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Kuo D, Gifford DR, Stein MD. Curbside Consultation Practices and Attitudes Among Primary Care Physicians and Medical Subspecialists. JAMA. 1998;280(10):905–909. doi:10.1001/jama.280.10.905
From the Department of Medicine (Drs Kuo, Gifford, and Stein) and the Department of Community Health (Dr Gifford), Brown University, Providence, RI.
Context.— Informal (curbside) consultations are an integral part of medical culture
and may be of great value to patients and primary care physicians. However,
little is known about physicians' behavior or attitudes toward curbside consultation.
Objective.— To describe and compare curbside consultation practices and attitudes
among primary care physicians and medical subspecialists.
Design.— Survey mailed in June 1997.
Participants.— Of 286 primary care physicians and 252 subspecialists practicing in
Rhode Island, 213 primary care physicians and 200 subspecialists responded
(response rate, 76.8%).
Main Outcome Measures.— Self-reported practices of, reasons for, and attitudes about curbside
Results.— Of primary care physicians, 70.4% (150/213) and 87.5% (175/200) of subspecialists
reported participating in at least 1 curbside consultation during the previous
week. In the previous week, primary care physicians obtained 3.2 curbside
consultations, whereas subspecialists received 3.6 requests for curbside consultations.
Subspecialties most frequently involved in curbside consultations were cardiology,
gastroenterology, and infectious diseases; subspecialties that were requested
to provide curbside consultations more often than they were formally consulted
were endocrinology, infectious diseases, and rheumatology. Curbside consultations
were most often used to select appropriate diagnostic tests and treatment
plans and to determine the need for formal consultation. Subspecialists perceived
more often than primary care physicians that information communicated in curbside
consultations was insufficient (80.2% vs 49.8%; P<.001)
and that important clinical detail was not described (77.6% vs 43.5%; P <.001). More subspecialists than primary care physicians
felt that curbside consultations were essential for maintaining good relationships
with other physicians (77.2% vs 38.6%; P <.001).
Conclusions.— Curbside consultation serves important functions in the practice of
medicine. Despite the widespread use of curbside consultation, disagreement
exists between primary care physicians and subspecialists as to the role of
curbside consultation and the quality of the information exchanged.
A CURBSIDE consultation is an informal process whereby a physician obtains
information or advice from another physician to assist in the management of
a particular patient.1,2 The consultant
is generally unfamiliar with the patient and has not reviewed the patient's
chart or examined the patient.2 Thus, in contrast
with a formal consultation, the consultant's recommendations or comments are
based almost exclusively on information provided by the physician seeking
advice, rather than from the patient or medical record.
With increasing complexity in the diagnosis and management of medical
problems, Americans value their access to subspecialists.3
One feature of managed care has been to limit patients' access to subspecialists
in an effort to cut costs for third-party payers.3,4
As a result, many primary care physicians have had to assume greater responsibility
for the care of conditions that have previously been considered the realm
of the subspecialist. Thus, it is possible that primary care physicians will
use more curbside consultations to obtain clinical advice and information
in an attempt to maintain quality care while limiting the number of formal
Despite the importance of this informal part of medical practice, there
has been little research to characterize physician behavior related to curbside
consultation. Previous studies investigating curbside consultation have been
limited to reports in endocrinology, infectious disease, or gastroenterology.1,2,6-8
In the current study, we describe curbside and formal consultation patterns
among Rhode Island physicians and examine differences in attitudes about curbside
consultation between primary care physicians and internal medicine subspecialists.
