Abstract
Informal consultations are discussions between healthcare professionals outside of formal clinical settings. The process involves a physician directly involved in a patient’s care requesting informal advice or recommendations from a specialist, often an infectious disease colleague who is not directly involved in the patient’s care. Informal consultations are common in the daily practice of clinical infectious disease. When performed appropriately, these interactions can improve patient care, help build professional relationships, and foster business development. At the same time, informal consultations present challenges for busy infectious disease practitioners, including maintaining a high level of care, time constraints, documentation concerns, financial concerns, and potential legal liability. This paper reviews the prevalence, benefits, risks, and ethical implications of curbside consults in the practice of infectious disease.
Introduction
Informal consultations (often called “curbside consults” or “hallway consults”) refer to brief, informal discussions that take place without any direct involvement or contact with the patient (Table 1). This exchange is usually hinges on a question posed by the attending physician to the infectious disease (ID) consultant. The ID consultant is asked to give advice or make recommendations without formally consulting on the patient. The ID consultant does not physically see the patient, review the medical record, or document in the patient’s chart.
| No formal infectious disease consultation order |
| No chart review |
| No history obtained directly from the patient |
| No physical examination |
| No documentation in the patient’s chart |
| No billing |
Informal consultations are a common feature of contemporary medical practice. While these interactions can enhance clinical efficiency, knowledge sharing, and foster collegiality, they also raise concerns regarding patient care, time limitations, documentation, and medical–legal responsibility.
Advantages of Informal Consultations
Informal consultations are common because they can provide significant benefits to both the patient and the medical care providers (Table 2). The primary and most important benefit is improved patient care. Presumably, the inquiring physician requests an informal ID consultation because they do not feel completely confident in addressing an infectious disease issue. Through education, training and experience, the ID consultant is in a better position to provide reassurance that appropriate care is being supplied or to offer additional or different recommendations if necessary. This can sometimes be accomplished in a rapid and cost-effective manner through an informal consultation, without the time and expense associated with a formal consultation.
| Advantages | Description |
|---|---|
| Improved patient care | ID expertise helps ensure patients receive appropriate treatment when the primary physician lacks confidence or experience. |
| Reassurance | ID consultant confirms or refines care plans, boosting the inquiring physician’s confidence. |
| Business development | Trust built through informal consults can lead to formal referrals and practice growth. |
| Positive working relationships | Frequent collaboration fosters supportive, collegial ties among medical staff. |
An additional benefit to the ID consultant is the potential to develop business relationships to build one’s practice. In private practice, professional relationships serve as the fundamental building blocks of a referral-based business model. Informal consultations are highly valuable for fostering comfort and trust between referring and consulting physicians.
Aside from business development, informal consultations are an invaluable part of building good working relationships with other medical care providers. ID and other consulting services work with medical care providers in multiple medical specialties every day. Developing respectful and supportive working relationships with colleagues fosters a healthy and productive work environment, where colleagues feel comfortable requesting or providing assistance to each other [1].
Because of these benefits, informal consultations can be an appropriate use of an ID physician’s time and effort. In most cases, it is not good practice to refuse to respond to a request from an inquiring physician.
Disadvantages of Informal Consultations
Despite the benefits of informal consultations, there are also potential disadvantages that should be considered (Table 3). The limitations of informal consultations have the potential to negatively impact patient care and increase stress (given the additional time commitments), while also exposing the ID consultant to medical–legal risk.
