Supreme Court Rules Physician-Patient Relationship is Not Necessary to Sue Docs

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Would the lawsuit turn the same way had the primary healthcare person were a physician instead of an NP?

Should there now be a consultation fee to the primary (the patient ultimately) since you are now on the hook for a lawsuit?

My understanding is NPs need a physician within a certain radius for questions. Did this hospitalist act as the covering physician or was there another specific physician?
 
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That’s some bs right there. If NP didn’t push the case for admission enough, or couldn’t convince the MD for admission, it’s ultimately the MDs fault? **** that. Does that I can never refuse a NP admission or APRN consult? How does this make sense? Sure let the nurses practice independently, but hold the physician liable. Good luck to those who does supervision, which is the reason I didn’t take a job in the opt out state which the crna does their own case, MD does not direct them. Ultimately we are still ****ing liable?!?!
 
This sounds more formal than a typical “curbside” consult. I’ve know quite a few docs who don’t do curbsides for this very reason. Even a simple question is worthy of a short note in the chart and a bill.

It doesn’t sound like the NP was asking a quick “hey what would you do here?,” but rather looking to direct admit a patient to a hospitalist service, but was turned down. I’m not sure what the arrangement was, but you can be sure the NP was writing “discussed case with Dr XYZ” all over the chart. The hospitalist screwed up in that he not only gave a bad recommendation to not admit this patient, but he did no documentation of the encounter. I guess the question is, would the outcome be the same if it was a primary care physician in this exact same scenario rather than an NP?

A similar scenario could be a hospitalist calls a surgeon and presents a potential surgical case to a surgeon over the phone for belly pain and white count. The surgeon says “you don’t need a surgical consult, send the patient home with some Cipro.” The patient dies of a perforated bowel. Should the surgeon be held liable even though he never established physician-patient relationship?
 
I'm sure the article doesn't do the actual chain of events justice. But from what I read, the hospitalist couldn't view the chart and was only giving recommendations based on the NP's story. If the hospitalist was adamant that this patient didn't warrant an admission without seeing the chart or the patient, then I can see to a degree some liability in that. However, the NP having seen the patient, should have sent the patient to the ED for evaluation regardless. What the hospitalist should have said is "I don't consider this a case for direct admission based on the information provided, but I haven't seen this patient and if you are really concerned, send them to the ED." Isn't this a solid example of why physicians aren't supposed to give medical advice over the phone/internet?
 
Ronin786 said:
Very unclear story. I've wondered about this from an ICU standpoint. If a floor team asks for an ICU bed and I deem a patient not requiring ICU-level care, does this constitute liability if something bad happens?
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Perfect analogy.

Outpatient vs inpatient treatment.
Floor vs ICU.
 
This sets the precedence that triaging hospitalists should never turn down a patient from a medicolegal perspective. If every hospital had infinite beds and infinite personnel then this is not a logistical problem. However, in the real world, it would simply lead to overcapacity and access would decrease for people that actually need hospitalization.
 
DrZzZz said:
I'm sure the article doesn't do the actual chain of events justice. But from what I read, the hospitalist couldn't view the chart and was only giving recommendations based on the NP's story. If the hospitalist was adamant that this patient didn't warrant an admission without seeing the chart or the patient, then I can see to a degree some liability in that. However, the NP having seen the patient, should have sent the patient to the ED for evaluation regardless. What the hospitalist should have said is "I don't consider this a case for direct admission based on the information provided, but I haven't seen this patient and if you are really concerned, send them to the ED." Isn't this a solid example of why physicians aren't supposed to give medical advice over the phone/internet?
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Too much is unclear about this case. I’ve done triage as a hospitalist and the number of absurd calls I got from providers seeking direct admission was unbelievable. If I took every single direct admission, our beds would have been filled by 9am everyday.

The job of the triage hospitalist is to determine, to the best of their ability, whether a patient needs DIRECT ADMISSION to a hospitalist service. Refusal does not mean that a patient should not be directed to the ED or other healthcare setting.
 
They both screwed up: The nurse practitioner should have simply sent the patient to the ER where a proper workup could be started, and the physician should not have decided to not admit a patient that he did not see, and he should have told the NP to send the patient to the ER.
Poor judgement on both sides.
 
Planktonmd said:
They both screwed up: The nurse practitioner should have simply sent the patient to the ER where a proper workup could be started, and the physician should not have decided to not admit a patient that he did not see, and he should have told the NP to send the patient to the ER.
Poor judgement on both sides.
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Wait, so your options are 1. never refuse a patient (triage hospitalists by definition never see the patient) 2. send every patient to the ER.

So then why even have a triage physician? Just admit until you're full, then send everything else to ED. Or vice versa.
 
bronx43 said:
This sets the precedence that triaging hospitalists should never turn down a patient from a medicolegal perspective. If every hospital had infinite beds and infinite personnel then this is not a logistical problem. However, in the real world, it would simply lead to overcapacity and access would decrease for people that actually need hospitalization.
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It’s hard to know the full story from the information presented, but I can say the hospitalist triaged incorrectly. He made a bad triage decision that the vast majority of hospitalists would not make. If you told me a patient had a white count, abdominal pain, and hyperglycemia, I would say that patient needs further evaluation even if I knew nothing else about the patient.

This hospitalist was consulted regarding a possible inpatient admission. It’s not the patient’s fault he didn’t take the time to review the chart and do an exam. He gave a consequential recommendation that was wrong. The floor to ICU is a good analogy. If a request to transfer a patient to the ICU is made, the intensivist is effectively being consulted. If the recommendations made by the intensivist are bad then he should be held liable...whether or not he took the time to review the chart or examine the patient.
 
