Curbside 

looking up st St. Peter's Basilica

Curbside Consult: To ask another physician a question about the management of one of your patients when they are not actively seeing that patient.

In residency I was taught to never curbside another physician. 

Mainly it was presented as a liability and courtesy issue. You don’t ask another physician to take legal responsibility for giving advice on a patient they have not examined and are not receiving payment for… payment that is going to help cover their malpractice insurance in case it is needed, God forbid. In residency I even had physicians refuse to discuss cases that I was referring to them until I had done the referral and they had actually seen that patient in their clinic and if I did ask a question, I had to be very careful how I asked it. They were downright ugly about it at times. I expect it is exceedingly frustrating for them to get asked the same dang questions each year by each new set of residents.

The bottom line when you are in residency for primary care is that specialists just don’t want to see your patients. They are often disagreeable patients and have been fired from other practices (they take their toll emotionally on you and your staff) or they are indigent or on Medicaid or Medicare (unless you are paying residents a tiny pittance as indentured servants you cannot take more than a certain percentage of these patients and still remain a viable business). Often the waiting time to get patients in is months long so you learn to treat a lot of stuff yourself. You eventually get to the point where referring a patient feels like a sign of weakness and you try to avoid it all costs.

Then, you graduate and start practicing in the real world and discover that no matter how good you are at treating something, patients would generally rather see a specialist. As primary care, it is thought by many that you know next to nothing.

The flip of this is that all of a sudden you find that specialists actually want to see your patients. They are nice to you. They say nice things about you to your patients. They may even curbside you for something not in their scope of practice as if you are the expert. Now I have the cell phone numbers of tons of specialists handwritten written on their business cards stashed in my desk. They hand them to me and say, “Call or text anytime!” I still have a hard time believing it and cannot bring myself to ever do it. 

For some, networking like this comes easy. They are very good at it. They build vast collections of people they can consult at any moment and asking for help doesn’t bother them. Not for me, though. This is one of my weaknesses, one of the drawbacks of being a physician who is a closet introvert. Asking for help is painfully difficult. So is ordering pizza by phone.

Until this week.

I had something that I really needed help with, something I had never seen before and could not find the answer to myself. Ultimately doing the right thing by patients has to take precedence over my discomfort. So I phoned a friend, so to speak. I don’t intend to make it a habit, but it was super nice to be able to get good advice quickly without feeling stupid about it.

So thank you. 

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67 thoughts on “Curbside 

  1. Interesting. I’d sorta assumed like other professions, doctors assist and advise one another. I’m a two-heads-are-better-than-one thinker.
    I do understand the confinements of introversion. Your post makes me wonder why my extrovert never calls to order the pizza…or the Chinese… I think I may confer with other introvert wives. Hmm…

    Liked by 3 people

  2. I thought a curbside consul was what happens with Maria, my grandchildren’s paediatrician. Her kids go to the same school, so at birthday parties she usually gets to look at spots and peer down throats! She doesn’t seem to mind too much, though.
    Having worked a lot with vets and seen the difficulties of diagnosis, I think collaboration is a good thing.

    Liked by 2 people

    • That is a curbside. Many physicians do mind but they have learned not to show it. Collaboration in a hospital is easy. You see each other every day. Everyone is there consulting each other. In private practice this is much more difficult. You don’t see the people you refer to on a regular basis, if ever. Most of the time it doesn’t matter. You get to know specialists by how they treat your patients and you have time to work something up and get them in with someone. Sometimes, though, you get something that looks bad, that needs to be addressed urgently, and then you just do whatever needs to be done to take care of the patient.

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  3. So, it worked out then? Good show.damned if you do and damned if you don’t. I’m glad you called – so often the system works against the patient for many reasons,like malpractice insurance.

    Ha! The first truck I bought I financed it with 11 different loans – most of which did not know about each other. It was a masterful spiderweb. So, anyway when the day of delivery came,I went to the bank that did the biggest chunk of financing and they said that I had to have proof that I had operating financing in place as well as a lender’s mortgage. I got a copy of the lender’s mortgage agreement and then went to my little credit union who was financing the operating loan and explained that I had to have their contribution before the main finance kicked in. The manager laughed and told me that they required that I have the money from the main lender before releasing the operating capital. I just raised my eyebrows at him and he agreed it made no sense and he would give me the money.

