Curbside consultations have value, are free of many administrative encumbrances

July 1, 2013

My hospital requires documentation of how I spend my time, tabulated in hours per week, for one representative week every month, an exercise related to CMS funding. The time can be allotted among only three mutually exclusive categories: “Hospital Activities,” “Teaching Activities” and “Patient Care.” My university also quantifies my productivity in RVUs, clinical charges, grants submitted, grants awarded and publications.

 

My hospital requires documentation of how I spend my time, tabulated in hours per week, for one representative week every month, an exercise related to CMS funding. The time can be allotted among only three mutually exclusive categories: “Hospital Activities,” “Teaching Activities” and “Patient Care.” My university also quantifies my productivity in RVUs, clinical charges, grants submitted, grants awarded and publications.

I work a lot. I usually get to my office around 7:30 a.m. and leave about 12 or 13 hours later. I am on-call for ER and inpatients 24-7, and see scheduled clinic patients four days per week. But even my non-clinic days are consumed by multitasked attention to multiple simultaneous demands.

I rarely dedicate exclusive time for eating or attending to bodily functions. The pace often feels like taking a drink of water from a fire hose. But sometimes, at the end of a long day, when I haven’t been able to focus on the task at the top of my to-do list, I take a mental inventory of how my time was spent.

Consultations catch on

One category requiring increasing attention - but largely unrecognized or quantified - is curbside consultation. A recent PubMed search on the topic yielded 42 articles since 1984. The majority addressed the problem as an occupational hazard of hospital-based subspecialists, especially infectious diseases. Several publications focused on inadequate compensation and medicolegal liability. Only one mentioned dermatology.1 This is not surprising, because prior to cell phone cameras, an in-the-flesh exam was an important dermatologic diagnostic prerequisite.

The one dermatology-related publication was a recent “Dermatoethics Consultation” from the Journal of the American Academy of Dermatology. The editorial discussed various pitfalls that can result when either laypeople or colleagues want off-the-record advice. It was illustrated by a clinical scenario that one of the authors endured “many years ago.”

I was confronted by a similar experience in the pre-digital era, when a male acquaintance asked me to “look at something” and led me to a private, poorly-lit space (in my case, a hospital stairwell) where he proceeded to drop his drawers to show me an inguinal skin lesion.

Fortunately, the curbsides I get these days are less uncomfortable, and more clinically rewarding. But they are also much more frequent. My hospital actually encourages these calls with an established “Access Center,” marketed to community physicians as a direct line to subspecialists.

Last month, I started a tally of every phone call, email, text and hallway consult. Not a day goes by that doesn’t include at least one. The total for the month was 72. The series included an email about an infant seen by a colleague in an African clinic; a phone call from a physician who works at my institution (but I have never met), for my opinion about a picture of his daughter’s armpit; cell phone images of two patients by their dermatologist attending Grand Rounds with me; and texted images from my cousin and college roommate.

Effective and efficient

Many of the consults provided advice to a local physician in lieu of an urgent work-in appointment, because my clinics are too full to accommodate one more patient. Curbside consultation is an efficient and effective way to provide access to dermatologic care for the 50 percent of children in the United States who are Medicaid-insured. 2 Phone or email advice supports the primary care physician, strengthens the medical home, and avoids overburdening my staff and generating patient dissatisfaction with unpredictable wait times.

For the great majority of my curbsides, I believe I am able to help. And that feels good. Added bonuses are that I don’t have to document my advice in Epic (electronic health record system) - making sure to include “a key portion of two of three key elements” so diligently sought by the university compliance auditor - detail my recommendations in eighth-grade language and do “feedback” teaching, all within a 10-minute time slot, or decide how to code the bill, submit a prior authorization for medication or worry about fitting a follow-up appointment into my packed clinic schedule.

In a fee-for-service world, curbside consultation is often viewed as a convenience by the requestor, and exploitation by the consultant, because the work is not formally recognized or reimbursed. But having enough expertise to be able to make a positive impact on a patient’s course is one of the main reasons that doctors choose a career in medicine. Being able to do so without the administrative encumbrances that often dominate daily clinical practice is a chance to rediscover the joy in patient care. For me, curbside consultation is so rewarding that if money were not an issue, I would love to do it full-time.

Fortunately, experts across many specialties seem to share my sentiments. Some are co-workers who give and take curbside advice with me, others I may have met briefly or know only by national reputation. But when I have contacted them for help with clinical conundrums, they have been genuinely interested in the patients and solving the problem, generous with their wisdom and their time, and are eager to help, seemingly unaware they are paying-it-forward. Most, but not all, of these mensches are salaried physicians who work full-time in the knowledge-sharing environment of academic institutions: microbiologists, immunologists, rheumatologists, oncologists, gynecologists, gastroenterologists, geneticists, cardiologists, child abuse specialists, social workers, otolaryngologists, plastic surgeons, ophthalmologists, infectious diseases, pediatricians, anesthesiologists, pharmacologists, statisticians.

This network of expertise is the underappreciated scaffolding of excellent and cost-effective tertiary healthcare. I have high hopes that the future accountable care world will recognize value and support curbside consultation as an efficient complement to primary care.

 

1. Grant-Kels JM, Kels BD. The curbside consultation: legal, moral, and ethical considerations. J Am Acad Dermatol. 2012 May;66(5):827-829.

2. Chaudhry SB, Armbrecht ES, Shin Y, Matula S, Caffrey C, Varade R, Jones L, Siegfried E. Pediatric access to dermatologists: Medicaid versus private insurance. J Am Acad Dermatol. 2013 May;68(5):738-748.