GravelRider said:
It’s hard to know the full story from the information presented, but I can say the hospitalist triaged incorrectly. He made a bad triage decision that the vast majority of hospitalists would not make. If you told me a patient had a white count, abdominal pain, and hyperglycemia, I would say that patient needs further evaluation even if I knew nothing else about the patient.

This hospitalist was consulted regarding a possible inpatient admission. It’s not the patient’s fault he didn’t take the time to review the chart and do an exam. He gave a consequential recommendation that was wrong. The floor to ICU is a good analogy. If a request to transfer a patient to the ICU is made, the intensivist is effectively being consulted. If the recommendations made by the intensivist are bad then he should be held liable...whether or not he took the time to review the chart or examine the patient.
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I understand that. He made the wrong call. Wrong calls are inevitable. If laws can cut out the tail risk of bad outcomes without unintended consequences, then we would all be living in Utopia right now.

The problem with this ruling is that it substantially changes the risk and benefit from the perspective of the triage physician. Every law should be considered with the understanding that there will be unintended consequences, and the question is does the good outweigh the bad. In this situation, is it good for the healthcare system and patients to be able to hold triage physicians or curb-side physicians liable for a bad outcome? I don't know, but the public needs to be ready for the unintended consequence. As a medical subspecialist, if I knew that a curb-side consult or phone call from a referring doctor means I'm on the hook for a "bad outcome" then I will never in a million years give my opinion on any case. All patients would need to wait in line for their appointment in 3 months.

And whether or not other hospitalists would have made the same call is not the point, because once you realize that you can be sued if you say no as a triage physician, then you will inevitably say yes to everything and everyone. Once you realize that you can be sued for a curb-side consult, then you will inevitably say no to everything and everyone. The fundamental phenomenon of defensive medicine is that it changes the behavior of everyone, not just the "bad apples."
 
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bronx43 said:
Wait, so your options are 1. never refuse a patient (triage hospitalists by definition never see the patient) 2. send every patient to the ER.

So then why even have a triage physician? Just admit until you're full, then send everything else to ED. Or vice versa.
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I didn't say admit the patient, I said send the patient to the ER!
Where hopefully a real physician can look at her and try to find out why she had fever, high white count and abdominal pain.
 
bronx43 said:
I understand that. He made the wrong call. Wrong calls are inevitable. If laws can cut out the tail risk of bad outcomes without unintended consequences, then we would all be living in Utopia right now.

The problem with this ruling is that it substantially changes the risk and benefit from the perspective of the triage physician. Every law should be considered with the understanding that there will be unintended consequences, and the question is does the good outweigh the bad. In this situation, is it good for the healthcare system and patients to be able to hold triage physicians or curb-side physicians liable for a bad outcome? I don't know, but the public needs to be ready for the unintended consequence.

And whether or not other hospitalists would have made the same call is not the point, because once you realize that you can be sued if you say no as a triage physician, then you will inevitably say yes to everything and everyone. The fundamental phenomenon of defensive medicine is that it changes the behavior of everyone, not just the "bad apples."
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Well I think that is the issue here. There should be no such thing as a “curbside” consult. If the recommendation being made is consequential to the patient’s care then it is a consult. It’s not the patient’s problem that the full chart wasn’t reviewed or documentation wasn’t done. I think if the hospitalist documented this transfer request and documented reasons why he was refusing the direct admission, he would have been safer from a lawsuit. Maybe the primary care presented the information poorly? Maybe he didn’t have all the information? Documentation provides evidence of the information he reviewed and why he made the decision he made. If any behavior should change, it should be the lack of documentation of all these informal consults when the recommendation being made is of real consequence.

A triaging hospitalist should have a mechanism in place where he can document all direct admission requests. The process should be formalized...and billed for.
 
Good discussion.

My initial thought is, poor diagnostic skills by the NP, should have sent the patient to the ED and scanned them. Hard to tell though, maybe the person looked fine on exam. Not enough info in the article.

I’m sure the hospitalist didn’t have access to all the info, but probably didn’t ask enough information. Your opinion is largely influenced by what the referring provider tells you and how they tell you.
 
Ronin786 said:
Very unclear story. I've wondered about this from an ICU standpoint. If a floor team asks for an ICU bed and I deem a patient not requiring ICU-level care, does this constitute liability if something bad happens?
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Send them to the E.R.?
 
GravelRider said:
This sounds more formal than a typical “curbside” consult. I’ve know quite a few docs who don’t do curbsides for this very reason. Even a simple question is worthy of a short note in the chart and a bill.

It doesn’t sound like the NP was asking a quick “hey what would you do here?,” but rather looking to direct admit a patient to a hospitalist service, but was turned down. I’m not sure what the arrangement was, but you can be sure the NP was writing “discussed case with Dr XYZ” all over the chart. The hospitalist screwed up in that he not only gave a bad recommendation to not admit this patient, but he did no documentation of the encounter. I guess the question is, would the outcome be the same if it was a primary care physician in this exact same scenario rather than an NP?

A similar scenario could be a hospitalist calls a surgeon and presents a potential surgical case to a surgeon over the phone for belly pain and white count. The surgeon says “you don’t need a surgical consult, send the patient home with some Cipro.” The patient dies of a perforated bowel. Should the surgeon be held liable even though he never established physician-patient relationship?
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What about when one hospital physician calls another physician at another hospital with more experience in whatever rare disease for advice? What if they give you bad advice? Are they liable?
 
