Interesting lawsuit. Thoughts??

[ventana]

By GLENN HOWATT , STAR TRIBUNE 
May 27, 2019 - 6:58 AM

In a ruling that is causing a stir in Minnesota’s medical and legal communities, the state Supreme Court has said that a doctor can be sued for malpractice even in the absence of a traditional physician-patient relationship.

Medical groups say the opinion could subject physicians to more lawsuits, even in cases when they are simply giving informal advice to colleagues. The expansion of liability, they say, could also increase malpractice insurance premiums and have a chilling effect on consultations.

 

correction

the whole article did not paste first time.  Here it is. 

Issue I see is NP

 

MINNEAPOLIS (AP) — A recent ruling from the Minnesota Supreme Court saying doctors can be sued for malpractice even if they're not directly treating a patient is causing angst in the state's medical and legal communities.

The high court said in its ruling last month that the decision was aimed at doctors whose decisions have consequences. The decision came in a case involving a hospital doctor who allegedly refused to admit a patient who was being treated by a nurse practitioner at the Essentia Health Clinic in Hibbing in August 2014.

The nurse spoke with Dr. Richard Dinter at Fairview Range Medical Center and asked him to admit 54-year-old Susan Warren because she was suffering from abdominal pain, fever, chills and other symptoms, according to the lawsuit from the patient's family. The lawsuit alleges Dinter declined admission after a 10-minute phone call.

But court records in the case show that the doctor and nurse disagree about several aspects of their conversation, including whether the nurse made the request for Warrant to be admitted. Warren died several days later.

[sas5814]

I'd have to have more information about what "informal advice" constitutes and, further, may depend on what your colleague does with it. If I ask my colleague to look at a picture of a skin lesion just because I'm stumped and he/she gives me an off the cuff suggestion that I may or may not use that would be one thing. If I am the kind of paranoid doofus that then writes in the chart "Dr Smith reviewed an image of this lesion and stated it was a blah blah" then, sadly, I just dragged my friend and colleague formally into the case against his/her will.

That said the law has never made any sense to me. I think of laws as rules and rules are well....rules. But a law can be interpreted and reinterpreted many many times with educated people rendering different opinions over and over. Boggles my mind.

[SHU-CH]

We are evolving into a society where everyone is going to be afraid to talk to anyone about anything.

[Cideous]

42 minutes ago, SHU-CH said:

We are evolving into a society where everyone is going to be afraid to talk to anyone about anything.

We are already there.

I would NEVER document an informal consult.  It's why I am very leery about giving any medical advice to anyone at anytime.  I have co-workers all the time asking for curbside consults.  This is exactly why I don't give them.  It sucks because my natural instinct is to try and help, but I have to force myself not too.  Welcome to medicine in a sue sue sue society.

[mgriffiths]

I specifically do NOT chart curbside consults or even a more formal "informal consult."  The exception is when I ask a physician a question and they take over and start telling me what to do...I will not do something I believe is wrong, harmful, etc. regardless of physician direction, but if they are giving direction rather than collegial input then I chart their name as it is their thought process and medical decision making at that point.

I also will provide a curbside consult to colleagues when asked but always specifically tell them to leave me out of the note.  If they want my input in the chart they need to refer the patient to me so I can personally evaluate the patient.

[jmj11]

I have quoted (in the chart) specialists, including their names, when I've received curbside advice. It has been to protect my own ass. I've been in situations where people (SPs, other physicians) have asked, "Why did you do X?" I want to be able to say, "Dr. Y, the head of the Z department a the local University Medical Center recommended that I do X, so that they would not think I just pulled the idea out of my ass. But I think it is a travesty to hold Dr. Y responsible for the out come as he/she did not know the patient or the full story. Only I, the immediate provider knew both the patient and the adviser and I should be held legally responsible. However, in a court of law, me mentioning the name of Y shows that I did due diligence in trying to find the best treatment and not just throwing darts at a wall of options.

[sas5814]

I hear what you are saying. I think the distinction is actually getting a consult, formal or informal, as opposed to just doing a drive by to get an idea.

Perhaps the distinction could be some wording in the chart to sort of make a distinction between the 2. I don't know what difference it would make in court.

[ventana]

Crud.  The whole article did not paste. 