We used the Rhode Island Department of Health Board of Medical Licensure
and Discipline database to identify potential physicians for our study. The
database included 3114 physicians with active licenses as of June 1996. We
excluded 2188 physicians who did not identify themselves as having a primary
or secondary specialty of internal medicine (IM), family practice (FP), or
general practice (GP). Of the 926 remaining physicians, we categorized 651
as primary care physicians and 275 as subspecialists. We defined primary care
physicians as those who reported their primary specialty as IM, FP, or GP
and listed either no secondary specialty or a secondary specialty as IM, FP,
GP, or adolescent medicine. We defined subspecialists as physicians with a
primary specialty of one of the following internal medicine subspecialties:
allergy, allergy and immunology, cardiovascular diseases, cardiac electrophysiology,
critical care medicine, diabetes, endocrinology, gastroenterology, geriatrics,
hematology, infectious diseases, medical oncology, nephrology, pulmonary diseases,
or rheumatology. Of the 651 primary care physicians, we randomly selected
50% to obtain a sample of 325. We included all 275 subspecialists in our sample.
A total of 39 primary care physicians and 23 subspecialists were ineligible
(no longer in practice, unreachable at current address, moved out of state,
or deceased) and therefore were excluded.
We developed a self-administered survey with 4 sections (the survey
is available from the authors). We defined curbside consultation as "an informal
process whereby a physician obtains information or advice from another physician
to assist in the management of a particular patient. The consultant neither
reviews the patient's record nor examines the patient and does not document
his/her recommendations." We defined formal consultation as "a process whereby
a physician refers a patient to another physician. The consultant reviews
the patient's record, examines the patient, and formally documents his/her
We asked physician respondents to estimate how many formal and curbside
consultations they had requested (inpatient and outpatient) during the previous
week and how many minutes they spent on average during these consultations.
We asked respondents to indicate on a 4-point scale ranging from never to
frequently how often they obtained curbside consultations from 5 different
physical locations and how often they used curbside consultations for assistance
in 8 different patient care situations. We also asked respondents to indicate
their agreement on a 5-point Likert scale ranging from strongly disagree to
strongly agree with 10 statements about curbside consultation, which addressed
issues of general satisfaction, quality of information, professional relations,
autonomy, time, financial incentives, and medical education. We included questions
about physician practice characteristics and demographics.
Survey questions given to subspecialists sought to obtain information
about their receiving requests to provide curbside consultations, whereas
the questions given to primary care physicians sought information about their
requesting curbside consultations. The survey sent to primary care physicians
contained 2 additional questions: what characteristics of subspecialists do
primary care physicians deem most important when selecting subspecialists
to approach, and which 3 subspecialties do they most frequently consult formally
and informally? The survey was pilot-tested for clarity and content by 7 physicians
from the Division of General Internal Medicine and subspecialty departments
of Rhode Island Hospital, Providence, and its contents were revised.
Each physician who was selected to participate was sent the survey with
a self-addressed, postage-paid return envelope and a letter detailing the
purpose of the study. The first mailing occurred in June 1997. Nonresponders
received up to 3 follow-up reminder mailings 3, 5, and 10 weeks later. Each
follow-up mailing included another copy of the survey. The study was approved
by Rhode Island Hospital's institutional review board.
Survey responses were linked with data contained in the Rhode Island
medical licensure file for descriptive statistics. Wilcoxon rank sum tests, χ2 tests, and t tests were used as was appropriate.
All analyses were performed using STATA software, Version 5.0 (STATA Corp,
College Station, Tex).
Overall, 413 (76.8%) of 538 physicians responded to the survey. The
response rate did not differ between primary care physicians (213/286, 74%)
and subspecialists (200/252, 79%) and it did not differ across the 4 most
common subspecialties (cardiology, gastroenterology, hematology/oncology,
and pulmonary disease). There was no significant difference between responders
and nonresponders with respect to sex, age, number of years in practice, or
number of years licensed to practice medicine in Rhode Island.
Of the primary care physicians, 55% were internists, 38% were family
physicians, and 7% were general practitioners (Table 1). Of the subspecialists, the largest groups were cardiology
(27%), gastroenterology (16%), and hematology/oncology (16%) (Table 1). There was no significant difference between subspecialists
and primary care physicians with respect to age, number of hours of reported
direct patient care, or years licensed to practice medicine in Rhode Island.