GravelRider said:
Well I think that is the issue here. There should be no such thing as a “curbside” consult. If the recommendation being made is consequential to the patient’s care then it is a consult. It’s not the patient’s problem that the full chart wasn’t reviewed or documentation wasn’t done. I think if the hospitalist documented this transfer request and documented reasons why he was refusing the direct admission, he would have been safer from a lawsuit. Maybe the primary care presented the information poorly? Maybe he didn’t have all the information? Documentation provides evidence of the information he reviewed and why he made the decision he made. If any behavior should change, it should be the lack of documentation of all these informal consults when the recommendation being made is of real consequence.

A triaging hospitalist should have a mechanism in place where he can document all direct admission requests. The process should be formalized...and billed for.
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Ok, so there are two separate issues here.

One is the curbside consult, which isn't really core to this particular story, but it is part of the potential Pandora's box that this ruling can open. Curbside consults are usually the result of limited resources, or if the inquiring physician thinks the question being posed is of minimal complexity. The latter is usually of lower importance, since it's something that one can usually find quickly with an uptodate search. In areas of limited resources, some clinicians often use curbside consults to get an idea for whether a patient needs to be seen by a particular specialist and to do the necessary early steps for management or diagnosis. This also is of importance when dealing with uninsured or Medicaid patients who can often only get access in large academic centers, most of whom are booked out for months. (where I live, the academic institution is booking out 6-7 months for my field). So it's not as simple as "there should be no curbside consults."

In regards to the documentation, I agree. But how do you know he didn't? This wasn't explicit in the article one way or the other. But does documentation of his decision really protect him from a lawsuit? At the end of the day, he still made the bad call, and I don't believe that this ruling would have been any different. He may have more of a leg to stand on for the actual verdict, but he would have been sued regardless.

My original contention about unintended consequences still stands, whether or not you can bill for triage intake. If there's even a slight possibility that you get sued for triaging or "curbsiding," you will behave differently. I know I would.
 
urge said:
What about when one hospital physician calls another physician at another hospital with more experience in whatever rare disease for advice? What if they give you bad advice? Are they liable?
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That’s a consult. Who should take responsibility for that expertise if it results in bad care?
 
bronx43 said:
Ok, so there are two separate issues here.

One is the curbside consult, which isn't really core to this particular story, but it is part of the potential Pandora's box that this ruling can open. Curbside consults are usually the result of limited resources, or if the inquiring physician thinks the question being posed is of minimal complexity. The latter is usually of lower importance, since it's something that one can usually find quickly with an uptodate search. In areas of limited resources, some clinicians often use curbside consults to get an idea for whether a patient needs to be seen by a particular specialist and to do the necessary early steps for management or diagnosis. This also is of importance when dealing with uninsured or Medicaid patients who can often only get access in large academic centers, most of whom are booked out for months. (where I live, the academic institution is booking out 6-7 months for my field). So it's not as simple as "there should be no curbside consults."

In regards to the documentation, I agree. But how do you know he didn't? This wasn't explicit in the article one way or the other. But does documentation of his decision really protect him from a lawsuit? At the end of the day, he still made the bad call, and I don't believe that this ruling would have been any different. He may have more of a leg to stand on for the actual verdict, but he would have been sued regardless.

My original contention about unintended consequences still stands, whether or not you can bill for triage intake. If there's even a slight possibility that you get sued for triaging or "curbsiding," you will behave differently. I know I would.
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It’s not up to the jury to decide the unintended consequences to the health care system. That’s a tall order for a malpractice jury. The jury is deciding who is at fault in this particular patient’s death. It is up to the healthcare system to figure out what went wrong and how to prevent that from happening again. Maybe hospitalists shouldn’t be deciding who gets admitted to a hospital based on a telephone call without a chart review and exam?

When I was a hospitalist (for 1 year), I had no such ability. I either got admissions directly from primary care doctors who admitted to my service or from the ED. Never once did I get a phone call from a primary care doctor asking if I was going to accept the admission. It would have been inappropriate for me to refuse (despite the many ridiculous admissions) because I never laid eyes on the patient until they appeared on the unit.
 
bronx43 said:
Ok, so there are two separate issues here.

One is the curbside consult, which isn't really core to this particular story, but it is part of the potential Pandora's box that this ruling can open. Curbside consults are usually the result of limited resources, or if the inquiring physician thinks the question being posed is of minimal complexity. The latter is usually of lower importance, since it's something that one can usually find quickly with an uptodate search. In areas of limited resources, some clinicians often use curbside consults to get an idea for whether a patient needs to be seen by a particular specialist and to do the necessary early steps for management or diagnosis. This also is of importance when dealing with uninsured or Medicaid patients who can often only get access in large academic centers, most of whom are booked out for months. (where I live, the academic institution is booking out 6-7 months for my field). So it's not as simple as "there should be no curbside consults."

In regards to the documentation, I agree. But how do you know he didn't? This wasn't explicit in the article one way or the other. But does documentation of his decision really protect him from a lawsuit? At the end of the day, he still made the bad call, and I don't believe that this ruling would have been any different. He may have more of a leg to stand on for the actual verdict, but he would have been sued regardless.

My original contention about unintended consequences still stands, whether or not you can bill for triage intake. If there's even a slight possibility that you get sued for triaging or "curbsiding," you will behave differently. I know I would.
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I think there’s another issue here. The fact it was a mid-level calling for a direct admission. If it wasn’t a mid-level would the outcome be different? Hard to say of course. But I know even when I was an intern, I would once in a while order a test just to chase a correct diagnose. I’ve ordered a rapid HIV test during admission, as a hospitalist, in the middle of the night, because no one would tell the patient that he had the classical sign of AIDS. No. I am not a great diagnostician, I am saying my training and mindset are fundamentally different. I’ve never been trained to rely on a “safety net.”

