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The Consultant-Patient Relationship

Traditionally, the consultant relationship is seen as a physician-to-physician relationship, a view that derives from the business side of consultant practice. Until the recent growth in managed care plans, consultants were dependent on the goodwill of attending physicians for referrals. Specialists who took patients from primary care physicians by turning consultations into referrals saw their consultations dry up, as did those who questioned the probity of the attending physician's care of the patient. The law, however, insists that the consultant's primary duty is to the patient, not the treating physician.

A physician who is requested to consult on a particular case must first establish a physician-patient relationship with the patient--usually accomplished by an introduction to the patient and an explanation of the consultation requested. A consultant should never assume that the patient has consented to the consultation simply because the attending physician has requested it. Consultants should not rely on blanket consents such as those that authorize treatment from "Dr. Smith and other physicians he or she may designate." Although these are adequate for radiology and pathology consultations and others that do not require direct patient contact, they should be avoided by other consultants. Observing the courtesy of consultation is important. Treating the patient rudely increases the probability of a lawsuit if anything goes wrong and will encourage the patient to refuse to pay for the consultant's services if they are not fully covered by insurance.

The consultant should discuss with the patient what has been said about the consultation and any tests or procedures that will be done. It is wise to make sure that the expectations of the patient and the attending physician are not too high. The consultant should give the patient any additional information that may be needed but dissuade the patient from the idea that specialists can work miracles. A patient who has a close and long-standing relationship with his or her attending physician is likely to blame the impersonal consultant for problems that arise. This is sometimes implicitly encouraged by attending physicians, who may raise patient expectations unreasonably.

Consultants should do a complete evaluation of the case as soon as the patient accepts the consultation: reviewing the patient's chart, examining the patient fully, and talking with both the patient and the attending physician. Relying on information gathered second hand is dangerous. The assumption in bringing a consultant into a case is that the attending physician is not as skilled or as knowledgeable about the problem as the consultant. This makes it unacceptable to rely entirely on the history and physical in the chart. Items critical to the specialty consultation should be verified by the consultant.

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