"A casual consultation is just that - Casual" - Unknown
This blog has three stories and a couple of statements that may save your life and career.
First Story: Poonam
Major Poonam was getting late for her introduction parade and was rushing out to report in time. She was shouting instructions to her children about breakfast and catching the school bus
Poonam had passed her MBBS from Shimla about 11 years back and had married an Army officer. Later she had also joined the Army Medical Corps. Presently, her husband’s battalion was posted in a non-family field area and she lived with her children in an Army cantonment outside a second tier city. She was working at the local military hospital, which was being inspected by the GOC today. Poonam was proud to be working as MI Room (now called the Casualty) incharge and would be introduced to the GOC in the introduction parade.
She lived in a ‘temporary’ officer’s accommodation, which was nothing but a modified second World War granary barrack. It consisted of a series of large rooms with an open verandah in front and back. A single large room was allotted to each family with a common front verandah. The back verandah of the barrack had been converted into attached makeshift kitchenette and a toilet. Her daughter aged 9 and a son aged 7 lived with her. Normally she saw them off to school, but today she could not afford to be late for the introduction parade.
Burning in stomach
As she stepped out of her room into the verandah, she was confronted by the neighboring officer’s wife: “My husband is having burning in stomach, can you advise something for him.”
Poonam was nonplussed, “Please bring him to the MI Room, I am getting late for the introduction parade.”The neighbouring officer’s wife persisted, “Oh, Just tell me something to give for his stomach, and I’ll bring him later.”
Poonam continued moving towards her Scooty and shouted “Okay, give him ‘Digene‘.” and went rushing for her duty.
Two hours later, the neighbour’s husband died of a massive heart attack. The lady doctor was sued in court for criminal negligence.
Friends turned foes
There were no mobiles then, but it soon became the talk of the town. There was a parallel trial in all social gatherings. “The lady doctor should have stayed back and properly examined the patient.” “Why would she jeopardize her own career?” “Why did she advise without examining the patient?” “If she hadn’t, the neighbour would have been very upset.” “As if now she is not!”
Opinion amongst the lay public was divided. “It was wrong for the neighbour to consult her when she was not in her chamber.” “Why else would one want to live near a doctor’s house?” “Neighbor did not follow her full advice, so doctor is not at fault!” “Do patients ever follow full advice?”
A long legal battle followed. After a lot of harassment and notoriety, the doctor was declared not guilty by the honourable court. But…….she was socially boycotted and taunted as a murderer in social gatherings. Later she resigned from service and was not heard of again!
Second Story: I fell into a trap
This one is more recent. In 2017, I lived in a rented flat on the second floor in an apartment building. The ground floor was occupied by my landlord, and first floor was owned by an old school friend of mine called Monty. We had met after nearly 40 years. He mostly lived with his son in Sweden and used to come to India for 3 months when the winter became too severe there. This incident happened on the early morning of 29th Sep 2017. I was not aware that he had come back to india a month earlier than expected on the previous night.
I was leaving my house at 7 in the morning, wondering if I was late for a flight to Hyderabad, where I had to give a talk in a conference. Monty’s wife met me in stairway as I was coming down, “AC, Monty has been advised this preloaded injection. Doctor had said that I could just jab it in his thigh. I could do it alright, but now that I see a doctor available, I thought, you are the best person to do the honors!”
“Ma’am, I am getting late for a flight. And then there can be reactions” I protested
She laughed and responded, “Oh, Don’t worry. He has taken one last week. There was none in the last dose. It will take precisely 2 seconds. He is lying there with his bottoms bared.”
Dilemma
I now had two options:
First, I could explain the implications to the lady over next 15 minutes unsuccessfully and miss my flight plus spoil our friendship! (And keep hearing about it for rest of my life)
Second, Give a jab and get along!
Against all my training, I went in to give the injection and asked her on the way, ” What is it for?”
She picked up her cup of tea lying on the side table and answered,”Oh nothing, just to counteract some side effects of an earlier injection”
I had my distance specs on, and so I could not read what fine print on the label said on the pre-filled syringe. In any case it was an unfamiliar foreign trade name.
