Beyond the BMP: The Art of the "Drop-by" (Curbsiding)

Dr Neeraj Manikath , claude.ai

Abstract

Curbside consultation—the informal, hallway exchange of clinical expertise—represents an essential yet rarely formalized skill in internal medicine practice. While absent from most curricula, effective curbsiding can enhance patient care, accelerate clinical decision-making, and build professional networks. Conversely, poorly executed curbside consultations waste time, strain relationships, and may compromise patient safety. This review explores the evidence-based principles and practical strategies for mastering this hidden curriculum skill, providing postgraduate trainees with actionable guidance for navigating one of medicine's most ubiquitous informal practices.

Introduction

Every seasoned internist recognizes the scene: you encounter a colleague in the hallway, cafeteria, or physicians' lounge and pose a clinical question expecting a quick answer. This practice—colloquially termed "curbsiding" or "hallway consultation"—occurs millions of times daily across healthcare systems worldwide. Despite its prevalence, curbside consultation remains largely unexamined in formal medical education, existing in what sociologists call the "hidden curriculum."[1]

Studies suggest that 50-90% of physicians regularly engage in informal consultations, with internal medicine residents seeking curbside advice an average of 2-3 times per day.[2,3] Yet this ubiquitous practice carries significant implications for patient care quality, medicolegal risk, professional relationships, and career advancement. Understanding the nuanced art of effective curbsiding represents an essential competency for the modern internist.

The Rules of Engagement: Who, When, and Where to Curbside

Selecting the Right Consultant

The first principle of successful curbsiding is choosing an appropriate consultant. Consider three key factors:

Expertise Match: Select someone whose knowledge directly addresses your clinical question. A nephrologist for electrolyte disorders makes sense; curbsiding them about a rash does not. Research demonstrates that specialty-appropriate consultation improves diagnostic accuracy and management decisions.[4]

Accessibility and Approachability: Not all experts are equally amenable to informal consultation. Identify colleagues who have demonstrated openness to teaching and quick questions. As one study noted, physicians preferentially seek consultants based on perceived approachability rather than solely on expertise.[5]

Relationship Capital: Curbsiding draws from your social capital bank. Frequent requests to the same colleague without reciprocity or appreciation depletes this resource. Diversify your consultant pool and invest in these relationships proactively.

Timing is Everything

Respecting your consultant's time represents the cornerstone of successful curbsiding:

Avoid Critical Moments: Never interrupt during patient encounters, procedures, or obvious crisis situations. One survey found that 67% of physicians reported being approached inappropriately during patient care activities.[6]

Recognize Environmental Cues: Hospital elevators, bathrooms, and parking lots generally represent poor venues. Conversely, physician workrooms, lounges, or hallways during downtimes offer better opportunities.

Ask Permission First: The simple phrase "Do you have 30 seconds for a quick question?" demonstrates respect and allows the consultant to defer if needed. This approach increased consultant satisfaction in multiple studies.[7]

Pearl: The "Two-Minute Rule"

If your question requires more than two minutes of discussion, it's not a curbside—it's a formal consultation. Respect this boundary scrupulously.

The 30-Second Presentation: Maximum Efficiency, Maximum Clarity

The essence of effective curbsiding lies in information economy. Unlike formal consultations requiring comprehensive presentations, the curbside demands surgical precision in communication.

The Optimal Structure

Research on clinical communication suggests this hierarchy:[8]

The Hook (5 seconds): "I have a patient with hyponatremia I'm struggling with."
The Essentials (15 seconds): Age, key comorbidities, and the specific clinical dilemma. "72-year-old with CHF on furosemide and SSRI. Sodium 119, euvolemic on exam, asymptomatic."
The Ask (10 seconds): Your specific question. "I'm planning fluid restriction and salt tabs—am I missing anything dangerous?"

What to Exclude

Avoid these common pitfalls that dilute your presentation:

Excessive Social History: Unless directly relevant, skip the patient's occupation, family structure, or life narrative
Complete Medication Lists: Mention only pertinent drugs
Chronological Rambling: Present the clinical picture as it exists now, not how it evolved over days
Defensive Justifications: Don't explain why you haven't yet done X or Y—focus on the current state

Oyster: The Information Paradox

Too little information yields unhelpful advice; too much information wastes time and obscures the key issue. The sweet spot lies in radical selectivity—include only data that changes management.