If my patient I deemed needing an admission, either I convince the admitting physician to take my patient or send them to ED. Why is that even a discussion? “Oh, my colleague who has not seen my patient told me it’s okay.....” is that ever a defense? I’ve made the determination, patient needs to be seen prompto? I have only worked at places unless you have admitting privileges, you go through ED, probably to prevent this precise scenario.

Tl:dr Mid levels are not the same, they may be able to do the work, but they are trained differently.
 
GravelRider said:
It’s not up to the jury to decide the unintended consequences to the health care system. That’s a tall order for a malpractice jury. The jury is deciding who is at fault in this particular patient’s death. It is up to the healthcare system to figure out what went wrong and how to prevent that from happening again. Maybe hospitalists shouldn’t be deciding who gets admitted to a hospital based on a telephone call without a chart review and exam?

When I was a hospitalist (for 1 year), I had no such ability. I either got admissions directly from primary care doctors who admitted to my service or from the ED. Never once did I get a phone call from a primary care doctor asking if I was going to accept the admission. It would have been inappropriate for me to refuse (despite the many ridiculous admissions) because I never laid eyes on the patient until they appeared on the unit.
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This wasn’t a jury. It was the MN Supreme Court decision.

I refused transfers from outside hospitals on the regular but I usually defer outpatient inquiries to the ED., I’m not defending this guys decision. He screwed up. But the Supreme Court allowing malpractice for non patient physician relationship was a short sighted decision, imho.
 
bronx43 said:
This wasn’t a jury. It was the MN Supreme Court decision.

I refused transfers from outside hospitals on the regular but I usually defer outpatient inquiries to the ED., I’m not defending this guys decision. He screwed up. But the Supreme Court allowing malpractice for non patient physician relationship was a short sighted decision, imho.
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So should we let doctors who make bad recommendations or routinely give bad curbside advice be immune from lawsuits because they didn’t establish a chart with the patient? Maybe if I’m not sure what to do in a given situation, I will give a recommendation to keep up appearances of my expertise, but I won’t submit a bill or chart it?

In my opinion, this hospitalist made a medical error that was arguably based on negligence. The consequences to the healthcare system are significant, but it is a practice that should be fixed.

The NP being involved is a red herring here. The outcome would be the same if it was a primary care physician instead of an NP. Maybe the NP didn’t have admitting privileges and needed permission from the hospitalist whereas a PCP would be able to direct admit himself? Who knows? Either way, there was malpractice in this case and the system error should be addressed.
 
GravelRider said:
In my opinion, this hospitalist made a medical error that was arguably based on negligence. The consequences to the healthcare system are significant, but it is a practice that should be fixed.

The NP being involved is a red herring here. The outcome would be the same if it was a primary care physician instead of an NP. Maybe the NP didn’t have admitting privileges and needed permission from the hospitalist whereas a PCP would be able to direct admit himself? Who knows? Either way, there was malpractice in this case and the system error should be addressed.
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We don’t really know what NP presented to the physician. Even as an intern I learned to say a certain words to make sure my patients get seen.

Chest pain 7/10 radiating to left arm. I gave some nitro, seem to be a little better.

Sats in the toilet, on NRB. Breathing in the 30s.

Writhing in pain. Jumps when I lay my hands on her.

WBC 20k, doesn’t look good, I am not sure of the source.

You bet, my consultants will see my patients. I may get my ass chewed by my attendings, but these are my patients, I know what my limitations are.

Edit: sure I’ve also threaten my consultants. Dr. Cardiologist, are you refusing to see my patient? Can I document the reasons for not seeing my patient?
 
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GravelRider said:
So should we let doctors who make bad recommendations or routinely give bad curbside advice be immune from lawsuits because they didn’t establish a chart with the patient? Maybe if I’m not sure what to do in a given situation, I will give a recommendation to keep up appearances of my expertise, but I won’t submit a bill or chart it?
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Yes, they should be immune. If there isn't a physician patient relationship then it's little more than hearsay. Can you prove that a recommendation was actually provided or what the recommendation actually was? Ultimately, it's up to the inquiring clinician to determine course of treatment. They may not do everything I say, or anything that I say.

Not sure what you mean by not submitting a bill. In clinic, if a patient is on my schedule and they arrive and get roomed, the relationship is established whether or not I actually submit the bill or chart.

On a side note, I don't think we have enough information to say that the hospitalist made an error. He very well may have, but we don't have the information to indict him. If he explicitly said don't send this patient to the ED AND I won't admit her, then that's one thing. Simply saying abdominal pain with leukocytosis doesn't necessitate direct admission prior to ED evaluation is not a medical error, imo. In fact, such a patient SHOULD have gone to the ED initially regardless. If she showed up with acute peritonitis and needed emergent surgical intervention, then direct admission to a internal medicine service would have been the wrong move.
 