| Disadvantages | Description |
|---|---|
| Improper or incomplete impressions | Advice may be inaccurate due to limited information. |
| Relying on inquiring physician for data | Critical details may be missed or omitted. |
| Confirmation bias | Tendency to favor information that supports existing beliefs, ignoring conflicting evidence. |
| Anchoring bias | Overemphasis on initial impressions, even if later evidence contradicts them. |
| Accuracy of provided data uncertain | Incorrect or incomplete data from the referring provider can misguide advice. |
| Lack of follow-up | Changes in the patient’s condition may not be communicated. |
| Time commitment | Requests can be frequent and time-consuming, especially with modern technology. |
| Immediate response expected | Pressure to answer quickly may affect quality of recommendations. |
| Financial considerations | Curbside consults are typically uncompensated. |
Potential Incomplete Recommendations
The most concerning potential disadvantage is that an informal consultation may result in incomplete or improper advice or recommendations. By definition, an informal consultation does not involve the ID consultant obtaining an in-person history, performing a physical examination, and undertaking a chart review. Instead, the ID consultant relies on the inquiring physician to provide the complete and accurate information necessary to make appropriate recommendations.
Taking a complete history is an art form, developed over time by training and experience. Further, relevant history is often specific to the medical specialty performing the consultation. A physician who seeks help but does not specialize in infectious disease may not obtain all significant historical information. Therefore, important subjective information can be missed or inaccurately relayed, particularly when passed from one person to another.
Similarly, performing a physical examination is a skill that develops with experience. A finding may not be appreciated by a less experienced physician or a physician in a different medical specialty. Further, important aspects of a physical examination may differ by medical specialty; a physical examination finding relevant to an infectious disease consultant may not seem relevant to a hospitalist or intensivist.
More concerning, the inquiring physician may inadvertently relay inaccurate information from a patient’s history, examination, laboratory results, or radiology results. For example, an inquiring physician might request an opinion on the appropriate antibiotic for a culture positive for Enterococcus, when the culture result was actually positive for Enterobacter.
Not surprisingly, the result of such a conversation can be incomplete, with inaccurate advice or recommendations from the ID consultant. Any ensuing harm would be through no fault of the ID consultant, who is responding to the information provided. However, that would be of little consolation if the patient does not receive the most appropriate care.
Lack of Follow-Up
An additional concern is that informal consultations often lack necessary follow-up mechanisms, risking patient safety. Things can change quickly in a hospital setting, with new information requiring alteration in a patient’s assessment and plan. An informal consultation may result in recommendations that are initially appropriate. However, because the ID physician is not formally consulting, they will typically not follow-up regarding the patient. The inquiring physician often does not want to continue to “bother” the ID physician, and therefore, may not provide updates regarding new information. Examples would include updated laboratory trends or microbiology results, new radiology results, and a patient’s response to recommended treatment. Without concurrent information, the informal consultant does not have the opportunity to adjust recommendations based on the most current information.
Time Commitment
Informal consultations can add substantial time commitments to an already busy schedule. Studies dating back decades have shown that ID is one of the most frequently requested specialties for informal consultation [1]. It is not uncommon for an ID physician to receive multiple requests weekly for informal consultation, which can add hours to an already stressful work week.
The number of requests for informal consultation has grown over time. Previously, an inquiring physician would need to physically see the ID consultant or try to contact them. Presently, it is much easier for inquiring physicians to request an informal consultation, since ID consultants now receive text messages or emails. However, a near immediate response is often expected.
The additional time commitment made necessary by regular informal consultation requests can negatively impact patient care, as well as physician quality of life. Time spent responding to informal consultation requests subtracts from time spent providing care to patients who are being seen for formal consultation and follow-up. Therefore, frequent informal consultations can add to an already high stress level, increase the risk of physician burnout and errors in judgment.
Documentation Concerns
Lack of documentation is an additional disadvantage of informal consultations. By definition, the informal ID consultant does not document his involvement in the patient’s chart. However, the inquiring physician may document that they discussed the case with the ID consultant and that recommendations were made. If incomplete or inaccurate information was provided to the consultant, leading to incomplete or inaccurate recommendations, the problem may be further compounded: other physicians may rely on that documentation to the detriment of the patient.
