19. Getting a hard case to an academic expert
Clinicians with complex patients; providers of specialized services Planned episode, referrals and the system. Getting a hard case to the right expert, and getting an answer back.
Listener title: Getting a hard case to an academic expert, and an answer back
Listener description: An academic clinical geneticist talks with the host about the routes from an independent practice to an expert opinion, including e-consults, case reviews and cash consults, and about how the answer gets back to the physician who asked. For clinicians caring for complex patients and the consultants who take their cases.
Run of show (about 40 minutes)
| Time | Segment | What happens |
|---|---|---|
| 0:00 to 2:00 | Opening | The host introduces the topic and the guest's role, an academic clinical geneticist. The guest discloses any industry relationships and notes that they speak for themselves, not for their institution or the network. No patient information on this episode. |
| 2:00 to 11:00 | Which routes work | Talking point 1. The guest explains the routes they know from the inside: e-consult, case review, cash consult and a referral to clinic. What does each one ask of the referring physician, and what does each one return? The host notes the clinical expertise roster's criterion that academic experts qualify through a published route for an anchor's case: a cash consult, an e-consult or a case-review fee. The host asks, in general terms and without legal advice, how licensure shapes which route fits. |
| 11:00 to 19:00 | What the expert needs to answer | The guest explains what they need in hand to answer: the question, the record, prior testing, a return date. What is most often missing when a case arrives? The host compares the answer with the CCN referral and the roster's planned one-page request template. When the next step is a second read of a variant, the host reads the roster's line as written: "when nine laboratories piloted the same criteria on 99 variants, interlaboratory concordance was 34% at first and 71% after consensus discussion," and asks the guest when a second read changes management. |
| 19:00 to 27:00 | Closing the loop | Talking point 2. How does the answer come back, and who acts on it? The roster asks consultants to write back to the anchor, not only to the patient: the answer to the question asked, the evidence, the next step, and what would change the answer, on the CCN consult reply within seven days. The guest compares that with how replies leave an academic center today. The host asks how the referring physician should follow up when the answer is "not yet." |
| 27:00 to 34:00 | Composite scenario, not a real patient | An anchor physician has an adult patient with a thorough prior workup, a non-diagnostic result and one question for an expert. Host and guest choose a route, write the question in one sentence, list what goes with it, and agree what the reply should say and who does what next. No clinical detail beyond what the exercise needs. |
| 34:00 to 38:00 | Easier from both sides | Talking point 3. What would make the route easier for the expert, and for the referring physician? The host reads the clinical expertise roster's line as written: "A structured, multidisciplinary evaluation of patients who had already been thoroughly worked up reached a diagnosis in 35% (132 of 382), three quarters of them by exome or genome sequencing." The guest explains what that kind of evaluation would need to look like when the referring physician is in independent practice. |
| 38:00 to 40:00 | Closing | One practical takeaway: send the expert one question, the record that bears on it, and a return date. Members can propose a consultant in #cohort-clinical-expertise on Slack, the roster is seeking a lead, and listeners can reach the network at hello@coloradocarenetwork.com or through the interest form at coloradocarenetwork.com/join. |
Guest prep questions (sent to the guest a week ahead)
- Which routes does your institution offer for an outside physician's case (e-consult, case review, cash consult, clinic referral), and how is each one arranged and billed? We will discuss method only, not amounts.
- When a case arrives from an independent practice, what is most often missing, and what would you want on a one-page summary instead?
- How does your answer leave your institution today: to whom, in what format, and how long after the review?
- When your answer is that the case needs a second read of a variant, or more testing, how do you hand that back so the referring physician knows who does what next?
- What would make it easier for you to take cases from physicians in independent practice, and what would lead you to decline one?
Show notes
An academic clinical geneticist joins the host to compare the routes an independent physician can use to get a hard case to an expert: e-consult, case review and cash consult. They discuss what the expert needs in hand to answer, how the answer comes back to the physician who asked, and what would make the route easier on both sides. The episode includes a composite exercise that chooses a route and writes the question.
- Sources and tools:
- Clinical expertise: https://coloradocarenetwork.com/cohorts/clinical-expertise/
- Referral standard: https://coloradocarenetwork.com/referrals/
- CCN referral: https://coloradocarenetwork.com/referrals/referral-form/
- CCN consult reply: https://coloradocarenetwork.com/referrals/consult-reply/
- From the References on the clinical expertise roster:
- Splinter K, Adams DR, Bacino CA, et al. Effect of genetic diagnosis on patients with previously undiagnosed disease. N Engl J Med. 2018;379(22):2131-2139. doi:10.1056/NEJMoa1714458
- Amendola LM, Jarvik GP, Leo MC, et al. Performance of ACMG-AMP variant-interpretation guidelines among nine laboratories in the Clinical Sequencing Exploratory Research Consortium. Am J Hum Genet. 2016;98(6):1067-1076. doi:10.1016/j.ajhg.2016.03.024
- No patient information is discussed on this episode.
All planned episodes. To be the guest for this episode, email hello@coloradocarenetwork.com with the episode number.
Colorado Care Network. 19. Getting a hard case to an academic expert. Version 2026-10-30.