    Sometimes systems are not well considered.

    Liked by 3 people

    • It did work out. If I am honest with myself my reluctance comes down to not wanting to abuse the privilege, pride, and not wanting to look foolish (what will they think when I have to ask for help?!?!?). Silly, I know, but there you go!

      Liked by 2 people

      • You have definitely been trained that way. In any work environment I always encouraged employees to ask their co-workers about any issues. I trained them all that their best resource was a fellow employee. Especially when it came to rare occurrences that were not covered by training. We actually had gripe sessions when we would all get together and tell each other about issues or surprises we had had. When I was hauling fuel every site had a different configuration for unloading and we had delivery plans with diagrams for every site, but there were still surprises.I remember one cold February night when I was delivering at a station in Ottawa when, out of a clear sky at -20, it seemed to begin to rain. My brain would not process this as the rain was not freezing but running down everything. Then I smelled my wet coat and realized it was gasoline falling from above. My trainer had been an old pro who insisted I call him no matter the time of day if I had a problem. So at 2 am I got him out of bed, told him where I was and what was happening (I had shut down the flow of gasoline into the storage tank and the rain stopped). He actually laughed and told me it was OK. The station had put on an expansion and when they did they stupidly built the vent pipes that allow fumes to escape, into the roof line so they were not visible. That particular site was very old and the underground vent from the tank to the vertical had sagged at one end. Every time a driver went over a certain level in the tank gas ran down the vent pipe and because of the tilt stayed there until the next fill when it was shot out the top by the pressure of the incoming gas. He said to just run the delivery slow for about 10 minutes and all the remaining gas in the vent line would evaporate and be expunged as fumes. That stuff is never taught in training.

        Liked by 1 person

  4. I too dislike asking for help. But in my case, I think it is misplaced pride: I think of it as a weakness.

    But with time, I’ve learned that is the wrong was to look at it. Most ppl I talk to that are further along in their careers than I love coaching and mentoring others, be it their peers or their juniors. I myself LOVE it if someone turns to me for advice. Of course, there are assholes everywhere who believe we are all in competition with one another, but from what I can tell, most professionals can ID false pride from a mile away, and know what it costs to ask for help, and react kindly and helpfully.

    Maybe the stakes are different in medical practice bc of the legal implications?

    Liked by 1 person

  5. It’s funny, because professionally phone calls don’t bother me much, but as an introvert, social phone calls are like kryptonite to me. But I hear you on not liking having to ask for help. But it’s much easier for me to ask for help for others than for myself.

    Liked by 1 person

  6. also glad you had a good experience !. I do get why it doesn’t come easy….Me on the other hand, who is 50/50 introvert/ extrovert, I “curbside” all the time as a contractor . I have (cross fingers) been blessed with a small network of other local builders whose brains I can tap into w/o embarrassment.

    Liked by 1 person

    • Well, actually, getting records probably would not fall into that. It is a simple thing to have staff fax the patient signed request form. Now, if you are asking a physician to call another physician to get a verbal run down from them about their history, I think patients don’t understand that would not ever be received well on the other end. I have tried this a couple of times and either never got a call back OR if I did the other physician was ugly about it. If it is a matter of not wanting to review a copy of a patient’s old paper records that sort of sounds like laziness.

      Liked by 1 person

  7. When we were living in a small town in Northern, Ontario, Canada, I heard that the female doctors had a difficult time to get advice from other doctors. The male doctors almost always gave them the cold shoulder. It sounded so unprofessional. I would have thought the specialists would be counting on these referrals.
    Leslie

    Liked by 1 person

  8. Curbside in the context is a new word for me. It’s an aspect on the lives of medical practitioners I’ve never thought of! I do know as a musician that people think music services should be free because “You must love doing it” !