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What about when a junior anesthesiologist asks a senior anesthesiologist for an anesthetic plan and the jr guy documents "duscussed with sr anestgesiologist Joe Schmo, will proceed with GA RSI" and the guy aspirates and dies? Is the sr anesthesiologist on the hook? What if the intubating skills are not great? What if he didn't give enough sux or didn't give it time enough for the meds to kick in?
 
urge said:
What about when a junior anesthesiologist asks a senior anesthesiologist for an anesthetic plan and the jr guy documents "duscussed with sr anestgesiologist Joe Schmo, will proceed with GA RSI" and the guy aspirates and dies? Is the sr anesthesiologist on the hook? What if the intubating skills are not great? What if he didn't give enough sux or didn't give it time enough for the meds to kick in?
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As far as I am concerned. No H&P or eyeball test is performed, (should) not my problem.
 
bronx43 said:
Yes, they should be immune. If there isn't a physician patient relationship then it's little more than hearsay. Can you prove that a recommendation was actually provided or what the recommendation actually was? Ultimately, it's up to the inquiring clinician to determine course of treatment. They may not do everything I say, or anything that I say.

Not sure what you mean by not submitting a bill. In clinic, if a patient is on my schedule and they arrive and get roomed, the relationship is established whether or not I actually submit the bill or chart.

On a side note, I don't think we have enough information to say that the hospitalist made an error. He very well may have, but we don't have the information to indict him. If he explicitly said don't send this patient to the ED AND I won't admit her, then that's one thing. Simply saying abdominal pain with leukocytosis doesn't necessitate direct admission prior to ED evaluation is not a medical error, imo. In fact, such a patient SHOULD have gone to the ED initially regardless. If she showed up with acute peritonitis and needed emergent surgical intervention, then direct admission to a internal medicine service would have been the wrong move.
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Simple solution: stop providing treatment recommendations for patients you never met or never evaluated. Don’t allow triaging of patients via the telephone. Physicians should both get credit for (bill) and take responsibility (liability) for their expertise. Honestly, it’s a matter of patient autonomy. The patient is having care directed by a physician he or she never met or may not know is involved in the care. That’s not ok as far as I’m concerned.

urge said:
What about when a junior anesthesiologist asks a senior anesthesiologist for an anesthetic plan and the jr guy documents "duscussed with sr anestgesiologist Joe Schmo, will proceed with GA RSI" and the guy aspirates and dies? Is the sr anesthesiologist on the hook? What if the intubating skills are not great? What if he didn't give enough sux or didn't give it time enough for the meds to kick in?
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No. An anesthesiologist should know when a patient needs an RSI or not. Aspiration is a known risk and so long as appropriate precautions are taken, he shouldn’t be sued in the first place. It’s not the same thing. The hospitalist in this case made a decision that affected this patient’s care in a way the NP could not have.
 
GravelRider said:
Simple solution: stop providing treatment recommendations for patients you never met or never evaluated. Don’t allow triaging of patients via the telephone. Physicians should both get credit for (bill) and take responsibility (liability) for their expertise. Honestly, it’s a matter of patient autonomy. The patient is having care directed by a physician he or she never met or may not know is involved in the care. That’s not ok as far as I’m concerned.
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Lol, ok. Let me just keep that in mind the next time one of the community hospitalists calls and asks about my thoughts on a rheumatology case (i don't cover inpatient) that can't get transferred to the university hospital due to capacity. I'll simply tell him to F off. Because apparently this is good for patients somehow or another.

And no... it's not direction. It's a question posed by one physician to another. What the treating physician ultimately does is up to him/her.
 
GravelRider said:
No. An anesthesiologist should know when a patient needs an RSI or not. Aspiration is a known risk and so long as appropriate precautions are taken, he shouldn’t be sued in the first place. It’s not the same thing. The hospitalist in this case made a decision that affected this patient’s care in a way the NP could not have.
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What about when it is less clear cut. The above patient is a female 10 weeks pregnant? 12 weeks pregnant? 14 weeks pregnant? X weeks pregnant?

Or let’s say another anesthesiologist asks you if he should proceed with MAC for a colonoscopy for chronic diarrhea in the setting of severe hypokalemia. You tell him you would go ahead. Are you liable now if something happens?
 
GravelRider said:
That’s a consult. Who should take responsibility for that expertise if it results in bad care?
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Like hell it is!! Lol.

It’s not a “consult” until I’ve seen a patient or at minimum CAN see them (like in the ED). You want to run a pulmonary question past me? We are just talking. Caveat: if I think the question will require me to see the patient because someone doesn’t recognize or there is a potential for something serious or requiring a bronchoscopy, I will recommend transfer to our hospitalist service so I can see them.
 
So, moving forward I think curbside consults are still ok provided they are simply specialty related questions and not questions pertaining to a specific patient. For example:

Colleague: “Hey Salty, do you think a pregnant female at 14wks gest. having a GA needs to be intubated?”
Me: “Assuming she is appropriately fasted and has no other risk factors, I don’t think intubation is necessary.”

Vs.

Colleague: “Hey Salty, my next case is a lower extremity I&D on a 28yo F G2P1 currently pregnant at 14wks gest. She refuses regional. Should I intubate her?”
Me: “GTFOH.”
 
So how does this apply to these “collaborative” set ups where anesthesiologists do their cases and CRNAs do theirs, but you are there in the event they have a question. I’ve always had major concerns about these set ups from a medico legal perspective. What happens when they chart that they “collaborated” with you on a patient?
 
bronx43 said:
Lol, ok. Let me just keep that in mind the next time one of the community hospitalists calls and asks about my thoughts on a rheumatology case (i don't cover inpatient) that can't get transferred to the university hospital due to capacity. I'll simply tell him to F off. Because apparently this is good for patients somehow or another.

And no... it's not direction. It's a question posed by one physician to another. What the treating physician ultimately does is up to him/her.
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I was told in residency to never document or mention to the patient anything about talking to the specialist in cases like this for exactly this reason.
 
