By Charles A. Pilcher MD FACEP
May, 2013
Part I: Consults
[Editor’s Note: This “Perspective” covers “Consults.” Part II on “Handoffs” will appear in the next issue of Medical Malpractice Bulletin.
All too often the responsibility for a patient becomes unclear when an emergency physician requests a consult or transfers care to another doctor. The result can be catastrophic for a patient, and a catastrophe for the patient becomes a catastrophe for the doctor.
Lets talk first about consults.
In general there are 5 reasons why an emergency physician might call a consultant:
- To arrange urgently needed follow-up care for a patient who is being discharged. Example: A 70 yo man with benign prostatic hypertrophy develops urinary retention. A catheter is inserted in the ED and the bladder drained. The patient needs to be seen by a urologist in a day or two to remove the catheter and plan future care.
- To advise a specialist that a patient is being admitted emergently for either medical or surgical reasons and should be seen expeditiously, if not immediately. Example 1: The ED physician confirms via CT scan the presence of appendicitis. The patient is admitted for appendectomy. Example 2: Treatment has been started for pulmonary embolus on a stable patient with chest pain and DVT.
- To request the performance of a procedure in the ED that is beyond the scope of the treating physician’s skill set. Example: A dog bite resulting in a deep facial laceration on a 9 yo girl.
- To request a second opinion that requires a face-to-face encounter between the patient and the consultant. Example: A 13 yo boy with classic symptoms of testicular torsion and an equivocal exam and ultrasound examination.
- To discuss a case with a specialist before making a final disposition. Examples: Too numerous to count. See discussion below.
Whenever a true consultation takes place, the patient should be advised of the decision to seek the advice of another physician and clearly be made aware when the consult becomes an actual “handoff,” at which point responsibility for care transfers to someone else. More on that in the next “Perspective.”
Discussion:
1. The “Courtesy” call: This is a call made out of courtesy to both the consultant and to the patient. The patient will definitely need followup care. The ED physician needs to assure that he gets it. The availability of that follow up care must be confirmed (e.g., too many on call docs are “leaving on vacation in the morning.”) And the patient needs to know who will be responsible for his followup care, especially if he has no other physician. Documenting a call such as this when providing discharge instructions to a patient indicates appropriate concern on the part of the emergency physician for the welfare of the patient.
2: The “It’s your case now” call: A seriously ill or injured patient needing inpatient care requires an admitting physician to whom the ED doctor can transfer responsibility (see “Handoffs” in next issue). This care may be assumed by an inpatient care specialist (e.g., hospitalist) or a staff physician or surgeon. The ED doc and the admitting specialist must agree on two things: 1) the patient is definitely being admitted – a decision that the ED physician must have made before calling the specialist – and 2) the time frame within which the doctor accepting care must see the patient. (This may be a matter of hospital policy, but can sometimes be negotiated while still maintaining safety for the patient.) In general, until the patient actually leaves the ED for the OR, ICU or other inpatient location, the ED physician and staff remain responsible for the patient.
3. The “Help! I need your expertise” call: This, and point 2 above, is why emergency departments maintain a backup roster of specialists. Again, however, the ED doc must have already determined the absolute need for the skill set of the consultant, and not be “bullied” into delay, negotiations, excuses, etc. Failure of a consultant to respond when an appropriate request is made by another physician is usually both an EMTALA violation and the subject of medical staff disciplinary procedures. The ED physician may, in fact, maintain ultimate control of the patient – especially if the patient never leaves the department – and discharge the patient or assist the consultant in that process.
4. The “I need you to evaluate this patient, or else I’m admitting him/her to you” call. This is similar to the above and – given the current state of diagnostic technology and emergency physician training – rather infrequent. When a second set of eyes, ears and hands are necessary to determine a safe patient disposition, consultants are obligated to respond. This is probably the classic definition of a true “consultation,” and in this instance, the patient’s care cannot be relegated to the consultant. The ED physician remains responsible for the patient, and if uncomfortable with the opinion of the consultant, must pursue the matter until a mutually satisfactory outcome is assured.
5. The “I’m not sure what I’m doing and hope to dump responsibility for this patient on you” call. Fortunately, most well-trained ED docs in this day and age are beyond this. Such an approach may be appropriate for a student, but not a board certified practitioner. Almost always, a good doc can mold a call like this into one of the options above. In fact, the call should not even be made until that is done. And, there is likely no legal way to transfer responsibility for the care of a patient to a physician who has never seen that patient. The ED doc owns his or her decisions. So a call like this serves no one.
Bottom line: There is probably a wealth of case law addressing this issue, but from this physician’s perspective, a consultant is just that: “a person from whom one receives advice or with whom one exchanges views.” It is up to the physician requesting the consult to accept or reject that advice. Nothing about a consultation relieves the physician requesting it from responsibility for the patient – unless, of course, a clearcut transfer of that responsibility takes place. That is called a “handoff” and is the subject of next month’s “Perspective.”