 

The critical cal point was that the doc getting sued refused to admit the patient because it the patients provider was an NP!!

[mgriffiths]

Well that does change things just slightly...

[Kaepora]

Yeah, this doesn't sound like a curbside consult.  This physician was blocking an admission from a NP.  The NP did not have privileges to admit.  This physician didn't just "fail to diagnose", but actively blocked the admission of this patient despite recommendation from the NP.  The NP had the diagnosis, the physician ignored it.  

[mgriffiths]

13 hours ago, ventana said:

But court records in the case show that the doctor and nurse disagree about several aspects of their conversation, including whether the nurse made the request for Warrant to be admitted. Warren died several days later.

The highlighted is the key.  Arguing over "he said...she said" is useless...did the NP state in his/her note that admission was requested?  Further, did the NP actually ask for admission?  Is it possible the NP did NOT ask for admission, but then lied putting in his/her note that Dr. Dinter refused admission?  How can the doc possibly defend himself when he has no control over what the NP puts in his/her note...honestly if it happened as the article suggests then doc should be sued and lose (in my opinion).  But, how do you prove this...and if you can't, then I see this as a VERY slippery (and scary) slope!

 

Then of course the other question is how well did the NP do in presenting the case?  Did the NP leave out important information?  Did the NP have more information that he/she included in their clinic note after talking with Dr. Dinter?  Example: NP didn't have temp...Dr. Dinter asked if patient has a fever and NP assumed no.  After conversation NP gets a temp and fever found...therefore Dr. Dinter did NOT have all of the data to make a full assessment on whether to admit.  But, NP puts in note the fever, disregarding that he/she did not include the presence of fever when requesting admission.  Again...slippery slope.

 

Lastly...if the NP was truly concerned...why didn't the NP send the patient to the ED regardless of Dr. Dinter's refusal to admit?  At the ED there MUST be someone in the hospital who can evaluate and has the authority to admit.

Edited May 30, 2019 by mgriffiths

[Cideous]

11 hours ago, mgriffiths said:

Lastly...if the NP was truly concerned...why didn't the NP send the patient to the ED regardless of Dr. Dinter's refusal to admit?  At the ED there MUST be someone in the hospital who can evaluate and has the authority to admit.

and this is important.  Maybe she did but there was a delay in getting treatment etc.  I think the whole supreme court decision was centered around "could" the doc be sued just from a consult, not "should" he be sued.  We are kinda going down a rabit hole on the treatment.

My questions are:

1.  Was he on call?  Did he deny admission while on call?

2.  Was he the patients pcp and that is why she called him?

3.  Why exactly did she call this guy?  I mean, why him?

 

If he was just some radom doc, not on call and not the PCP....man that would suck for him to be tagged in a lawsuit just because he answered the phone....

[Boatswain2PA]

Can you link to original article?  I would like to leave this up for some hospitalists to see.

Main shop I work at has hospitalists who dont want to admit anything, their answer is usually "they dont meet criteria". I document that I requested admission but Dr. So-and-so said they dont meet admission criteria.

[ventana]

2 hours ago, Boatswain2PA said:

Can you link to original article?  I would like to leave this up for some hospitalists to see.

Main shop I work at has hospitalists who dont want to admit anything, their answer is usually "they dont meet criteria". I document that I requested admission but Dr. So-and-so said they dont meet admission criteria.

https://www.apnews.com/23e5e89c97bd401faaf934ca9a501d9c

[surgblumm]

Informal consultation is just that, informal. It is a breach of medical ethics to document a thought that the expert had given. this was the best answer thus far; I also will provide a curbside consult to colleagues when asked but always specifically tell them to leave me out of the note.  If they want my input in the chart they need to refer the patient to me so I can personally evaluate the patient.

[mgriffiths]

Seems the entire article didn't post again...

But I believe this is the crux of the whole case (not specifically the supreme court ruling) and what I was getting at above - '“Dr. Dinter’s response was appropriate based on the limited information provided,” the company said in a statement, which added that the hospital believes “Fairview and Dr. Dinter will be found to have acted appropriately.”'

