Avoiding the “Curbside Consult”

Physicians frequently get named in lawsuits not because of direct negligence on their part, but simply because they were in the chain of care of a patient who suffered an injury. The lesson of the so-called “curbside consult” is that a physician should either formally enter that chain, or stay completely out of it.

Dr. C is a well-respected member of his hospital’s obstetrical staff. Dr. TO is the treating obstetrician for a 29-year-old G1 P0 patient who was admitted in early labor at 35 weeks with blood pressure of 170/110 and 4+ protein in her urine.

Dr. TO obtained a telephonic consultation with a perinatologist upon the patient’s admission and began the patient on a 24-hour course of magnesium sulfate to allow the fetus’s lungs to mature. The next day, Dr. TO ordered Pitocin for the patient, and, shortly after noon, asked Dr. C to examine the patient for a second opinion. Dr. C told Dr. TO that the patient was at 6 cm., that there no fetal swelling of the head or face, no molding, and no evidence of cephalopelvic disproportion. Further, the monitor strip did not look critical. Dr. C told Dr. TO that he agreed with her management plan, but he did not write any kind of note for the chart.

The patient continued to labor until 5 p.m., when Dr. TO decided to perform a cesarean section for failure to progress. The infant was born 30 minutes later, weighing 1600 grams and with Apgars of 3/4. After developing respiratory failure, the infant was transferred to another facility. A CT scan performed a year later showed evidence of a middle cerebral artery stroke, leaving the infant with hemiplegic palsy.

When the minor filed suit for her injuries, she included both Dr. TO and Dr. C in her allegations of negligence.

Upon review of the claim, the expert reviewers focused their attention on Dr. TO’s pre-admission management of her patient’s care. Especially troubling to the reviewers was the fact that despite symptoms of possible preeclampsia, Dr. TO did not see the patient for some 2 + weeks prior to admission.

Though there was a consensus that the infant’s injury likely occurred prior to the mother’s hospitalization, the expert reviewers nevertheless had some pointed recommendations for Dr. C. In particular, one reviewer suggested the proper protocol when agreeing to a consultation:

• Evaluate the pre-natal record;
  
• Elicit a history;
  
• Determine the patient’s specific pathology and reason for hospitalization;
  
• Determine the medication and dosage the patient is currently receiving;
  
• Review the labor curve and monitor strip; and
  
• Give a formal clinical opinion as to the patient’s prognosis, with a written note.

Curbside consults may be sought in almost any specialty. When a physician is asked an opinion on a patient’s care, that physician should simply decline the request unless he or she can take the time to perform all the steps necessary to give the best possible advice.

Given that one never knows which patient may become an eventual litigant, the best practice when responding to a colleague’s request for advice is to either step in with both feet, or keep walking.

Gordon Ownby, CAP-MPT’s general counsel, can be reached at gownby@cap-mpt.com.