Infectious Disease Consultations As Sound Bites
ABSTRACTS & COMMENTARY
Synopsis: Infectious disease consultants are more commonly requested to provide informal ("curbside") consultations than other specialists, and they are asked several times more frequently than they are requested to perform formal consultation. The value of informal consultation to patient care remains undetermined.
Sources: Keating NL, et al. Physicians' experiences and beliefs regarding informal consultation. JAMA 1998;280:900-904; Kuo D, et al. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA 1998;280:905-909.
Keating and colleagues at harvard surveyed 1370 practicing Massachusetts physicians, 705 (28%) of whom responded, concerning their use of and beliefs about informal consultation. Based on responses regarding their most recent week of usual practice, generalists (pediatricians and internists) requested a mean three consultations, while specialists (cardiologists, orthopedic surgeons, and infectious disease specialists) requested only one (P < 0.001). At the same time, specialists were asked to provide five informal consultations, while generalists were asked to provide only two (P < 0.001). Physicians who received more than 30% of their income from capitation were more likely to request informal consultation.
Infectious disease specialists, while seeing the fewest number of patients, received, by far, the most requests for informal consultation (10) and requested the fewest.1 In contrast, the results for internists were, respectively, two and three per week; for pediatricians, one and two; for cardiologists, four and two; and for orthopedists, three and two. Of all the informal consultations requested, cardiologists and pediatricians were most likely to request them of infectious disease specialists.
Generalists were more likely than specialists to believe that informal consultation improves the quality of care and were less likely to be concerned that the curbside consultant's recommendations may be based on incomplete or inaccurate information.
Kuo and colleagues at Brown University received survey responses from 413 (76.8%) of 538 practicing Rhode Island physicians who were asked about their activities during the previous week. Thirty percent of primary care physicians (internists, family, or general practitioners) and 12.5% of subspecialists reported requesting no informal consultations in the previous week. More informal consultations were requested of infectious disease specialists (6.8) than from any other group. Furthermore, infectious disease specialists, along with endocrinologists and rheumatologists, received significantly more informal than formal consultations. For instance, the 53 cardiologists responding to the survey had received 115 curbside and 139 formal consultations, while the 13 infectious disease specialists received 57 curbside and only 20 formal consultations.
COMMENT BY STAN DERESINSKI, MD, FACP
Previous studies have documented the remarkable frequency with which infectious disease specialists are requested to provide informal consultation.1 The studies reviewed here examine multiple specialties and provide useful additional information, confirming that infectious disease specialists are the targets of requests for such advice more frequently than their colleagues in other specialties. Of particular interest and concern is the finding by Kuo et al that infectious disease specialists were requested to provide approximately three informal for every formal consultation!
There have repeatedly been dire predictions about the impending redundancy of infectious disease specialists. In the current medical economic environment, infectious disease specialists are in danger of sealing their doom by acceding to a system that insists upon their providing informal consultations without placing any economic value on those consultations. In the evolving medical environment, if you cannot justify your existence from a purely financial point of view, you will not exist professionally.
Furthermore, the specialty is potentially sealing its own doom as a consequence of devaluing its skills and knowledge by reducing its advice to the brief sound bites necessary in the setting of curbside consultations. As expressed by the specialists in the studies reviewed here, those sound bites may be based on inadequate information and may preclude the degree of nuance and specificity necessary for optimal patient care. Furthermore, the medicolegal implications and potential liability of the specialist performing informal consultations remains an important issue.2
In an editorial accompanying the papers reviewed here, Golub suggests that informal consultation be formally evaluated to determine its value in patient care (see the previous article in this issue).3 In the meantime, Golub suggests a series of steps on the part of both the requester and the consultant that would, in essence, extend the informal consultation into a formal one.