The majority of the respondents for both the primary care and subspecialist
groups were men, although nearly twice as many primary care physicians were
women compared with subspecialists (29% vs 12.5%; P<.001).
Subspecialists were more likely than primary care physicians to be US medical
school graduates and board certified.
The majority of both primary care physicians and subspecialists were
in solo or single specialty practices. Less than 10% of reimbursement was
derived from capitated contracts. Primary care physicians saw more patients
than subspecialists in the outpatient setting (80 vs 51 visits per week; P<.001) but fewer inpatients (10 vs 18 visits per week; P<.001).
Nearly 30% of primary care physicians reported obtaining no curbside
consultations during the previous week, whereas 12.5% of subspecialists reported
providing no curbside consultations during the previous week. Physicians who
did not obtain any curbside consultations were significantly older (51 years
vs 45 years; P<.001), in practice longer (15.2
years vs 11.2 years; P<.001) and more likely to
be in solo practice (42% vs 23%; P<.001). Primary
care physicians who obtained curbside consultations obtained an average of
3.2 consultations per week. Subspecialists received 3.6 requests for curbside
consultations per week. Both groups of physicians participated in formal consultations
approximately 3 times more often than curbside consultations. Subspecialists
estimated that curbside consultations require much less time to complete than
formal consultations (8 minutes vs 51 minutes). When the curbside consultation
practices were examined by subspecialty, specialists in infectious disease
and endocrinology received more consultations in the previous week (6.8 and
4.2 per week, respectively) compared with other subspecialties: cardiology
(3.4), gastroenterology (3.6), pulmonary disease (3.6), and hematology/oncology
Primary care and subspecialist respondents both reported that curbside
consultations occurred most frequently in person in the hospital, in person
in the office setting, or by telephone (Table 2). Few physicians used e-mail sometimes or frequently as
a route for curbside consultation. The location of consultations did not differ
significantly across these subspecialties (data not shown). Primary care physicians
felt that the quality of the consultant's formal consultations and the consultant's
superior skills or knowledge base compared with that of other physicians in
that specialty were the most important characteristics in selecting a curbside
consultant (percentage responding fairly important or very important, 88.6%
and 82.5%, respectively).
Primary care physicians who were employed by health maintenance organizations
(HMOs, group or staff model) were more likely to obtain curbside consultations
than those not employed by HMOs (5.6 vs 2.9 consultations per week; P=.02). Primary care physicians who estimated that at least
20% of their patients were enrolled in capitated contracts had similar rates
of curbside consultation as physicians who estimated that fewer than 20% of
their patients were enrolled in capitated contracts (2.6 vs 2.2 curbside consultations
per week; P=.38).
The most common reasons cited by primary care physicians for obtaining
curbside consultation were to help select an appropriate diagnostic test,
to determine need for formal consultation, to select an appropriate treatment
plan, and to interpret laboratory or radiology data. Subspecialists cited
helping select an appropriate diagnostic test, diagnosing a specific medical
problem or condition, selecting an appropriate treatment plan, and determining
the need for a formal consultation as the most common reasons they received
curbside consultations (Table 2).
However, specialists in pulmonary diseases and infectious diseases were much
more likely to report that they provide curbside consultations sometimes or
frequently to select an appropriate treatment plan (87% and 100%, respectively)
compared with the other specialties (range, 52%-79%). Hematology/oncology
and pulmonary disease specialists were more likely to report receiving requests
for curbside consultations to help assess prognosis (59% and 52%, respectively)
compared with other specialties (range, 32%-46%).
Primary care physicians most frequently requested curbside consultations
from cardiology, gastroenterology, and infectious diseases. Formal consultations
were most frequently obtained from cardiology, gastroenterology, and neurology.
Seven subspecialties had significant differences between rates of formal and
curbside consultation. Endocrinology, infectious diseases, and rheumatology
received significantly more curbside consultations compared with formal consultations.
Cardiology, neurology, ophthalmology, and surgery received requests for significantly
fewer curbside consultations compared with formal consultations (Table 3).
