Curbside consultations have value

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.”

One category requiring increasing attention - but largely unrecognized or quantified - is curbside consultation. A recent editorial, “Dermatoethics Consultation” from the Journal of the American Academy of Dermatology, discussed various pitfalls that can result when either laypeople or colleagues want off-the-record advice.

My hospital actually these calls with an established “Access Center,” marketed to community physicians as a direct line to subspecialists. Last month, I tallied 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.

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. 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.

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.

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.

Elaine Siegfried, M.D., is professor of pediatrics and dermatology, Saint Louis University Health Sciences Center, St. Louis.

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