“I valued our friendship, as I cannot make new friends at my age. They were happily married for 35 years; I knew she would not want to harm him. I reluctantly agreed to help. “Okay, I will guide you. You hold it vertically and jab on his buttocks perpendicularly…. yes and quickly withdraw!” So, I supervised the jab, and fled, but remained uncomfortable throughout my trip
When I came back two days later, and asked them about details, I learnt that Monty was diagnosed with a cancer and was on chemotherapy. The injection we gave that day was GMCSF. I had made her give the injection intramuscular, when it was supposed to be given subcutaneous. I was fortunate, no adverse effects occurred! It was a near miss disaster and I had survived despite my foolishness.
What is Curbside Consultation?
I am sure readers know what I am talking about. Curbside consultation means when you are professionally consulted as a doctor at a time you are least prepared for it. Such informal consultations—also called “hallway,” or “sidewalk” or “Social” consultations—typically involve a “brief presentation of the patient’s history, recitation of the diagnostic test results obtained to date and discussion of potential avenues of treatment for this patient.1 It is of two types2 It is of two types:
(a) A lay person may ‘corner’ any physician, seeking an opinion about a medical condition, diagnostic modality, or therapeutic option at unexpected time, place and setting, or
(b) A physician may ask a colleague in another specialty for the best method for managing a particular clinical patient.
It can be dangerous for many reasons. Physician being cornered may not have expertise in the area e.g. a psychiatrist may be asked about cancer chemotherapy. In second story above, I was such victim.
The lay person may be asking for information about third person i.e. Lucknow wali aunty with gallstones, in which case the information being exchanged is confusing and will become gibberish by the time that Lucknow-wali aunty receives it second-hand.
You may be professionally consulted when you least expect it!
When can you be consulted?
It happens only in India! You may be consulted at the street corner, pan-shop, at parties, in restaurants, at the barber shop and even while standing in the public toilets. Another form is through your mobiles. Every time, I open my WhatsApp, I always have 20 odd such casual consultations waiting for me, full of lab reports, x-rays and CT pictures from patients who do not bring these at time of physical/ formal consultation. What can you do when some of them are relatives and very close friends.
Here is one example: A patient I had seen 7 years back suddenly sent 27 lab reports, one ultrasound report with 5 pictures, one unreadable CT Scan along with a pictures of an unthinkable area of his body with following message:
“Doc-saab, My pain abdomen has not changed. I had one loose motion 7 days back. Feel constipated for last two days. Am burping a lot. I have enclosed all my blood reports and ultrasound pictures, please send me the fresh prescription. PS: Can I eat butter chicken?”
Is the doctor criminally liable?
Doctors often reply to such requests out of politeness. They often take decision on incomplete information. Wrong diagnosis or wrong treatment makes the doctor criminally liable for malpractice.
If the patient is harmed by any such consultation, the doctor is legally liable even if he was not paid. Hon’able Supreme Court has opined that “”No prescription should ordinarily be given without actual examination. The tendency to give prescription over the telephone, except in an acute emergency, should be avoided.”3
Medical malpractice has developed as a theory of liability discrete from common law negligence, imbued with both contract and tort principles. Tort literally means assault, battery, intentional infliction of emotional distress, and false imprisonment. Also included are trespass to chattels, property, and conversion. Hon’able Courts require following to decide guilt:
(a) There must be a relationship of a certain kind.
(b) The wrongful act must be related to the relationship in a certain way.
(c) The wrongful act must be done within the course of relationship.
The Hon’able court has observed, “Professionals do not owe a duty to exercise their particular talents, knowledge, and skill on behalf of every person they encounter in the course of the day.”4,5,6, 7,8
Relationship in casual consultation
In the eyes of the Court, curbside consultation is a consensual relationship whereby a patient “knowingly seeks the assistance of the physician and the physician knowingly accepts him as a patient. (Doctor patient relationship)”
If a doctor diagnoses, treats, or prescribes for an ailment, (s)he is obligated to possess and use skill and care, independent of an express agreement of employment or promise to pay for services.
The doctor, therefore may be held responsible for negligence or lack of skill when “any act is done, or advice given, that may reasonably be construed [as] indicating” that doctor knowingly gave advice.
Why casual consultation on the run?
Only reason why such consultations are asked for is, that it is convenient for the person seeking such consultation. If the doctor has not learnt to say no, these casual consultation have the potential for being very dangerous for both the parties.
It is well known fact that “Medical errors are potentially a lot higher in curbside consultations because
(a) The doctor may not be in a frame of mind to seriously analyse, may be exhausted, sleepy, driving, or drinking.
(b) The doctor does not have complete information, he is asked to decide on what limited information has been provided.
(c) Much may also be lost in translation. Patient may chose to follow the advise he thinks doctor has given.