Financial Considerations
Although not a primary concern, it is noteworthy that informal consultations are, by definition, not compensated. Frequent informal consultations reduce the time available to perform duties for which compensation is available. In a 1-year prospective study, Grace et al. (2010) reported an estimated US $93,979 (2480 work relative value units [wRVU]) lost in inpatient and outpatient curbside initial and follow-up consultations [2]. In a rebuttal, Stemer (2011) suggested that the method of valuation was flawed because each curbside consultation probably consumed no more than 7 minutes, and it may not be realistic for a complex consultation [3]. It is difficult to ascertain the specific monetary value of time spent on a curbside consultation, but there is likely some financial value that is lost.
Medical–Legal Considerations
In addition to the disadvantages already discussed, informal consultations may subject the ID consultant to the risk of medical–legal liability. This concern is obviously secondary to providing appropriate patient care. However, medical negligence litigation represents a significant concern for physicians, posing financial and psychological challenges. Even a single lawsuit can lead to financial losses, anxiety, and reputational damage that can be difficult to overcome. Because litigation is a slow-moving process in many jurisdictions, the anxiety, frustration, and reputational concern caused by these factors can go on for years, negatively impacting the provider’s professional and personal life. The risk of litigation derives, in part, from the nature of the informal consultation. As discussed, despite the benefits of informal consultations in appropriate cases, there are certain unavoidable risks, including the possibility of basing decisions on incomplete or inaccurate information, the lack of follow-up, and documentation concerns.
The nature of documentation regarding an informal consultation is particularly worrisome. While the informal consultant cannot document information via the patient’s chart, the inquiring physician may document the informal consultation. The informal ID consultant has little or no control over how the inquiring physician documents the encounter, whether the inquiring physician understands the recommendations, whether the inquiring physician will implement the recommendations, or whether the inquiring physician will follow-up by providing the consultant with additional relevant information as it becomes available.
State laws regarding legal liability for informal consultations are variable and case-specific [4,5]. There is no bright-line test that can be used to give a definitive answer as to whether an informal consultation might give rise to legal consequences. Because a detailed 50-state analysis of state laws on informal consultations is beyond the scope of this article, we provide a general outline of the legal landscape on this issue.
In any medical negligence lawsuit, a plaintiff must establish that a defendant (1) owed a duty of care to the patient, (2) that the duty was breached by a violation of the standard of care, and (3) that an injury and damages resulted from that breach. At issue regarding informal consultations is whether the informal ID consultant owed a duty of care to the patient. Without a legal duty to the patient, there can be no legal liability.
In a majority of states, duty attaches through the establishment of a physician–patient relationship. Put another way, in the absence of a physician–patient relationship, a physician is protected from medical malpractice liability [4]. A physician–patient relationship is often defined as a consensual relationship in which the patient knowingly seeks the physician’s assistance, and the physician knowingly accepts the person as a patient [6]. When an ID physician agrees to perform an informal consultation, the patient typically has no knowledge that the ID physician is providing assistance. Therefore, in theory, there is no physician–patient relationship and no duty of care owed to the patient, which should prohibit legal liability.
Unfortunately, state courts have established numerous exceptions to the requirement of a physician–patient relationship in order to establish a duty of care [4]. Those states typically reason that circumstances create an “implied” or “special” physician–patient relationship. Such circumstances may include the following:
- The informal consultant should have reasonably expected the inquiring physician to rely upon and follow the recommendations.
- The informal consultant provided specific advice that influenced treatment decisions.
- The informal consultant was supervising the inquiring physician (e.g., a resident or fellow)
- The informal consultant was the “on-call” physician for his group or the hospital, and as a result, they were obligated to respond to the request for an informal consultation.
- The informal consultant was obligated to respond to the request for an informal consultation pursuant to a contractual agreement with the hospital or with a managed care organization.
[4]
In summary, regardless of the jurisdiction, there are no guarantees that an informal consultation will not subject an ID physician to litigation and potential liability. As a result, ID physicians performing an informal consultation should assume that their involvement could potentially lead to their involvement in litigation.
