Caring ‘informally’ for colleagues, others?

A recent medical malpractice case involved a physician treating his significant other for a chronic pain problem with narcotics and muscle relaxants that resulted in an overdose and death.

“It was never clear whether the overdose was inadvertent or intentional, but the family was awarded a settlement in excess of $1 million,” reports Richard J. Wadas, MD, FACEP, president and chief medical officer at Emergency Resource Management in Pittsburgh, and clinical associate professor of emergency medicine at University of Pittsburgh (PA).

In another case, an emergency department (ED) nurse developed a headache while at work and was treated with intravenous fluids and prochlorperazine. No chart was created, despite the fact that the care was provided in the ED. “She returned the next day with subarachnoid hemorrhage and went on to have mild to moderate disability,” says Wadas. “She filed suit against the physician on duty that day as well as the hospital and was awarded a settlement at trial.”

A current malpractice case in New York involves a woman who suffered a cardiac arrest seven days after an undocumented encounter with her physician of 20 years. “She went to the office on a day when they were not seeing patients, but ran into the physician in the parking lot,” says Wadas. “She informed him that she had been having problems with chest pain. He prescribed nitroglycerin and a stress test. However, she expired before the test was ever obtained.”

In general, physicians have an obligation not to provide care outside of established physician-patient relationships, says Charissa Pacella, MD, FACEP, chief of emergency services at UPMC Presbyterian in Pittsburgh and associate professor of emergency medicine at University of Pittsburgh. “The reasoning is straightforward. Quality medical care requires openness and objectivity that cannot be guaranteed when the patient is a friend or family member,” say Pacella.

Pacella says to imagine prescribing antibiotics for a teen-age niece who is reluctant to tell you she is taking an oral contraceptive, or treating abdominal pain and vomiting in a friend who doesn’t want to tell you how heavily he drinks. “A risk with all of these underlying relationships may be increased frequency of cognitive medical errors such as premature closure, given one’s personal knowledge of the ‘patient,’” says Wadas.

Physicians might alter medical decision-making based on the pre-existing relationship, he warns. “Deviations in care may be accentuated by real or perceived medical knowledge on the part of a staff member and may lead to errors in over- or under-testing,” he explains.

“Informal” advice

If a physician-patient relationship already clearly exists, “legal risks are clearly higher,” says Wadas. For example, a primary care physician might have a casual, undocumented encounter with a patient in the grocery store.

“Giving ‘informal’ advice in very general terms is probably OK, but should always include a recommendation to seek formal care,” says Wadas.

A physician might say, for example, “If you are having these symptoms, it could be something more serious. There is no way for me to tell what the cause is,” and instruct patients to seek a formal evaluation.

Specific or personalized advice regarding a specific condition likely would be construed as establishing a patient/physician relationship, and prescribing a specific treatment plan, such as by issuing a prescription, almost always would be interpreted as establishing such a relationship, Wadas says.

Avoid recommendations regarding treatment specific to the patient’s symptoms, such as stating, “That cough is probably just bronchitis. Just take some cough medicine and get some rest,” he says.

“One should be clear that the encounter does not establish a diagnosis,” says Wadas. “Providing any instructions or specific treatment in writing should also be avoided.”

Sources

Charissa Pacella, MD, FACEP, Chief of Emergency Services, UPMC Presbyterian, Associate Professor of Emergency Medicine, University of Pittsburgh. Phone: (412) 647-9922. Email: pacellacb@upmc.edu.

Richard J. Wadas, MD, FACEP, President and Chief Medical Officer, Emergency Resource Management, Clinical Associate Professor of Emergency Medicine, University of Pittsburgh. Phone: (412) 432-7400. Email: wadasrj@upmc.edu.