Therefor, when a curbside consultation is used as a substitute for the physician seeing the patient, One should expect much higher chance of an incorrect diagnosis and medical errors.”
Third story
It happened in Chandigarh. A 16-year old boy was hospitalized with headache and generalised weakness after he had a fallen from a wall about 1.5 meters high. X-rays of his spine were normal. The treating paediatrician telephoned a neurosurgeon classmate, who asked whether the boy’s neck was stiff, discussed diagnostic possibilities with the paediatrician, and suggested doing a lumbar puncture.
The neurosurgeon also offered to see the boy if referred, but the formal referral never happened, and the neurosurgeon earned nothing. The paediatrician later diagnosed Guillain-Barre syndrome on the basis of CSF examination. The boy developed quadriplegia few hours after after lumber puncture
A spinal cord injury was discovered after the patient was transferred to PGI Chandigarh. The case went to the Court. Ultimately, the neurosurgeon paid 10-times more compensation than treating paediatrician.
What do the Courts think?
The Courts often allow suits to proceed against doctors, trying to decide ‘whether a doctor-patient-relationship existed?’ And if so, whether the [consulting] physician’s advice amounts to the alleged malpractice. They also look at what was said, and if there is documentation to prove it. Was advice specific or general?
Curbside Consultation’ can be a bona-fide Doctor-patient-relationship if one is on call duty at hospital and Emergency Room (ER) doctor asks his/her advice on a patient in ER. One has a relationship with patient that entails a duty of care. Similarly if you are covering a friend’s duty, and a nurse rings you for advice. You may have never seen the patient, but you will be liable for your advice if given on phone. Also if one is supervising an intern, he/she bears vicarious liability for adverse events caused by the intern. Be specially careful, if you think that such a curbside consultation will be used by seeker to select a treatment option.
If general information is given, or a question is answered in a conference about a situation, there is no duty of care. It is best, therefore, to offer advice in general terms as if teaching a colleague or patient. Example “As you describe it, I believe in this situation one may consider . . . , but without a more in-depth evaluation, I can’t be sure.”
What about telemedicine?
COVID-19 pandemic had forced NMC to issue formal guidelines to conduct telemedicine sessions.9 As per these guidelines, the doctor has to use his discretion to decide whether he is confident about what he is doing and that he has all the information he needs. Can he can make a clear diagnosis? The telemedicine sessions are recorded and a written prescription is supposed to be given. The doctor has the right to ask the patient for physical consultation if he/she is not sure about the diagnosis. However, the doctor’s liability is not diluted at all.
In many social gatherings people introduce the doctor as his or her friend. The doctor should remember that any one who consults him is NOT his friend but his patient. In today’s scenario, being socially polite has finished many a doctors. Also remember that curbside consultation has highest chances of medical errors. Even a famous fiction hero once said, “My dear Watson, do not jump to conclusions before knowing all the facts of the case.”
Tail Piece
Nearly 40 years back, my own professor of medicine had taught me what I have quoted on the top. Casual consultation is just that – ‘casual‘. One should avoid it if one can. He had also told us an interesting point. He had said, “My home has my nameplate where I have boldly written – I. M. AHUJA. Below that there is an inscription that say – If you have come to see Doctor Ahuja, he will be available only in the Clinic.“
[Note: As always, the names of the characters are mostly fictitious but the issues are real.]
References
| ↑1 | Patricia C. Kuszler, Telemedicine and Integrated Health Care Delivery: Compounding Malpractice Liability, 25 AM. J.L. & MED. 297, 313 (1999). |
| ↑2 | Kassirer JP. Access to specialty care. N Engl J Med. 1994 Oct 27;331(17):1151-3. doi: 10.1056/NEJM199410273311709. Erratum in: N Engl J Med 1994 Dec 1;331(22):1535. PMID: 7779175. |
| ↑3 | Martin F Dsouza vs Mohd Ishfaq, Para 54b Feb 2009 Supreme Court. https://indiankanoon.org/doc/1092676/ |
| ↑4 | St. John, 901 S.W.2d at 423 (citing 1 LOUISELL & WILLIAMS, MEDICAL MALPRACTICE § 8.01 at 82, 818 to 819 (1990) (noting that “medical malpractice developed under the theory of ‘public calling’ prior to the time negligence emerged as a separate tort”)). |
| ↑5 | Buttersworth v. Swint, 186 S.E. 770 (Ga. Ct. App. 1936) at https://digitalcommons.law.lsu.edu/cgi/viewcontent.cgi?article=3886&context=lalrev |
| ↑6 | Peterson v. Phelps, 143 N.W. 793 (Minn. 1913) at https://case-law.vlex.com/vid/143-n-w-793-617870787 |
| ↑7 | Young v. Crescente, 39 A.2d 449 (N.J. 1944) at https://www.courtlistener.com/opinion/3583717/young-v-crescente/? |
| ↑8 | Miller v. Dumon, 64 P. 804 (Wash. 1901) at http://courts.mrsc.org/washreports/024WashReport/024WashReport0648.htm. |
| ↑9 | Telemedicine Practice Guidelines at https://www.mohfw.gov.in/pdf/Telemedicine.pdf |
Awesome, as always! Congratulations
As always , such a topical subject. So close home. Very effective prose. We need to curb curb sides.. More power to your pen Sir.