    Liked by 2 people

  9. When I worked at my doctor’s practice (5 docs, 2 PAs) they often did & do consult each others patients only because we were all in same practice/office & briefed each other. Kinda a 2nd and/or 3rd of eyes & minds. When they had hospital consults, if it wasn’t life threatening, they’d prefer to see them status post DC (*especially if in patient room biopsy was warranted due to hospital being a pathogen condo/community. I totally get your mindset. 🙂

    Liked by 2 people

  10. Also they did phone consult with fellow physicians in the respective needed field. I would often call their practice asking “Hi this is Diane from Dr “””,’is Dr *** available? Dr B would like to speak with him/her, ,,”

    Liked by 1 person

  11. Oh how i would love it if I could just go to my GP and forget all the specialists! But my GP always refers me to someone else. Sigh… I think that is just the way medicine is trending now. I often wish it weren’t the case. And it may be that since I’m a complicated patient he just wants to be sure I get the care I need.

    i get the introvert, thing. My husband is that way. I was once, but when I was lobbying I had to call and ask stupid questions of people all the time. It was great training for getting over that discomfort. Now I can ask anybody anything over the phone as long as it’s not illegal!

    Liked by 1 person

    • Ha! Medicine has helped me out immensely in that respect. I would be cowering in a corner somewhere if I had not had that stretching my comfort zone. I am pretty good at faking an outgoing personality in the clinical setting now I think… 🙂

      Liked by 1 person

    • I cannot tell you how many times I find out after the fact about a patient that self referred somewhere. They picked exactly the wrong person to see and ended up with bad experiences or wasting tons of money. If you absolutely want to see a specialist, go see your PCP first so they can direct you to someone they trust. Some insurance plans require a PCP referral, however, which is why they end up in my office. Some things require specialists. Often, though, there are things to try or do before you even need one.

      Liked by 1 person

  12. It’s funny, I used to feel the same way working in Primary Care. But now I work in pediatric ENT and I get curbsided all the time, from the Hospitalists and even the PICU docs. I remember when I dreaded calling the specialists as a Primary Care practitioner but it doesn’t seem like a big deal (we are always calling Infectious Disease, Immunology and Pulmonology) now that I am in a sub specialty. It’s funny how life works.

    Liked by 2 people

  13. Curbside? Never heard the term.
    However, have patient, curbsided
    both my physicians & physician friends.
    My OB of over 25 yrs has at his front desk a list of referrals for his patients. Easy – call & get a great referral. If there is an important issue ( my sons kidney cancer – he talked to me about the surgeon, and visited my son in the hospital on his rounds). His referrals bar none are the best. The very best refer to the very best.
    Our two physician close friends are both always ready to help.
    One a hand orthopedic surgeon did a complicated surgery on me. As soon as he was home, he was at our house to feel my fingers and examine the cast? My husband was upset at his super attention. He did not want to impose.
    Sounds like you are one of those great internist’s, your patients never will leave you. You will get to know the best in other specialtys.

    Liked by 1 person

  14. As an OPhthalmologist, it was super-specialists for me. The retina guys, the cornea specialists. After preening themselves at every conference during their training period, they’d turn around and cold-call you asking for referrals. 😀

    Liked by 1 person

  15. I seriously thought the happy ending was going to be that you called someone and ordered a pizza… The other week at work, someone had the idea to call the cafe downstairs to pre-order coffees, but no one was game enough to make the call (even though we all talk on the phone so much at work already!) It’s kinda weird how it’s suddenly a different story when we become the customer…

    Interesting also that you can kinda have “office politics” without sharing the same office/workplace

    Liked by 1 person

  16. There is something with clinicians that is a detriment and that is the inability to seek help. I understand that it seems like a sign of weakness. We are struggling with a new model in our CHHA of interdisciplinary teams. Seemed like a terrific idea, but it is not working. The therapists resent the RN managers and team mates and the RN’s do not use the therapists and think the PT managers are idiots. We are trying to push OT’s being used in all admissions and that is not happening either. The silos we tried to break down are even stronger. And forcing the issue is not helping.
    The more I live in the health care field, the more I see it as the most dysfunctional career anyone could choose. I thought teaching in a public school was bad. You could not pay me to be a doctor or for that fact, any clinician. Partially because I do not like bodily goo but also I cannot stand the craziness of the business.
    I honor you for the perseverance to get through it all and still survive.

