Monday, July 23, 2012
"Curbside" or "Curbstone" Consults - by Jeff Kanne, "The QA Guy"
Informal radiologic consultations are common in the practice of radiology. Not uncommonly, clinicians will call or stop by the reading room and ask you “to take a quick look at Mr. X’s outside chest CT and let me know if I should be worried about this lung nodule” or ask your opinion regarding a case reported on by one of your colleagues. While establishing and maintaining professional relationships with referring physicians is an essential component of a successful radiology practice, radiologists must be aware that these “informal” discussions may alter medical management. The careful clinician may document in the clinic note “outside chest CT scan was reviewed with radiology and was felt to show organizing pneumonia.” However, many of us have likely seen in a clinic note “outside chest CT scan was reviewed with Dr. Kanne and was felt to show organizing pneumonia. Steroid therapy will be started” when in reality what was actually discussed was that organizing pneumonia was the likely pattern but it could be the result of infection. Sometimes these consultations occur in the setting of multidisciplinary conferences, where the proceedings are formal yet documentation may be spotty and may rely on the memory of the clinician who requested the case review.
These types of requests can bring up all sorts of issues including medicolegal, medical decision making based on verbal reports, discordance between written reports and referring or consulting physicians’ understanding of the case, and even patient confusion. While there is no one answer on how to handle these requests, documentation is critical. Some practices may have a pre-existing policy on over-reads or informal interpretations including requiring that a formal interpretation be reported. Some PACS allow you to make a note in the study that archives with date and time stamps.
Because patients are more and more often receiving copies of diagnostic testing reports, problems may arise when your colleague’s report says “favor benign lung nodule” and your informal interpretation, which is passed along verbally to a clinician, states “favor lung carcinoma.” Each practice or department should have a policy on how to handle discrepant cases when medical management is going to be altered. In general, it behooves us all to notify a colleague about a disagreement rather than that colleague learning of the disagreement second-hand from a clinician or even from the patient!
In summary, “curbside” consultations in radiology are not going to go away, and they are the primary avenue for “face time” with clinicians in the PACS age. Radiologists and their respective practices should develop and maintain clear guidelines on how to handle these requests and, most importantly, how to document the communications that occur.
Berlin L. Curbstone consultations. AJR Am J Roentgenol. 2011 Jul;197(1):W191.