Thank you for sharing your article sir. It was truly inspiring to curb our practices. In present era of digital science doctors needed to guard themselves. Deep regards
Glad to get reminded sir. These often happen and one needs to develop a skill to say no.
So well written sir.. On a dilemma we encounter so frequently..
If you can write on how to deal with it .
A masterpiece in the series once again,Sir.
We have done and so often, still do casual consults on daily basis esp for friends and relatives.Take home is to avoid such curbside consults.If unavoidable,then reroute it to concerned spl or hosp.
An interesting and useful read for all medicos in this age of ulra communication through smart phones and social media groups. Every now and then we fall in trap due to our basic nature of helping the medical advice seekers ,who mist of the times are our friends and relatives and some times our colleagues too , with out thinking of legal consequences due to social compulsions. The article is useful to all medicos and we all are sometimes caught in inavoidable curbside consultations. Great article as always !
Your simple, clearly written and thought-provoking article is much appreciated! All of us face similar situations everyday. Social politeness shall remain a virtue, though due discretion becomes necessary during such casual consultations. A polite ‘no’ can save lives… is my takeaway!
Will eagerly wait for your upcoming paper!
Very elaborate. Covid 19 has increased the curbside consultation with masks on. Most of us do not know how to say NO without offending our friends and relatives. Thanks.
Excellent as usual. Clear messages with practical day to day examples. Keep writing. You have exceptional quality of clear communication
Fantastic account of trials, tribulations and dilemmas that face a medical practitioner today. Even more relevant in a closed loop society such as the Armed Forces! Completely related with the sentiment.
Sir, while you have devoted a part of your blog to Telemedicine, you, perhaps, should have included a specific paragraph on Whatsap gyan and consultation – and how they tend to go on endlessly.
Brilliant as always.
Very well written piece on a very pertinent issue with a dilemma so often faced by us medicos.I guess we need to be firm and say NO to curbsides
Excellent & lucid as it could have been.
Insightful & paradoxical.
Extremely important and contemporary topic. Thank you very much for writing on this topic to help us.
Warmest regards Sir.
Amazing and very apt blog Sir. Most of us are truly forced into Curbside Consultations. We must really learn to say a polite and firm ” No”. And, this thing needs to be taught to all medical students right from the beginning.
A great insightful read sir. Thanks.
Remarkably well expressed exact odd experiences most Indian doctors experience day in & day out!
Things to ponder:when a doctor treats a patient humanitarian approach is every time expected by the patient,presumed by the society & inherent to most doctors.His prescription & treatment become service not unlike any other professional services but is paid in pennies not in percentage like many other dignified services but
any adverse outcome is gauged with criminal law & is liable for capital punishment which probably is not the case with any other professional service!
High-time a doctor should always remember that doctor-patient relationship & any medical service should have no sentimental drive or personal relationship as a view-point.
Dear doctor,from patient’s view-point the fact he is asking for your advice/service it is implied that he is asking for professional service since you are a doctor.He doesn’t ask other neighbour or non-doctor-friend.He is ignorant about detailed history-taking & clinical-examination as necessary prerequisite for any treatment.High-time,my dear friend,to educate this lay person & express your limitations very politely in a language(tone & reasons)which he can understand well!
Thankyou sir.
As always, your wisdom and outlook inspire and definitely positively impact us.
Enlightened indeed, will definitely think ten times before asking for advice to doctors on the run. Blessings to your noble lot for all the good work.
