Arranging follow up: medical-legal risk?

[holabuster]

I'm a newish EM attending, who recently started practicing in a new hospital that has much fewer resources than places I've previously worked. The call panel gets more and more bare bones everyday--no neurosurg, cardiothoracic, ENT, ophtho, OMFS, ortho, plastics, hand. On top of that, the population is heavily Spanish-speaking only, heavily uninsured/Medicaid only, and patients frequently have no PMD.

Wondering if anyone can share best practices on how they set up follow up care with specialists?

For example:
1) If you don't have ENT on your call panel, do you just Google an ENT in your area?
2) How do you ensure the ENT you Google takes uninsured/Medicaid patients?
3) If you do have ENT on your call panel, are they obligated to take uninsured/Medicaid patients?
4) If a patient does have a PMD, do you just refer to the PMD and tell the patient to ask for ENT referral? Is this medical-legally defensible?
5) If a patient has HMO, can emergency physicians even refer directly to specialists, or do they still need referral by their PMD? What if it's for urgent (<48-72 hour) follow up?
6) If a patient has no PMD, do you just write "please follow up with an Ear, Nose, Throat doctor," without specifying who, and relying on the patient to call around or call their insurance?
7) What if it's a peds case and the on call ENT doesn't take peds?

I feel like I'm getting stressed out about patients getting lost to follow up, having a bad outcome, and getting sued. Would greatly appreciate any thoughts.

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[Apollyon]

What insurance the ENT takes is zero of your concern. If you don't have a specialty on your call list, you will soon learn who is whom in the community - who's a good guy, and who's a money grubber. What you do NOT want to do is write, "follow up with an ears/nose/throat doctor". That is on the spectrum of patient abandonment. Similarly, if you write, "follow up with your doctor", and your dutiful nurse has clicked the "no pmd" box, and you don't give the pt a new physicians list, you are completely uncovered.

Remember, "Good discharge instructions are better than an accurate diagnosis". That includes giving the name and number for "John Doe, MD".

 

[turkeyjerky]

Man, I'm 5 years out and still struggle with this. It really never gets easier imho.

I'm a newish EM attending, who recently started practicing in a new hospital that has much fewer resources than places I've previously worked. The call panel gets more and more bare bones everyday--no neurosurg, cardiothoracic, ENT, ophtho, OMFS, ortho, plastics, hand. On top of that, the population is heavily Spanish-speaking only, heavily uninsured/Medicaid only, and patients frequently have no PMD.

Wondering if anyone can share best practices on how they set up follow up care with specialists?

For example:
1) If you don't have ENT on your call panel, do you just Google an ENT in your area?

Yes, I've done this.

2) How do you ensure the ENT you Google takes uninsured/Medicaid patients?

Can't

3) If you do have ENT on your call panel, are they obligated to take uninsured/Medicaid patients?

Nope. Whether or not they are obligated to see them in followup is generally dependant on hospital policy (ie hospital could require them to see ER fu's X1 or something as part of being on call). When I've had issues, I generally tell patients that the doctor has a responsibility to see them in clinic, they also have a right to bill them for their services.

4) If a patient does have a PMD, do you just refer to the PMD and tell the patient to ask for ENT referral? Is this medical-legally defensible?

Yes, I believe so. I always tell patients to followup with their pcp. Even if they have a staightforward, non-emergent condition that merits speciality referral. I typically tell patients that insurance generally requires that their PCP writers a referral to any specialist and that, while I can google the name of an ENT and give it to them, I cannot write an outpatient referral--I can only consult patients on an emergent basis in the ED.

5) If a patient has HMO, can emergency physicians even refer directly to specialists, or do they still need referral by their PMD? What if it's for urgent (<48-72 hour) follow up?

See above. Every patient (who actually needs followup) gets told to make 3 calls: specialist, pcp and insurance company.

6) If a patient has no PMD, do you just write "please follow up with an Ear, Nose, Throat doctor," without specifying who, and relying on the patient to call around or call their insurance?

No, never. I tell them their PMD is the 'quarterback of their medical team' and needs to be involved and help them out.

7) What if it's a peds case and the on call ENT doesn't take peds?