Do we know if the hospitalist here did not recommend er eval? It may have been that he wanted the patient to go through er to see if patient needed Emergent surgery instead of going to an inpatient medicine service with peritonitis which is appropriate. Accepting patients with no workup for direct admission is unusual and if there is a potential surgical problem it would be possible malpractice to do so since floor level workup is much slower than an er.

Also not viewing the medical record is being slung against him like it's some kind of error. It was an unrelated hospital system, how was he supposed to look at the record? Have them fax over her records while sitting in clinic septic (after signing a consent of course and waiting for the records to be copied etc, all told a process of over an hour minimum)? The np was either inexperienced or some external pressure encouraged him/her to not refer this patient to an er.

If you can't physically assess someone (and thus can't bill) why assume any risk? Lots of us will talk people through things to try to help but if the lawyers want to burn the medical system to the ground with exploding er coats and punish good faith collaboration instead of hold the only person truly responsible at fault then it's another nail in the coffin. Every clinic phone call will go straight to er and any direct admit not from someone you trust also goes to the er.
 
Last edited:
jdh71 said:
Like hell it is!! Lol.

It’s not a “consult” until I’ve seen a patient or at minimum CAN see them (like in the ED). You want to run a pulmonary question past me? We are just talking. Caveat: if I think the question will require me to see the patient because someone doesn’t recognize or there is a potential for something serious or requiring a bronchoscopy, I will recommend transfer to our hospitalist service so I can see them.
Click to expand...

If someone is documenting “discussed case with Dr XYZ,” then it’s a consult and you’d better make sure you are treating it as such. In the case discussed here, you can damn well be sure the NP documented all over the chart her discussion about the possible admission. Let’s not forget the paper trail of how she sought direct admission and was randomly assigned this hospitalist to speak with. Most of our physician to physician “curbsides” are not documented as such and will probably not be affected by this ruling (though, I would argue it’s a bad habit for many cases beyond a simple quick piece of advice). This particular case went well beyond simple quick advice and a consequential treatment decision was made by both the NP and the hospitalist. The decision to admit or not is a pretty big one, in my opinion. If you don’t feel comfortable making that decision over the phone (you shouldn’t) then you don’t do it. You advise further evaluation and stop taking direct admit triaging phone calls over the phone.

If it were my mom who was the patient here, you can be sure as **** I would want to sue the pants off the NP, the hospitalist, and whoever designed this phone triage system.
 
GravelRider said:
If someone is documenting “discussed case with Dr XYZ,” then it’s a consult and you’d better make sure you are treating it as such. In the case discussed here, you can damn well be sure the NP documented all over the chart her discussion about the possible admission. Let’s not forget the paper trail of how she sought direct admission and was randomly assigned this hospitalist to speak with. Most of our physician to physician “curbsides” are not documented as such and will probably not be affected by this ruling (though, I would argue it’s a bad habit for many cases beyond a simple quick piece of advice). This particular case went well beyond simple quick advice and a consequential treatment decision was made by both the NP and the hospitalist. The decision to admit or not is a pretty big one, in my opinion. If you don’t feel comfortable making that decision over the phone (you shouldn’t) then you don’t do it. You advise further evaluation and stop taking direct admit triaging phone calls over the phone.

If it were my mom who was the patient here, you can be sure as **** I would want to sue the pants off the NP, the hospitalist, and whoever designed this phone triage system.
Click to expand...
brb, chart stalking every curbside to make sure the NP/MD/PA doesn’t document speaking to me. Because we all know that during every conversation there is 100% agreement and understanding about the nature of said conversation.

Please just drop the curbside argument.. everyone with half a brain knows that curbsides help patients far more often than they hurt. This case isn’t even pertinent to curbsides and is the last thing these judges wanted to disincentivize, but it may be the collateral damage with sweeping court rulings like this.
 
bronx43 said:
brb, chart stalking every curbside to make sure the NP/MD/PA doesn’t document speaking to me. Because we all know that during every conversation there is 100% agreement and understanding about the nature of said conversation.

Please just drop the curbside argument.. everyone with half a brain knows that curbsides help patients far more often than they hurt. This case isn’t even pertinent to curbsides and is the last thing these judges wanted to disincentivize, but it may be the collateral damage with sweeping court rulings like this.
Click to expand...

That’s your decision. If you don’t mind having your name in a chart and trust every person you talk with to not misrepresent the advice you give and not misinterpret what you said then good for you. Me, I don’t trust people that much. Some call it a personality flaw, I call it self preservation.

Most lawyers I speak with say the thing that gets the majority of malpractice decisions against a physician is bad documentation. Even if you make an error, you are much safer if you document well than if you didn’t make an error and document poorly.

I honestly don’t understand the argument here that this hospitalist shouldn’t have been sued in order to protect some sacred piece of our current medical practice. This hospitalist is a *****, made a dumb decision that an intern wouldn’t make, and in doing so exposed a lazy practice in our profession. Let’s be real here, he probably had a census approaching 20, had a line of admissions waiting for him on his shift, his pager is going off with inane pages from nurses about Colace pills, and now he gets a call from “some idiot NP” looking to add to his workload. He disregarded the call and gave bad advice. Maybe that’s not what happened, but I was a hospitalist long enough to know that is what probably happened.
 
GravelRider said:
If someone is documenting “discussed case with Dr XYZ,” then it’s a consult and you’d better make sure you are treating it as such. In the case discussed here, you can damn well be sure the NP documented all over the chart her discussion about the possible admission. Let’s not forget the paper trail of how she sought direct admission and was randomly assigned this hospitalist to speak with. Most of our physician to physician “curbsides” are not documented as such and will probably not be affected by this ruling (though, I would argue it’s a bad habit for many cases beyond a simple quick piece of advice). This particular case went well beyond simple quick advice and a consequential treatment decision was made by both the NP and the hospitalist. The decision to admit or not is a pretty big one, in my opinion. If you don’t feel comfortable making that decision over the phone (you shouldn’t) then you don’t do it. You advise further evaluation and stop taking direct admit triaging phone calls over the phone.