Discussion and Recommendations
Like most things in medicine, informal ID consultations carry advantages and disadvantages. On balance, the potential benefits outweigh the risks when consultations occur appropriately.
When asked to perform an informal consultation, ID physicians can implement certain risk-reduction strategies to minimize the inherent risk.
- Clarify: General Discussion or Specific Patient?
It is important to clarify if the inquiring physician is asking about a general medical topic or a specific patient under his or her care. A legal duty of care is much less likely to be established if an informal consultant is providing general medical advice for purposes of education and training regarding how a particular condition might be diagnosed and/or treated [7]. By contrast, a legal duty of care is more likely to attach if the topic is a specific patient.
- Discuss Ordering a Formal ID Consultation
If practical, an ID consultant should discuss entry of an order for a formal ID consultation. This is the safest way to eliminate many of the concerns inherent to informal consultations. For the reasons discussed earlier, it is usually preferable to obtain information firsthand from chart review, history, and physical examination, and subsequently use that information to determine the most appropriate course of action. This ensures that the ID consultant has access to complete and accurate information upon which to make recommendations. It also allows for follow-up throughout the admission, and beyond, if necessary. Finally, it allows the ID consultant to enter their own documentation, avoiding the risk of confusion and mis-characterization of the recommendations when other medical care providers review the infectious disease care.
Frequently, an inquiring physician requests an informal consultation because they are concerned about encroaching on the ID consultant’s time and/or concerned that the need for assistance reflects poorly on their own knowledge and decision-making. Understanding this perspective can frame your approach to the conversation. Providing reassurance that seeing the patient is worthwhile for both you and the patient and not unduly burdensome can significantly impact the way referring providers feel in requesting your opinion. Remember that all questions are valid, and what may seem like a simple question to you may warrant a more nuanced answer. For instance, a consultation for a recurrent urinary tract infection with mixed bacterial flora may lead to the diagnosis of a colovesical fistula that was previously unrecognized.
Thoughtful explanations can alleviate the referring provider’s concerns regarding the initial questions posed and provide reassurance that the initial question was appropriate and valid. Engaging in informal conversations that culminate in formal consultations can be a highly effective strategy for demonstrating your comprehensive expertise and establishing trust with the referring providers when executed appropriately.
Evaluating these patients in a timely manner also provides reassurance that seeking your formal opinion will not delay care. On the contrary, by minimizing the risk of acting on incomplete or incorrect information, a formal consultation may expedite the implementation of an appropriate and comprehensive treatment plan for the patient.
Conclusions
Informal consultations are an increasingly common feature of contemporary medical practice. Such consultations will continue to be a regular part of an ID physician’s practice. When handled appropriately, there can be significant benefits, such as improved patient care through more timely diagnosis and treatment, cost efficiency, education of non-infectious disease providers, and practice-building among colleagues. However, informal consultations also raise concerns regarding patient care, physician time constraints, and medical–legal responsibility. The strategies outlined herein can be implemented to maintain the potential benefits while reducing the risks. In appropriate cases, with safeguards, the benefits of informal consultation outweigh the potential concerns. Therefore, ID consultants should remain open to discussion with colleagues and provide assistance when appropriate, while taking measures to reduce risk.
Author Contributions
All authors contributed to writing, reviewing and editing of this project.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
References
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- See, eg, Reynolds v. Decatur Memorial Hospital, 277 Ill.App.3d 80, 660 N.E.2d 235, 239 (4th Dist. 1996). Available online: https://www.quimbee.com/cases/reynolds-v-decatur-memorial-hospital (accessed on 1 October 2025).
- See, eg, Hill v. Kokosky, 463 N.W. 2d, 265 (Mich Ct. App. 300) (1990); Ranier v. Grossman, 107 Cal. Rptr. 469, 472 (Cal. Ct. App. 1973). Available online: https://case-law.vlex.com/vid/hill-by-burston-v-886952870 (accessed on 1 October 2025).