Approximately half (49%) of the primary care physicians reported that
their patients' care was sometimes or frequently "taken over" by the consultants
following a formal consultation. Most of the subspecialists (61%) also reported
that this happened sometimes or frequently (Table 4).
Slightly more than half of all subspecialists and primary care physicians
reported that they enjoyed obtaining or receiving curbside consultations (Table 4). However, subspecialists perceived
more often than primary care physicians that the information communicated
in curbside consultations was insufficient (80.2% vs 49.8%; P <.001) and that important clinical information was missed (77.6%
vs 43.5%; P<.001). Subspecialists also felt that
after curbside consultations, primary care physicians would feel less obligated
to follow the consultants' recommendations (46.9% vs 26.9%; P<.001).
Subspecialists were more likely than primary care physicians to report
that curbside consultations were essential for maintaining good relations
with other physicians (77.2% vs 38.6%; P <.001).
Nearly half of both groups agreed that curbside consultations saved money
for the patient and third-party payer and that these consultations were an
important way for physicians to stay current with medical knowledge. Less
than one quarter of both groups felt that curbside consultations should be
used more often to reduce the number of inappropriate formal consultations.
These results did not differ when board certified and non–board certified
physicians were compared.
When attitudes about curbside consultation were compared across subspecialties,
infectious disease specialists appeared to differ from the other specialties
(Table 4). Infectious disease
specialists were less likely than other specialists to report that they enjoy
curbside consultations (15% vs 42%) and more likely to agree that insufficient
information is exchanged (92% vs 80%) and that primary care physicians are
less obligated to follow recommendations made during a curbside consultation
(69% vs 47%). They were also more likely to agree that consultants are less
enthusiastic with curbside consultations because they do not get reimbursed
(54% vs 40%) and were less likely to consider curbside consultations essential
for maintaining good professional relations (54% vs 77%).
Our data suggest that the majority of primary care physicians and subspecialists
in internal medicine participate in curbside consultations. However, these
physicians have differing viewpoints about the purpose and quality of curbside
consultations. Most subspecialists are concerned about the adequacy of this
method of providing input into the care of patients, whereas half of primary
care physicians agree that the quality of information obtained by curbside
consultation is adequate.
Primary care physicians request curbside consultations from subspecialists
for a variety of reasons. Frequently, they ask for assistance with diagnostic
test selection and interpretation of laboratory or radiology data, and they
use curbside consultations to help determine the need for formal consultation.
To answer such clinical questions, accurate and complete data need to be exchanged.
However, subspecialists often feel that during curbside consultations, insufficient
clinical information is provided compared with a formal consultation. In addition,
subspecialists often feel that important findings may have been missed by
their primary care colleagues. These results may suggest that subspecialists
do not trust either primary care physicians' ability to communicate information
or their history-taking and examining ability. Our findings corroborate those
of Myers,1 who found that incorrect information
about the patient's history, physical examination, or laboratory data was
given during curbside consultation.
Nearly half of subspecialists felt that primary care physicians would
be less likely to follow a consultant's curbside advice compared with that
which results from a formal consultation. Despite these concerns, 87.5% of
subspecialists reported providing curbside consultations. Most subspecialists
felt that curbside consultations were essential for maintaining good professional
relations, acknowledging that curbside consultation is part of medical culture
and that primary care physicians depend on it for patient care.
Nearly three quarters of primary care physicians requested curbside
consultations, even though half also expressed concerns about the quality
of information exchanged. This finding is consistent with a survey of physicians
who requested curbside consultation from an infectious disease specialist
at one hospital.1 In that study, a majority
of physicians requesting curbside consultations felt that inaccurate information
was exchanged during a curbside consultation. Primary care physicians may
continue to request curbside consultations despite these concerns because
of the possible advantages of time and money saved and the educational information
In our study, primary care physicians and medical subspecialists reported
that curbside consultations constituted one quarter of all consultation activity.
