Consultant obligations question

[txterp98]

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Hey guys, I have a question to all who are well-versed on EMTALA, the medicolegal aspects of medicine, and the like....

Everyday, we diagnose, treat, stabilize, and send patients on their way. For example....

1) Hand extensor tendon laceration - irrigate, repproximate skin, splint, follow-up with Plastics-Hand
2) Distal radius fracture - reduce if needed, splint, follow-up with Ortho
3) Lower GI bleed - not orthostatic, not anemic, follow-up with GI
4) Bronchitis with bronchospasm - abx, b2-agonist, follow-up with IM/FP on-call

Obviously the list goes on.

Assuming the patients in my following questions are unfunded, do not have primary care doctors, and have been seen in a community hospital ER....

1) Is the on-call doctor required to see the patient for follow-up ONLY if I make telephone consultation with them? Or, does it suffice that because they were on-call on the day the patient came to the ER, they are required to see them in follow-up in a reasonable amount of time?

2) If you ask the on-call doctor to see them in follow-up and instead they choose to come to the ER, does this fulfill their consultation requirement of seeing the patient? For example, ortho applies the splint to the distal radius fracture and says to follow-up in their office fully aware the patient will not be able to afford the next visit. Or the plastic surgeon takes the measures from above and says follow-up in 2 days so we can discuss when we'll go to the OR - also knowing the patient won't be able afford any of this.

I thought I knew the answers to these questions when I came out of residency, but I've learned the last few years that I really haven't. As a result, I plead ignorance and am trying to relearn about EMTALA and medicolegal medicine.

Thanks everyone for your help.

 

[docB]

Excellent questions! I love discussing EMTALA almost as much as I hate EMTALA as legislation. I'll take some shots at answers. Bear in mind that I don't know for sure what the real answers are. In many cases the govt. doesn't know either because they have avoided making specific designations so they can make it up as they go.

1) Is the on-call doctor required to see the patient for follow-up ONLY if I make telephone consultation with them? Or, does it suffice that because they were on-call on the day the patient came to the ER, they are required to see them in follow-up in a reasonable amount of time?

I don't believe they are required by EMTALA to see the patient outside the hospital at all. They are required to respond to emergent issues. If you've stabilized a fracture with a splint then the emergent issue is over. That said most hospitals that I have worked in have requirements in their bylaws that every patient seen in the ED gets one follow up visit with the on call specialist. Again, the way I have seen it work, is that that's a hospital requirement for staff priveledges for the consultants.

I frequently see situations where a consultant will see an ED follow up patient who would then need a delayed repair such as a tendon injury and would tell the patient that they (the patient) is responsible for finding a doc who will do the repair. ie. they won't do it because the patient can't pay. That situation creates a lot of ethical and liability problems for the consultant. It also results in many instances where theings that are not really "emergent" get consulted inpatient because everyone knows they'll never get proper care as an outpatient. Needless to say that creates a lot of annoyance on the part of consultants.

2) If you ask the on-call doctor to see them in follow-up and instead they choose to come to the ER, does this fulfill their consultation requirement of seeing the patient? For example, ortho applies the splint to the distal radius fracture and says to follow-up in their office fully aware the patient will not be able to afford the next visit. Or the plastic surgeon takes the measures from above and says follow-up in 2 days so we can discuss when we'll go to the OR - also knowing the patient won't be able afford any of this.

As above, I don't think they really have an EMTALA derived follow up requirement so I think that seeing them in the ED certainly satisfies their EMTALA mandate. If they see them in the ED and then refuse to see them in follow up they may have some liability and ethical issues but I don't think they would be at risk for an EMTALA violation.

 

[GeneralVeers]

As above, I don't think they really have an EMTALA derived follow up requirement so I think that seeing them in the ED certainly satisfies their EMTALA mandate. If they see them in the ED and then refuse to see them in follow up they may have some liability and ethical issues but I don't think they would be at risk for an EMTALA violation.

I end up admitting a lot of these patients who could otherwise be discharged. Example:

30 year old hispanic male with large testicular mass getting bigger by a year. Diagnosed as solid mass on ultrasound. I called the Urologist on call who refused to see him in clinic because he couldn't pay. I admitted the patient to medicine, and that same urologist who was on call had to do the surgery the following day.

The system sucks, but if you know your system and consultants you can usually find your way through it.

 

[docB]

I end up admitting a lot of these patients who could otherwise be discharged. Example:

30 year old hispanic male with large testicular mass getting bigger by a year. Diagnosed as solid mass on ultrasound. I called the Urologist on call who refused to see him in clinic because he couldn't pay. I admitted the patient to medicine, and that same urologist who was on call had to do the surgery the following day.

The system sucks, but if you know your system and consultants you can usually find your way through it.

Sometimes the consultants want it this way. Consultants can get screwed by the system too. A great example is symptomatic cholelitiasis. Needs GB out but no indication for emergent chole. Patient follows up as an outpatient and now the surgeon, even if they're willing to do the operation unfunded, can't get an OR or an anesthesiologist. In reality they can probably cajole one of their regular gas guys to do it but it puts them in a spot. They may not be able to get an OR though. Since there's no EMTALA obligation the hospital isn't obligated to provide an OR. And I've seen them refuse. If the consultant comes in and comes up with some reason the operation needs to be done now then the hospital is obligated. Sometimes the consultants are also subsidized by the hospitals for the uninsured. If they take it from the ED or in house they get paid by the hospital, if it goes to their clinic and then they need something they're screwed.

 

[txterp98]

docB, I never thought about checking with our bylaws on consultant expectations pertaining to ER patients. I'll definitely have to check into that. Thanks for the help.

General, you're definitely right, as we learn our individual systems, there are certainly loopholes and ways to get around these situations. The problem we all face, though, is picking and choosing our battles. Speaking specifically of the case you gave with the guy who had a testicular mass - nice move. It's the right thing to do and I'm sure the patient/family was very appreciative of what you had done.

 

[docB]

The problem we all face, though, is picking and choosing our battles.

You're absolutely right about picking your battles. It's one of the toughest things to learn as a new attending.