 

My guess on how this plays out if becomes a bigger issue with malpractice and administrators hear about it...when a provider calls for a consult and/or request for admission both providers will be required to "chart" said conversation.  Not sure how Dr. Dinter would chart this conversation if patient is not in their EHR system - but I'm sure they would find a way, and likely isn't too complicated.

[surgblumm]

There are many doc's who will get a call not asking for a formal admission but is presented with the crux of the presentation. should that Doctor give no res[onse and hang up or at least be given enough information where they can make a comment, not necessarily on the patient but upon their participation without comment. Id that doctor even in the same system? all points of debate and confusion. I assume it is better to stay within the legal guidelines of consultation and be able to chart the advise given. 

 

http://bit.ly/modern-meded-clinical-documentation

[Cideous]

If I missed it, can someone answer my previous question....why did *this* doctor get a call from the NP?

Edited May 30, 2019 by Cideous

[mgriffiths]

25 minutes ago, Cideous said:

If I missed it, can someone answer my previous question....why did *this* doctor get a call from the NP?

This is what the article provides, "The nurse spoke with Dr. Richard Dinter at Fairview Range Medical Center and asked him to admit 54-year-old Susan Warren because she was suffering from abdominal pain, fever, chills and other symptoms, according to the lawsuit from the patient’s family."

 

So, the reality is that we don't know.  I work in an outpatient FP clinic that is linked to a hospital system...there are ZERO direct admits.  Doesn't matter if you are an MD/DO, NP, PA, MA, CNA, God himself, etc.  If I believe a patient is sick enough to be admitted they MUST be directed to the ED without exception.  Never really thought about it before, but this policy effectively removes the risk of this specific type of case entirely - maybe intentionally.

 

Personally, I would say that whoever is making the decision to admit should be evaluating the patient him or herself.

Edited May 30, 2019 by mgriffiths

[sas5814]

Yea we have a direct admit line that gets the hospitalist on the phone but, as you said, they really don't like to do that. Even when the admit is appropriate the ER can get some tests done and initiate treatment etc. It can be a hassle but I think it is probably the best way to go especially since we are a UC with very limited diagnostic and treatment capability.

[ventana]

We used to have direct admits.  But they have fallen out of favor.  

 

I had had a few instances in the ER where hospitalist declined admission.   I asked them to come write a note stating this..... they would come down and likely the patient ended up admitted.  Seems it is harder to say no when you have to sign your name to it

 

now that I am not ED I prefer to let the ED attending decide rather patient gets admitted (usually we agree). 

[Kaepora]

"Fairview (the hospital / hospitalist) and Essentia (the clinic / NP) had a working agreement that it would be Fairview that took these calls and did the admissions.  Providers at the Essentia clinic did not have hospital admitting privileges, and they typically talked with a Fairview staff doctor, known as a hospitalist, who made the decision."

Also, how often do physicians cover for their colleagues on call overnight or on the weekend, and take calls from nurses, and prescribe meds and other therapies based on their report - without ever seeing the patient.  I think it's fair to say if the NP made the call to the hospital, she knew the patient met admission criteria, and, that was the intent of the conversation. 

Further, I have, more than once, told a patient to go to the ER (my office is right across the street) and they didn't!  I had a patient a few months ago with critical carotid artery stenosis who called the office c/o amaurosis and hemiparesis and he refused EMS, refused my recommendation to go the ER emergently, and WAITED 2 DAYS TO GO TO THE ER!  Obviously, I chart the heck out of this stuff, but it happens.  

We don't know enough about this case, but let's not pretend hospitalists are agreeable to every admission - even when it's clearly warranted.  More than once I've had to have my attending get on the phone because some hospitalists are just difficult.  

[Cideous]

Hard to make a call on this situation if we don't know the answer to my previous question so...yeah.

[Boatswain2PA]

19 hours ago, Cideous said:

If I missed it, can someone answer my previous question....why did *this* doctor get a call from the NP?

While I obviously don't know with certainty, it seems that *this* doctor was the hospitalist with admitting privileges.

I initially thought this might be a NP from the ED calling for admission and denied (because I'm in that position a lot at one place I work), but it looks like Essentia is a primary care clinic.  The NP should have sent the pt to the ED. 

[surgblumm]

Perhaps this physician was on a call list and was unaware. I've seen this happen because of lousy administration.