If it were my mom who was the patient here, you can be sure as **** I would want to sue the pants off the NP, the hospitalist, and whoever designed this phone triage system.
Click to expand...

Sorry. It’s *not* a consult. I can’t give anyone a full consult without seeing a patient.
 
chessknt87 said:
Do we know if the hospitalist here did not recommend er eval? It may have been that he wanted the patient to go through er to see if patient needed Emergent surgery instead of going to an inpatient medicine service with peritonitis which is appropriate. Accepting patients with no workup for direct admission is unusual and if there is a potential surgical problem it would be possible malpractice to do so since floor level workup is much slower than an er.

Also not viewing the medical record is being slung against him like it's some kind of error. It was an unrelated hospital system, how was he supposed to look at the record? Have them fax over her records while sitting in clinic septic (after signing a consent of course and waiting for the records to be copied etc, all told a process of over an hour minimum)? The np was either inexperienced or some external pressure encouraged him/her to not refer this patient to an er.

If you can't physically assess someone (and thus can't bill) why assume any risk? Lots of us will talk people through things to try to help but if the lawyers want to burn the medical system to the ground with exploding er coats and punish good faith collaboration instead of hold the only person truly responsible at fault then it's another nail in the coffin. Every clinic phone call will go straight to er and any direct admit not from someone you trust also goes to the er.
Click to expand...

Let’s not kid ourselves, when I told this case to my wife, not-at-all medical person, her response was 1. How can the doctor be responsible when he hasn’t seen the patient. 2. Doesn’t the patient him/herself know they are very sick? Why can they just go to the ER.

The ship has long sailed for point #2. We are sitting here blaming the system, there must be more mechanisms to ensure safety.
As I proposed, I think NPs training is different. You can call them naive, I call them more harsh words than that. They play by a different set of rules. They may never told, documenting a private conversation between “providers” are not acceptable. How many times I’ve heard I will write you up if you don’t do such and such. Being a physician for 10 years I don’t even know how to “write someone up”. In the above examples, I am a physician threaten to document, so to expose my colleagues, I am saying I accept a “mutual” destruction. In the case of NP vs a physician, you already had a disparity of power and status. Should there be? You bet your ass it should.

My frustration with a “systemic” approach to eliminate this kind of problems is that, how are we any different than protocol driven nurses training? Common sense is dying, because if it’s not written it is not done. My curbside consult is exactly what it is. I mis-diagnosed one of my colleague recently when he called me on a Sunday and started treatment on his own. Two days later he went to his pcp. We had a good laugh together. But it was “understood” it wasn’t anything more than a courtesy of talking a case through with him.

Why do we claim “this is not a medical advice” when we post online. Because I don’t know you Jane from Dick. Because I didn’t see you. Because for all I know your second cousin third remove is you, and you will take my advice and follow it when I don’t know anything you tell me is correct. I don’t know how many times the nurse on L&D rolls their eyes when I go into EMR and check platelet myself. Trust but verify.

One pretty wise nurse manager told me once, doctors gave up their power when they left the administration suite in the hospital to all others. And this nurse manager is studying to become an APRN and will be working in ICU. A late fifties, with 30 year nursing and administrative experiences person is gunning for your jobs.

Don’t get me started on lawyers.

Tl;dr. No personal responsibility. No common sense. No courtesy. No lawyers. In medicine.
 
GravelRider said:
Good. I agree. Then don’t make important treatment recommendations, like whether or not to admit a patient, without seeing a patient either.
Click to expand...

But we don't know that is the recommendation he made because these communications have no mechanism for documentation at the receiving facility unless a formal transfer MRN and encounter are created so the hospitalist didn't write anything down. He could just have easily said she shouldn't be directly admitted (and as an aside no pcp would try to direct admit this, attempting to do so was malpractice) because we don't know how bad it is and the np stopped listening after the first 6 words and documented that. The onus of responsibility is on the clinician taking care of the patient not the physician in another health system on the other end of the phone. Holding that person responsible is insane unless there is a formal telemedicine consult or documented resual to accept a formal transfer request. This is like the er calling to ask me if they should admit a patient with xyz--its their job to decide that, not mine and if a negative consequence occurs it is on them, not me.

Are you in a field that gets curbside regularly or does Ed consults for potential admits? When was the last time you rounded on a medicine ward?
 
I used to work with a CRNA whose spouse was an attorney. He documented every single conversation he had with the attending anesthesiologist. He would also call for every single unexpected thing during the case, which he would then document.
I assume a mid level is going to document anything I say in order to shield themselves if something goes wrong.
 
IMGASMD said:
Let’s not kid ourselves, when I told this case to my wife, not-at-all medical person, her response was 1. How can the doctor be responsible when he hasn’t seen the patient. 2. Doesn’t the patient him/herself know they are very sick? Why can they just go to the ER.

The ship has long sailed for point #2. We are sitting here blaming the system, there must be more mechanisms to ensure safety.
As I proposed, I think NPs training is different. You can call them naive, I call them more harsh words than that. They play by a different set of rules. They may never told, documenting a private conversation between “providers” are not acceptable. How many times I’ve heard I will write you up if you don’t do such and such. Being a physician for 10 years I don’t even know how to “write someone up”. In the above examples, I am a physician threaten to document, so to expose my colleagues, I am saying I accept a “mutual” destruction. In the case of NP vs a physician, you already had a disparity of power and status. Should there be? You bet your ass it should.