Good question. If it's urgent, I've called the local peds hospital to talk to their ENT on call in order to secure followup. In my experience, many age-generalized specialists (ortho, ent, ophtho, etc) will at least see them once in the clinic and then refer them on.

I feel like I'm getting stressed out about patients getting lost to follow up, having a bad outcome, and getting sued. Would greatly appreciate any thoughts.

Yup...

To tell you the truth, although it's something we all stress about (myself especially) I don't actually think this is as major a medicolegal risk as most of us think. Generally, we'll get sued for missing the condition that we should've admitted the patient for, rather than failure to secure outpatient care for a non-emergent condition.

 

[GeneralVeers]

What insurance the ENT takes is zero of your concern. If you don't have a specialty on your call list, you will soon learn who is whom in the community - who's a good guy, and who's a money grubber. What you do NOT want to do is write, "follow up with an ears/nose/throat doctor". That is on the spectrum of patient abandonment. Similarly, if you write, "follow up with your doctor", and your dutiful nurse has clicked the "no pmd" box, and you don't give the pt a new physicians list, you are completely uncovered.

Remember, "Good discharge instructions are better than an accurate diagnosis". That includes giving the name and number for "John Doe, MD".

If it's a minor ENT issue, and you have no ENT on-call then who do you have them follow up with? I usually give them a clinic name, but there's no guarantee they will be seen.

 

[Apollyon]

If it's a minor ENT issue, and you have no ENT on-call then who do you have them follow up with? I usually give them a clinic name, but there's no guarantee they will be seen.

You can always find an academic place, but it might be 100 miles away (in my last job, that was the closest academic shop, and they had to take anything we referred to them). If you're giving them a clinic name, you're golden. You can't make anyone follow up, but, an easy deposition goes like this: "Did you follow up with the specialist?" "Were you given a follow up provider or clinic?" "Why didn't you follow up as directed?" "Since you knew to be seen in the ED, why didn't you return to the ED?"

You can only do your part; but, you should do your best to buff the chart from your side. Sometimes, the end result is follow up in the ED in 3 days for rapid Rhino removal. Not optimal, but also not abandonment.

 

[namethatsmell]

You can always find an academic place, but it might be 100 miles away (in my last job, that was the closest academic shop, and they had to take anything we referred to them). If you're giving them a clinic name, you're golden. You can't make anyone follow up, but, an easy deposition goes like this: "Did you follow up with the specialist?" "Were you given a follow up provider or clinic?" "Why didn't you follow up as directed?" "Since you knew to be seen in the ED, why didn't you return to the ED?"

You can only do your part; but, you should do your best to buff the chart from your side. Sometimes, the end result is follow up in the ED in 3 days for rapid Rhino removal. Not optimal, but also not abandonment.

Exactly. We can't solve the world.

Every patient gets a specific clinic name, phone number, and ideal follow-up time frame.

Every patient gets a few specific reasons to RTED along with "or for any other symptoms that concern you."

After that, it's up to the patient to adult for themself.

The mental bandwidth I used to spend on worrying about patients deciding to take my advice and actually obtain follow-up...has long been shifted to trying to convince admin to have a working otoscope in the dept, getting the lab to run the d*mn urine, and ensuring there's an adequate supply of turkey sammies on hand to keep the demons at bay.

 

[bravotwozero]

oh yeah, if i had a nickel for everytime I walked into a patient room and the otoscope light didn't work...

 

[turkeyjerky]

oh yeah, if i had a nickel for everytime I walked into a patient room and the otoscope light didn't work...

So frustrating. And ear/eye complaints seem to get preferentially sent to these rooms.

Then the "fix" is to provide a portable otoscope, which also doesn't get maintained...

 

[VA Hopeful Dr]

So frustrating. And ear/eye complaints seem to get preferentially sent to these rooms.

Then the "fix" is to provide a portable otoscope, which also doesn't get maintained...

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[The Knife & Gun Club]

Are there med mal cases that really show you can get in hot water for not referring approximately?

Document the conversation, provide a name, discharge.

I’m no expert but it seems absurd (much like the rest of Med mal) to expect the EP to find an insurance and accepting patients appropriate doc for their chronic nonsense.

