The risks of being popular—and how to manage them

The risks of being popular—and how to manage them


As hospitalists touch more patients, their liability risk grows

April 2017
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Published in the April 2017 issue of Today’s Hospitalist

Editor’s note: This is a first in a two-part series on how to minimize your malpractice risk. Click here to read the second article. 

ONE OF THE MOST GRATIFYING aspects of working in a growing hospitalist practice is gaining the respect of the medical community. While your group may have started with only “no doc” patients coming to the hospital’s ER, now you’re serving on committees and being asked to admit patients for your subspecialty consultants.

That growth is not surprising considering that we’re always available. We don’t have office practices, we don’t spend hours in the operating room, and we don’t have a schedule of patients needing fluoroscopic or endoscopic procedures.

As early as 25 years ago, hospitalists got the idea of admitting for everybody—surgeons, psychiatrists, whoever. The neurologists were already asking internists to admit their patients and manage their medical problems. It was a short step from there to handling the day-to-day care of people whose main reason for a hospital stay was an invasive procedure.

There’s this downside to hospitalists’ growing role: We’re increasingly being named in malpractice lawsuits.

 

Hospitalists write medication orders, take calls for “housekeeping” issues and do the discharge paperwork. With us, quality of care and patient satisfaction generally improve, and the surgeon isn’t being called at 2 a.m. with requests for Tylenol or laxatives. What’s not to like?

But there is this downside to the growing role of hospitalists: We’re increasingly being named in malpractice lawsuits. My expert-witness practice is producing a depressing number of cases in which another doctor is to blame for a bad outcome, but hospitalists—usually two or three—are named in the suit. If the records support what you did, you may be dropped from the suit, or you may not.

Because we are so popular, we need to adopt strategies to avoid—or at least minimize—our risk.

“Just call the hospitalist … “
You accepted a hip fracture patient for the on-call orthopedist. The patient is medically cleared and stable on Buck’s traction and morphine. But it’s nearly 48 hours since her fall, and you know that mortality rates increase if surgery is delayed more than a day or two. So why isn’t her name on the OR schedule?

Or maybe that headache patient is still on a Dilaudid drip, and the normal CT scan isn’t as comforting as it was. Can’t the neurologist move a little faster on his diagnostic workup? And shouldn’t that cholecystectomy patient be walking and eating by now?

We ought to be able to trust our colleagues in other specialties. It’s tempting to think that because that surgeon has seen more fractures/gallbladders/chest tubes than we have, maybe we should just step back and wait for her to do her job. But look at the chart or EMR screen: That’s your name at the top. You are the captain of the ship, whether you’re fresh out of training or the practice group leader, and the primary responsibility is yours.

Calling for help
Make a note in the chart or EMR of all the complaints, physical findings and test results that add up to a problem.

Call the doctor you think should handle it, and remind yourself to get his or her cellphone number so you won’t have to deal with a secretary or receptionist the next time. This goes triple if you’re a female hospitalist. Many female office assistants have trouble with the concept that a woman could be licensed to practice medicine, so you may have to tell them two or three times that you are the doctor in charge of this patient and need to solve a problem.

And add your conversation with that doctor to your notes.

It often helps to enlist a different consultant: a pulmonologist for that chest tube problem or a GI doctor for the postop abdominal pain. Get the most senior doctor you can, because many hospitalists tend to be at the lower end of the age range for their hospital’s staff. In an extreme case, you may need to call the service chief—something you don’t want to do at 2 a.m. unless you are very sure of your position.

If you’re really frustrated, consult someone else in the same specialty. Surgeons have a longstanding rule that the one who performed the first operation should handle any complications. But even if surgeon No. 2 refuses to see the patient, the record needs to show that you tried to consult him.

The most extreme action of all, transferring the patient to another hospital, will probably consume time the patient may not have. But it will at least call attention to the situation.

Checking with the real boss
If you’ve tried everything and are still concerned, you are going to have to break the code of silence and tell the patient and family that you’re not comfortable with what’s happening. They can help you by requesting a second opinion or even demanding a transfer. In that case, you’re less likely to develop an ongoing feud with the first doctor.

Meanwhile, consider additional testing to document what you think is happening: scans for postop bleeding or a bile leak, or a lumbar puncture if encephalitis is a concern.

Hunt down a colleague in the doctors’ lounge who can explain the standard of care and help you build your case for immediate action rather than watchful waiting.

Plus, you need—really, really need—to tell your partners what’s worrying you. All those articles about the importance of good handoffs rarely mention inter-doctor problems as something you need to sign out on. But you owe it to the patient to make sure your weekend rounder or next-week hospitalist knows the full story. She might otherwise lose another day or two figuring out the things you’ve already realized. Word your entry on the rounding list tactfully, but make your concerns clear.

Looking ahead
Be as diplomatic as possible and avoid sounding critical. The specialist whose complications you spot this week may be the one who saves you from making a mistake next time. On the other hand, you and your partners may be the first to realize that a pattern is developing and be able to start the intervention process.

It’s your patient. Your care is the first defense against not only lawsuits, but the disasters that 
lead to them.

Stella-FitzgibbonsStella Fitzgibbons, MD, has been a hospitalist since 2002 and an expert witness in hospital medicine since 2008.

 

 

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Emily Paterson
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Thanks for recognizing some of the problems occurring. Dr. Makary’s 2016 Johns Hopkins study finds medical errors are now the 3rd leading cause of death. We need more articles like this one.

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