Friday Reflection 54: The Extra-clinical Curbside
VR is an 85-year-old woman. She is hypothyroid and has been on a stable dose of levothyroxine for years. At a routine visit, a TSH is checked as it has been a year since the last check. She has no signs of hyper- or hypothyroidism. The TSH is mildly elevated, reflecting subclinical hypothyroidism. VR’s doctor calls her and asks if she might have missed any doses recently. She admits that it is possible. The doctor encourages her to get a pill box and schedules a lab visit for six weeks later to recheck the value.
Two weeks later, the doctor receives a MyChart message from VR, in which she requests a referral to an endocrinologist. Her doctor calls her and asks why she wants to see an endocrinologist. VR says that she showed her labs to one of her friends, a retired physician, who noted that her thyroid tests were abnormal, pointed out that her general internist had not reacted to this finding, and suggested that she see a specialist immediately to manage her thyroid disease. VR tells her doctor; that her friend told her; that he had read an article in the Times; that reported on a study; that found that hypothyroidism can lead to dementia.
A lot of my conversations with colleagues end with, “This is just a really hard job.” The conversations that precede this statement recount a clinical situation in which there are no good solutions. Rather than the single problem with a simple solution, these are the situations that seem designed by an evil superpower. Treatments indicated for a problem are contraindicated by a second problem. Well-informed, well-meaning, expert consultants are at odds. Apart from agreeing that they disagree with the medical team's recommendations, family members do not agree with each other about anything.
The curbside consultation is just what it sounds like: nothing official, just picking the brain of a smart colleague while standing on a curbside. At academic medical centers, where an official consultation generates no revenue but creates work, curbsides are common. For complicated problems, a formal consultation is requested, and the consult team sees the patient, researches the history, and crafts a literate note with thoughtful recommendations. For simpler problems, the curbside is appropriate.
“Let’s not call a consult here, let’s just curbside ID and make sure they think a vanc taper makes sense.”
When done appropriately, everyone benefits. The patient is cared for by a team whose decisions are vetted by a specialist, without having to entertain yet another team of doctors. The consultants are saved the work of completing a full consultation. Most consultants will call out bad curbsides, “That’s a really complicated question. Why don’t we do an official consult here?”
The extra-clinical curbside almost certainly occurs more frequently than the clinical curbsides that take place in hospitals and clinics. Here, a patient discusses their case with someone who might be qualified to have an opinion. The consultant is usually a friend or family member. Their expertise ranges from being highly trained and clinically active in the appropriate specialty to having once been employed in a healthcare-adjacent job.
Before I bemoan the extra-clinical consult, let me be entirely clear: calling an extra-clinical consult is the right of every patient. It is their story and their health. Discussing a medical problem with friends and family is often therapeutic and can feel empowering. Doctors are not perfect and do not have a God-given right not to be second-guessed.1
This is why the job is hard. The extra-clinical consult is the patient's right; it can also make the patient’s care more difficult and potentially worse.
Extra-clinical consults often lead to overuse. The consultant recommends diagnostic tests and potential diagnoses based on incomplete information. The patient becomes concerned about why these have not been considered. The doctor will yield and order tests he does not feel are indicated.
The extra-clinical consult often undermines the patient-doctor relationship. I should be mature enough not to let a patient’s calling an extra-clinical consult bother me. I am not always. I have felt annoyed, doubted, and undermined when a patient relays the consultant's recommendations.
I know it is not about me, I really do, but the extra-clinical consult is bad for my well-being. Not only does the questioning hurt, but it adds extra work. A visit has been completed, a plan created, an evaluation underway, and then the extra-clinical consult reopens Pandora’s proverbial box.
I am guilty of doing extra-clinical consults. On occasion, I am called by friends who are unhappy with the inability of their doctors to explain their symptoms or adequately treat their diagnosed conditions. I’ll make suggestions for them to bring to their doctors. I often suggest language to present my ideas, realizing how mad I’d be if my patient uttered a sentence that began, “My buddy from college, who is a professor of medicine at The University of Chicago, said…” This approach seems not terrible.
More often, a friend tells me about the care he or she is receiving, and I can’t help myself. I rant about what I see as poor clinical reasoning leading to overuse.2 I do care deeply about this, poorly practiced medicine really galls me, and this is my schtick, but my behavior here is inexcusable. I should be much more reserved, thoughtful, and productive.
The practice of medicine is hard. Patients are presented with loads of diagnoses and data (lab tests, radiology reports, the results of internet searches). Many patients have lingering symptoms that are not adequately managed. We should expect that patients will reach out to trusted people beyond their official healthcare team. However, this expected and warranted act often complicates their medical care and their relationship with their actual doctors.
Those of us in healthcare should be cautious about the recommendations we make when we are outside the clinical setting. In most cases, we should reassure our unofficial patient and support their care team. When warranted, we might suggest what the patient could raise with their team, and how to do it, productively. In the rare situation when something truly egregious seems to be happening, maybe we should volunteer to speak to the team ourselves.
Not that I didn’t already have a sense, but I have learned, from the messages we receive here at Sensible Medicine, that many doctors deserve to be second guessed constantly.
A decade ago, my rants were about needless endoscopies; now they’re about coronary artery calcium scans.
Photo Credit: Adam Cifu
I am a general internist practicing in Ottawa and I can completely relate to every aspect of this beautifully articulated essay. I have seen it from both sides. I have been pressured to order unnecessary tests and to prescribe unnecessary medications by advice given to patients from well meaning colleagues leading to over diagnosis and over treatment. I have also seen friends and relatives who are clearly not being well treated by their physicians. It's a delicate road to navigate. However, one thing that I have learned the hard way is not to become directly involved in the care of friends and relatives. While it sometimes works out, it often leads to both bad medical care and loss of friendship.
This is just a really hard job.
It is.
And I know that I, too, have been guilty of making other doctors' lives harder by suggesting "Just ask them about XYZ." When one does not have the whole picture, things can look different, but when one's loved one is getting what seems like less than ideal care, it is difficult to stand by and watch.
Being a doctor is a really hard job.
Being a loved one is a really hard job, too.
Thank you for this essay, which, as usual, perfectly articulates what is in my heart.