Recently I served as an expert witness in two cases; in each a hospitalist was being sued. While I can’t share details of these confidential cases, I can share my insights using a couple of hypothetical cases that illustrate the key lessons I learned:
- A 75-year-old woman was admitted by orthopedics after a fall requiring hip fracture repair. A hospitalist automatically saw her per the standing agreement. The hospitalist adjusted her diabetes regimen and held her aspirin because of bleeding. On the evening prior to discharge she developed right lower-extremity pain. The on-call orthopedist ordered a lower-extremity ultrasound from home.
The patient felt better the next morning and was discharged with hospitalist recommendations to increase her basal insulin, restart her aspirin, and follow up with her primary care provider (PCP). Three days later the patient presented in respiratory extremis and died in the emergency department. Post-mortem chart review noted a sonographic venous thrombosis in the right femoral vein that went unnoticed during her hospital stay.
- A 58-year-old woman was admitted after an uncomplicated appendectomy. On post-op day two, the surgeon asked the hospitalist to see the patient for a depressed mood. The hospitalist recommended starting an antidepressant and following up with her PCP after discharge. She also noted that the patient had right lower-extremity pain and swelling and recommended an ultrasound for workup of a deep venous thrombosis (DVT). The hospitalist did not see the patient again, and the ultrasound was not completed. Two days after discharge, the patient died at home after complaining of chest pain. Post-mortem autopsy revealed massive pulmonary embolism.
Two difficult cases, indeed. And I learned plenty from them:
Lesson one: Most lawsuits do not stem from deficiencies of medical knowledge.
In both cases, the hospitalists’ clinical reasoning was sound. In the first he was unaware of the patient’s overnight symptoms, which were not documented in the chart because the patient was not seen by the on-call orthopedist—a major systems error and lack of professionalism. This was compounded by a system that did not alert providers that an ultrasound was ordered or read as abnormal.
In the second case, the hospitalist got it right and made the correct recommendation—but the surgeon didn’t follow through.
Lesson two: Clarify your role—consultant or co-manager.
The differences between consultant and co-manager are subtle but crucial.
A consult is a request to answer a specific question: “Is this patient depressed, and how would you manage this problem?” This results in a detailed, focused appraisal of that issue, culminating in a note listing recommendations for further evaluation and management. It is the primary team’s responsibility to follow up on recommendations as they deem appropriate.
With this decision-making capacity, the primary team accepts near-full clinical and medical legal responsibility. As long as the consultant does due diligence and makes sound recommendations, it is unlikely he/she will be successfully sued for a bad outcome if the recommendations are not followed.
However, the hospitalist movement has changed this landscape considerably. We often function in a co-management model with our consulting colleagues, each of us caring for the issues within our respective scope of expertise.
This paradigm demands a level of responsibility sharing and communication that differs significantly from the traditional consultative model.
Knowing which model you are functioning under and who is responsible for which problems can be tricky. In the first case, who owned the decision-making for the patient’s DVT work-up?
The orthopedist may assume his role is focused on the care of the hip fracture surgery, while all else is the hospitalist’s purview. The hospitalist may assume DVT is a complication of the hip fracture surgery and is the orthopedist’s responsibility.
The second case seems easier as the hospitalist was clearly functioning as a consultant and therefore his obligation ends with his recommendation to further evaluate for DVT.
Or does it?
Lesson three: Communication is imperative.
The role we are functioning in—consultant versus co-manager—is not always intuitive. This perplexity can be further exacerbated by poor communication.
In both cases the hospitalists’ role was not established up front. Further, the hospitalists and their colleagues never spoke directly about the case or the management decisions.
In the second case the surgeon saw the recommendation but presumed the hospitalist would write the order for the ultrasound because they were co-managing the patient. He argued that he is not expert in the care of DVT and could not determine if the recommendation was sound. He assumed the hospitalist would appropriately evaluate this situation and complete the work-up if warranted. Because the hospitalist did not, the surgeon assumed the hospitalist was no longer concerned about DVT.
The hospitalist countered that she was specifically consulted to answer a question about depression. The recommendations regarding the swollen calf were also done in a consultative fashion, and the decision to obtain the ultrasound would fall to the surgeon.
The hospitalist argued that because the surgeon did not consult her again for this specific issue, she assumed he was comfortable evaluating and managing DVT.
This foray into the legal system reminded me that our patients trust we will give them the best care. When system and communication inadequacies get in the way of this, we can get sued—but our patients can lose their lives. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.