Curbside Consultations – A Vanishing Beast

A 71-year-old fairly healthy woman with atypical chest pain is admitted to an academic medical center and placed on telemetry. The rhythm strip below was recorded while she was sleeping. She has no history of syncope or symptoms suggestive of bradycardia.

In 1992: The resident who rounds on the patient a few hours later prints the rhythm strip, brings it down to the EP lab control room, and reviews it with an available EP fellow and attending. The EP fellow points out to the resident that there is slight prolongation of the PR interval before there is high-grade AV block, and that there is sinus slowing associated with AV block. The resident learns that this is consistent with normal vagally mediated AV block that can occur during sleep, and that in the absence of other symptoms suggesting intermittent heart block, there is no indication for a pacemaker. The resident later reviews the strip with the attending on service.

In 2017: The hospitalist who rounds on the patient a few hours later sees the bradycardia in the telemetry history log and asks a mid-level provider to consult the EP consult service. The EP consult team sees and examines the patient that evening, reviews the medical and telemetry records, and enters a five-page consult into the electronic medical records (EMR) concluding that no pacemaker is indicated. The next day, the mid-level provider reads the consult and tells the hospitalist that the EP service did not recommend a pacemaker.

The online Free Dictionary defines a curbside consultation as an “informal discussion between two health care professionals about the likely causes of a patient’s illness, the natural history of the disease, possible interventions, remedies, or treatments, etc.”¹ Although the above scenarios are hyperbolized, there clearly has been a change over the last 25 years in how consultations are made in medicine. Curbside consults were once common. The demise of curbside consultations has been driven by many forces, including busier clinical schedules, stricter work hour rules, the ability to enter consults electronically rather than in person, an obsession with documentation, and pressures toward maximizing charge capture. There has also been a shift in emphasis by training programs toward outpatient medicine. Recently, an internal medicine resident expressed an interest in specializing in cardiology. When asked if he knew where the EP lab was located in the hospital, he had to acknowledge that he did not know the answer. 

Although this may be lamenting a bygone era, and one could argue that a thorough “level five” new patient consultation is more likely to result in best care, there is clearly a tradeoff to elimination of curbside consults. An advantage of curbside consultations is that they allow for personal interactions among generalists and subspecialists (and between subspecialists) with a focus on the specific clinical question being asked. They are also efficient, expedite care, reduce costs, and most importantly, provide an opportunity for the consultant to provide education and feedback. Because a curbside consult does not create a physician–patient relationship between the consulted physician and the patient, liability to the consultant is limited. Recommendations when being curbsided are to keep the advice brief, offer the option of a formal consult when the situation is complex, and consider a formal consult when curbsided again about the same patient.²

So the next time the EP consult service is asked to review something seen on telemetry, call the person who made the consultation and encourage him or her to simply come to the EP lab with the strips so that they can be reviewed in person. The patient will get the same care, but much faster and way cheaper.

References

1. Curbside consultation. The Free Dictionary by Farlex. Available at https://bit.ly/2E9pyru. Accessed February 6, 2018. 
2. Manian FA, Janssen DA. Curbside Consultations. A Closer Look at a Common Practice. JAMA. 1996;275(2):145-147. doi:10.1001/jama.1996.03530260059032.