This finding is similar to reports by specialists in endocrinology2 and infectious diseases6
who prospectively tracked formal and curbside consultations. For subspecialists,
the economics of curbside consultation is double-edged. On one hand, curbside
consultation can lead to formal consultation and help maintain a referral
base. On the other hand, subspecialists are not reimbursed for the time spent
curbsiding. For cognitive subspecialties such as infectious diseases and endocrinology,
in which providing information is often the only marketable service (as opposed
to performing a procedure), curbside consultations may have substantial economic
impact.5 We found that cognitive subspecialists
received more curbside consultations than formal consultations and suspect
that such disciplines may be more amenable to the brief, focused questions
that characterize curbside consultation.9 Primary
care physicians may feel more comfortable managing problems related to these
disciplines independently because they either received better training in
these areas or perceive the range of problems to be of lower acuity. In contrast,
subspecialties that require specialized or hands-on physical examination (eg,
dermatology) or the use of invasive procedures (eg, cardiology) received greater
numbers of formal consultations.
The phenomenon of the consultant taking over the care of a patient is
quite common according to both primary care physicians and subspecialists.
This was also a concern of consulting physicians interviewed by an infectious
disease specialist who tracked all his curbside consultations during a 12-month
period.1 The factors associated with takeovers
of patient care have not been studied, but in our experience, formal referrals
often result in follow-up care by the consultant, even when the referring
physician did not request such concurrent follow-up care.
Curbside consultation may reduce the overall number of formal referrals
required.8 This would allow primary care physicians
to continue to care for their patients independently, a potential advantage
to physicians practicing in a managed care or capitated setting. In our study,
physicians practicing in a group-model or staff-model HMO were twice as likely
to obtain curbside consultations than physicians not practicing in an HMO
setting. An endocrinology group practice also reported that they were approached
more frequently by HMO physicians than by fee-for-service physicians.2 However, HMO-physician curbside consultations were
more likely to result in formal consultations compared with fee-for-service
physician curbside consultations.2
Physicians may use curbside consultation to keep current with medical
information in addition to using journal articles, textbooks, and continuing
medical education course material.10 Primary
care physicians are responsible for patients presenting with a broad range
of symptoms and illnesses. Covell et al10 observed
that physicians contacted a colleague to answer 53% of their patient care
questions resulting from an office visit. Nearly half of our surveyed primary
care physicians agreed that curbside consultations are an important way to
stay current with medical knowledge (data not shown). Information that primary
care physicians seek may not yet be available in textbooks, and conducting
a literature search may take more time than making a telephone call to a consultant.
Our study has several limitations. First, reported rates of curbside
consultations may not necessarily reflect actual practice. However, our estimates
of the duration and frequency of curbside consultation are similar to or less
than those reported in other studies of informal consultation based on direct
For example, we found that infectious disease specialists received an average
of 6.8 curbside consultations in the previous week, which is similar to the
number of curbside consultations reported in 2 prospective studies by infectious
disease specialists (5.6 and 6.5 per week).3,4
Second, our study was based in Rhode Island and may differ from curbside practices
found in other states. There may be geographic variation in curbside consultation
due to subspecialist availability and variations in physicians' perceptions
of their own responsibilities. For instance, in Rhode Island, managed care
remains relatively uncommon. Third, we assessed only curbside consultations
requested by primary care physicians of subspecialists. We did not assess
curbside consultations provided by primary care physicians or those requested
by subspecialists. Finally, we did not assess the quality or appropriateness
of curbside consultations and we did not evaluate the effect of curbside consultations
on patient care.
In conclusion, curbside consultations are common and appear to be an
integral part of medical culture. However, there remains disagreement between
primary care physicians and subspecialists in Rhode Island regarding the quality
of the information exchanged. Given this concern and the frequency with which
curbside consultations occur, the effect of this common practice on patient
outcomes needs to be studied. Until such data become available, physicians
should keep in mind the potential disadvantages and advantages of curbside
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