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Release: July 24, 2000

Note to editors: The Archives of Family Medicine article cited can be accessed at

Outcome of physicians' e-mail consults depends on questions

IOWA CITY, Iowa -- When primary care physicians have questions about how to care for a patient, they often use "curbside" consultation -- informal discussion typically in person or by phone with a specialist -- to get advice. These informal consultations can save a patient from having to visit a specialist for a formal consultation, saving the patient time and money. However, it has not been clear how primary care physicians can make the best use of this important medical resource.

A recent University of Iowa Health Care study sheds light on the informal consultation process and reveals ways primary care physicians might make better use of these consults. Based on the UI Hospital and Clinics' innovative E-mail Consultation Service, the study specifically found a link between how primary care doctors structured their questions in e-mails and whether specialist consultants answered the questions without requesting a formal consultation. The findings were published in the June issue of the Archives of Family Medicine.

The researchers found that well-structured questions were those that clearly identified the treatment the primary doctor was proposing to use and the desired outcomes they hoped their patient would experience, said George Bergus, M.D., UI associate professor of family medicine and the study's lead investigator and primary author.

"When both components were present, primary care doctors had successful outcomes from their curbside consultations 90 percent of the time," Bergus said. "However, when neither component was included in the e-mailed question, only 70 percent of consultations were successful."

The observational study analyzed nearly 700 e-mail queries from, and responses to, 60 primary care physicians in eastern Iowa, including UI faculty, residents and community practitioners. The 33 specialty physicians and other health professionals who responded to the queries were all within the UI Hospitals and Clinics.

Bergus said that only 38 percent of the queries examined contained both components (proposed treatment and desired outcome) that made up a well-defined question. Neither the clinical experience of the primary physician nor the clinical area involved in the patient's care seemed to be related to how well the queries were constructed.

Primary care physicians' questions were categorized by how well defined they were, whether they identified both the treatment and desired outcome, and other components. Consulting specialists' responses were analyzed for whether they answered the questions and recommended formal consultation. The study did not assess the thoroughness or accuracy of the answers or whether requests for formal consultation were appropriate.

Bergus said the findings reflect what is known about problem solving, and they also suggest that primary care physicians might make better use of e-mail curbside consultation by carefully constructing questions they want answered.

An example of a clearly stated question more likely to elicit the answers needed to help a patient would be: "Will the addition of a beta-blocker lengthen the life of a 58-year-old woman with moderate congestive heart failure who is already taking an angiotensin-converting enzyme inhibitor?"

In contrast, a less clearly stated question would be: "What should I do for a 58-year-old woman with moderate heart failure who is already taking an angiotensin-converting enzyme inhibitor?"

"While e-mail consults are on the rise, phone curbside consults remain the most common form of consults for primary care physicians," Bergus said. He added that curbside consults of any type fill about one-third of the information needs of primary care physicians, with the remaining needs being met by consulting textbooks and journals, and other methods.

Bergus cautioned that specialists must respond differently to e-mail consults than they do to telephone or in-person consults. He said that studying the structure of clinical questions asked over the phone or in face-to-face exchanges also merits study.

Curbside consultations represent any exchange between physicians about a patient where there is no legal relationship between the consultant-physician and the patient. The consulting physician gives advice only to the treating physician and does not examine or communicate directly with the patient, does not review the patient's record and charges no fee for the consulting services.

In addition, to Bergus, UI investigators involved in the study were Christina S. Randall, Ph.D., research assistant in family medicine; Suzanne D. Sinift, project assistant for the E-Mail Consult Service; and David M. Rosenthal, Ph.D., UI associate professor of family medicine. Staff in the UI College of Medicine Informational Systems also provided technical support.

The study was supported in part by a grant for graduate training from the Human Resources and Services Administration in the federal Department of Health and Human Services.

The UI offers a physician tutorial on formulating clinical questions at:

University of Iowa Health Care describes the partnership between the UI College of Medicine and the UI Hospitals and Clinics and the patient care, medical education and research programs and services they provide.