    Liked by 1 person

  17. Pingback: My Article Read (4-23-2016) – My Daily Musing

  18. Hello!
    I read this post with interest and I so admire your incredible honesty… and your bravery in sharing here!
    I’m going to challenge something okay? Please… hate me if you feel irritated… (I too would hate it if someone did this… but I just can’t NOT…) I’m not in the habit of this, so please bear with me…

    “Ultimately doing the right thing by patients has to take precedence over my discomfort. So I phoned a friend, so to speak. I don’t intend to make it a habit, but it was super nice to be able to get good advice quickly without feeling stupid about it.”

    So you did the ‘right’ thing… The professional thing.
    Why NOT make a habit of it? It felt good. It was efficient. It was ‘super nice’.
    Why NOT do it more? It sounds like such good habit to get into, and yet your immediate reaction to writing this is to preface it with ‘I don’t intend…’, as though it’s a weakness that you must steel yourself against.

    I might be WAY off the mark here.. So please disregard it totally if so!

    Sending warmth your way

    firefly

    Liked by 1 person

    • It is an excellent question. The issue is overusing it. For a rare emergency, sure, it is fine. But if every physician did this for all of the patients they were a bit stumped on, those specialists would never get to their own patients. Let’s say a dermatologist receives referrals from a few dozen primary care physicians. Each of them wants to get a curbside consult once or twice a week. It just is not possible. In this case I needed to know two things: first, should this patient go to the ER and two, should they see this specialist or be referred to a specialized surgeon. If it were not a potentially emergency situation I would just do a simple referral to this specialist and be done with it. 🙂

      Liked by 1 person

  19. My spouse is a physician. Actually, he’s a surgeon. I started following you because you replied to someone else’s blog post. I liked your concept of Behind the White Coat. Physicians’ partners are part of the same family…we understand….and we love you for all you do for others….and miss you when their needs have to come before our needs. And we understand.

    Hubby and I married the year before he began Med School….stupid, perhaps…..but it made sense at the time. 🙂 However, during all this time (37 years), I have never heard about anyone refusing a Curbside. Hubby is in a surgery specialty and most of his Curbsides are from physicians wanting advice about their family members. Maybe that’s why….physicians and their families ask for a Curbside understanding what it is and the thought to litigate doesn’t come into the equation. If it is not in your own particular specialty, it makes sense to ask those colleagues whom you work with and whom you respect for advice.

    When Hubby asks others for a Curbside, it is often about one of our family members…. such as my mother’s colon cancer and her two recurrences. Mom had cutting edge treatment when others didn’t know about the Cyber-Knife simply because Hubby asked a radiologist friend in the cafeteria what was new for colon cancer at the exact time we needed something new. We would never have heard about the Cyber-Knife when all her other options had failed us perhaps until it wouldn’t have made a difference. We would never have gotten those last six years with her.

    Liked by 1 person

    • Asking for advice regarding a family member is different than asking about an actual patient, simply because there is no thought about suing over that. It is our family. If something goes bad for an actual patient and a lawsuit ensues, it is a different story. We have no control over what that family does. This is why we were instructed in residency that if we ever did curbside, we should not document that in any medical records in order to protect that other physician. This is not isolated to only my residency program. I have heard similar stories from others, though I am sure that is not the experience everywhere. I got married the Saturday before starting med school. Bless you for sticking it out and understanding. 🙂

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  20. Interesting… I feel like we have a lot of these “hallway consults” at every level of education and training. In fact, I couldn’t imagine not having these types of “opinions.” In the OR we will can in the general surgeons to have them “look” at an adherent bowel and decide if they need to be consulted. Sometimes we will call a speciality for a consult and they’ll respond by saying: “try this/order this and if you’re still having problems, call us back…” Seems like such a different world! I’m glad that it’s gotten better out of training and that you were able to get some benefit from the “favour.”

    Liked by 1 person

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