Everyone thinks doctors are morally and socially bound to listen to them and answer where ever asked about their health problems. No one ever thinks of problems doctor can face . Stories are elucidated by AC as usual
Very insightful
Excellent write up.I fully agree with your professor : a ” casual consultation is just that ‐ casual.
Can we advice our own patients seen by us earlier personally, if they seek advice over phone?
Doctor Saab
Very good information better to say NO .
But in your article more female ,house wife,Lady Doctor,friends wife even chandigarh pedestrian who took advice from Neaurosurgeon…Bachara khaya pita kuch nahi glass phodha old Mumbai 😉 restaurant language. I personally feel patient will always go to clinic and tell his/her problem to Doctor to get best treatment.
Moral of the story:- next time I will come to Mumbai for my treatment……Doctor Saab.
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Excellent teaching for all doctors .Such things are not in Medical Colleges.Giving a message in stories will be always registered best in our brains.I have found “GAS” ,the biggest killer self diagnosis ,which stumped many docs too.After Covid crisis ,tele consultation is legalised and picture is very confusing.With people well armed with pulse oximeter,auto bp recorder and Google access.Steroids familiarity is a rampant and it is freely available without prescription outside Metro cities.Our responsibility and liabilty has not changed a bit.Again salute to Dr Anand for these distilled knowledge for our welfare.
It made great reading
Very well written dilemmas faced by the medical practitioner which needs attention to avoid legal issues
Excellent piece sir. Truly could identify with the dilemma we all face with casual consults every other day. Thanks for the insights!
Sir This grey area of casual is actually in minds of patients quite equated with ‘ insider trading’. Stock tips from brokers on casual terms. The problems stem when judicial overreach makes doctors liable. A consultation must be by proper appointment and documented, in person or through video conference. There must be monetary aspect, or it must be a state or 3rd party sponsored cover for it fiscally. Then only the court too should use the concept of consent and subject the doctors to liability for deficiency of care. That is why in the first case the judiciary exonerated the lady medical officer! In actual practise, I am sure, no doctor would exist who has not been waylaid curbside! Good read Sir as always!
Very well elaborated.,have taught to be careful @ casual consultation.,thanks for good article.
I have learnt so much from.this blog
.
It’s really an eye opener and.hearaftet nomore outside clinic consulting….thanks Depak for sharing..dr kiran somi
This article is an eye opener. Thank you for sharing it. I guess, as in all things in life, better to be safe than sorry. Borrowing a medical tenet… prevention is always better than cure. I infer here thatcaution and a courteous avoidance of curbside consultation is way better than a tedious court case and an unfortunate loss of brand value.
Thank you for re-opening our eyes
We are always happy to help with or without fees
Now that you have given such a lucid and clear message, we only have one thing to do……office consultation…..
For all other times….only answer we should give…..Please visit your nearest doctor…..I am not available at present
Good illustrations
Sir,
What a read! We need to say, “No means No”, more frequently! Waiting for more such pearls!
Sir , I am a dermatologist , people take the skin problems for granted , and take consultation on commute , or even while shopping – How to face them ?
It is very hearty to read but in spot it is difficult to act
But better to avoid curb consultation
It is an ubiquitous phenomenon with doctors . In recent years I learnt to say a clear “No” over Whataspp , phone , in person etc …. lost a numerous “friends”….. but no regrets .
As usual you have expressed it in your eloquent style sir. Will continue to look forward to your blogs. Regards
Eye opener we must learn to say No for curb side consultation
Dear Gen Anand, as usual you have presented excellent write-up for everyone associated with the field of medical science and also for patients!
I remember the recent case during pandemic of a doctor husband (MS Gen surgeon) giving injection of Diclofenac to his MD anaesthesia student wife for treating post covid myalgia leading to rare adverse reaction of anaphylactic shock taking her life! Of course this wasn’t a case of curbside consultation, but taking risk of injecting a drug (with some potential of precipitating ADR) at home instead of well equipped hospital!
As a physician, I can relate to this article much!! It is such an apt description of what happens in everyday life of a socially polite , practicing doctor!! Curbside consultations are so common that sometimes one doesn’t even realize you are providing a professional advise which could be taken to court given the strict laws that have been created against doctors!!
Drs Should be careful to tread this path!! Fantastic read and lesson to learn!!!
Jai Hind sir.
Superb article. Very common and very relevant. Politeness leading to such adverse situations. Not a happy moment for anyone, the doctor or the patient. But, this article makes us aware of such incidents and the outcomes.
Regards