 

[Mushdoc]

The question really comes down to things that could be managed outpatient if follow up can be arranged in a few days, but if close follow up cannot be arranged would likely be transferred to the local tertiary care center - certain hand, eye, ortho situations - in that situation do you need to have a conversation with the specialist or is just referring them enough

 

[RoyBasch]

Are there med mal cases that really show you can get in hot water for not referring approximately?

Document the conversation, provide a name, discharge.

I’m no expert but it seems absurd (much like the rest of Med mal) to expect the EP to find an insurance and accepting patients appropriate doc for their chronic nonsense.

There is absolutely malpractice related to not assuring appropriate follow up.

You're responsibility for insurance issues is usually not the issue.

As outlined by Apollyon above as long as you give a specific place, name, contact information, and correct window of time, you should be ok. On some level the patients do have some responsibility for their own care, we do not have to go so far as to do a wallet biopsy and make sure the care outside of the ER environment is paid for.

The question really comes down to things that could be managed outpatient if follow up can be arranged in a few days, but if close follow up cannot be arranged would likely be transferred to the local tertiary care center - certain hand, eye, ortho situations - in that situation do you need to have a conversation with the specialist or is just referring them enough

You're going to get different opinions on this, but if the next day (or two or three) follow up is truly essential, than I usually like to actually discuss with the physician on call to assure it. I think in these cases just giving them information and telling the patient to make an appointment is not adequate from a care perspective; however, from a legal/malpractice standard you might be covered.

 

[EM Junkie]

To be fair, I don’t think the Spanish speaking uninsured population are the ones doing most of the suing. I’m just saying......

 

[GeneralVeers]

There is absolutely malpractice related to not assuring appropriate follow up.

You're responsibility for insurance issues is usually not the issue.

As outlined by Apollyon above as long as you give a specific place, name, contact information, and correct window of time, you should be ok. On some level the patients do have some responsibility for their own care, we do not have to go so far as to do a wallet biopsy and make sure the care outside of the ER environment is paid for.


You're going to get different opinions on this, but if the next day (or two or three) follow up is truly essential, than I usually like to actually discuss with the physician on call to assure it. I think in these cases just giving them information and telling the patient to make an appointment is not adequate from a care perspective; however, from a legal/malpractice standard you might be covered.

Calling the specialist to ensure follow-up is not practical. If I'm discharging 15 patients in a shift, putting in 15 extra calls to specialists (who will be annoyed) for mostly non-urgent follow up is not going to work. I only call if I feel it's something that needs to be seen urgently in the next week. Sprains, strains, chronic abdominal pain, chronic chest pain, and non-acute patients can make their own PCP or specialist follow-up. At some point people have to be adults.

 

[Zebra Hunter]

I am currently being sued. It sucks, especially because I know I did everything appropriately, but at the end of the day, I know all it is is just lawyers fighting over my insurance money. There was nothing I could have done or documented that would have prevented this suit, it is just a terrible situation that was going to happen to any doctor that cared for this patient.

Regardless of how good a doctor you are, you will probably be named in a case at least once in your career, and it will most likely have minimal to do with your patient instructions or documentation. Most EM docs are not getting sued numerous times unless you are in New York or Philly, however. You are stressing about a situation that will probably only at most happen 2-3 times to you in your career, and if they are like most cases, it will either be dropped, or you will settle and your med mal insurance will cover you. Unless you are in a state with a very poor med mal climate, I would not stress too much about this. The patients that are going to sue you are going to sue you regardless of what you put in your note. The primary driver of a lawsuit is a bad outcome. Sure you might protect yourself slightly by calling the docs you are sending your patients to for follow up, although most of the time this provides absolutely no protection in the case of a lawsuit, as the patient ended up having an emergent condition that required hospitalization, and the doctor inappropriately sent them home.

This isn't to discourage you from charting and practicing defensively, it is just to mention that there is no need to waste much mental energy on this. Treat patients the way you would like your family to be treated, document well when you do something out of the norm, document well when someone leaves AMA and don't withhold appropriate care, don't chart like you are upset with a patient, be sure that your work up and note are pristine on the patient that is upset with your care, and just don't be an idiot.

