The corridor consult

Informal curbside or corridor consultations have been an established yet invisible part of the medical environment. “Questions such as ‘Can I get your thoughts?’ or ‘Can I run something by you?’ are familiar to many of us who specialize in purely ‘cognitive’ disciplines.”¹ In a study of physicians in Rhode Island in 1998, 87.5% (175/200) of subspecialists reported participating in at least one curbside consultation during the previous week and subspecialist physicians received an average of 3.6 requests per week.² In a prospective study within the discipline of infectious diseases, over a one-year period, the service was consulted officially about 532 patients and unofficially about 269 patients. Only 31 of the 269 (11.5%) were subsequently referred for formal consultation.³

Obstetric medicine, as compared with obstetrics or maternal–fetal medicine, is certainly a cognitive discipline. For the busy obstetrician, anesthetist or internal medicine specialist, a chance meeting in the car park with an obstetric physician is a perfect opportunity to obtain the answer to a clinical problem or hear up-to-date information rather than searching through textbooks or journals. These interactions are free, quick, and may solve a particular problem without having to refer the patient for consultation. For many of us, informal consultations optimize our precious time and may engender a sense of professional satisfaction from educating another physician and potentially improving patient care.

In the internet era, many such consultations take place by phone, email, or video-conferencing. In locales that do not have the services of a specialist obstetric physician, it may be considered entirely appropriate to ask for informal advice without the physician ever meeting with the patient. The ObMed ListServ is a perfect example of the informal consultation which has been an effective tool for many within our specialty.⁴

Manian and Janssen identified that with complex multidisciplinary care, the consulting doctor

may choose to obtain curbside rather than formal consultation to minimize the number of additional consultants. Also, for physicians who may be concerned about loss of patients to the consultants, curbside discussion of a case may be a safer alternative to formal consultation.¹

In the setting of the maternity hospital, there are also frequent requests from staff for advice about their own or a relative’s normal pregnancy or complications. How often have we offered specific pharmacological advice to our nurses or medical colleagues suffering from nausea and vomiting of pregnancy without a formal consultation? The corridor consult also offers the opportunity to share with colleagues information about potential patients, without “bothering” about formal referral.

But what are the disadvantages of this custom? The quality of the advice is clearly dependant on the information received. Not uncommonly, this may be incomplete, inaccurate, or biased which may lead to inappropriate, inadequate, or even dangerous advice. The absence of record keeping or follow-up is clearly a risk to good patient care. In the fee-for-service environment, the inquiring doctor may not appreciate that cognitive consultations are the only potentially reimbursable procedure performed by obstetric physicians. How do doctors feel about providing informal consultation? In a study of hospital doctors in Israel, most of them (91%) agreed to such requests because of “willingness to help,” because “it's unpleasant to refuse,” or “it's the acceptable thing to do”. In general, the attitude to hallway medicine was negative (54%) or ambiguous (37%)”.⁵

Medico-legally, merely answering a colleague's question or performing a curbside consultation may not give rise to a physician-patient relationship and, hence, there is no liability.⁶ Similarly, assuming an informal consultation does not entail any danger to the patient or others, the physician may agree to the request although no generalization can be made to the effect that informal medicine is or is not ethical.⁷ Occasionally, colleagues will document these informal consultations in the patient record as “discussed with … ,” implying a level of responsibility, and potentially culpability, that should not have been inferred.

In a small, highly specialized area such as Obstetric Medicine, our colleagues will continue to rely on our expertise and goodwill in providing informal advice to best manage their patients. To ensure the best outcomes for our patients, both the requesting doctor and the subspecialist need to ensure that where necessary, formal consultation is arranged in an appropriate and timely manner. Medicine is a collegial speciality and even Hippocrates recognized this declaring:

…to teach them this Art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples …

This issue highlights the diversity of problems that may affect the pregnant woman requiring formal or corridor consultation, from hematological malignancies, hepatitis, and diabetes to concurrent maternal and fetal tachyarrythmias. Idel et al. describe the training paths to Obstetric Medicine in Australia and New Zealand; for comparison, see the United Kingdom⁸, Canadian⁹ and Latin American¹⁰ descriptions. Jeffrey Post describes hepatitis C management during pregnancy and the importance of diagnosis and curative treatment prior to conception. A single-centre experience by Puyade documents the outcomes of pregnancy in patients with myeloproliferative disorders. Keeping up the hematological theme, we also have case reports on relapsed Hodgkin’s lymphoma diagnosed during pregnancy and a woman with Chronic Lymphocytic Leukaemia (CLL) first identified during pregnancy.