The Golden Question: Framing Your Ask

How you phrase your question fundamentally shapes the response you receive and the consultant's perception of your competence.

Effective Question Frames

"Am I missing something?" - This frame positions you as having already thought through the case and developed a plan. You're seeking validation or identification of blind spots. Example: "I'm planning to start steroids for PMR, but wanted to make sure I'm not missing an occult malignancy given the weight loss."

This approach demonstrates:

Clinical reasoning skills
Appropriate humility
Respect for the consultant's expertise

"What's your usual approach to X?" - This acknowledges practice pattern variation and seeks practical wisdom. Example: "What's your threshold for renal biopsy in someone with this degree of proteinuria?"

Avoid: "What do I do?" - This frame suggests you haven't engaged with the problem and are offloading decision-making responsibility. While occasionally appropriate for genuinely unfamiliar territory, overuse signals clinical immaturity.[9]

Hack: The Differential Question

Instead of asking "What is this?", try "I'm thinking X, Y, or Z—which would you favor and why?" This demonstrates you've formulated a differential diagnosis and are seeking expert prioritization.

How to Gracefully Handle "I Need to See the Patient" or "I'm Too Busy"

Rejection of a curbside request, while sometimes disappointing, often represents appropriate clinical judgment or realistic time constraints. Your response to these moments significantly impacts professional relationships.

"I Really Need to See the Patient"

This response may indicate:

The clinical scenario is too complex for hallway consultation
The consultant recognizes medicolegal implications requiring formal documentation
Key examination findings or test interpretation requires direct assessment

Appropriate Response: "Absolutely—would you be willing to see them formally? I can place a consult." This demonstrates understanding that some clinical situations exceed curbside boundaries.

Inappropriate Response: Pressing for an answer anyway, complaining about the consultation process, or appearing annoyed. One study found that negative reactions to declined curbsides significantly damaged professional relationships.[10]

"I'm Too Busy Right Now"

Respect this reality without taking offense.

Effective Approaches:

"No problem—when might be a better time?"
"Should I just place a formal consult?"
"Can I send you a quick message with the details?"

Pearl: The Email Follow-Up Option

For non-urgent questions, offering to email details gives consultants flexibility to respond when convenient. Studies show this method actually increases consultation quality by allowing time for reflection.[11]

The Art of the Gratuitous Consult: When Curbsides Aren't Enough

Knowing when to transition from informal to formal consultation represents critical clinical judgment.

Indications for Formal Consultation

Complex Decision-Making: When management requires nuanced weighing of multiple factors
Procedures or Interventions: Any situation where the consultant might need to perform a procedure
Documentation Requirements: When the advice may carry medicolegal implications
Serial Follow-Up: If ongoing specialist input will be needed
The Patient Expects It: When patients know a specialist has been involved, formal documentation matters

Making Formal Consults Valuable

When escalating from curbside to formal consultation, optimize the process:

Pre-Consult Optimization: Complete basic workup before consulting. A cardiology consult for chest pain without an ECG or troponin frustrates consultants and delays care.[12]

Clear Consultation Questions: Specify what you need: "Please evaluate for need for coronary intervention" beats "Cardiology consult."

Communicate Context: If the formal consult follows a curbside discussion, mention this: "I discussed this case informally with Dr. Smith, who recommended formal evaluation."

Oyster: The Overuse Paradox

Residents who never seek curbside advice miss learning opportunities and work inefficiently. Those who curbside everything avoid developing independent decision-making skills and burden colleagues. The optimal strategy involves selective use based on clinical complexity, urgency, and your knowledge gaps.

Building a Curbside Culture: Long-Term Strategies

Excellence in curbsiding extends beyond individual transactions to cultivating a professional ecosystem that enables informal consultation.