I see way too many of my colleagues dictating gigantic MDMs, spending hours after their shift writing notes, and calling a million consults just to "limit their liability". Don't be like them.

 

[southerndoc]

don't chart like you are upset with a patient

This is a major point that gets a lot of people in trouble. If you start quoting a patient's curse words at you, a plaintiff's counsel will argue you documented that because you were upset, and your upset caused you to mistreat the patient which hastened their bad outcome.

 

[RoyBasch]

Calling the specialist to ensure follow-up is not practical. If I'm discharging 15 patients in a shift, putting in 15 extra calls to specialists (who will be annoyed) for mostly non-urgent follow up is not going to work. I only call if I feel it's something that needs to be seen urgently in the next week. Sprains, strains, chronic abdominal pain, chronic chest pain, and non-acute patients can make their own PCP or specialist follow-up. At some point people have to be adults.

I would not call for any of the cases you cited.

I do not call to arrange follow up for 98% of discharges.

Arrange follow up usually means discharge instructions with a specific physician or clinic, their phone number, the location of their clinic, and a time frame when to make the appointment.

The cases I call are things where the follow up is fairly mission critical and the patient is likely to need an urgent (but not emergent) procedure.

 

[Old_Mil]

I'm a newish EM attending, who recently started practicing in a new hospital that has much fewer resources than places I've previously worked. The call panel gets more and more bare bones everyday--no neurosurg, cardiothoracic, ENT, ophtho, OMFS, ortho, plastics, hand. On top of that, the population is heavily Spanish-speaking only, heavily uninsured/Medicaid only, and patients frequently have no PMD.

Wondering if anyone can share best practices on how they set up follow up care with specialists?

Residents, this is how you don't pick a job as an EM attending.

 

[thegenius]

I'm a newish EM attending, who recently started practicing in a new hospital that has much fewer resources than places I've previously worked. The call panel gets more and more bare bones everyday--no neurosurg, cardiothoracic, ENT, ophtho, OMFS, ortho, plastics, hand. On top of that, the population is heavily Spanish-speaking only, heavily uninsured/Medicaid only, and patients frequently have no PMD.

Wondering if anyone can share best practices on how they set up follow up care with specialists?

For example:
1) If you don't have ENT on your call panel, do you just Google an ENT in your area?
2) How do you ensure the ENT you Google takes uninsured/Medicaid patients?
3) If you do have ENT on your call panel, are they obligated to take uninsured/Medicaid patients?
4) If a patient does have a PMD, do you just refer to the PMD and tell the patient to ask for ENT referral? Is this medical-legally defensible?
5) If a patient has HMO, can emergency physicians even refer directly to specialists, or do they still need referral by their PMD? What if it's for urgent (<48-72 hour) follow up?
6) If a patient has no PMD, do you just write "please follow up with an Ear, Nose, Throat doctor," without specifying who, and relying on the patient to call around or call their insurance?
7) What if it's a peds case and the on call ENT doesn't take peds?

I feel like I'm getting stressed out about patients getting lost to follow up, having a bad outcome, and getting sued. Would greatly appreciate any thoughts.

I don't think it's your responsibility to ensure people have follow-up. Your responsibility is to stabilize critically ill people and rule out medical emergencies. Unfortunately that puts you in a tough spot for things like PTA's. If someone has a PTA and you couldn't drain it, I would consider this a medical emergency until it's stabilized. You gotta make phone calls and try to get the guy transferred. Even if it's 3 hours away.

It's the medical urgencies that can be tough. Stable rectal spotting / bleeding in a healthy person doesn't have to be admitted, and they should follow-up with their doctor. Basically you keep on discharging these patients until they stabilize themselves or they declare themselves an emergency, like their Hg drops from 12 -> 8 over 5 days. The real problem is the patients get the shaft because they only get medical care when they are really sick.

I wouldn't want to work at a hospital like that. There is only so much you can do and you can't fix everything.

 

[DocEspana]

So frustrating. And ear/eye complaints seem to get preferentially sent to these rooms.

Then the "fix" is to provide a portable otoscope, which also doesn't get maintained...

you spelled "gets stolen" wrong.