My frustration with a “systemic” approach to eliminate this kind of problems is that, how are we any different than protocol driven nurses training? Common sense is dying, because if it’s not written it is not done. My curbside consult is exactly what it is. I mis-diagnosed one of my colleague recently when he called me on a Sunday and started treatment on his own. Two days later he went to his pcp. We had a good laugh together. But it was “understood” it wasn’t anything more than a courtesy of talking a case through with him.

Why do we claim “this is not a medical advice” when we post online. Because I don’t know you Jane from Dick. Because I didn’t see you. Because for all I know your second cousin third remove is you, and you will take my advice and follow it when I don’t know anything you tell me is correct. I don’t know how many times the nurse on L&D rolls their eyes when I go into EMR and check platelet myself. Trust but verify.

One pretty wise nurse manager told me once, doctors gave up their power when they left the administration suite in the hospital to all others. And this nurse manager is studying to become an APRN and will be working in ICU. A late fifties, with 30 year nursing and administrative experiences person is gunning for your jobs.

Don’t get me started on lawyers.

Tl;dr. No personal responsibility. No common sense. No courtesy. No lawyers. In medicine.
Click to expand...

The patient did seek medical care and the system failed her. She went to her “provider” probably feeling like she had the flu. That question then gets kicked up the chain and she is told it’s her diabetes acting up (wtf?). Sepsis can be a b!tch where one minute you feel like you have an awful cold and the next you are dead. This has nothing to do with personal responsibility (though is a problem elsewhere) and more due to multiple flaws in the system.
 
GravelRider said:
That’s your decision. If you don’t mind having your name in a chart and trust every person you talk with to not misrepresent the advice you give and not misinterpret what you said then good for you. Me, I don’t trust people that much. Some call it a personality flaw, I call it self preservation.

Most lawyers I speak with say the thing that gets the majority of malpractice decisions against a physician is bad documentation. Even if you make an error, you are much safer if you document well than if you didn’t make an error and document poorly.

I honestly don’t understand the argument here that this hospitalist shouldn’t have been sued in order to protect some sacred piece of our current medical practice. This hospitalist is a *****, made a dumb decision that an intern wouldn’t make, and in doing so exposed a lazy practice in our profession. Let’s be real here, he probably had a census approaching 20, had a line of admissions waiting for him on his shift, his pager is going off with inane pages from nurses about Colace pills, and now he gets a call from “some idiot NP” looking to add to his workload. He disregarded the call and gave bad advice. Maybe that’s not what happened, but I was a hospitalist long enough to know that is what probably happened.
Click to expand...
What are you evening talking about? When did I say I don't mind my name in a chart for a patient I never saw? My point, which you seem to have missed entirely, is that unless you never speak to another clinician about medicine in general, you CANNOT prevent someone from typing in the computer that they spoke to you and you recommended XYZ.

"Hey Dr. Bronx, what would you do about a lupus patient with XYZ?"
"I would consider ABC."

So you don't understand the argument here? You don't understand the concept of unintended consequences? Because that's what we are arguing here... that sweeping rulings can bring about effects which you do not want and is detrimental to everyone as a result.

A rational statement that I can buy (but ultimately disagree with) is the following:

I believe that, despite the possibility of disincentivizing a commonplace and mostly beneficial practice of curbside consults, the benefit of allowing malpractice lawsuits without a patient-physician relationship in order to sue this hospitalist (assuming he actually made a mistake) outweighs aforementioned risks.
 
Last edited:
GravelRider said:
Good. I agree. Then don’t make important treatment recommendations, like whether or not to admit a patient, without seeing a patient either.
Click to expand...

Just abdominal pain, white count, and elevated glucose by report from an outside provider doesn’t necessarily warrant admission to a hospital. I wouldn’t have recommended a direct admit either. That problem is the primary providers problem and the only way to make the case it should be someone else’s problem is a visit to an ED. I fail to see where the hospitalist has any legal liability for a bad outcome here.
 
bronx43 said:
What are you evening talking about? When did I say I don't mind my name in a chart for a patient I never saw? My point, which you seem to have missed entirely, is that unless you never speak to another clinician about medicine in general, you CANNOT prevent someone from typing in the computer that they spoke to you and you recommended XYZ.

"Hey Dr. Bronx, what would you do about a lupus patient with XYZ?"
"I would consider ABC."

So you don't understand the argument here? You don't understand the concept of unintended consequences? Because that's what we are arguing here... that sweeping rulings can bring about effects which you do not want and is detrimental to everyone as a result.

A rational statement that I can buy (but ultimately disagree with) is the following:

I believe that, despite the possibility of disincentivizing a commonplace and mostly beneficial practice of curbside consults, the benefit of allowing malpractice lawsuits without a patient-physician relationship in order to sue this hospitalist (assuming he actually made a mistake) outweighs aforementioned risks.
Click to expand...

I’m done. I think the NP and hospitalist both deserved to be sued. There was a preventable death that exposed a system problem. I think the judgment here was the right one. I think the fear that this is going to result in massive lawsuits for all curbsides or hospitals full beyond capacity is not correct. I am confident that the hospitalist’s biggest misstep (in terms of protecting against liability) was one of documentation. The system of an NP calling a randomly assigned hospitalist when seeking hospital admission should have never existed in the first place. That was the system problem and someone had to take the fall.
 
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