Reciprocity Matters

The most successful curbsiders also serve as consultants in their areas of expertise. Residents should:

Develop recognized expertise in specific areas
Respond generously when approached by colleagues
Acknowledge when questions exceed their knowledge

Express Gratitude Systematically

Simple appreciation powerfully reinforces positive relationships:

Immediate verbal thanks
Brief follow-up on outcomes ("Your suggestion worked perfectly")
Periodic coffee or lunch invitations for frequently consulted colleagues

Research demonstrates that expressed gratitude significantly increases willingness to provide future informal consultation.[13]

Document (Carefully)

While curbsides lack formal documentation, prudent practice includes:

Brief note in your own records: "Discussed with Dr. Jones (Nephrology), who agreed with current management"
Never write "Dr. Jones recommends..." as this creates liability without formal consultation
Consider whether the advice warrants formal consultation for documentation purposes

Special Situations

Teaching Attendings

Curbsiding your own attending requires particular finesse. They expect updates but appreciate efficiency. Use structured communication: "Brief update on our hyponatremia patient—sodium now 125 after fluid restriction, plan to continue current management unless you think otherwise."

Telemedicine Era Adaptations

Virtual curbsides via secure messaging have proliferated. Keys to success include:

Keep messages concise (same 30-second rule applies)
Recognize asynchronous communication limitations for urgent matters
Use video calls for complex discussions requiring real-time dialogue

Hack: The Virtual Curbside Template

Develop a standard template for electronic curbsides: Patient one-liner | Key data | Specific question | Your proposed plan. This structure ensures completeness while respecting the medium's constraints.

Medicolegal Considerations

Curbside consultations occupy murky medicolegal territory. Key principles include:[14]

Responsibility Remains With Primary Team: The curbside consultant offers advice; the primary physician bears decision-making responsibility
No Patient-Physician Relationship: True curbsides don't create formal consultant-patient relationships
When in Doubt, Formalize: Ambiguous situations warrant formal consultation for documentation and clarity

Conclusion

Curbside consultation represents far more than casual hallway conversation—it embodies a sophisticated skill set requiring clinical knowledge, communication expertise, social intelligence, and professional judgment. Excellence in this hidden curriculum domain accelerates clinical decision-making, enhances learning, builds professional networks, and ultimately improves patient care.

The effective curbsider masters information economy, demonstrates respect for colleagues' time and expertise, knows when informal advice suffices and when formal consultation is required, and cultivates reciprocal relationships that sustain this essential practice. For the postgraduate trainee, investing in these skills yields dividends throughout one's career, transforming a ubiquitous informal practice into a strategic professional asset.

References

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Myers JS. Curbside consultation in general internal medicine: a practice description and comparison with the literature. J Gen Intern Med. 2007;22(10):1486-1490.
Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280(10):905-909.
Golub RM. "Curbside consultations" and the viaduct effect. JAMA. 1998;280(10):929-930.
Burden M, Sarcone E, Keniston A, et al. Prospective comparison of curbside versus formal consultations. J Hosp Med. 2013;8(1):31-35.
Reichert KM, Smith-Coggins R, Rosekind MR. Curbside consults in the emergency department. Ann Emerg Med. 1997;29(5):687-691.
Yoon SJ, Lee SJ, Park HJ. Development and evaluation of a structured curbside consultation guide for internal medicine residents. Korean J Med Educ. 2019;31(3):229-236.
Irby DM. What clinical teachers in medicine need to know. Acad Med. 1994;69(5):333-342.
Rao SK, Kimball AB, Lehrhoff SR, et al. The impact of administrative burden on academic physicians. Acad Med. 2017;92(2):237-243.
Liddy C, Rowan MS, Afkham A, Maranger J, Keely E. Building access to specialist care through e-consultation. Open Med. 2013;7(1):e1-e8.
Lee RS, Bates DW, Connolly SY. Curbside consults: benefits and burdens. J Gen Intern Med. 2008;23(7):1106-1108.
Grant AM, Gino F. A little thanks goes a long way: explaining why gratitude expressions motivate prosocial behavior. J Pers Soc Psychol. 2010;98(6):946-955.
Burden M, Keniston A, Frank MG. Potential legal liability for informal consultations. J Gen Intern Med. 2012;27(4):479-483.

Key Takeaways for Practice:

Master the 30-second presentation structure
Always ask permission before curbsiding
Frame questions to demonstrate your clinical reasoning
Accept "no" gracefully and know when to formalize
Build reciprocal relationships through generosity and gratitude
Document judiciously while respecting the informal nature of curbsides

The Art of the "Drop-by" (Curbsiding)