|Year : 2017 | Volume
| Issue : 3 | Page : 211-214
Curbside (Corridor to the E-corridor) consultations and the dermatologists
Karalikkattil T Ashique
Department of Dermatology, KIMS AL SHIFA Super Speciality Hospital, Perinthalmanna, Kerala, India
|Date of Web Publication||11-May-2017|
Karalikkattil T Ashique
Consultant Dermatologist, Department of Dermatology, KIMS AL SHIFA Super Speciality Hospital, Perinthalmanna, Kerala - 679 322
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ashique KT. Curbside (Corridor to the E-corridor) consultations and the dermatologists. Indian Dermatol Online J 2017;8:211-4
|How to cite this URL:|
Ashique KT. Curbside (Corridor to the E-corridor) consultations and the dermatologists. Indian Dermatol Online J [serial online] 2017 [cited 2019 Jul 21];8:211-4. Available from: http://www.idoj.in/text.asp?2017/8/3/211/206124
“Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.” - William Osler
It is a normal thing these days, for any medical professional to be encountered by people “out of the blue,” be it friends, relatives, or even strangers, and asked to prescribe medications for “that illness” which they have been carrying along since ages and were too busy to go and consult a doctor. There would hardly be a medical professional, irrespective of their years of experience, who would not have experienced this situation.
Such a request is often made at odd places like a super market aisle, hospital car parking area, cafeteria, elevator, social gatherings, and even funerals. It is all the more common in India, where majority medications are available over-the-counter, and pharmacists are liberal with refills, not asking for a proper prescription. Needless to say, such a trend has fostered the misuse of topical preparations especially corticosteroid containing formulations.,
| Problem Statement (Scope of the Problem)|| |
Curbside consultation (CC) is quite embarrassing, irritating, and often gives very less professional satisfaction to the people who are serious about their job. CC need not be limited to the patients alone, it can even be between professional colleagues about their own or relatives' illness and even about the patients being co-managed.
Why does this happen?
It happens mainly because people underestimate the importance of a serious clinical consultation, especially when the problem is 'only skin deep,' and also because they are often able to get away with it. Another reason is the mistaken view that the treatment of skin ailments is all about scribbling something (some “ointment”) on a chit of paper with minimal history and examination whatsoever. In a personal one-to-one survey among colleagues at work (ranging from emergency physician to cardio thoracic surgeon), I observed that the dermatologists are probably one of the worst hit from the CC point of view (author's personal experience).
| E-corridor|| |
This is the latest entree on the block and even more bothersome. The information super highway (the World Wide Web including but not limited to the various social networking platforms) has opened up a new arena for CCs. This area could be christened the “e-corridor consultation” (ECC). This includes the consults done on WhatsApp ™, Facebook ™, SMS (short messaging services), or even email (with or without images) to substantiate the conversation. The electronic consults are often the first presentation to the consulting dermatologist. These tend to be even more confusing and cumbersome. Often, only investigation reports are provided and one is expected to dole out a diagnosis, treat, and even prognosticate sans any relevant history or clinical examination. More often than not, the digital photographs of skin lesions taken by the patients themselves, are blurred, over focused, or underexposed. Based on such substandard photography, the dermatologist is expected to provide solutions. To complicate matters further, photographs of modified dermatoses (shot after some application) may also be provided and an outcome expected.
To our understanding, the principal reason behind such ECC is the inherent technological features of social media, which aid and abet invasion of privacy. Social networking platforms such as WhatsApp have an inbuilt feature, where a number once saved in the phone's contact list becomes automatically visible in the network contacts. This leads people to believe that it is acceptable behavior to get into conversation with anyone through social network apps without even bothering to check if the other person is comfortable with the exercise.
