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I've started to wonder recently if the e-consult will replace the curbside consult, and think in fact that this might actually be a really good thing.

For years, we've been buttonholing our colleagues and asking them for an opinion about a patient we are taking care of, without them formally getting involved. This has always been a big part of taking care of patients in the inpatient wards and, to a lesser degree, the outpatient world.

Across both of these settings, we sometimes need a little more help than we can get from a textbook or even an online resource, and we turn to our learned colleagues who have more experience managing these particular issues for recommendations on how to proceed next. It happens in the hallways of the hospital and clinic, on the phone and via e-mail, and sometimes actually at the curbside when you grab a colleague who is leaving work and desperately trying to get home at last.

It often comes down to, "I've tried A, B, C, and D, and I don't know what to do next; in your years of experience managing these kind of patients, what do you think I should try?" It's always kind of flattering to be curbsided, thinking that someone values your opinion and experience, but it's also always met with a little bit of trepidation.

I've heard of lots of situations where someone has offered up an opinion in the cafeteria of the hospital, only to discover later that their name and medical recommendations have been written down in a patient's chart, thus inexorably linking them to that patient they've never met as well as any subsequent outcomes, good or bad. The more we know and trust and work with each other, the better we are able to manage these, and the more likely we are to offer up our advice and suggestions. But there's certainly a limit to this, to how much we can offer expert advice when we don't actually "know" the patient.

The advent of new features of the electronic medical record has certainly created an opportunity for more involvement from peripheral specialties, without the need for formal office visit consultation. The e-consult creates a paradigm whereby a subspecialist can be asked a very particular question, and they can have all of our notes, medical records, lab results, imaging, and even photographs available for perusal, to help them come to the best decision. At that point they can offer up a recommendation, or say that they just don't have enough information to safely make any suggestions.

Missing from this, of course, is that specialist's own opportunity to query the patient about their symptoms, and to perform a physical exam and any additional testing that they feel may be warranted. But so far at least, for us, it's proved to be really powerful, and well taken up by a growing number of specialists as a model of providing great care. And since these encounters are billable, they often provide a really great avenue for patients to get great care without having to wait the long amount of time often needed to get in to see a specialist in their office.

I remember many, many, years ago there was a resident at our practice who used to stop in at various attending's offices while they were seeing patients and ask if they could "just run a case by you" to find out how you might manage this particular condition. "There's this patient I'm taking care of with recurrent sinusitis who has persistent symptoms -- which antibiotic would you choose if he's penicillin allergic?"

After this had been going on for many months, we discovered that they were doing this right before they went into the office of the attending who was supervising them for that practice session and presented those ideas and suggestions for management as their own. There's nothing wrong with seeking expert guidance, but those experts like their role in the process to be acknowledged, at least most of the time.

This all occurred in the days before online resources such as UpToDate® and others became ubiquitous, and for the most part first- and even second-level management plans can be worked out without the guidance of "experts." But sometimes we like to get a little bit of reassurance from someone with a little more experience in this particular clinical conundrum, a constellation of symptoms or a disease that we don't often see or manage ourselves.

The e-consult allows someone to make a measured set of recommendations, with the clear caveat that they have not seen and examined the patient on their own, but merely reviewed the medical record, and that they are going on faith that this is a fairly accurate representation of the true state of the clinical question.

In an ideal world, in a better healthcare system, all of our patients would have access to whatever we wanted them to get done to get them to a better state of health, right when we wanted it to happen. We wouldn't need laborious approval for a medication trial, or to argue with an insurance company about getting imaging that we think they need, and the wait to get in to see that famous sub-subspecialist wouldn't be 3 to 6 months or more.

Until that time comes, creating new ways to care for our patients, workarounds around the periphery such as the e-consult, may help our patients in ways we've only heretofore imagined.

, of Weill Cornell Internal Medicine Associates and weekly blogger for 番茄社区, follows what's going on in the world of primary care medicine from the perspective of his own practice.

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