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 good will 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: the attending physician is seen as the patient’s agent, with the delegated authority to hire other physicians on the patient’s behalf.

A physician who is requested to consult on a particular case that involves contact with the patient 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 not 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 explain the nature of 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 unreasonable. The consultant should 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 oversell the consultant’s services.

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 secondhand 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.