Physicians tend to share personal cell phone numbers with the patients out of compassion; however, this is not taken in the right spirit by some people. Many patients believe it to be normal and acceptable to call their doctor about dietary advice, skin pigmentation (hypo or hyper), clarifications regarding the medicine prescribed ages ago, etc. These are just some of the common queries that I personally have encountered. Professionally, we may agree that it is often the rich, powerful, or famous people (who are supposedly busy enough to have time to visit their doctor) who tend to be the worst offenders when compared to the illiterate, poor, or the genuinely deserving. Having said that, I would like to reiterate that NO doctor would/should hesitate to attend to a true emergency at any time of the day, provided, it has presented in person.
| Points to Ponder|| |
Hit some, miss many more
The lay public is generally unaware of the fact that the time spent in a doctor's chamber is the time where a lot of things are analyzed and evaluated by the doctor before he comes to a conclusion. Writing the medicine is probably the least time consuming thing for a doctor. The dialogue and elicitation of history are completely overlooked when we bypass the systematic approach by consulting on a social network, even if it is on a one-to-one basis. The chances of misdiagnosis and mismanagement are likely to be much higher in such situations. It is difficult to ask all the questions at a hurried/quick consultation and some may even be uncomfortable and embarrassing at times.
There are certain facts that the physicians have to keep in mind before embarking on to “help someone by which he/she doesn't lose anything.” From the patient's point of view, he has got what he wanted – a consult from the doctor for the illness. However, we do not realize that the prescription given thus are often incomplete and may not guarantee complete satisfaction. Needless to say, the patient will go to another doctor and most likely cite the previous doctor's medications [sourced online] as having failed to work. Thereby, the “helper” becomes “helpless” as he failed to treat adequately in the first place. To cite common examples, a dermatophyte infection on an atypical site can be mistaken as nummular eczema, if classical sites are not examined. A Hansen's disease patch could be missed and mismanaged as any hypopigmented or inflammatory dermatoses; and such scenarios could be disastrous for the patient in the long run. There are too many similar examples, where even the most brilliant physician could err, if proper time is not spent on history taking and examination. This is why I would like to be on the defense, comparing a quick curb side consultation in odd places vis-à -vis a professional office milieu.
The absence of a true consultation setting, lack of privacy, and access to earlier medical records and most importantly, the inability to perform a complete physical examination makes the physician execute the job half-heartedly and less professionally.
Are they really worth it?
The prescriptions given in the corridor or even the social networks are most of the time not fully honored or adhered to. The time and efforts of the physician are mostly wasted. The chances for review/follow-up are also not very high as the patient does not realize the importance of a serious consultation. The patient may follow the prescription partially or may choose one item according to his fancy, from those prescribed. This is a situation that a sensible physician would never like to confront.
Legal strings attached
From the legal point of view, there are a lot of gray areas and an element of risk is always present. For example, a drug rash left unattended can sometime be fatal if missed or misdiagnosed as a viral exanthem. The legal responsibility of the doctor could be the same over the phone as it is with a personal consultation. The doctor may be held legally responsible for the phone consultation, depending on the merit of the individual case, as felt by the court. However, there is paucity of literature from the Indian subcontinent on this matter. With medicolegal suits being filed to the tune of crores of rupees, in a setting where there is meagre coverage by protective medical insurance, unlike the west, there are serious professional risks attached to such consults. Some health personnel may land up in medicolegal arena while obliging or helping someone over a nagging ECC. Giving treatment advice on telephone/WhatsApp/SMS/emails must be avoided, except in cases of grave emergencies where the emergency has to be clearly recorded and signature of the attended to be obtained. The law pertaining to these aspects is not clear in India. Under the Indian Medical Council Regulations, 2002, every doctor is bound to give medical advice after physically examining the patient. Thus, insist on the physical presence of the patient. It is mandatory to record on proxy prescriptions that the patient should be physically bought for evaluation at the earliest. Prescribing in a casual manner, without referring to the relevant medical records of the patient, is deemed to constitute medical negligence.,
CC between colleagues about the cases they are co-managing involves the infectious disease specialists mostly. It invites legal tangles if something goes wrong at a later time. All such informal communications are left undocumented with possible loopholes that may backfire.
A study conducted by Mayers et al. showed that almost half of the unofficial consultations between physicians with regard to infectious diseases were tedious and most interestingly, ineffective and inefficient.
