, regarding multiple issues, and requiring a prolonged (or repeated) conversation, or review of images should suggest that a formal consultation may be more appropriate. “This traditional professional exchange need not be abandoned but engaged in prudently”. There is no clear cut law, or “standard of care” on this topic.

17. Click on link or copy and paste link into your browser to access post test. http://www.surveygizmo.com/s3/2122037/PR CME0515-Post-Test Thank you for your participation. A CME certificate will be emailed to you after you successfully complete the post test.