In a study assessing ethical issues involved in this process, it was suggested that as long as the informal consultation does not entail any danger to the patient or others, the service provider may oblige. However, on the contrary, if it is a reportable infectious disease posing a serious danger to the patient or the community, the physicians should refrain themselves from doing it. In yet another opinion, physicians have been warned from accepting friend requests and allowing patients to connect via social networking sites.
| Do we Have a Way out? Who Will Bell the E-consult Cat?|| |
When and where to draw the line, is totally within the physician's purview. Not willing to do a curbside consult is in a way rude, but one has to consider all the factors before taking a decision. On a personal front, when I am sent a clinical image or a report on the electronic media and am asked to comment or suggest treatment, I bluntly refrain from going further if I find that the disease needs a serious consult and a detailed examination by a specialist. I ask them to either see me in the consulting room or guide them to a specialist in their vicinity. This has been at the cost of making a lot of enemies or at least inviting comments that I am “rude and arrogant.” But I find that my conscience is clear and I could sleep well with the sense of having done no wrong. I have also had instances where close relatives and friends pressurized me to write some medicine and I found that prescribing inert medication is practical to tide over such situations.
| Solutions (Ten Commandments/Talisman)|| |
- Hospital Staff (Medical or Paramedical) asking for a CC is quite normal. One reason they attempt this is because they may have to go through a financial strain for a proper consult and may incur an economic burden in spite of being an employee in the same institution. It has been proposed way back in 1958 that creation of an employee health program in an institutional set up is the best option to provide fringe benefits to the less paid, frequently ill and/or the physically challenged employee. This actually benefits the institution and improves the quality of life of the health provider machinery (be it medical, paramedical, or even nonmedical staff) who may otherwise be harboring serious infectious diseases that can be transmitted to the patients and even colleagues. It also promotes a sense of belonging towards the institution, in the employee. Over years, this has been implemented in many hospitals across the globe positively
- Always encourage the patients to communicate by mail rather than by Whatsapp or other phone-based applications. Unlike emails, these apps create expectations of immediate response, as the sender is aware whether the recipient has seen the message or not
- Maintain a separate phone number for social networks. However, this may not be a very comfortable idea especially to those who are not very keen on using more than one phone. It would be ideal to route all phone calls to the office landline and these can be screened by an assistant, and then directed to the consultant. Handing over one's personal phone numbers is inevitable sometimes, but the do's and don'ts need to be put across gently and firmly, right at the beginning. Rescheduling appointments is one such thing that can be done on phone and often wins the confidence of the patients
- Ask them to text and inquire about the right time to speak and then one can revert accordingly. One could even give a different number for telephonic conversation at a particular time
- Direct people to authentic websites for their queries, rather than trying to clear all the doubts yourself. There are chances of the answers being incomplete and we may end up giving incorrect/incomplete information due to haphazard reading and lack of time
- Prescribe medications keeping in mind the principle of “primum non nocere.” Always prescribe innocuous medications such as calamine lotion, and white petroleum jelly. outside personal consults
- A patient who genuinely needs a verbal order from you can reach a nearby chemist to whom the doctor can directly dictate the drugs in addition to a typed message sent on the phone to the pharmacist who can comprehend the orders better than the patient. This avoids errors in interpretation
- Write down the drug on a paper in CAPS (even if it is calamine lotion for that matter) and take a screenshot, and send it across to people rather than verbal dictations to avoid sound-alike and look-alike drugs and the errors they invite
- Leave a rider that there are limitations and nothing can match or equate a formal consultation in the office. Nevertheless, this may not hold much water in the court of law
- Refrain from commenting or prescribing beyond one's domain for obvious reasons.
| Way Forward|| |
There exists a difference of opinion regarding corridor consults as well as the ethical issues in treating a friend or family member after the office hours.,
All said and done, CC and ECC are here to stay in the coming times, if not left open wider. It's up to the conscience of both the seeker and the provider to decide, whether it is alright to go ahead with the consult, and when to draw the line, deciding how much is too much.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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